Improvement In Motor Scores Research Articles

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.

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 < 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.

Abstract WP56: Improvement In Motor And Language Domains Mediates Most Of The Effect Of 24h NIHSS Improvement On Functional Independence

Introduction: Improvement in NIH stroke scale scores on 24h follow-up is considered a key prognostic element after endovascular thrombectomy (EVT). We aimed to evaluate the proportion of effect of 24h NIHSS improvement on mRS 0-2 at 90d mediated through improvement in motor and language domains. Methods: From SELECT study, EVT patients with detailed NIHSS components on presentation and 24h follow-up as well as complete mRS on discharge and 90d were selected. Motor improvement was defined as ≥2 point in cumulative arms and legs score or 0 score at 24h and language improvement was defined as ≥1 point in cumulative aphasia and dysarthria scores at 24h. Mediation analysis framework using 4-step method (Figure 1a) was used to evaluate the effect of 24h NIHSS improvement mediated through improvement in motor and language scores. Results: Of 192 eligible EVT patients, 176 demonstrated motor deficits and 187 demonstrated language deficits. 24h NIHSS improvement was significantly associated with mRS 0-2 (aOR:1.15[1.07-1.23], p<0.001) - step 1. 24h NIHSS improvement was also significantly associated with motor (aOR:1.77[1.48-2.12],p<0.001) and speech improvement (aOR:1.25[1.16-1.36],p<0.001) - step 2. In the full model, motor (aOR:3.00[1.07-8.46],p=0.037) and speech improvement (aOR:3.15[1.37-7.27],p=0.007) were significantly associated with mRS 0-2, whereas 24h NIHSS improvement was no longer a significant predictor (aOR:1.05[0.96-1.15],p=0.33) - step 3 of figure 1a. Motor improvement mediated 68% and speech improvement mediated 27% of the association of 24h NIHSS improvement with mRS 0-2 (Figure 1b) - step 4. Conclusions: Almost all (~95%) of the effect of 24h NIHSS improvement on functional independence (mRS 0-2) was mediated through specific improvement in motor and language domains, suggesting a large role of improvement in motor and language domains in achieving better functional independence. Further studies are needed to confirm the findings.

Patients with Cognitive Impairment in Parkinson's Disease Benefit from Deep Brain Stimulation: A Case-Control Study.

Deep brain stimulation (DBS) for Parkinson's disease (PD) is generally contraindicated in persons with dementia but it is frequently performed in people with mild cognitive impairment or normal cognition, and current clinical guidelines are primarily based on these cohorts. To determine if moderately cognitive impaired individuals including those with mild dementia could meaningfully benefit from DBS in terms of motor and non-motor outcomes. In this retrospective case-control study, we identified a cohort of 40 patients with PD who exhibited moderate (two or more standard deviations below normative scores) cognitive impairment (CI) during presurgical workup and compared their 1-year clinical outcomes to a cohort of 40 matched patients with normal cognition (NC). The surgery targeted subthalamus, pallidus or motor thalamus, in a unilateral, bilateral or staged approach. At preoperative baseline, the CI cohort had higher Unified Parkinson's Disease Rating Scale (UPDRS) subscores, but similar levodopa responsiveness compared to the NC cohort. The NC and CI cohorts demonstrated comparable degrees of postoperative improvement in the OFF-medication motor scores, motor fluctuations, and medication reduction. There was no difference in adverse event rates between the two cohorts. Outcomes in the CI cohort did not depend on the target, surgical staging, or impaired cognitive domain. Moderately cognitively impaired patients with PD can experience meaningful motor benefit and medication reduction with DBS.

Methylprednisolone in acute traumatic spinal cord injury: case-matched outcomes from the NASCIS2 and Sygen historical spinal cord injury studies with contemporary statistical analysis.

Methylprednisolone (MP) to treat acute traumatic spinal cord injury (ATSCI) remains controversial since the release of the second National Acute Spinal Cord Injury Study (NASCIS2) in 1990. As two historical studies, NASCIS2 and Sygen in ATSCI, used identical MP dosages, it was possible to construct a new case-level pooled ATSCI data set satisfying contemporary criteria and able to clarify the effect of MP. The new pooled data set was first modernized by excluding patients with injury levels caudal to T10, lower-extremity American Spinal Injury Association (ASIA) motor scores (LEMSs) ≥ 46, Glasgow Coma Scale scores ≤ 11, and age < 15 or > 75 years, and then standardized to the ASIA grading and scoring format. A new updated NASCIS2 data set from this pooled data set contained 31.6% fewer patients than the 1990 NASCIS2 data set. In the new pooled data set, recovery of LEMSs from baseline to 26 weeks, the primary outcome variable, was separated statistically into five different injury severity cohorts (p < 0.0001). The severity cohorts contained groups with severe floor (62.9%) and ceiling (10.7%) effects, which do not contribute to drug effects. The new NASCIS2 data set duplicated the p value for MP versus placebo in the sub-subgroup analysis of MP initiated ≤ 8 hours (the subgroup) and recovery of motor function on only the right side of the body (a further subgroup within the ≤ 8-hour subgroup), presented as the positive MP effect in the original NASCIS2 reporting. However, current statistical interpretation considers results seen only in post hoc sub-subgroups, without multi-test corrections, to be random effects without clinical significance. The combined case-level pooled data set from the NASCIS2 and Sygen studies increased the MP group from 106 to 431 patients, creating a new MP combined group. This new data set served as a surrogate for a contemporary MP study and found that administration of MP did not enhance ASIA motor score improvement in the lower extremities at 26 weeks. Secondary analysis of descending ASIA motor and sensory cervical neurological levels in cervical ATSCI patients at 26 weeks also found no MP drug effect. Analysis of both the new updated NASCIS2 data set and the new case-matched pooled data set from two historical ATSCI studies revealed that administration of MP after spinal cord injury did not demonstrate any enhancement in neurological recovery at 26 weeks. The results of this analysis warrant review by clinical guideline groups.

Sensory Processing and Visual Motor Integration of Children with Autism

<h3>Research Objectives</h3> To investigate the visual motor integration performance and sensory processing of preschool aged children with autism spectrum disorder. <h3>Design</h3> Multiple linear regression was employed. Retrospective data on preschool aged children with autism who received six months of occupational therapy was collected from an outpatient clinic in Florida. Three research questions were analyzed using data from 36 children (32 males, 4 females) who met the inclusion criteria. <h3>Setting</h3> Data was retrieved from an outpatient rehabilitation clinic in Florida. <h3>Participants</h3> A non-probability purposive sampling strategy was employed for the study. Patient charts of children aged two to five years of age with diagnoses of ASD were reviewed. The data reviewed spanned from June 1, 2017 to March 13, 2020. Patient charts with pre and six-month-post SSP and Beery VMI scores who attended at least one therapy treatment session were included in the study. <h3>Interventions</h3> Children with ASD who attended at least one outpatient occupational therapy treatment session were included in the study. Pre SSP, post SSP, pre Beery VMI scores, and post Beery VMI scores were recorded with relevant demographic information (e.g., age and gender) based on attendance and participation in occupational evaluations. <h3>Main Outcome Measures</h3> Beery-Buktenica Developmental Test of Visual Motor Integration and the Short Sensory Profile 2 were utilized for pre and post scores. <h3>Results</h3> There was a statistically significant improvement in visual motor scores, with pre scores being highly predictive of post scores. There was no significant difference between pre and post sensory scores and they were not predictive of Visual Motor scores. <h3>Conclusions</h3> The findings showed significant improvements in VMI and non-significant improvements in SSP. The final predictive model for VMI can be utilized by clinicians to create realistic goals for therapy. Additionally, these findings suggest that VMI may improve regardless of a child's sensory processing difficulties. <h3>Author(s) Disclosures</h3> The authors declare no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in the information being presented.

Training with noninvasive brain–machine interface, tactile feedback, and locomotion to enhance neurological recovery in individuals with complete paraplegia: a randomized pilot study

In recent years, our group and others have reported multiple cases of consistent neurological recovery in people with spinal cord injury (SCI) following a protocol that integrates locomotion training with brain machine interfaces (BMI). The primary objective of this pilot study was to compare the neurological outcomes (motor, tactile, nociception, proprioception, and vibration) in both an intensive assisted locomotion training (LOC) and a neurorehabilitation protocol integrating assisted locomotion with a noninvasive brain–machine interface (L + BMI), virtual reality, and tactile feedback. We also investigated whether individuals with chronic-complete SCI could learn to perform leg motor imagery. We ran a parallel two-arm randomized pilot study; the experiments took place in São Paulo, Brazil. Eight adults sensorimotor-complete (AIS A) (all male) with chronic (> 6 months) traumatic spinal SCI participated in the protocol that was organized in two blocks of 14 weeks of training and an 8-week follow-up. The participants were allocated to either the LOC group (n = 4) or L + BMI group (n = 4) using block randomization (blinded outcome assessment). We show three important results: (i) locomotion training alone can induce some level of neurological recovery in sensorimotor-complete SCI, and (ii) the recovery rate is enhanced when such locomotion training is associated with BMI and tactile feedback (∆Mean Lower Extremity Motor score improvement for LOC = + 2.5, L + B = + 3.5; ∆Pinprick score: LOC = + 3.75, L + B = + 4.75 and ∆Tactile score LOC = + 4.75, L + B = + 9.5). (iii) Furthermore, we report that the BMI classifier accuracy was significantly above the chance level for all participants in L + B group. Our study shows potential for sensory and motor improvement in individuals with chronic complete SCI following a protocol with BMIs and locomotion therapy. We report no dropouts nor adverse events in both subgroups participating in the study, opening the possibility for a more definitive clinical trial with a larger cohort of people with SCI.Trial registration: http://www.ensaiosclinicos.gov.br/ identifier RBR-2pb8gq.

Effect of Smoking on Motor Recovery After Cervical American Spinal Injury Association Grade D Traumatic Spinal Cord Injury.

Smoking is a known neurotoxin that has been shown to negatively impact neurological function and recovery in multiple animal studies. Patients who smoke have been shown to have decreased rates of motor improvement, fusion, and overall successful outcomes after elective spinal surgery, but the effect of smoking on outcomes after traumatic spinal cord injury (TSCI) has not been demonstrated in prior literature. This study aims to investigate how smoking effects motor recovery after TSCI. Using the National Spinal Cord Injury Statistical Center database, patients who underwent surgical management of American Spinal Injury Association grade D cervical TSCI between 2009 and 2016 were included. Patients were grouped by smoking or nonsmoking status. Overall total motor score and change in motor scores at rehabilitation admission, rehabilitation discharge, and 1-year follow-up visits were compared between groups. Multiple linear regression analysis was completed, including any possible confounding demographic or injury variables. A total of 152 patients (121 smokers and 31 nonsmokers) completed their 1-year follow-up interview and physical examination and were included in the study. There were no differences in motor score between groups at rehabilitation admission or discharge. Smokers had worse improvement in motor score at 1 year (7.99 nonsmokers vs 4.61 smokers; P = 0.019 on multivariate analysis) and worse overall total motor score at 1 year (94.0 nonsmokers vs 90.0 smokers; P = 0.018 on multivariate analysis) after controlling for confounders. These results indicate diminished motor recovery in patients who continue to smoke after TSCI. These patients should be targeted for aggressive smoking cessation and require intervention from providers and peers in order to maximize recovery after injury. This study demonstrates that smoking cessation may be beneficial for patients with cervical ASIA grade D spinal cord injury and may be a focus for providers of these patients.

Intraoperative Sensory Signals Predict Prognosis for Patients with Traumatic Cervical Spinal Cord Injury

In patients with traumatic cervical spinal cord injury (tCSCI), the potential role of intraoperative neuromonitoring as a prognostic tool has been insufficiently studied. This study aimed to determine if detectable signals during intraoperative neuromonitoring portend a greater likelihood of recovery for patients with tCSCI. Patients who underwent decompression and surgical fixation following tCSCI were retrospectively reviewed through previously prospectively collected data from the Surgical Timing in Acute Spinal Cord Injury Study. Improvement in American Spinal Injury Association (ASIA) motor score and ASIA Impairment Scale grade conversion rates at final follow-up were compared between patients with detectable intraoperative neuromonitoring somatosensory evoked potential (SSEP) signals and those without detectable signals. Forty-nine patients had intraoperative neuromonitoring. Patients with incomplete tCSCI had detectable lower extremity SSEPs more often than patients with complete tCSCI (56.3% vs. 23.5%, P= 0.028). There was no difference in detectable upper extremity SSEPs between complete and incomplete tCSCI (65.6% vs. 58.8%, P= 0.638). Of the 17 patients with complete tCSCI, patients with detectable lower extremity SSEPs had ASIA motor scores similar to the nondetectable cohort on admission (21.5 vs. 16.2, P= 0.609) but higher ASIA motor scores at final follow-up (57.5 vs. 27.1, P= 0.041). Of the 32 patients with incomplete spinal cord injury, there was no difference in grade conversion or motor scores between detectable and nondetectable SSEP cohorts. The presence of upper extremity SSEP signals in patients who present with complete tCSCI portends greater improvement in ASIA motor scores and likelihood of American Spinal Injury Association Impairment Scale grade conversion at final follow-up.

Added value of the instrumented Timed-Up and Go test (iTUG) in the long-term assessment of PD patients with bilateral subthalamic nucleus deep brain stimulation (STN-DBS)

STN-DBS is an effective long-term treatment in PD, improving a broad spectrum of symptoms, including tremor, rigidity, and bradykinesia (Fig. 1a) together with dopaminergic treatment. Among axial symptoms, gait disorders are common in PD. This study examines the long-term effects of different combinations of these two treatments in a cohort of advanced PD patients by means of the iTUG. Observational study on consecutive PD patients previously treated with bilateral STN-DBS. Disease severity was assessed using the UPDRS part III. Accelerometric data were acquired using an inertial sensor (G-WALK, BTS Bioengineering). Three iTUG trials were recorded in each of four stimulation and drug conditions: on-stimulation/off-medication, off-stimulation/off-medication, on-stimulation/on- medication and while preforming a cognitive task (counting backward, DUAL TASK) with both stimulation and medication on. Data were segmented into six phases (e.g., rising from chair, walking) as in [1]. A set of indices was computed including durations, RMS amplitudes, peak accelerations, peak angular velocities, indices of symmetry (improved Harmonic Ratio) and smoothness (Spectral Arc) [1]. A one-way non-parametric ANOVA was carried out, with the condition as a factor, followed by paired comparisons when appropriated. Statistical significance was set at 5% for all analyses. Twenty-five patients were re-evaluated 3 to 7 years after STN-DBS surgery, with a mean five-year postoperative follow-up. Clinical characteristics were age 64(5) y, 8/17 F/M, PD duration 16(5) y, distance from STN-DBS intervention 5(1) y, median (IQR) UPDRS-III 12(12), WHS 5(1), FAC 5(2). Most patients were able to perform the test in all conditions. Both STN-DBS alone and the combination of STN-DBS and medications led to an improvement of clinical motor scores and most iTUG parameters (p<0.001). In particular: 1) the elevation/sitting gestures and the turn phases differently improved in the different conditions; 2) on average, the effect of the DUAL TASK condition led to indices similar to those in the off-off condition 3) data from the DUAL TASK condition suggest the existence of two subgroups of patients, whose performance is either affected or not affected by the cognitive task ( Fig. 1 ). The protocol resulted feasible. Our results indicate that both STN-DBS and levodopa can improve walking ability even in the long-term after surgery. Results during DUAL TASK suggest the use of attentional strategies in the rehabilitation of selected patients, as indicated in the EU physiotherapy guidelines for PD [2]. A rehabilitative intervention should be strongly recommended in those patients whose performance in DUAL TASK becomes so impaired as in the STIM-OFF/MED-OFF, as measured by the iTUG. In conclusion, the iTUG test could be used in PD patients with STN-DBS to support the selection of tailored rehabilitative interventions and to identify patients whose performance is highly affected during cognitive tasks.

Machine learning predicts improvement of functional outcomes in traumatic brain injury patients after inpatient rehabilitation.

Survivors of traumatic brain injury (TBI) have an unpredictable clinical course. This unpredictability makes clinical resource allocation for clinicians and anticipatory guidance for patients difficult. Historically, experienced clinicians and traditional statistical models have insufficiently considered all available clinical information to predict functional outcomes for a TBI patient. Here, we harness artificial intelligence and apply machine learning and statistical models to predict the Functional Independence Measure (FIM) scores after rehabilitation for traumatic brain injury (TBI) patients. Tree-based algorithmic analysis of 629 TBI patients admitted to a large acute rehabilitation facility showed statistically significant improvement in motor and cognitive FIM scores at discharge.

194. Expansile duraplasty improves motor outcomes after acute traumatic spinal cord injury

<h3>BACKGROUND CONTEXT</h3> Traumatic spinal cord injury (SCI) can lead to debilitating motor weakness with long term impacts on quality of life. Following the initial trauma, secondary injury mechanisms, including edema, ischemia and inflammation can lead to considerable extension of the injury, providing a window of opportunity for interventions to preserve function. Early surgical decompression and optimization of spinal cord perfusion have emerged as potential targets. Expansile duraplasty could provide benefit by extending surgical decompression to the intrathecal space and increasing spinal cord perfusion; however, there remains a paucity of data on whether this provides a measurable benefit. <h3>PURPOSE</h3> Assess whether expansile duraplasty is associated with greater motor recovery in patients with acute traumatic SCI compared with bony decompression alone. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of medical records. <h3>PATIENT SAMPLE</h3> Patients who underwent surgical spinal decompression and stabilization for traumatic spinal cord injury from February 2017 to June 2021 at an academic, Level 1 trauma center. Patients were excluded from analysis if they did not attend inpatient rehabilitation after their acute hospital stay. <h3>OUTCOME MEASURES</h3> Change in American Spinal Injury Association (ASIA) motor scores between preoperative evaluation, acute hospital discharge, and discharge from inpatient rehabilitation. <h3>METHODS</h3> Patients were divided between those who had expansile duraplasty performed at the time of surgical stabilizationand those who did not. Data collected included patient demographics, injury type, surgery performed, and ASIA motor scores (International Standards for Neurological Classification of SCI, range 0-100) preoperatively and at the time of hospital and inpatient rehabilitation discharge. <h3>RESULTS</h3> A total of 101 patients were included: 12 treated with expansile duraplasty and 89 treated without duraplasty. Patients were 76% male with a mean age of 50.9 years. The mean preoperative motor score for all patients was 48.7+/-29.3 (mean +/- std.dev.), 50.5+/-19.7 for the control group and 35.7+/-23.0 for the expansile duraplasty group (p=0.06). From preoperative exam to hospital discharge, the mean improvement in motor score for the control group was 3.7+/-11.3, compared to 9.3+/-11.4 in the expansile duraplasty group (p=0.12). Mean change in motor score from preoperative exam to rehabilitation discharge was 10.9+/-13.4 for controls and 19.9+/-11.0 for expansile duraplasty patients (p=0.02). <h3>CONCLUSIONS</h3> In this contemporaneous, 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. These data present an independent and the first US validation of preliminary data from international centers in favor of expansile duraplasty. Further prospective studies are warranted to assess whether this adjunctive surgical technique is efficacious in treating acute traumatic SCI. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

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

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

21. Early vs delayed surgery for incomplete cervical spinal cord injury with pre-existing cervical stenosis: the OSCIS randomized clinical trial

<h3>BACKGROUND CONTEXT</h3> The timing of surgery for acute traumatic cervical spinal cord injury (SCI) has long been an issue of intense debate. The superiority of early surgical decompression for incomplete cervical SCI without concomitant bone injuries has not been established. <h3>PURPOSE</h3> The aim of this study was to determine whether early surgical decompression within 24 hours results in better motor recovery than delayed surgery following at least two weeks of conservative treatment. <h3>STUDY DESIGN/SETTING</h3> Multicenter randomized controlled trial conducted at 43 tertiary referral hospitals in Japan. <h3>PATIENT SAMPLE</h3> Patients aged 20 to 79 years with motor-incomplete cervical SCI with pre-existing canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. The presence of canal stenosis was verified based on baseline imaging studies, including MRI and CT. <h3>OUTCOME MEASURES</h3> The primary endpoints were improvement in the mean ASIA motor score, total score of the spinal cord independence measure (SCIM), and the proportion of patients able to walk independently at one year post-injury. <h3>METHODS</h3> Participants were allocated (11) by computer-based randomization to urgent surgery within 24 hours after admission or delayed surgery (later than two weeks post-injury). <h3>RESULTS</h3> Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; 5 women and 65 men) were included in the full analysis population at one year post-injury (37 patients assigned to early surgery and 33 to delayed surgery). We found a consistent, but insignificant, trend favoring early surgery more than delayed surgery (mean change in ASIA motor score, 53.7 vs 48.5, difference, 5.2; 95% confidence interval, -4.2 to 14.5; p=0.27; mean SCIM total score, 77.9 vs 71.3, p=0.34; the proportion of ambulatory patients, 70% vs 61.5%; p=0.51). A mixed-design analysis of variance revealed a significant difference in the ASIA motor scores between the groups (p=0.03). The early surgery group showed greater motor scores than the delayed surgery group at 2, 3 and 6 months post-injury. Complications were common in both groups (death, 3 patients vs 3 patients). <h3>CONCLUSIONS</h3> Among motor-incomplete cervical SCI patients, early surgery produced similar motor regain at one year post-injury as delayed surgery, but showed accelerated recovery within the first six months. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Real-life benefits of intrajejunal levodopa infusion therapy in four patients with the parkinsonian variant of progressive supranuclear palsy: A 1-year follow-up data report.

BackgroundProgressive supranuclear palsy (PSP) is a progressive neurodegenerative condition presenting with different clinical endophenotypes. The parkinsonian variant of PSP (PSP‐P) is characterised by early but fading responsiveness to high‐dose levodopa therapy; however, high‐dose oral therapy is often associated with intolerance due to dopaminergic side effects and so doses may have to be capped despite clinical benefits. Evidence from animal models and real‐life registries suggest far higher doses of levodopa can be tolerated if given in a continuous drug delivery (CDD) manner. We investigated tolerance and possible clinical benefits in patients with PSP‐P still responsive to levodopa after initiating CDD in the form of intrajejunal levodopa infusion (IJLI) therapy as part of a compassionate usage program (CU).MethodsThis is an observational clinical data report from the IJLI implementation program undertaken in regional tertiary referral Parkinson's centres in India and at King's College Hospital London, Dubai as part of a CU. Four patients with PSP‐P receiving IJLI as a part of a CU underwent evaluations of liver and renal function, motor and nonmotor function, quality of life, sleep dysfunction, fatigue, anxiety and depression, and cognitive impairment at baseline and 6 and 12 months post‐IJLI initiation.ResultsIn total, three out of four patients successfully completed 12 months of treatment (6 months in one patient). All four patients showed good tolerability to IJLI even at higher doses (1400 and 1960 mg at 6 and 12 months, respectively) when compared to oral levodopa (812.5 ± 103 levodopa equivalent daily dose [LEDD]) and presented with overall persistent improvements in motor and nonmotor scores and quality‐of‐life scores at 6 and 12 months post‐IJLI. All patients showed improvement in estimated glomerular filtration rate (43.50 ml/min/1.73 m2 to 67.5 ml/min/1.73 m2 and 79.5 ml/min/1.73 m2 at 6 and 12 months, respectively).ConclusionsIJLI led to persistent beneficial effects on motor and some nonmotor aspects in patients with PSP‐P at up to 12 months after treatment with associated improvement in overall renal function.

Glutathione in the Pons Is Associated With Clinical Status Improvements in Subacute Spinal Cord Injury.

In spinal cord injury (SCI), the primary mechanical injury is followed by secondary sequelae that develop over the subsequent months and manifests in biochemical, functional, and microstructural alterations, at the site of direct injury but also in the spinal cord tissue above and below the actual lesion site. Noninvasive magnetic resonance spectroscopy (MRS) can be used to assess biochemical modulation occurring in the secondary injury phase, in addition to and supporting conventional MRI, and might help predict and improve patient outcome. In this article, we aimed to examine the metabolic levels in the pons of subacute SCI by means of in vivo proton MRS at 3 T and explore the association to clinical scores. In this prospective study, between November 2015 and February 2018, single-voxel short-echo MRS data were acquired in healthy controls and in SCI subjects in the pons once during rehabilitation. Besides the single-point MRS examination, in addition, in participants with SCI, the clinical status (ie, motor, light touch, and pinprick scores) was assessed twice: (1) around the MRS session (approximately 10 weeks postinjury) and (2) before discharge (at approximately 9 months postinjury). The group differences were assessed with Kruskal-Wallis test, the post hoc comparison was assessed with Wilcoxon rank sum test, and the clinical correlations were conducted with Spearman rank correlation test. Bayes factor calculations completed the statistical part providing relevant evidence values. Twenty healthy controls (median age, 50 years; interquartile range, 41-55 years; 18 men) and 18 subjects with traumatic SCI (median age, 50 years; interquartile range, 32-58 years; 16 men) are included. Group comparison showed an increase of total N -acetylaspartate and combined glutamate and glutamine levels in complete SCI and a reduction of total creatine in incomplete paraplegic SCI. The proton MRS-based glutathione levels at baseline correlate to the motor score improvement during rehabilitation in incomplete subacute SCI. This exploratory study showed an association of the metabolite concentration of glutathione in the pons assessed at approximately 10 weeks after injury with the improvements of the motor score during the rehabilitation. Pontine glutathione levels in subjects with traumatic subacute incomplete SCI acquired remote from the injury site correlate to clinical score and might therefore be beneficial in the rehabilitation assessments.

Association of clinical outcomes and connectivity in awake versus asleep deep brain stimulation for Parkinson disease.

Deep brain stimulation (DBS) for Parkinson disease (PD) is traditionally performed with awake intraoperative testing and/or microelectrode recording. Recently, however, the procedure has been increasingly performed under general anesthesia with image-based verification. The authors sought to compare structural and functional networks engaged by awake and asleep PD-DBS of the subthalamic nucleus (STN) and correlate them with clinical outcomes. Levodopa equivalent daily dose (LEDD), pre- and postoperative motor scores on the Movement Disorders Society-Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS III), and total electrical energy delivered (TEED) at 6 months were retroactively assessed in patients with PD who received implants of bilateral DBS leads. In subset analysis, implanted electrodes were reconstructed using the Lead-DBS toolbox. Volumes of tissue activated (VTAs) were used as seed points in group volumetric and connectivity analysis. The clinical courses of 122 patients (52 asleep, 70 awake) were reviewed. Operating room and procedure times were significantly shorter in asleep cases. LEDD reduction, MDS-UPDRS III score improvement, and TEED at the 6-month follow-up did not differ between groups. In subset analysis (n = 40), proximity of active contact, VTA overlap, and desired network fiber counts with motor STN correlated with lower DBS energy requirement and improved motor scores. Discriminative structural fiber tracts involving supplementary motor area, thalamus, and brainstem were associated with optimal clinical improvement. Areas of highest structural and functional connectivity with VTAs did not significantly differ between the two groups. Compared to awake STN DBS, asleep procedures can achieve similarly optimal targeting-based on clinical outcomes, electrode placement, and connectivity estimates-in more efficient procedures and shorter operating room times.

Brain-Computer Interface Priming for Cervical Transcutaneous Spinal Cord Stimulation Therapy: An Exploratory Case Study.

Loss of arm and hand function is one of the most devastating consequences of cervical spinal cord injury (SCI). Although some residual functional neurons often pass the site of injury, recovery after SCI is extremely limited. Recent efforts have aimed to augment traditional rehabilitation by combining exercise-based training with techniques such as transcutaneous spinal cord stimulation (tSCS), and movement priming. Such methods have been linked with elevated corticospinal excitability, and enhanced neuroplastic effects following activity-based therapy. In the present study, we investigated the potential for facilitating tSCS-based exercise-training with brain-computer interface (BCI) motor priming. An individual with chronic AIS A cervical SCI with both sensory and motor complete tetraplegia participated in a two-phase cross-over intervention whereby they engaged in 15 sessions of intensive tSCS-mediated hand training for 1 h, 3 times/week, followed by a two week washout period, and a further 15 sessions of tSCS training with bimanual BCI motor priming preceding each session. We found using the Graded Redefined Assessment for Strength, Sensibility, and Prehension that the participant's arm and hand function improved considerably across each phase of the study: from 96/232 points at baseline, to 117/232 after tSCS training alone, and to 131/232 points after BCI priming with tSCS training, reflecting improved strength, sensation, and gross and fine motor skills. Improved motor scores and heightened perception to sharp sensations improved the neurological level of injury from C4 to C5 following training and improvements were generally maintained four weeks after the final training session. Although functional improvements were similar regardless of the presence of BCI priming, there was a moderate improvement of bilateral strength only when priming preceded tSCS training, perhaps suggesting a benefit of motor priming for tSCS training.

Impact of visual field loss post-stroke on activities of daily living: a prospective cohort study

ABSTRACT This study investigated the ADL performances of people with VFL after an acute stroke using an observation-based evaluation of ADL skills, the Assessment of Motor and Process Skills. The AMPS was administered on initial assessment and at ≥11 weeks follow-up on 58 adults with a mild stroke, with (n = 16) and without VFL (n = 42), over a 13-month period. The AMPS guidelines on clinically relevant difference of 0.30 logits were used to determine the differences of the groups’ ADL performance on initial assessment and follow-up. The study found that the ADL motor and process scores did not differ significantly on initial assessment. The study observed no clinically relevant difference between the ADL motor and process scores of between the VFL and non-VFL on initial assessment and follow-up but demonstrated clinically relevant improvements in ADL motor and process scores of both groups from initial assessment to follow-up. VFL does not have an additional negative impact on ADL performance of those with a mild stroke and does not impede improvement of ADL performance over time.

179 Clinical Outcomes From a Single-Site Phase I Study of Neural Stem Cell Transplantation for Chronic Spinal Cord Injury

INTRODUCTION: We previously reported safe implantation and improvement in motor and sensory scores using neural stem cell line (NSC) NSI-566 in chronic thoracic complete spinal cord injury (SCI) patients. METHODS: A total of four subjects received NSI-566 spinal cord implantation. All subjects tolerated the procedure well with no serious adverse events in the immediate post-procedure period. Prospective data have been collected including ISNCSCI scores, functional and pain surveys, SCIM scores, electromyography (EMG), Brain Motor Control Assessment (BMCA), and serial MRI. RESULTS: Two patients experienced improvements in neurological level of injury (NLI), motor score, and sensory score. BMCA showed newly developed muscle responsiveness in lower limbs to reinforcement maneuvers in one patient. Three subjects experienced new EMG activity in lower muscle groups. Two patients had overall decreased pain scores post-operatively, which included both discomfort and allodynia in the transition zone, surgical site pain, and neuropathic and nociceptive pain elsewhere. MR imaging showed no radiographical evidence of immediate or delayed complications after the stem cell injections. CONCLUSION: Our current clinical data demonstrate that spinal grafting of the human NSI-566 cell line in chronic spinal trauma patients is safe with no detectable side effects identified at 60 months after cell delivery. Despite the small sample size, the key strengths of the study are the extensive follow-up period and the timeline of treatment. Like other Phase I studies, this study was intended to provide proof of safety and tolerability and proof of concept data that will justify the next cohort.