Association Impairment Scale Research Articles

Incidence of Acute Complications Associated with Spinal Cord Injury (SCI): A Study of the Ayub Teaching Hospital, Abbottabad

Objective: To document the occurrence of acute problems as well as post-surgical improvements in individuals suffering from spinal cord injury. Materials and Methods: This study was conducted retrospectively in the Department of Neurosurgery. All patients of any age and both genders were included who were admitted with spinal injuries. The patients with cervical fractures received the anterior cervical plating plus graft placement in the cervical spine, whereas the patient with thoracolumbar fractures received the transpedicular fixation in thoracolumbar spine fractures. ASIA Impairment Scale for neurological status, GCS at admission, and acute complications developed within two weeks were noted. Results: 200 patients were included (mean age of 34.6 years). The common cause of SCI was a fall from an elevated position of 62.5%. On admission, 50% of patients’ neurological state was Asia grade A. The most common location involved in patients (70%) was a thoracolumbar junction. 20% of patients presented with neurogenic shock. Postoperatively, the GCS scores in all patients were been improved. The commonest acute complications associated with SCI were pulmonary in 60% of patients. 17% of patients developed an infection, 5% suffered from gastrointestinal issues, and 3% suffered from renal issues. Deep vein thrombosis (DVT) was observed in 9%. Conclusion: During the early phase of hospitalization, respiratory difficulties were among the most prevalent complications encountered in those suffering from traumatic SCI. These outcomes exacerbate the eventual suffering caused by the spinal cord injury; hence, recognizing the likelihood of occurrence, early detection, exact surgical treatment, and prevention are essential.

A dynamic nomogram for predicting the probability of irreversible neurological dysfunction after cervical spinal cord injury: research based on clinical features and MRI data

BackgroundIrreversible neurological dysfunction (IND) is an adverse event after cervical spinal cord injury (CSCI). However, there is still a shortage of objective criteria for the early prediction of neurological function. We aimed to screen independent predictors of IND and use these findings to construct a nomogram that could predict the development of neurological function in CSCI patients.MethodsPatients with CSCI attending the Affiliated Hospital of Southwest Medical University between January 2014 and March 2021 were included in this study. We divided the patients into two groups: reversible neurological dysfunction (RND) and IND. The independent predictors of IND in CSCI patients were screened using the regularization technique to construct a nomogram, which was finally converted into an online calculator. Concordance index (C-index), calibration curves analysis and decision curve analysis (DCA) evaluated the model's discrimination, calibration, and clinical applicability. We tested the nomogram in an external validation cohort and performed internal validation using the bootstrap method.ResultsWe enrolled 193 individuals with CSCI in this study, including IND (n = 75) and RND (n = 118). Six features, including age, American spinal injury association Impairment Scale (AIS) grade, signal of spinal cord (SC), maximum canal compromise (MCC), intramedullary lesion length (IMLL), and specialized institution-based rehabilitation (SIBR), were included in the model. The C-index of 0.882 from the training set and its externally validated value of 0.827 demonstrated the model's prediction accuracy. Meanwhile, the model has satisfactory actual consistency and clinical applicability, verified in the calibration curve and DCA.ConclusionWe constructed a prediction model based on six clinical and MRI features that can be used to assess the probability of developing IND in patients with CSCI.

Time-related Complications in Patients with Traumatic Spinal Cord Injury according to the AIS Impairment Scale Grade: A Retrospective Review

Purpose: The aim of this study was to analyze time-dependent complications in patients with traumatic spinal cord injury (SCI) as a function of their initial neurological status determined by the ASIA Impairment Scale (AIS) grade.Methods: Consecutive patients with SCI who visited the emergency department at Asan Medical Center from 2005 to 2019 were included, and their electronic medical records were analyzed according to four time periods from initial visit to hospital discharge. Time-dependent SCI-related complications, including medical, urinary, musculoskeletal, and neurological complications and pain, were analyzed as well as the association between SCI complications and AIS grade. In-hospital recovery from neurological damage and long-term outcomes were also evaluated.Results: Of the 632 SCI patients who visited the emergency department during the study period, 110 patients were included in the study. The complication rates in patients initially assessed as AIS grades A, B, C, D, and E were 53.6%, 16.4%, 14.6%, 13.6%, and 1.8%, respectively. The most common complications after SCI were UTIs (n=37; 33.6%), pressure ulcers (n=36; 32.7%), neuropathic pain (n=34; 30.9%), and pneumonia (n=33; 30.0%). Patients with a poor neurological status (AIS grade A) had more medical complications and lower neurological resilience than did those with better neurological status (AIS grades B-E).Conclusion: Post-SCI complications differed by time after SCI and neurological status. Nurses should be aware that complications can occur at any time in patients with traumatic SCI. Patients with poorer AIS grades should be particularly closely observed and receive preventive care for complications.

Time Course and Characteristics of the Nutritional Conditions in Acute Traumatic Cervical Spinal Cord Injury.

This retrospective cohort study aimed to examine the nutritional time course and elucidate the critical period of undernutrition following acute traumatic cervical spinal cord injury (CSCI). The study was performed at a single facility that treated spinal cord injuries. We examined individuals with acute traumatic CSCI admitted to our hospital within 3 days of injury. Both prognostic nutritional index (PNI) and controlling nutritional status (CONUT) scores, which objectively reflect nutritional and immunological conditions, were assessed at admission and 1, 2, and 3 months after the injury. The American Spinal Injury Association impairment scale (AIS) categorizations and severity of dysphagia were evaluated at these time points. A total of 106 patients with CSCI were evaluated consecutively for 3 months after injury. Individuals with AIS categorizations of A, B, or C at 3 days after injury were significantly more undernourished than those with an AIS categorization of D at 3 months after injury, indicating that individuals with mild paresis better maintained their nutritional condition after injury. Nutritional conditions, as assessed by both PNI and CONUT scores, improved significantly between 1 and 2 months after injury, whereas no significant differences were found between admission and 1 month after injury. Nutritional status and dysphagia were significantly correlated at each time point (p<0.001), indicating that swallowing dysfunction is an important factor associated with malnutrition. Nutritional conditions showed significant gradual improvements from 1 month after the injury. We must pay attention to undernutrition, which is associated with dysphagia, especially in individuals with severe paralysis during the acute phase following injury.

Long-term Outcomes Following Periprocedural and Spontaneous Spinal Cord Infarctions: A Population-Based Cohort Study.

Spinal cord infarction (SCInf) is a rare condition where consensus regarding diagnostic criteria is lacking and mis- or delayed diagnosis can be detrimental. The aim of this study was to describe baseline findings and predictors of long-term functional outcome in a population-based cohort of patients with SCInf. All adult patients (≥18 years) treated at the Spinal Cord Injury Unit of the study center, between 2006-2019, and discharged with a G95 diagnosis ("other and unspecified disease of the spinal cord") were screened for inclusion. The diagnostic criteria proposed by Zalewski et al. were retrospectively applied to evaluate the certainty of the SCInf diagnosis. 270 patients were screened and 57 were included in the study, of whom 30 had a spontaneous and 27 had a periprocedural SCInf. The median American Spinal Cord Injury Association Impairment Scale (AIS) on admission was C, which at median follow-up of 2.1 years had improved to D (p=0.002). Compared to periprocedural cases, spontaneous SCInf showed significantly better admission-AIS (median AIS D vs. B, p<0.001), fewer multilevel SCInf (27% vs. 59%, p=0.029), shorter hospital stay (median 22 vs. 44 days, p<0.001), as well as better AIS (median AIS D vs. C, p<0.001) and ambulatory status on long-term follow-up (66% vs. 1%, p<0.001). Regression analyses revealed that spontaneous SCInfs (OR=5.91 [1.92-18.1], p=0.002) and more favorable admission-AIS (OR=33.6 [7.72-146], p<0.001) were significant predictors of more favorable AIS at follow-up, with admission-AIS demonstrating independent predictive ability (OR=35.9 [8.05-160], p<0.001). SCInf is a rare neurological emergency lacking specific management guidelines. While the presumptive diagnosis is based on the typical presentation and clinical findings, T2-weighted and diffusion-weighted MRI were the most useful diagnostic tools in establishing a definitive diagnosis. Our data shows that spontaneous SCInf mostly affected a single spinal cord segment while periprocedural cases were more extensive, had poorer AIS on admission, poorer ambulatory function, and longer hospital stays. Regardless of the etiology, significant neurological improvements were seen at long-term follow-up, highlighting the importance of active rehabilitation.

Quality of life after traumatic thoracolumbar spinal cord injury: a North Indian perspective.

Cross-sectional study. To determine the Quality of Life (QOL) in individuals with traumatic Spinal Cord Injury (SCI) of thoracolumbar region in Indian population, the factors affecting QOL and to compare this to other SCI populations. Tertiary level hospital in low-middle income country. 93 individuals with SCI of minimum 1 year duration since injury were included in the study. Baseline demographics, socioeconomic parameters, and incidence of complications were ascertained. World Health Organisation Quality of Life-BREF (WHOQOL-BREF) score was used for measurement of QOL and was then compared to healthy Indian population and other SCI studies. Subgroup analysis was done to find out impact of variables on different domains of WHOQOL-BREF. The median (IQR)age of the study participants was 35 (25, 45) with a male predominance. The median (IQR) duration since injury in the study population was 50 (26, 70) months. Lowest mean(SD)score was observed in the psychological domain -50.3 (12.1) and comparison to healthy Indian and high-income SCI populations revealed drastically decreased scoresacross all domains (p < 0.01). Employed individuals and housewives had significantly higher scores across all domains than unemployed individuals (p < 0.05). American Spinal Injury Association Impairment Scale (AIS) grade, socioeconomic status, pain and presence of complications all had significant impact on domain scores (p < 0.05). Multiple regression analysis revealed that mobilisation status and pain had the greatest effect on QOL. Individuals with SCI have low QOL scores as compared to general Indian population as well as SCI individuals from a high resource setting. Pain and dependent mobilisation were found to be most significant predictors of poor WHOQOL-BREF domain scores. Housewives were found to have domain scores comparable to employed individuals. Presence of complications negatively impacts QOL.

The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol.

Sleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction. This cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI. To our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI. The research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097.

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).

Association of upper-limb neurological recovery with functional outcomes in high cervical spinal cord injury.

High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI. A prospective cohort of high cervical SCI (C1-4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A-D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers. Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8-47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2-56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A-B) reduced the likelihood of gaining independence. After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery.

Data supporting the benefits of early surgical intervention in acute spinal cord injury (SCI) is growing. For early surgery to be accomplished, understanding the causes of variabilities that effect the timing of surgery is needed to achieve this goal. The purpose of this analysis is to determine factors that affect the timing of surgery for acute cervical SCI within the North American Clinical Trials Network (NACTN) for SCI registry. Patients in the NACTN SCI registry from 2005 to 2019 with a cervical SCI, excluding acute traumatic central cord syndrome, were analyzed for time elapsed from injury to arrival to the hospital, and time to surgery. Two categories were defined: 1) Early Arrival with Early Surgery (EAES) commenced within 24 h of injury, and 2) Early Arrival but Delayed Surgery (EADS), with surgery occurring between 24 to 72 h post-injury. Patients' demographic features, initial clinical evaluation, medical comorbidities, neurological status, surgical intervention, complications, and outcome data were correlated with respect to the two arrival groups. Of the 222 acute cervical SCI patients undergoing surgery, 163 (73.4%) were EAES, and 59 (26.6%) were EADS. There was no statistical difference in arrival time between the EAES and EADS groups. There was a statistical difference in the median arrival time to surgery between the EAES group (9 h) compared with the EADS group (31 h; p < 0.05). There was no statistical difference in race, sex, age, mechanism of injury, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores, or medical comorbidities between the two groups, but the EAES group did present with a significantly lower systolic blood pressure (p < 0.05). EADS patients were more likely to present as an American Spinal Injury Association Impairment Scale (AIS) D than EAES (p < 0.05). Early surgery was statistically more likely to occur if the injury occurred over the weekend (p < 0.05). There were variations in the rates of early surgery between the eight NACTN sites within the study, ranging from 57 to 100%. Of the 114 patients with 6-month outcome data, there was no significant change between the two groups regarding AIS grade change and motor/pin prick/light touch score recovery. A trend towards improved motor scores with early surgery was not statistically significant (p = 0.21). Although there is data that surgery within 24 h of injury improves outcomes and can be performed safely, there remain variations in care outside of clinical trials. In the present study of cervical SCI, NACTN achieved its goal of early surgery in 73.4% of patients from 2005-2019 who arrived within 24 h of their injury. Variability in achieving this goal was related to severity of neurological injury, the day of the week, and the treating NACTN center. Evaluating variations within our network improves understanding of potential systemic limitations and our decision-making process to accomplish the goal of early surgery.

Teaching Neuro Images : Acute neurologic deficits due to surfer's myelopathy

A previously healthy 32-year-old man developed acute onset of lower extremity weakness (American Spinal Injury Association [ASIA]–motor L2-S1, grade 2/5), T8 sensory level, and loss of bowel and bladder control (ASIA Impairment Scale [AIS] C) while surfing. The patient was a novice surfer and recalled a prolonged period in prone hyperextension. MRI spine was consistent with surfer's myelopathy, a rare nontraumatic cause of myelopathy found in novice surfers (figure).1,2 The etiology is postulated to be due to dynamic compression of the artery of Adamkiewicz. The patient recovered full function with conservative management over 3 days. Full recovery is expected in patients with AIS B or better, as opposed to patients with AIS A, who typically do not recover.1

Multicentric investigation on the safety, feasibility and usability of the ABLE lower-limb robotic exoskeleton for individuals with spinal cord injury: a framework towards the standardisation of clinical evaluations

BackgroundRobotic lower-limb exoskeletons have the potential to provide additional clinical benefits for persons with spinal cord injury (SCI). However, high variability between protocols does not allow the comparison of study results on safety and feasibility between different exoskeletons. We therefore incorporated key aspects from previous studies into our study protocol and accordingly conducted a multicentre study investigating the safety, feasibility and usability of the ABLE Exoskeleton in clinical settings.MethodsIn this prospective pretest-posttest quasi-experimental study across two SCI centres in Germany and Spain, in- and outpatients with SCI were recruited into a 12-session training and assessment protocol, utilising the ABLE Exoskeleton. A follow-up visit after 4 weeks was included to assess after-training outcomes. Safety outcomes (device-related adverse events (AEs), number of drop-outs), feasibility and usability measures (level of assistance, donning/doffing-time) were recorded at every session together with changes in gait parameters and function. Patient-reported outcome measures including the rate of perceived exertion (RPE) and the psychosocial impact of the device were performed. Satisfaction with the device was evaluated in both participants and therapists.ResultsAll 24 participants (45 ± 12 years), with mainly subacute SCI (< 1 year after injury) from C5 to L3, (ASIA Impairment Scale A to D) completed the follow-up. In 242 training sessions, 8 device-related AEs (pain and skin lesions) were reported. Total time for don and doff was 6:50 ± 2:50 min. Improvements in level of assistance and gait parameters (time, steps, distance and speed, p < 0.05) were observed in all participants. Walking function and RPE improved in participants able to complete walking tests with (n = 9) and without (n = 6) the device at study start (p < 0.05). A positive psychosocial impact of the exoskeleton was reported and the satisfaction with the device was good, with best ratings in safety (participants), weight (therapists), durability and dimensions (both).ConclusionsOur study results prove the feasibility of safe gait training with the ABLE Exoskeleton in hospital settings for persons with SCI, with improved clinical outcomes after training. Our study protocol allowed for consistent comparison of the results with other exoskeleton trials and can serve as a future framework towards the standardisation of early clinical evaluations.Trial Registrationhttps://trialsearch.who.int/, DRKS00023503, retrospectively registered on November 18, 2020.

Interhospital Transfer Delays Care for Spinal Cord Injury Patients: A Report from the North American Clinical Trials Network for Spinal Cord Injury.

Abstract The North America Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that has maintained a prospective SCI registry since 2004, and it has espoused that early surgical intervention is associated with improved outcome. It has previously been shown that initial presentation to a lower acuity center and necessity of transfer to a higher acuity center reduce rates of early surgery. The NACTN database was evaluated to examine the association between interhospital transfer (IHT), early surgery, and outcome, taking into account distance traveled and site of origin for the patient. Data from a 15-year period of the NACTN SCI Registry were analyzed (years 2005-2019). Patients were stratified into transfers directly from the scene to a Level 1 trauma center (NACTN site) versus IHT from a Level 2 or 3 trauma facility. The main outcome was surgery within 24 hours of injury (yes/no), whereas secondary outcomes were length of stay, death, discharge disposition, and 6-month American Spinal Injury Association Impairment Scale (AIS) grade conversion. For the IHT patients, distance traveled for transfer was calculated by measuring the shortest distance between origin and NACTN hospital. Analysis was performed with Brown-Mood test and chi-square tests. Of 724 patients with transfer data, 295 (40%) underwent IHT and 429 (60%) were admitted directly from the scene of injury. Patients who underwent IHT were more likely to have a less severe SCI (AIS D; p = 0.002), have a central cord injury (p = 0.004), and have a fall as their mechanism of injury (p < 0.0001) than those directly admitted to an NACTN center. Of the 634 patients who had surgery, direct admission to an NACTN site was more likely to result in surgery within 24 hours compared with IHT patients (52% vs. 38%) (p < 0.0003). Median IHT distance was 28 miles (interquartile range [IQR] = 13-62 miles). There was no significant difference in death, length of stay, discharge to a rehab facility versus home, or 6-month AIS grade conversion rates between the two groups. Patients who underwent IHT to an NACTN site were less likely to have surgery within 24 hours of injury, compared with those directly admitted to the Level 1 trauma facility. Although there was no difference in mortality rates, length of stay, or 6-month AIS conversion between groups, patients with IHT were more likely be older with a less severe level of injury (AIS D). This study suggests there are barriers to timely recognition of SCI in the field, appropriate admission to a higher level of care after recognition, and challenges related to the management of individuals with less severe SCI.

188 American Spinal Injury Association (ASIA) Impairment Scale (AIS) Conversion Underestimates Neurological Recovery Following Traumatic Spinal Cord Injury

INTRODUCTION: The predominant tool used in the evaluation of neurological outcomes following spinal cord injury (SCI) is the American Spinal Injury Association (ASIA) Impairment Scale (AIS), calculated within the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). However, there are significant clinical and functional differences within AIS grades A-E that can be better captured by ISNCSCI 0-100 full motor scores. METHODS: 55 patients with acute traumatic SCI who underwent surgery were retrospectively analyzed as part of a prospective cohort study, Transforming Research and Clinical Knowledge in SCI (TRACK-SCI). Clinical, radiographical and treatment parameters were collected, including AIS grades and full motor scores on presentation and discharge, Brain and Spinal Injury Center (BASIC) scores. Multivariable analysis was utilized to evaluate predictors of neurological recovery utilizing AIS grade and motor scores as endpoints. RESULTS: Improvement of at least 1 AIS grade from presentation was noted in 27% of patients (mean improvement of 0.3 AIS grades, p &lt; 0.001) upon discharge. Improvement of total motor scores was noted in 67% with a mean recovery of 8.4 points. The discordance between rate of AIS grade conversion and motor score recovery was greatest in patients with initial AIS grade D (16% vs 72%, respectively). Total motor score improvement was greatest for patients with initial AIS grade C, with a mean improvement of 20 points. Utilizing multivariate analysis, BASIC score and initial total motor score were significant predictors of motor score recovery. However, no variables were prognostic when utilizing AIS conversion as the endpoint. CONCLUSIONS: AIS conversion underestimates true degree of functional improvement following SCI. Changes in full motor score is a more robust outcome metric in the evaluation of factors prognostic of neurological recovery following injury.

200 Peripheral Nerve Transfer for Spinal Cord Injury: Lower Motoneuron Solutions for Upper Motoneuron Problems

INTRODUCTION: Nerve transfers (NTs) have been recognized as a promising strategy to improve traumatic spine cord injury (tSCI) patient function. Although different tSCI NT options have been detailed, little is known about the epidemiological and injury-related aspects of this patient population. METHODS: TSCI patients presenting to our institution were identified through a prospectively collected tSCI data registry. Inclusion criteria consisted of: i) admission with cervical tSCI (C1-T1) between 2005-2019, ii);18-years-old, iii) documented tSCI severity using the ASIA Impairment Scale (AIS). Two peripheral nerve (PN) experts independently evaluated each patient’s suitability for NT. Demographic, and traumatic and neurological injury-related variables were collected and analyzed. RESULTS: A total of 224 (32%) patients were selected for based on tSCI level (C1-T1). After initial review, there was 94% agreement between PN experts with discordant cases being discussed before reaching a final consensus. A total of 108 patients (15% of tSCIs and 48% of cervical tSCIs) were deemed appropriate NT candidates. Average age was 43-years-old and the majority were male (82/108, 76%). TSCI severity range included: 54 (50%) patients being AIS A, 17 (16%) AIS B, 34 (31%) AIS C, and 3 (3%) AIS D. AIS motor level range included: 7 (6%) C4, 40 (37%) C5, 22 (20%) C6, 38 (35%) C7, and 1 (1%) C8 patient. CONCLUSIONS: To our knowledge, this is the first study to detail the number of tSCI patients that may qualify for NT from a large prospective database. A large proportion of cervical tSCI patients were found to be candidates. Better characterizing the epidemiological and injury patterns of this patient population will form an important first step to increase awareness and inform tSCI NT candidate identification.

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.

Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania.

The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.

Clinical Profile and Predictors of Early Outcome in Patients with Traumatic Spinal Cord Injury in Jos, North-Central Nigeria.

Spinal cord injury is a devastating condition and has been recognised so since antiquity with evolving pattern of presentation and outcome. This study aimed to review the clinical profile and determinants of early outcome in patients with traumatic spinal cord injury (TSCI) in Jos, Nigeria. This retrospective cohort study, reviewed the health records of all patients with TSCI that were managed, based on the neurosurgical unit protocol for the management of TSCI in our institution from 2011 to 2021. Relevant data were retrieved into a preformed pro forma, analysis was done for determinants of outcome using SPSS and presented in tables and figure. A total of 296 patients, aged 20-39 years, with male to female ratio of 5.2:1 were studied. The median time from injury to presentation was 96 h, and the cervical spine was the most (139, 47.0%) affected region. Most of the patients (183, 61.8%) had complete injury (ASIA A) at presentation, the average, first week mean arterial blood pressure (MAP) of 89.98 ± 8.86. Mortality was 73 (24.7%) at 6 weeks post injury and complete TSCI, cervical spinal cord segment and the average "first week" MAP were, independent predictors of mortality. The admission ASIA impairment scale (AIS) and injury to presentation interval were predictive of AIS improvement at 6 weeks and length of hospital stay (LOHs). We also found that AIS at admission, level of spinal cord affected and the average first week MAP were early predictors of mortality, while the injury to presentation interval and admission AIS, predicted improvement of AIS at 6 weeks. The LOHs was seen more in patients with severe AIS at admission and those who had delayed presentation.

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data

PurposeTo identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs). MethodsData were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015 – 2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI). ResultsAltogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR = 3.06, 95% CI: 1.55 – 6.03, p = 0.001), and number of days in the ICU (OR = 1.06, 95% CI: 1.04 – 1.09, p < 0.001) maintained significance. ConclusionsThese data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.

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.