American Spinal Injury Association Motor Research Articles

Application of a novel nested ensemble algorithm in predicting motor function recovery in patients with traumatic cervical spinal cord injury

Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients.

Assessment of ability realization using the 4th version of the Spinal Cord Independence Measure

Context Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities after spinal cord lesions (SCL). Objective To adapt a Spinal Cord Ability Realization Measurement Index (SCI-ARMI) formula to the new Spinal Cord Independence Measure version 4 (SCIM4). Methods Using data from 156 individuals for whom American Spinal Injury Association Motor Score (AMS) and SCIM4 scores were collected, we obtained an estimate for the highest possible SCIM4 given the patient’s AMS value, using the 95th percentile of SCIM4 values at discharge from rehabilitation (SCIM95) for patients with any given AMS at discharge. We used the statistical software environment R to implement the quantile regression method for linear and quadratic formulas. We also compared the computed model with the SCIM95 model obtained using data from the present study group, positioned in the SCIM95 formula developed for SCIM3. Results The coefficients of the computed SCIM95 formula based on SCIM4 scores were statistically non-significant, which hypothetically reflects the small sample relative to the goal of estimating SCIM4 95th percentile. Predicting the ability using SCIM4 scores positioned in the SCIM95 formula used for SCIM3, however, yielded SCIM95 values, which are very close to those of the new SCIM95 formula (Mean difference 2.16, 95% CI = 1.45, 4.90). Conclusion The SCI-ARMI formula, which is based on the SCIM95 formula developed for SCIM3, is appropriate for estimating SCI-ARMI at present, when SCIM4 scores are available. When sufficient additional data accumulates, it will be appropriate to introduce a modified SCI-ARMI formula.

Riluzole for Degenerative Cervical Myelopathy

The modified Japanese Orthopaedic Association (mJOA) scale is the most common scale used to represent outcomes of degenerative cervical myelopathy (DCM); however, it lacks consideration for neck pain scores and neglects the multidimensional aspect of recovery after surgery. To use a global statistical approach that incorporates assessments of multiple outcomes to reassess the efficacy of riluzole in patients undergoing spinal surgery for DCM. This was a secondary analysis of prespecified secondary end points within the Efficacy of Riluzole in Surgical Treatment for Cervical Spondylotic Myelopathy (CSM-PROTECT) trial, a multicenter, double-blind, phase 3 randomized clinical trial conducted from January 2012 to May 2017. Adult surgical patients with DCM with moderate to severe myelopathy (mJOA scale score of 8-14) were randomized to receive either riluzole or placebo. The present study was conducted from July to December 2023. Riluzole (50 mg twice daily) or placebo for a total of 6 weeks, including 2 weeks prior to surgery and 4 weeks following surgery. The primary outcome measure was a difference in clinical improvement from baseline to 1-year follow-up, assessed using a global statistical test (GST). The 36-Item Short Form Health Survey Physical Component Score (SF-36 PCS), arm and neck pain numeric rating scale (NRS) scores, American Spinal Injury Association (ASIA) motor score, and Nurick grade were combined into a single summary statistic known as the global treatment effect (GTE). Overall, 290 patients (riluzole group, 141; placebo group, 149; mean [SD] age, 59 [10.1] years; 161 [56%] male) were included. Riluzole showed a significantly higher probability of global improvement compared with placebo at 1-year follow-up (GTE, 0.08; 95% CI, 0.00-0.16; P = .02). A similar favorable global response was seen at 35 days and 6 months (GTE for both, 0.07; 95% CI, -0.01 to 0.15; P = .04), although the results were not statistically significant. Riluzole-treated patients had at least a 54% likelihood of achieving better outcomes at 1 year compared with the placebo group. The ASIA motor score and neck and arm pain NRS combination at 1 year provided the best-fit parsimonious model for detecting a benefit of riluzole (GTE, 0.11; 95% CI, 0.02-0.16; P = .007). In this secondary analysis of the CSM-PROTECT trial using a global outcome technique, riluzole was associated with improved clinical outcomes in patients with DCM. The GST offered probability-based results capable of representing diverse outcome scales and should be considered in future studies assessing spine surgery outcomes.

Timing of decompression in central cord syndrome: a systematic review and meta-analysis.

This study compared the recovery of motor function and the safety of early and delayed surgical intervention in patients with central cord syndrome (CCS). PubMed, Embase, Cochrane Library, and Web of Science were employed to retrieve the targeted studies published from inception to February 19, 2023. Comparative studies of early versus delayed surgical decompression in CCS based on American Spinal Injury Association motor score (AMS) recovery, complication rates, and mortality were selected. The statistical analyses were performed using STATA 16.0 and RevMan 5.4. Our meta-analysis included 13 studies comprising 8424 patients. Results revealed that early surgery improved AMS scores significantly compared with delayed surgery, with an increase in MDs by 7.22 points (95% CI 1.98-12.45; P = 0.007). Additionally, early surgery reduced the complication rates than delayed surgery (OR 0.53, 95% CI 0.42-0.67, P < 0.00001). However, no significant difference was observed in mortality between the two groups (OR 0.97; 95% CI 0.75-1.26; P = 0.84). Early surgical decompression for CCS can improve motor function and reduce the incidence of complications without affecting the mortality rate in patients. Future research should focus on investigating and analyzing the optimal window period for early CCS surgery. Additionally, the timing of surgery should be determined based on the patient's condition and available medical resources.

The Impact of Magnetic Resonance Imaging Findings in Predicting Neurological Status Pre- and Post-Treatment of Spinal Dural Arteriovenous Fistulas: A 22-Year Experience in a Neurovascular and Spine Center.

Successful treatment of spinal dural arteriovenous fistulas (SDAVF) requires prompt diagnosis with definitive fistula localization and non-delayed treatment. Magnetic resonance imaging (MRI) is used for the screening and follow-up of SDAVF, although the value of MRI signs such as myelopathy and flow voids is controversial. Therefore, we investigated the predictive value of MRI signs pre- and post-treatment and their correlation with the neurological status of SDAVF patients. We retrospectively analyzed the clinical records of 81 patients who underwent surgical or endovascular treatment for SDAVF at our hospital between 2002 and 2023. A total of 41 SDAVF patients with follow-up MRI of 4.6 [2.9-6.5] months (median [interquartile range]) post-treatment and clinical follow-up of 3, 6, and 12 months were included. The extent of pretreatment myelopathy was seven [6-8] vertebral levels, with follow-up MRI showing no myelopathy in 70.7% of cases. The pretreatment flow voids extended over seven [4.5-10] vertebral levels and completely disappeared on follow-up MRI in 100% of cases. The modified Aminoff-Logue scale of disability (mALS) was four [2-7] pretreatment and two [0-4.5] at the third follow-up, with improvement in 65.9% of patients. The American Spinal Injury Association motor score (ASIA-MS) was 97 [88-100] pretreatment and 100 [95-100] at the third follow-up assessment, with 78% of patients improving. Pretreatment ASIA-MS correlated with the extent of myelopathy at admission (R2: 0.179; 95% CI: -0.185, -0.033; p = 0.006) but not with flow voids at admission, while pretreatment mALS showed no correlation with either MRI signs. The improvement in ASIA-MS and mALS between admission and the last follow-up showed no correlation with the extent of pretreatment myelopathy and flow voids or with pos-treatment MRI changes. The diagnostic sensitivity of magnetic resonance angiography (MRA) for localization of the fistula was 68.3% (28/41). The severity of the clinical condition in SDAVF patients has a multifactorial cause, whereby the ASIA-MS correlates with the extent of myelopathy pretreatment. MRI changes after treatment showed no correlation with the clinical outcome and cannot be used as a prognostic factor.

Diagnostic, clinical management, and outcomes in patients with spinal dural arteriovenous fistula.

Spinal dural arteriovenous fistulas (SDAVFs) are rare spinal vascular malformations, but account for 70 to 80% of all spinal arteriovenous malformations. SDAVFs can be treated either surgically or endovascularly, with surgical treatment appearing to lead to higher closure rates. Our aim was to analyze the demographic data, diagnostic history, treatment characteristics and clinical short- and long-term outcomes. The medical records of 81 patients who underwent surgical (n = 70, 86.4%) and endovascular (n = 11, 13.6%) treatment for SDAVF at a university hospital between 2002 and 2023 were retrospectively analyzed. SDAVF was observed more frequently in men than women (61, 75.3% vs. 20, 24.7%) with a mean age of 63.5 ± 12.7 years and a mean duration of symptoms to diagnosis of 12.0 ± 12.8 months. The most common first symptom was gait disturbance (36, 44.4%), followed by sensory disturbance (24, 29.6%). The location of the fistula point was most common in the lower thoracic region (36, 44.5%), followed by the lumbar region (23, 28.4%). Incomplete or failed occlusion of the fistula occurred in 8 patients (9.9%), with 6 patients (7.4%) undergoing further treatment either surgically or endovascularly. Treatment- or hospital-related complications were observed in 16 patients (19.8%). A single-level laminectomy was the most common approach (31, 44.3%), followed by single-level hemilaminectomy (28, 40.0%), and unilateral interlaminar fenestration (11, 15.7%). Back pain or radiculopathy was observed in 58% of patients (47/81) pre-treatment and had already decreased to 24.7% at hospital discharge (p < 0.001). No significant differences were observed in sensory disturbances (p = 0.681). The median of American Spinal Injury Association motor score (ASIA-MS) was 94 [82.5-100] at admission, 98 [86.5-100] at hospital discharge, 100 [90-100] at the first, second, and third follow-up (p = 0.019). The median modified Aminoff-Logue scale (mALS) was 5 [2-7] at admission, 3 [1-6] at hospital discharge, 2 [1-5] at the first follow-up, 2 [0.5-5] at the second follow-up and 2 [1-7] at the third follow-up (p = 0.006). SDAVF occurs predominantly in men in the 6th decade of life and can be safely and effectively treated surgically and endovascularly, improving symptoms such as pain and motor deficits, gait disturbances as well as bowel and bladder dysfunction, but not sensory disturbances.

Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis.

The objective was to evaluate the efficacy, outcomes, and complications of surgical intervention performed within 24 hours (≤ 24 hours) versus after 24 hours (> 24 hours) in managing acute traumatic central cord syndrome (ATCCS). Articles pertinent to the study were retrieved from PubMed, Scopus, Web of Science, and Cochrane. The authors performed a systematic review and meta-analysis of treatment procedures and outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. Seven articles comprising 488 patients were included, with 188 (38.5%) patients in the ≤ 24-hour group and 300 (61.5%) in the > 24-hour group. Significant differences were not found between groups in terms of demographic characteristics, injury mechanism, spinal cord compression level, neuroimaging features, and the American Spinal Injury Association (ASIA) motor score at admission. Both groups had a similar approach to surgery and steroid administration. The surgical complication rate was significantly higher in the > 24-hour group (4.5%) compared to the ≤ 24-hour group (1.2%) (p = 0.05). Clinical follow-up duration was similar at 12 months (interquartile range 3-36) for both groups (p > 0.99). The ≤ 24-hour group demonstrated a not statistically significant greater improvement in ASIA motor score, with a mean difference of 12 (95% CI -20.7 to 44.6) compared to the > 24-hour group. The present study indicates potential advantages of early (≤ 24 hours) surgery in ATCCS patients, specifically in terms of lower complication rates. However, further research is needed to confirm these findings and their clinical implications.

Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan.

Retrospective multicenter study. The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes. This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1month were excluded. The minimum follow-up period was 6months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared. Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6months after injury were observed between the matched cohorts. At 6months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory. Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Predicting the Progression of Spasticity in the Early Phase of Spinal Cord Injury: A Prospective Cohort Study.

Spasticity-defined as involuntary movements caused by insult to upper motor neurons after spinal cord injury (SCI)-interferes with patients' activities of daily living. Spasticity is generally identified and managed in the chronic phase of SCI, but few reports have examined the onset of spasticity after injury. The purpose of this study is to elucidate serial changes in spasticity after SCI and clarify the timing of severe spasticity. We prospectively examined individuals with acute traumatic SCI admitted within two weeks after injury. Severity of spasticity was evaluated using the Modified Ashworth Scale (MAS) at 2, 4, 6, and 8 weeks, followed by 3, 4, 5, and 6 months after injury. After completing evaluation of the cohort, the patients were divided into two groups: a spasticity group with MAS scores ≥3 (marked increase in muscle tone through most of the range of motion (ROM)) in at least one joint movement within 6 months of injury and a control group with MAS scores ≤2 in all joint movements throughout the 6 months after injury. Neurological findings such as the American Spinal Injury Association (ASIA) Impairment Scale grades and ASIA motor scores were also assessed at all time points, and the correlations between the onset of spasticity, severity of spasticity, and neurological findings were analyzed. There were 175 patients with traumatic SCI who were assessed consecutively for 6 months after injury. The MAS scores of the group significantly increased over time until 4 months after injury. The spasticity group had significantly higher MAS scores compared with the control group as early as 2 weeks post-injury. We found that the patients with earlier onset of spasticity had higher final MAS scores. No correlation was found between the ASIA Impairment Scale grade and the onset of spasticity. Our results reveal that the development of severe spasticity may be predictable from as early as 2 weeks after SCI, suggesting that early therapeutic intervention to mitigate problematic spasticity may enhance the benefits of post-injury rehabilitation.

Lower Extremity Somatosensory Evoked Potentials Predict Functional Outcomes in Complete Traumatic Cervical Spinal Cord Injury

Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients. A retrospective study was conducted on prospectively collected data from 2 academic institutions. Patients 18years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis. A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (P= 0.002), greater increases in ASIA motor scores at follow-up (P= 0.009), and a greater likelihood of clinically important improvement in ASIA motor score (P= 0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (P= 0.019) and clinically important improvement in ASIA motor score (P= 0.010), compared to AIS grade A or B injuries. The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury.

Association between injury severity scores and clinical outcomes in patients with traumatic spinal injury in an aging Japanese society.

The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of patients with spinal cord injury (SCI) in an aging Japanese population. This retrospective cohort study investigated patients admitted to a Japanese university hospital. In the study, 89 patients with traumatic SCI were included. Traumatic SCI was categorized as monotrauma or polytrauma, and the ISS was used to evaluate trauma severity. Spearman's correlation coefficient was used to estimate the correlation between ISS and the American Spinal Injury Association (ASIA) motor score, Barthel Index (activities of daily living assessment), and the European Quality of Life (QOL) scale (EQ5d) as an assessment of QOL at admission or the last follow-up with the adjustment for age, sex, and body mass index. Return to home and work were analyzed using the chi-squared test after the ISS was divided into three groups (<14, 14-19, and 20). The mean ISS was significantly higher for polytrauma than monotrauma. Significant negative correlations between the ISS and ASIA motor scores at the first visit (P < .001, r = -0.37) and the last follow-up (adjusted, P = .007, r = -0.30) were observed. The Barthel Index was also negatively correlated with ISS at the first visit (P = .04, r = -0.21) and at the last follow-up period (P < .001, r = -0.35). Moreover, ISS was significantly negatively correlated with EQ5d score at the last follow-up (P = .01, r = -0.28). The chi-squared test demonstrated that patients with an ISS of < 14 returned home (P = .03), while those with an ISS of < 19 returned to work (P = .02). ISS is associated with paralysis, activities of daily living, QOL, and lifestyle in patients with SCI and is an important initial injury assessment method.

Mortality in ASIA Impairment Scale grade A to D Patients With Odontoid Fracture and Magnetic Resonance Imaging Evidence of Spinal Cord Injury.

Odontoid fractures are common, often presenting in the elderly after a fall and infrequently associated with traumatic spinal cord injury (tSCI). The goal of this study was to analyze predictors of mortality and neurological outcome when odontoid fractures were associated with signal change on magnetic resonance imaging (MRI) at admission. Over an 18-year period (2001-2019), 33 patients with odontoid fractures and documented tSCI on MRI were identified. Mean age was 65.3 years (standard deviation [SD] = 17.2), and 21 patients were male. The mechanism of injury was falls in 25 patients, motor vehicle accidents in 5, and other causes in 3. Mean Injury Severity Score (ISS) was 40.5 (SD = 30.2), Glasgow Coma Scale (GCS) score was 13 (SD = 3.4), and American Spinal Injury Association (ASIA) motor score (AMS) was 51.6 (SD = 42.7). ASIA Impairment Scale (AIS) grade was A, B, C, and D in 9, 2, 3, and 19 patients, respectively. Mean intramedullary lesion length was 32.3 mm (SD = 18.6). The odontoid peg was displaced ventral or dorsal in 15 patients. Twenty patients had surgical intervention: anterior odontoid screw fixation in 7 and posterior spinal fusion in 13. Eleven (33.3%) patients died in this series: withdrawal of medical care in 5; anoxic brain injury in 4; and failure of critical care management in 2. Univariate logistic regression indicated that GCS score (p < 0.014), AMS (p < 0.002), AIS grade (p < 0.002), and ISS (p < 0.009) were risk factors for mortality. Multi-variate regression analysis indicated that only AMS (p < 0.002) had a significant relationship with mortality when odontoid fracture was associated with tSCI (odds ratio, 0.963; 95% confidence interval, 0.941-0.986).

193 Expansile Duraplasty Improves Motor Outcomes After Acute Traumatic Spinal Cord Injury

INTRODUCTION: Traumatic spinal cord injury (SCI) can lead to debilitating motor weakness. Early surgical decompression and optimization of spinal cord perfusion have emerged as potential therapies to prevent secondary injury caused by edema, ischemia, and inflammation. Expansile duraplasty extends decompression to the intrathecal space to optimize spinal cord perfusion. There remains a paucity of data on whether this provides a clinical benefit. METHODS: We included patients who underwent decompression and stabilization surgery for traumatic SCI from February 2017 to June 2021 at our level 1 trauma center. In duraplasty patients, a 1.5cm x3.5cm acellular, expansile patch was sutured into the dura at the injury site. We collected demographics, injury type, surgery performed, and American Spinal Injury Association (ASIA) motor scores (range 0-100) pre-operatively and at the time of hospital and inpatient rehabilitation discharge. RESULTS: 101 patients were included: 12 treated with expansile duraplasty and 89 without duraplasty. The mean pre-operative motor score was 48.7 ± 29.3 for all patients, 50.5 ± 19.7 for non-duraplasty and 35.7 ± 23.0 for expansile duraplasty (p = 0.06). At rehabilitation discharge, mean change in motor score from pre-operative exam was significantly higher in duraplasty patients (19.9 ± 11.0 for duraplasty vs. 10.9 ± 13.4 for non-duraplasty, p = 0.02). There were no wound complications in the duraplasty group. CONCLUSIONS: In this single-center, retrospective study, SCI patients undergoing expansile duraplasty had significantly greater improvement in ASIA motor scores at rehabilitation discharge compared to non-duraplasty controls. There was no increase in wound complications nor CNS infection. These data present an independent validation of preliminary data from international centers in favor of expansile duraplasty. Further prospective studies are warranted to assess whether this technique is efficacious in treating acute traumatic SCI.

Prognostic and risk factors for the surgical efficacy of central spinal cord syndrome in patients with preexisting degenerative cervical spinal cord compression.

To analyze the prognostic and risk factors related to surgical treatment of central spinal cord syndrome (CSS) and to find out the optimal timing of operative management. From January 2011 to January 2019, a consecutive series of 128 patients with CSS confirmed by magnetic resonance imaging (MRI) were retrospectively analyzed including their clinical records and radiologic data from a prospectively maintained database in a single center. According to the prognosis evaluated by the modified Japanese Orthopedic Association (mJOA), American Spinal Injury Association (ASIA) motor score (AMS), and ASIA impairment scale (AIS) grade, the overall postoperative outcome was good. Finally, it was found that surgical timing, presence of myelopathy or not at baseline, AMS at admission, and compression ratio were independent factors affecting the prognosis. Surgery as soon as possible after the occurrence of CSS is still advocated. Cervical myelopathy at baseline, compression ratio, and AMS score on admission were independent prognostic factors for the surgical treatment of CSS. If surgical indications are clear, early surgical intervention should be actively considered.

Ossification of the anterior longitudinal ligament affects the severity and distribution of neurological deficits following spinal cord injury without radiological abnormality

BackgroundThe incidence of spinal cord injury without radiological abnormality (SCIWORA) is increasing among older adults in developed countries. SCIWORA is commonly associated with ossification of the spinal ligament, specifically the ossification of the posterior longitudinal ligament (OPLL) and ossification of the anterior longitudinal ligament (OALL). OALL induces segmental spinal fusion and alters the biomechanical properties of the cervical spine; however, whether OALL modulates the severity of SCIWORA remains unknown. This study aimed to investigate the influence of OALL on the severity and distribution of neurological deficits following SCIWORA. MethodsThis retrospective study included 122 patients with SCIWORA who were admitted to our hospital from April 2008 to March 2022. The neurological function of all the included patients was assessed via the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at admission. Magnetic resonance imaging (MRI) and computed tomography were performed within 48 h of trauma. Central cord syndrome (CCS) was defined as the upper-extremity ASIA motor score being at least 10 points lesser than the lower-extremity motor score. ResultsThe study included 122 patients with a mean age of 65.1 years. Comparing mild (AIS grades C or D) and severe (AIS grades A or B) neurological deficits revealed that the former was independently associated with ground-level falls, OALL, and absence of prevertebral T2 high-intensity area on MRI. Although 39% of patients with SCIWORA exhibited OPLL as an etiology of cervical stenosis, OPLL demonstrated no significant effect on the severity of neurological deficits. CCS occurrence was independently associated with OALL and a larger cross-sectional cord area on MRI. Patients with OALL had significantly higher lower-extremity ASIA motor scores than those without OALL. ConclusionsOALL was significantly associated with mild neurological deficits in the lower extremities and with the occurrence of CCS after SCIWORA.

Demographics, Mechanism of Injury, and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries: An Analysis of 470 Patients in the Prospective, Multi-Center, North American Clinical Trials Network Registry.

There is a paucity of data comparing the demographics, mechanism of injury, and outcomes of upper versus lower cervical spinal cord injuries (cSCI). The study objective was to define different clinical manifestations of cSCI. Data were collected prospectively through centers of the North American Clinical Trials Network (NACTN). Data was collected on 470 patients (21% women, mean age 50 years). Cervical vertebral level was analyzed as an ordinal variable to determine a natural demarcation to classify upper versus lower cSCI. For continuous variable analysis, falls were associated with C3 more than C4 vertebral level injuries (60% vs. 42%; p = 0.0126), while motor vehicle accidents were associated with C4 more than C3 (40% vs. 29%; p = 0.0962). Motor International Standards for Neurological Classification of Spinal Cord Injury scores also demonstrated a natural demarcation between C3 and C4, with C3 having higher median American Spinal Injury Association (ASIA) motor scores (40 [4-73] vs. 11 [3-59], p = 0.0227). There were no differences when comparing C2 to C3 nor C4 to C5. Given the significant differences seen between C3 and C4, but not C2 and C3 nor C4 and C5, upper cSCI was designated as C1-C3, and lower cSCI was designated as C4-C7. Compared with a lower cSCI, patients with an upper cSCI were more likely to have a fall as their mechanism of injury (54% vs. 36%; p = 0.0072). Patients with an ASIA C cSCI were likely to have an upper cervical injury: 23% vs. 11% (p = 0.0226). Additionally, patients with an upper cSCI were more likely to have diabetes prior to injury: 37% versus 22%, respectively (p = 0.0084). Lower cSCI were more likely injured through sports (19% vs. 8%, p = 0.0171) and present with ASIA A (42% vs. 25%, p = 0.0186) neurological grade. Patients with lower cSCI were also significantly more likely to have complications such as shock, pulmonary embolism, and pleural effusion. In conclusion, there appears to be a natural demarcation of injury type between C3 and C4. Upper cSCI (C1-C3) was more associated with falls and diabetes, whereas lower cSCI (C4-C7) was more associated with sports, worse ASIA scores, and more complications. Further research will be needed to understand the mechanistic and biological differences between these two groups and whether different treatments may be appropriate for each of these groups.

Efficacy of mesenchymal stromal cells intraspinal transplantation for patients with different degrees of spinal cord injury: A systematic review and meta-analysis

Background aimsSeveral studies have reported that mesenchymal stromal cells (MSCs) may improve neurological functions in patients with spinal cord injury (SCI). In this study, we conducted a systematic review and meta-analysis to summarize the effects of MSC treatment on different degrees of severity of SCI. MethodsSystematic searching of studies reporting outcomes of MSCs on specific injury severities of patients with SCI was performed in The National Library of Medicine (MEDLINE), Embase and Cochrane for published articles up to the 6 July 2022. Two investigators independently reviewed the included studies and extracted the relevant data. The standardized mean differences of American Spinal Injury Association (ASIA) motor score, ASIA light touch scores, ASIA pinprick scores and the Barthel index between baseline and follow-ups were pooled. ResultsA total of eight studies were included. A large majority focused on patients with ASIA grade A classification. The pooled mean differences of ASIA motor scores, ASIA light touch scores, ASIA pinprick scores and the Barthel index were –2.78 (95% confidence interval [CI] –5.12 to –0.43, P = 0.02), –18.26 (95% CI –26.09 to –10.43, P < 0.01), –17.08 (95% CI –24.10 to –10.07, P < 0.01) and –4.37 (95% CI –10.96 to 2.22, P = 0.19), respectively. ConclusionsMSC transplantation was a significantly effective therapy for patients with SCI with ASIA grade A. In the future, further studies are warranted to confirm the potential beneficial effects of MSC therapy.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study

BackgroundAlthough previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury. MethodsIn this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery. ResultsThe relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement. ConclusionsAlthough further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Early Phase Functional Recovery after Spinal Intramedullary Tumor Resection Could Predict Ambulatory Capacity at 1 Year after Surgery.

This is a single-center retrospective cohort study with a university hospital setting. This study aims to evaluate the short-term course of physical function and walking ability after intramedullary spinal cord tumor (ISCT) resection and predict walking independence 1 year after surgery. Although several reports have shown the postoperative functional prognosis of spinal intramedullary tumors with long-term follow-up, no reports have identified the predictors associated with the functional outcome at an early stage. A total of 79 individuals who underwent ISCT resection at our institute between 2014 and 2019 were enrolled in the study, whose preoperative walking state was independent ambulator regardless of cane support with the Functional Independence Measure Locomotor Scale (FIM-L) score of ≥6. The FIM-L, the American Spinal Injury Association (ASIA) motor and sensory scores in the lower extremities, and the Walking Index for Spinal Cord Injury II (WISCI II) were assessed for walking independence, lower-limb function, and walking ability, respectively. These evaluations were performed at 4 time points: preoperatively, 1 week (1W), 2 weeks (2W), and 1 year after surgery. In the early phase after surgery, 71% and 43% of the participants were nonindependent ambulators at 1W and 2W, respectively. Histopathology indicated that patients with solid tumors (ependymoma, astrocytoma, or lipoma) showed significantly lower indices at 1W and 2W than those with vascular tumors (hemangioblastoma or cavernous hemangioma). Regarding tumor location, thoracic cases exhibited poorer lower-limb function at 1W and 2W and poorer walking ability at 2W than cervical cases. According to the receiver operating characteristic (ROC) analysis, 2 WISCI II points at 2W had the highest sensitivity (100%) and specificity (92.2%) in predicting the level of walking independence at 1 year postoperatively (the area under the ROC curve was 0.99 (95% confidence interval, 0.93-1.00). The higher the lower-limb function scores in the early phase, the better the improvement in walking ability is predicted 1 year after ISCT resection.

Effectiveness of different surgical methods in the treatment of acute central cord syndrome without fractures and dislocations of the cervical spine.

Acute central cord syndrome (ACCS) without fractures or dislocations is the most common form of incomplete spinal cord injury. To evaluate the effectiveness of different surgical methods in the treatment of acute central cord syndrome without fractures or dislocations of the cervical spine. A total of 164 patients with ACCS without fracture or dislocation of the cervical spine treated in our hospital from May 2012 to October 2019 were recruited and assigned to study group A and study group B according to different treatment modalities, with 82 cases in each group. Study group A underwent anterior cervical discectomy and fusion, and study group B was treated with posterior cervical laminectomy. The American Spinal Injury Association (ASIA) classification and motor scores of all cases at admission and at discharge were recorded, and the treatment outcomes of the two groups were compared. No significant differences were found in the ASIA classification and ASIA motor scores between the two groups at admission (P> 0.05). One year after surgery, the ASIA motor scores and sensory scores were not statistically significant between the two groups (P> 0.05) but showed significant improvement compared to the preoperative scores (P< 0.05). Both anterior cervical discectomy and fusion and posterior cervical laminectomy can improve the ASIA classification, ASIA motor scores, and sensory scores of ACCS patients without fractures or dislocations of the cervical spine. Therefore, surgical methods should be adopted based on the patients' conditions.