Cord Injury Association Impairment Scale Research Articles

Long-term functional outcome in patients with acquired infections after acute spinal cord injury

To investigate whether prevalent hospital-acquired pneumonia and wound infection affect the clinical long-term outcome after acute traumatic spinal cord injury (SCI). This was a longitudinal cohort study within the prospective multicenter National Spinal Cord Injury Database (Birmingham, Alabama). We screened datasets of 3,834 patients enrolled in 20 trial centers from 1995 to 2005 followed up until 2016. Eligibility criteria were cervical SCI and American Spinal Cord Injury Association impairment scale A, B, and C. Pneumonia or postoperative wound infections (Pn/Wi) acquired during acute medical care/inpatient rehabilitation were analyzed for their association with changes in the motor items of the Functional Independence Measure (FIMmotor) using regression models (primary endpoint 5-year follow-up). Pn/Wi-related mortality was assessed as a secondary endpoint (10-year follow-up). A total of 1,203 patients met the eligibility criteria. During hospitalization, 564 patients (47%) developed Pn/Wi (pneumonia n = 540; postoperative wound infection n = 11; pneumonia and postoperative wound infection n = 13). Adjusted linear mixed models after multiple imputation revealed that Pn/Wi are significantly associated with lower gain in FIMmotor up to 5 years after SCI (-7.4 points, 95% confidence interval [CI] -11.5 to -3.3). Adjusted Cox regression identified Pn/Wi as a highly significant risk factor for death up to 10 years after SCI (hazard ratio 1.65, 95% CI 1.26 to 2.16). Hospital-acquired Pn/Wi are predictive of propagated disability and mortality after SCI. Pn/Wi qualify as a potent and targetable outcome-modifying factor. Pn/Wi prevention constitutes a viable strategy to protect functional recovery and reduce mortality. Pn/Wi can be considered as rehabilitation confounders in clinical trials.

Clinical and Radiological Outcome of Thoracolumbar Fractures Treated by Transpedicular Fixation

Background: The injuries involving the spinal cord are generally challenging to manage. The aim of this study was to analyze and compare the clinical including neurological and radiological outcome of thoracolumbar burst fractures treated by short segment and long segment transpedicular instrumentation and posterolateral fusion. Methods: 34 patients with or without neurological deficit were studied. Gaines scoring, American Spinal Cord Injury Association impairment scale was used for study. Results: The mean intra-operative correction of K-angle in the short segment group was 14.68° and the loss of correction observed at the last follow-up evaluation was 6.62° with a final gain of 8.06°. The mean intra-operative correction in the long segment group was 19.76° and the loss of correction observed at the last follow-up evaluation was 6.61°. Final gain was 13.15°. On radiological evaluation of wedge angle, mean correction loss of 3.87 degrees and 3.4% implant failure was noted in the short segment group while the long segment group had 1.53 degrees of mean correction loss and no implant failure. There was no positive correlation found between Gaines score with progression of deformity. Neurological Outcome in the short segment group four grades of improvement was found in 1 patient, three grades in 1 patient, two grades in 2 patients and one grade in 6 patients. In the long segment group, three grades of improvement were found in 3 patients, two grades in 2 patients and one grade in 2 patients. 1 of the grade D patient showed improvement within the grade and 3 patients did not show any improvement. Average ASIA motor score improved with treatment from 28.31 to 39.56 points (11.25 points) in short segment group and from 19.91 to 28.46 points (8.55 points) in long segment group. Conclusion: Transpedicular fixation is a stable, reliable and less surgically extensive construct for addressing thoracolumbar burst fractures. About 6-8° loss of correction was observed with both short and long segment stabilizations in our study. Long segment has better results in terms of maintenance of reduction and final gain. The length of instrumentation does not seem to have any effect on the neurological outcome. Key Words: Thoracolumbar fractures, Clinical, Radiological outcome.

Validation of Duruöz Hand Index in patients with tetraplegia

Study designCross-sectional, clinical measurement. PurposeTo investigate the validity of the Duruöz Hand Index (DHI) in the assessment of hand function in patients with tetraplegia. MethodsA total of 40 patients with tetraplegia participated. Patients' upper extremities were assessed on the level of ‘body function and structure’ [The American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS) 2000 revised criteria, upper extremity motor score (UEMS), neurologic level of injury and visual analogue scale of hand function (VAS-HF)], ‘activity’ [DHI and Quadriplegia index of function-short form (QIF-SF)] and ‘body function and structure, activity and participation’ [Health Survey Short Form-36 (SF-36)] according to International Classification of Function. ResultsThe DHI showed significant correlations with UEMS, AIS, QIF-SF, VAS-HF, physical functioning and physical compound summary scores of SF-36. ConclusionsThe DHI was found a valid method in the assessment of hand functions in patients with tetraplegia. Level of evidenceDiagnostic III.

Noninvasive Reactivation of Motor Descending Control after Paralysis.

The present prognosis for the recovery of voluntary control of movement in patients diagnosed as motor complete is generally poor. Herein we introduce a novel and noninvasive stimulation strategy of painless transcutaneous electrical enabling motor control and a pharmacological enabling motor control strategy to neuromodulate the physiological state of the spinal cord. This neuromodulation enabled the spinal locomotor networks of individuals with motor complete paralysis for 2-6 years American Spinal Cord Injury Association Impairment Scale (AIS) to be re-engaged and trained. We showed that locomotor-like stepping could be induced without voluntary effort within a single test session using electrical stimulation and training. We also observed significant facilitation of voluntary influence on the stepping movements in the presence of stimulation over a 4-week period in each subject. Using these strategies we transformed brain-spinal neuronal networks from a dormant to a functional state sufficiently to enable recovery of voluntary movement in five out of five subjects. Pharmacological intervention combined with stimulation and training resulted in further improvement in voluntary motor control of stepping-like movements in all subjects. We also observed on-command selective activation of the gastrocnemius and soleus muscles when attempting to plantarflex. At the end of 18 weeks of weekly interventions the mean changes in the amplitude of voluntarily controlled movement without stimulation was as high as occurred when combined with electrical stimulation. Additionally, spinally evoked motor potentials were readily modulated in the presence of voluntary effort, providing electrophysiological evidence of the re-establishment of functional connectivity among neural networks between the brain and the spinal cord.

The durotomy or myelotomy for the spinal cord extensive swelling with/without intramedullary hemorrhage

Objective To evaluate the necessity and feasibility of durotomy or myelotomy for the spinal cord extensive swelling with/without intramedullary hemorrhage. Methods Data of 21 cases with spinal cord extensive swelling with/without intramedullary hemorrhage who underwent durotomy or myelotomy from January 2009 to September 2014 were retrospectively analyzed. There were 13 males and 8 females, with an average age of 39.1 (range, 13-69) years old. 16 cases had the situation of spinal fracture or dislocation, 9 cases had locked facet, and 12 cases had disc injury. The swelling locations of 18 cases were at cervical cord, and 3 at thoracolumbar cord. The swelling area of 17 cases were at 2-4 segments, and 4 cases over 4 segments. Results No wound infection, aggravated disk hernia, aggravated spinal cord injury, vertebral artery injury or aggravated disc injury happened in any cases. The MRI of two weeks after operation showed that the high signal of swelling disappeared in T2WI. According to the American Spinal Cord Injury Association (ASIA) Impairment Scale, 6 grade A cases were still grade A, but the feeling and movement improved obviously. 7 grade B cases improved to grade C, 2 grade B cases improved to grade D, and 1 grade B case improved to grade E. 4 grade C cases improved to grade D, and 1 grade C case improved to grade E. For the patients with intramedullary hemorrhage, 2 grade A cases were still grade A with improvement in feeling and movement, 1 grade B improved to grade C, 1 grade B improved to grade D, and 1 grade C improved to grade D. Conclusion For the patients with spinal cord extensive swelling with/without intramedullary hemorrhage, the durotomy or myelotomy is safe and efficacious which could relief the blockade of spinal epidural veins, arteriole of cord. It may also reduce the secondary injury, create conditions for improving breathing, circulating and rescuing the life, and it could be helpful for the recovery of spinal cord neurological function. Key words: Spinal cord injuries; Hematoma, subdural, spinal; Decompression, surgical

One stage atlantoaxial pedicle screw fixation for unstable atlas burst fracture

Objective To assess the clinical results of one stage posterior atlanloaxial pedicle screw fixation and fusion for unstable atlas burst fracture. Methods A retrospective analysis of clinical data including 32 cases, which were admitted according to the inclusion and exclusion criteria between May 2010 and December 2013. There were 11 females and 21 males whose age ranged from 22 to 59 years (mean 41.8 years). X-ray, CT scan reconstruction and MRI were done before operation to evaluate the injury of ligament and fracture. There were 17 cases of unstable atlas burst fracture,including 5 cases Jefferson fracture,8 cases untypical Jefferson fracture, and 4 cases lateral mass fracture combined with anterior arch or posterior arch fracture. There were 15 cases combined with axial fracture, 9 cases combined with dens fracture, 4 cases with axial body fracture, and 2 cases with Hangman fracture. The patients had various degrees of occipital neck pain, limited mobility and neurological dysfunction. Degree C in 1 case and degree D in 5 cases were assessed by the American Spinal Cord Injury Association (ASIA) impairment scale. All patients were treated with one stage posterior atlantoaxial pedicle screw fixation and fusion. All patients were assessed clinically by neurologic recovery, atlantoaxial reduc tion and bone graft fusion. The preoperative and postoperative atlanto-dens interval (ADI), lateral mass distance (LMD) and VAS were measured and statistically analyzed. Complications were observed. Clinical outcome of last follow-up was evaluated by dynamic X-ray and CT scan. Results All patients were followed up. The follow-up time ranged from 10 to 24 months (mean 15.6 months). The healing time of bone fusion ranged from 5 to 10 months with an average follow-up time of 6.9 months. The average preoperative VAS score was 5.0±1.4 while the score of last follow-up was 1.0±0.7, with statistically significant differences. Neurological status improved in all patients but one. Four cases with grade D improved to E, and one cases with grade C improved to D. Postoperative cervical spine X-ray and CT showed that the sagittal cervical spine alignment was restored. The preoperative ADI was 4.6±1.2 mm, which was statistically significant different with last follow-up the ADI of 2.4±1.0 mm. There were statistically significant difference between preoperative LMD of 5.6±2.2 mm and postoperative LMD of 1.2±1.0 mm. Conclusion The posterior atlantoaxial pedicle screw for unstable atlas burst fracture combined with atlantoaxial instability seems to be effective. It is technically demanding to place screw into thelateral mass of the atlas. Key words: Cervical atlas; Spinal fractures; Atlanto-axial joint; Joint instability; Spinal fusion

A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency

BackgroundMulti-channel surface functional electrical stimulation (FES) for walking has been used to improve voluntary walking and balance in individuals with spinal cord injury (SCI).ObjectiveTo investigate short- and long-term benefits of 16 weeks of thrice-weekly FES-assisted walking program, while ambulating on a body weight support treadmill and harness system, versus a non-FES exercise program, on improvements in gait and balance in individuals with chronic incomplete traumatic SCI, in a randomized controlled trial design.MethodsIndividuals with traumatic and chronic (≥18 months) motor incomplete SCI (level C2 to T12, American Spinal Cord Injury Association Impairment Scale C or D) were recruited from an outpatient SCI rehabilitation hospital, and randomized to FES-assisted walking therapy (intervention group) or aerobic and resistance training program (control group). Outcomes were assessed at baseline, and after 4, 6, and 12 months. Gait, balance, spasticity, and functional measures were collected.ResultsSpinal cord independence measure (SCIM) mobility sub-score improved over time in the intervention group compared with the control group (baseline/12 months: 17.27/21.33 vs. 19.09/17.36, respectively). On all other outcome measures the intervention and control groups had similar improvements. Irrespective of group allocation walking speed, endurance, and balance during ambulation all improved upon completion of therapy, and majority of participants retained these gains at long-term follow-ups.ConclusionsTask-oriented training improves walking ability in individuals with incomplete SCI, even in the chronic stage. Further randomized controlled trials, involving a large number of participants are needed, to verify if FES-assisted treadmill training is superior to aerobic and strength training.

Multicenter Prospective Nonrandomized Controlled Clinical Trial to Prove Neurotherapeutic Effects of Granulocyte Colony-Stimulating Factor for Acute Spinal Cord Injury

An open-labeled multicenter prospective nonrandomized controlled clinical trial. To confirm the feasibility of using granulocyte colony-stimulating factor (G-CSF) for treatment of acute spinal cord injury (SCI). We previously reported that G-CSF promotes functional recovery after compression-induced SCI in mice. On the basis of these findings, we conducted a multicenter prospective controlled clinical trial to assess the feasibility of G-CSF therapy for patients with acute SCI. The trial ran from August 2009 to March 2011, and included 41 patients with SCI treated within 48 hours of onset. Informed consent was obtained from all patients. After providing consent, patients were divided into 2 groups. In the G-CSF group (17 patients), G-CSF (10 μg/kg/d) was intravenously administered for 5 consecutive days, and in the control group (24 patients), patients were similarly treated except for the G-CSF administration. We evaluated motor and sensory functions using the American Spinal Cord Injury Association score and American Spinal Cord Injury Association impairment scale at 1 week, 3 months, 6 months, and 1 year after onset. Only 2 patients did not experience American Spinal Cord Injury Association impairment scale improvement in the G-CSF group. In contrast, 15 patients in the control group did not experience American Spinal Cord Injury Association impairment scale improvement. In the analysis of increased American Spinal Cord Injury Association motor score, a significant increase in G-CSF group was detected from 1 week after the administration compared with the control group. After that, some spontaneous increase of motor score was detected in control group, but the significant increase in G-CSF group was maintained until 1 year of follow-up. Despite the limitation that patient selection was not randomized, the present results suggest the possibility that G-CSF administration has beneficial effects on neurological recovery in patients with acute SCI. 3.

Exploring the determinants of fracture risk among individuals with spinal cord injury.

In this cross-sectional study, we found that areal bone mineral density (aBMD) at the knee and specific tibia bone geometry variables are associated with fragility fractures in men and women with chronic spinal cord injury (SCI). Low aBMD of the hip and knee regions have been associated with fractures among individuals with chronic motor complete SCI; however, it is unclear whether these variables can be used to identify those at risk of fracture. In this cross-sectional study, we examined whether BMD and geometry measures are associated with lower extremity fragility fractures in individuals with chronic SCI. Adults with chronic [duration of injury ≥ 2 years] traumatic SCI (C1-L1 American Spinal Cord Injury Association Impairment Scale A-D) reported post injury lower extremity fragility fractures. Dual-energy X-ray absorptiometry (DXA) was used to measure aBMD of the hip, distal femur, and proximal tibia regions, while bone geometry at the tibia was assessed using peripheral quantitative computed tomography (pQCT). Logistic regression and univariate analyses were used to identify whether clinical characteristics or bone geometry variables were associated with fractures. Seventy individuals with SCI [mean age (standard deviation [SD]), 48.8 (11.5); 20 females] reported 19 fragility fractures. Individuals without fractures had significantly greater aBMD of the hip and knee regions and indices of bone geometry. Every SD decrease in aBMD of the distal femur and proximal tibia, trabecular volumetric bone mineral density, and polar moment of inertia was associated with fracture prevalence after adjusting for motor complete injury (odds ratio ranged from 3.2 to 6.1). Low knee aBMD and suboptimal bone geometry are significantly associated with fractures. Prospective studies are necessary to confirm the bone parameters reported to predict fracture risk in individuals with low bone mass and chronic SCI.

Spinal cord injury: association with axonal peripheral neuropathy in severely paralysed limbs

Pressure sores are a major health problem in spinal cord injury (SCI). In this population pressure damage to peripheral nerves was not thoroughly investigated so far. However, intact peripheral nerves and innervated muscles are a prerequisite for the effectiveness of supportive therapies like functional electrical stimulation (FES). We assessed electroneurographic (ENG) data of lower limbs in SCI individuals admitted to our hospital due to severe pressure sores. Our centers prospectively acquired ENG data of the European Multicenter study about SCI (EMSCI) patients served as early control. In the pressure sore cohort (n = 15) all patients were sensory-motor complete (American Spinal Cord Injury Association Impairment Scale A). Most patients (10/15) suffered from a severe axonal sensory-motor polyneuropathy in paralysed legs with absent compound muscle action potentials (CMAPs) of tibial/peroneal nerves as well as absent sensory nerve action potentials of sural nerves. The onset of this polyneuropathy dates within the first year after incident SCI and was mainly associated with increasing sensory-motor completeness as demonstrated by a significant CMAP drop of our centers EMSCI-ENG data on serial tibial nerve recordings in 275 patients. Severe SCI is associated with an early-onset axonal polyneuropathy in paralysed limbs to which pressure damage might contribute. Because intact peripheral nerves are required for: (i) maintenance of motor function in centrally impaired muscles; and (ii) effectiveness of supportive therapies like FES, ENG-monitoring could serve as a low invasive screening method for peripheral nerve integrity in patients with SCI to initiate pressure relief procedures early enough.

Prevalence of Prostate Cancer in Patients With Chronic Spinal Cord Injury

To determine the prevalence of prostate cancer in patients with chronic spinal cord injury (SCI), with regard to the duration, level, and severity of injury. Retrospective chart review study. Inpatient and outpatient Veterans Affairs spinal cord unit. The electronic medical records of 350 veterans with chronic SCI and 344 veterans without SCI as a control group were reviewed. Prevalence of prostate cancer in patients with chronic SCI with regard to the duration, level, and severity of injury. Of 350 veterans with chronic SCI, 7 individuals (2%) had prostate cancer. In comparison, of 344 age-matched veterans without SCI, 18 (5.2%) had prostate cancer. In SCI group with prostate cancer, 2 patients had motor complete injury (American Spinal Cord Injury Association Impairment Scale [AIS] A and B), and 5 patients had motor incomplete injury (AIS C, D, and E). Patients with SCI and with prostate cancer were slightly older (mean [SD] age, 72.14 ± 8.25 years) than the control group (mean [SD] age, 69.83 ± 8.79 years) with cancer. Findings from this study indicate a lower prevalence of prostate cancer among veterans with chronic SCI in comparison with age-matched veterans without SCI. Given the small number of patients with SCI and with prostate cancer in this study, we did not find any statistically significant correlation between the prevalence of prostate cancer and the level, duration, and severity of injury.

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system.

Usually, cervical pedicle screw fixation has been considered too risky for neurovascular structures. The purpose of this study was to investigate the method and efficacy of the cervical pedicle screw system for fracture-dislocation of the cervical spine because of its rigid fixation. A prospective study was conducted involving 48 patients with cervical spine fracture-dislocation who underwent cervical pedicle screw fixation surgery between January 2003 and January 2007. All patients had various degrees of cord injury, and they were classified according to the American Spinal Cord Injury Association (ASIA) Impairment Scale: 18 cases were grade A, 15 grade B, 10 grade C, and 5 grade D. Six months after the operation, all patients had achieved solid bony fusion and stable fixation of the related segments. Thirty patients with incomplete spinal cord injury improved their ASIA Impairment Scale classification by 1 to 2 grades after the operation. Eighteen patients with complete spinal cord injury had no improvement in neural function. However, nerve root symptoms such as pain and numbness were alleviated to some extent. The cervical pedicle screw system is an effective and reliable method for the restoration of cervical stability. Sufficient pre-operative imaging studies of the pedicles and strict screw insertion technique should be emphasised.

Acute Spinal Cord Injury and Infection with Multidrug-Resistant Acinetobacter calcoaceticus-baumannii Complex Among Returning Operation Iraqi Freedom Soldiers

Concerns about drug-resistant infectious organisms are increasing in rehabilitation facilities. Resulting isolation protocols can potentially challenge the patients' access to medical care, psychological adaptation, mobility, and environmental interaction and therefore hinder the rehabilitation process. We report a systematic, retrospective case review of an active-duty Army sergeant who sustained a C5 American Spinal Cord Injury Association Impairment Scale A spinal cord injury while serving in Operation Iraqi Freedom. The patient's acute rehabilitation was complicated by an Acinetobacter calcoaceticus-baumannii complex infection, in the blood and urine, contracted while in Iraq. Isolation protocols were designed to enable regular hands-on contact for proprioceptive neuromuscular facilitation, transfers, wheelchair fitting, mobility training, and environmental control. After 1 mo of comprehensive acute interdisciplinary rehabilitation, delivered in a single room on the spinal cord injury unit, the patient acquired functional skills comparable with other complete C5 tetraplegics in our unit. If a patient with spinal cord injury must be placed in isolation, it is still feasible to conduct a comprehensive interdisciplinary rehabilitation program while strictly adhering to contact isolation protocols.

Brown-Sèquard syndrome produced by cervical disc herniation: report of two cases and review of the literature

Background context Brown-Sèquard syndrome is most commonly seen with spinal trauma and extramedullary spinal neoplasm. A herniated cervical disc has rarely been considered to be a cause of Brown-Sèquard syndrome. Purpose To report and discuss two cases of Brown-Sèquard syndrome produced by herniated cervical disc. Study design/setting Case studies in Japan. Patient sample The first patient was a 64-year-old man who presented with right leg weakness and diminished sensation to pain and temperature in the left side below the T4 dermatome. The second patient was a 39-year-old man who presented with right-sided weakness and diminished sensation to pain and temperature in the left side below the T6 dermatome. Outcome measures American Spinal Cord Injury Association (ASIA) impairment scale (only our cases). Methods These patients were diagnosed to have Brown-Sèquard syndrome produced by herniated cervical disc. Anterior cervical discectomy with fusion was performed for these patients. Results These cases revealed contralateral deficit in sensation of pain and temperature of more than a few levels below the cord compression, and showed paracentral protruded disc in magnetic resonance images and cervical spinal stenosis in cervical spine X-rays. Postoperatively, motor and sensory function of these patients returned to normal. Conclusions Characteristic finding in discogenic Brown-Sèquard syndrome are contralateral deficit in sensation of pain and temperature of more below than a few levels below the cord compression and paracentral protruded disc with cervical spinal stenosis. Outcomes are favorable in rapid diagnosis by magnetic resonance images and performance of anterior approach.