Incomplete Cervical Spinal Cord Injury Research Articles

Reliability of the Mini-BESTest and Brief-BESTest for assessing patients with incomplete spinal cord injury.

Single institution observational study. To investigate the ceiling and floor effects of the Berg Balance Scale (BBS), Mini-Balance Evaluation Systems Test (BESTest), and Brief-BESTest, as well as to determine the intra- and inter-rater reliabilities and minimal detectable change (MDC) of the Mini-BESTest and Brief-BESTest in patients with acute and subacute incomplete cervical spinal cord injury (SCI) classified as AIS D. Advanced critical care center of our university hospital. Twenty patients with incomplete cervical SCI who could stand without assistance were recruited. The floor and ceiling effects were evaluated by plotting histograms from the distribution of scores on the BBS, Mini-BESTest and Brief-BESTest, and calculating skewness. The Mini-BESTest and Brief-BESTest were evaluated and videotaped simultaneously, and intra- and inter-rater reliabilities were assessed. The MDC was also calculated. The skewness of the BBS was -1.57, and the full score was 35%, indicating a ceiling effect. However, no ceiling or floor effect was observed for the Mini-BESTest and the Brief-BESTest. Intraclass correlation coefficients for intra-rater and inter-rater reliabilities were 0.98 and 0.97 for the Mini-BESTest and Brief-BESTest, respectively. Individual item reliability was moderate or better for the Mini-BESTest and excellent or better for the Brief-BESTest. The MDC of total scores ranged 3.14-3.84 and 2.92-3.60 for the Mini-BESTest and Brief-BESTest, respectively. The Mini-BESTest and Brief-BESTest are reliable assessment tools for patients with acute and subacute incomplete SCI classified as AIS D. Clarified error ranges aid in estimating the treatment effect on balance abilities.

Acute intermittent hypoxia increases maximal motor unit discharge rates in people with chronic incomplete spinal cord injury.

Acute intermittent hypoxia (AIH) is an emerging technique for enhancing neuroplasticity and motor function in respiratory and limb musculature. Thus far, AIH-induced improvements in strength have been reported for upper and lower limb muscles after chronic incomplete cervical spinal cord injury (iSCI), but the underlying mechanisms have been elusive. We used high-density surface EMG (HDsEMG) to determine if motor unit discharge behaviour is altered after 15×60s exposures to 9% inspired oxygen, interspersed with 21% inspired oxygen (AIH), compared to breathing only 21% air (SHAM). We recorded HDsEMG from the biceps and triceps brachii of seven individuals with iSCI during maximal elbow flexion and extension contractions, and motor unit spike trains were identified using convolutive blind source separation. After AIH, elbow flexion and extension torque increased by 54% and 59% from baseline (P=0.003), respectively, whereas there was no change after SHAM. Across muscles, motor unit discharge rates increased by ∼4 pulses per second (P=0.002) during maximal efforts, from before to after AIH. These results suggest that excitability and/or activation of spinal motoneurons is augmented after AIH, providing a mechanism to explain AIH-induced increases in voluntary strength. Pending validation, AIH may be helpful in conjunction with other therapies to enhance rehabilitation outcomes after incomplete spinal cord injury, due to these enhancements in motor unit function and strength. KEY POINTS: Acute intermittent hypoxia (AIH) causes increases in muscular strength and neuroplasticity in people living with chronic incomplete spinal cord injury (SCI), but how it affects motor unit discharge rates is unknown. Motor unit spike times were identified from high-density surface electromyograms during maximal voluntary contractions and tracked from before to after AIH. Motor unit discharge rates were increased following AIH. These findings suggest that AIH can facilitate motoneuron function in people with incomplete SCI.

Prolonged intermittent hypoxia differentially regulates phrenic motor neuron serotonin receptor expression in rats following chronic cervical spinal cord injury

Low-dose (< 2 h/day), acute intermittent hypoxia (AIH) elicits multiple forms of serotonin-dependent phrenic motor plasticity and is emerging as a promising therapeutic strategy to restore respiratory and non-respiratory motor function after spinal cord injury (SCI). In contrast, high-dose (> 8 h/day), chronic intermittent hypoxia (CIH) undermines some forms of serotonin-dependent phrenic motor plasticity and elicits pathology. CIH is a hallmark of sleep disordered breathing, which is highly prevalent in individuals with cervical SCI. Interestingly, AIH and CIH preconditioning differentially impact phrenic motor plasticity. Although mechanisms of AIH-induced plasticity in the phrenic motor system are well-described in naïve rats, we know little concerning how these mechanisms are affected by chronic SCI or intermittent hypoxia preconditioning. Thus, in a rat model of chronic, incomplete cervical SCI (lateral spinal hemisection at C2 (C2Hx), we assessed serotonin type 2A, 2B and 7 receptor expression in and near phrenic motor neurons and compared: 1) intact vs. chronically injured rats; and 2) the impact of preconditioning with varied “doses” of intermittent hypoxia (IH). While there were no effects of chronic injury or intermittent hypoxia alone, CIH affected multiple receptors in rats with chronic C2Hx. Specifically, CIH preconditioning (8 h/day; 28 days) increased serotonin 2A and 7 receptor expression exclusively in rats with chronic C2Hx. Understanding the complex, context-specific interactions between chronic SCI and CIH and how this ultimately impacts phrenic motor plasticity is important as we leverage AIH-induced motor plasticity to restore breathing and other non-respiratory motor functions in people with chronic SCI.

Mild Intermittent Hypoxia Improves Hand Function in a Participant with Motor Incomplete Cervical Spinal Cord Injury

Mild Intermittent Hypoxia Improves Hand Function in a Participant with Motor Incomplete Cervical Spinal Cord Injury

Neuropathic pain development and maintenance and its association with motor recovery after cervical spinal cord injury

Background In our published randomized controlled trial, we revealed that patients with acute ASIA Grade C incomplete cervical spinal cord injury (SCI) who underwent early surgery (within 24 h post-injury) had accelerated motor recovery at six months than those with delayed surgery (>2 weeks post-injury); however, neuropathic pain (NeP) worsened regardless of surgery timing. Here, we conducted post-hoc analyses to intensively assess NeP development and maintenance. Methods Of 44 patients (median 64.5 years; three female; early intervention, n = 26), NeP was categorized into at-level and below-level pain and evaluated at two weeks and one year after injury using the Neuropathic Pain Symptom Inventory (NPSI). We compared the two groups based on background characteristics. A mixed-design analysis of variance with sex as a covariate was conducted to analyze motor recovery and Health-related quality of life (HRQOL) in groups with severe (NPSI ≥ 10) or mild (NPSI < 10) pain. Results Upper and lower limb motor impairments were comparable between both groups regardless of pain severity. Severe at-level pain remained stable and worsened at one year than mild at-level pain; however, the upper- and lower-limb motor scores and HRQOL had comparable recovery. Background characteristics did not affect severity or time course of NeP. Patients with severe below-level pain demonstrated slower lower-limb motor recovery than those with mild below-level pain, whereas HRQOL improved regardless of pain severity. Conclusions Both at-level and below-level NeP developed and persisted relatively early in the course of traumatic SCI with incomplete motor paralysis; their severities worsened over time or remained severe since onset.

Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury

Objective To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI). Design A retrospective observational study. Setting Intensive care unit or high care unit of a university hospital emergency center. Participants Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included. Interventions Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury. Outcome measures The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis. Results Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II. Conclusion Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.

Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK.

We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago. A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments. We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists. Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines.

Effects of Neuromuscular Electrical Stimulation for Quadriceps Muscle Thickness and Lower Extremity Motor Score in Individuals with Subacute Incomplete Cervical Spinal Cord Injury: A Randomized Controlled Trial

Effects of Neuromuscular Electrical Stimulation for Quadriceps Muscle Thickness and Lower Extremity Motor Score in Individuals with Subacute Incomplete Cervical Spinal Cord Injury: A Randomized Controlled Trial

Verification of the minimal clinically important difference of the Capabilities of Upper Extremity Test in patients with subacute spinal cord injury

Context The number of patients with cervical spinal cord injury (CSCI) is increasing, and the Capabilities of Upper Extremity Test (CUE-T) is recommended for introduction in clinical trials. We calculated the minimal clinically important difference (MCID) of the CUE-T using an adjustment model with an interval of 1 month. Design This was a prospective study. Setting This study was conducted with participants from the Chiba Rehabilitation Center in Japan. Participants The participants were patients with subacute CSCI. Interventions The CUE-T and spinal cord independence measure (SCIM) III were performed twice within an interval of 1 month. Outcome Measures The MCID was calculated using an adjustment model based on logistic regression analysis. The participants were classified into an improvement group and a non-improvement group based on the amount of change in the two evaluations using the 10-point SCIM III MCID as an anchor. Results There were 52 participants (56.8 ± 13.5 years old, 45 men/7 women) with complete or incomplete CSCI: 18 in the improvement group and 34 in the non-improvement group. A significant regression equation was obtained when calculating the MCID, and the total, hand, and side scores were 7.7, 2.0, and 3.7 points, respectively. Conclusion The calculated MCID of the CUE-T in this study was 7.7 points. The results of this study provide useful criteria for implementation in clinical trials. Future studies should use patient-reported outcomes, a more recommended anchor, and calculate the MCID using methods such as the patient’s condition.

CHARACTERISTICS OF REHABILITATION OF PEOPLE WITH SPINAL CORD INJURY

The article shows the results of the study concerning the rehabilitation peculiarities of young people with cervical spinal cord injuries. The aim of the study is to develop the optimal rehabilitation program, motor development and motor compensation, physical characteristics, mental health, nerve and muscle function, and the formation of positive motivation during special training programs. It will help young people adapt to their new situation, and to integrate them into society. The results of the experiment have shown quite a low level of development of motor skills, manual motor skills, daily living skills, and little regulation of the visceral motor system. The aim of the present work is to present correctional rehabilitation during three phases (early, late, and residual). 150 students, including 90 boys and 60 girls aged 16 to 18 with incomplete cervical spinal cord injuries participated in the study. It has been proven that the main psychological and pedagogical conditions, which fully ensure the effectiveness of psychophysical and social rehabilitation of elder students with incomplete cervical spinal cord injuries are: staged approach to rehabilitation that takes into account the complexity of this disease and personal characteristics, creating comfortable conditions and situations that form optimistic expectations about students’ capabilities, and positive didactic rehabilitation motivation; a comprehensive approach to the correction using psychological and social factors, specific motor training, methods of control, motor skills formation, physical development, correction, and motor compensation; control of the level of fundamental motor skills; a comprehensive approach to social adaptation; and finally high physical activity level of each person with disabilities in official and independent types of physical therapy. Specially organized training according to all the criteria and indicators, positively influenced the students from the experimental group in contrast to the control group, where the indicators remained quite low.

Effects of the combination of acupuncture and medication on orthostatic hypotension after incomplete cervical spinal cord injury

Effects of the combination of acupuncture and medication on orthostatic hypotension after incomplete cervical spinal cord injury

Knee Joint Extension Muscle Strength Required for Walking Independence by Patients with Acute Incomplete Cervical Spinal Cord Injury

Knee Joint Extension Muscle Strength Required for Walking Independence by Patients with Acute Incomplete Cervical Spinal Cord Injury

ASYMPTOMATIC DYSREFLEXIA AFTER POSTURAL CHANGES IN AN INCOMPLETE SPINAL CORD INJURY: CONSIDERATIONS FOR EXERCISE PHYSIOLOGISTS

https://youtu.be/Z6gJb7-F5Gw BACKGROUND Autonomic dysreflexia (AD) is a potentially life threatening hypertensive syndrome prevalent among patients with chronic spinal cord injuries (SCI) at spinal segment T6 or above. AD is due to the loss of supraspinal control over sympathetic preganglionic neurons and is triggered by noxious stimuli below the level of injury. The treatment of AD is multifaceted, from conservative management to topical and oral antihypertensive medications. Understanding AD's rapid onset and severity are extremely important for exercise physiologists working with patients with SCI. CASE PRESENTATION A 67-year old male with chronic motor incomplete cervical SCI (i.e., ASIA C4 C) and persistent orthostatic hypotension (OH) was enrolled in a study to determine the effects of biofeedback on blood pressure (BP) modulation when an episode of asymptomatic AD occurred. Baseline and resting BP were recorded at 122/82, with a resting mean arterial pressure (MAP) of 96. The BP was continuously monitored using a telemetric device (Caretaker, Charlottesville, VA). Upon positional changes required to measure OH with a tilt table, the participant showed an antagonist response with a sudden increase in BP consistent with AD symptoms, reaching a maximum level of 199/121. The participant was asymptomatic during the AD episode. CASE MANAGEMENT/OUTCOME BP returned to baseline levels after the participant was transferred back to a seated position in the wheelchair without using other measurements or medications. The titl test was modified with the participant positioned in a semi supine position (30° incline) and then tilted to approximately 45and remained in this position for 3 minutes. DISCUSSION AD is prevalent among people with cervical or upper thoracic SCI, and often the episodes are asymptomatic. As a part of the training routine, many patients with SCI are placed in a supine position for passive stretching and exercising. We are presenting data on this episode of asymptomatic AD due to postural changes to bring awareness to exercise physiologists of this life threatening condition. Trainers should carefully check for signs of AD in this population and measure BP often during the training sessions if a continuous assessment of BP is unavailable. Seated is recommended over a supine or semi-supine position. This could be accomplished by using physical therapy wedge cushions to maintain blood pressure homeostasis.

Effect of Age at Injury on Walking Ability Following Incomplete Cervical Spinal Cord Injury: A Retrospective Cohort Study.

Recently, the cases of elderly individuals with spinal cord injuries are increasing in Japan. For individuals with spinal cord injury, regaining the ability to walk independently after an injury is one of the most important aspects of rehabilitation. Nevertheless, instead of age-optimized programs, uniform rehabilitation programs are currently provided to all patients because there is no information available for predicting prognosis based on age at the time of injury. This study aimed to elucidate the effect of age at the time of injury on the walking ability of patients with incomplete cervical spinal cord injury. Of the 1,195 patients registered in the Japan single-center study for spinal cord injury database, those hospitalized within 28 days after injury, followed up for >180 days, had a cervical spinal cord injury, and had a lower extremity motor score of ≥42 points were examined. Patients were stratified into three groups according to the age at the time of injury (≤59, 60-69, or ≥70 years). The walking ability scores and independence levels of mobility were compared; these data were evaluated based on indoor mobility (item 12) and outdoor mobility (item 14) in the Spinal Cord Independence Measure III and Walking Index for Spinal Cord Injury II. All comparisons used data at discharge. The walking ability scores and independence levels of mobility were significantly lower in the group aged ≥70 years than those in the remaining two groups. In patients with cervical spinal cord injuries with the same limb function, if the age at the time of injury was ≥70 years, the decline in physical function due to aging exerted a substantial effect on walking ability.

Developing guiding principles for technology-based rehabilitation program by engaging people with motor incomplete tetraplegia

BackgroundTechnology-aided rehabilitation is well established in the field of neurologic rehabilitation. Despite the widespread availability, the development of technology-based interventions that incorporate perspectives of the people who will use them is lacking.ObjectivesThis qualitative study aims to understand how people with chronic motor incomplete cervical spinal cord injury view rehabilitation technology to improve upper extremity function and neuromuscular recovery to inform future intervention development.MethodsSeven participants with chronic upper extremity impairment due to spinal cord injury/dysfunction trialed five rehabilitation technology devices. After a 30–45 min trial for each device, participants engaged in a semi-structured interview. Interviews were analyzed using a qualitative approach to explore the experience using and understand features that support motivation to use of rehabilitation technology.ResultsQualitative analysis revealed three major themes: (1) devices must be flexible to meet diverse needs; (2) intervention protocols must be individualized to address unique needs and contexts of users; (3) intervention protocols should be developed and updated by a skilled clinician. These themes and subthemes were used to describe guiding principles to inform future intervention design.ConclusionThe experiences of people with cervical spinal cord injury can be elicited as part of the intervention design process to systematically develop protocols for future feasibility trials. The findings from this study can be used to inform the development of technology-aided rehabilitation programs to improve upper extremity function in people with chronic motor incomplete tetraplegia.Clinical trials registration number: NCT04000256

Inspiratory muscle reflex control after incomplete cervical spinal cord injury.

In healthy individuals, loading inspiratory muscles by brief inspiratory occlusion produces a short-latency inhibitory reflex (IR) in the electromyographic (EMG) activity of scalene and diaphragm muscles. This IR may play a protective role to prevent aspiration and airway collapse during sleep. In people with motor and sensory complete cervical spinal cord injury (cSCI), who were able to breathe independently, this IR was predominantly absent. Here, we investigated the reflex response to brief airway occlusion in 16 participants with sensory incomplete cSCI [American spinal injury association impairment scale (AIS) score B or C]. Surface EMG was recorded from scalene muscles and the lateral chest wall (overlying diaphragm). The airway occlusion evoked a small change in mouth pressure resembling a physiological occlusion. The short-latency IR was present in 10 (63%) sensory incomplete cSCI participants; significantly higher than the IR incidence observed in complete cSCI participants in our previous study (14%; P = 0.003). When present, mean IR latency across all muscles was 58 ms (range 29-79 ms), and mean rectified EMG amplitude decreased to 37% preocclusion levels. Participants without an IR had untreated severe obstructive sleep apnea (OSA), in contrast to those with an IR, who had either had no, mild, or treated OSA (P = 0.002). Insufficient power did not allow statistical comparison between IR presence or absence and participant clinical characteristics. In conclusion, spared sensory connections or intersegmental connections may be necessary to generate the IR. Future studies to establish whether IR presence is related to respiratory morbidity in the tetraplegic population are required.NEW & NOTEWORTHY Individuals with incomplete cSCI were tested for the presence of a short latency reflex inhibition of inspiratory muscles, by brief airway occlusion. The reflex was 4.5 times more prevalent in this group compared with those with complete cSCI and is similar to the incidence in able-bodied people. Participants without this reflex all had untreated severe OSA, in contrast to those with an IR, who either had no, mild, or treated OSA. This work reveals novel differences in the reflex control of inspiratory muscles across the cSCI population.

Altered functional connectivity between primary motor cortex subregions and the whole brain in patients with incomplete cervical spinal cord injury.

To investigate the reorganizations of gray matter volume (GMV) in each subregion of primary motor cortex (M1) after incomplete cervical cord injury (ICCI) and to explore the differences in functional connectivity (FC) between the M1 subregions and the whole brain, and further to disclose the potential value of each M1 subregion in motor function rehabilitation of ICCI patients. Eighteen ICCI patients and eighteen age- and gender- matched healthy controls (HCs) were recruited in this study. The 3D high-resolution T1-weighted structural images and resting-state functional magnetic resonance imaging (rs-fMRI) of all subjects were obtained using a 3.0 Tesla MRI system. Based on the Human Brainnetome Atlas, the structural and functional changes of M1 subregions (including A4hf, A6cdl, A4ul, A4t, A4tl, A6cvl) in ICCI patients were analyzed by voxel-based morphometry (VBM) and seed-based FC, respectively. Compared with HCs, no structural changes in the M1 subregions of ICCI patients was detected. However, when compared with HCs, ICCI patients exhibited decreased FC in visual related areas (lingual gyrus, fusiform gyrus) and sensorimotor related areas (primary sensorimotor cortex) when the seeds were located in bilateral A4hf, A4ul, and decreased FC in visual related areas (lingual gyrus, fusiform gyrus) and cognitive related areas (temporal pole) when the seed was located in the left A4t. Moreover, when the seeds were located in the bilateral A6cdl, decreased FC in visual related areas (lingual gyrus, fusiform gyrus, calcarine gyrus) was also observed. Our findings demonstrated that each of the M1 regions had diverse FC reorganizations, which may provide a theoretical basis for the selection of precise stimulation targets, such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tCDS), meanwhile, our results may reveal the possible mechanism of visual feedback and cognitive training to promote motor rehabilitation.

Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis—The significance of anorectal evaluation

BackgroundAlthough the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients. MethodsThis study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings. ResultsForty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (−), voluntary anal contraction (VAC) (−), anorectal tone (−), anal wink reflex (−), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up. ConclusionsIncomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

A Novel Method to Classify Cervical Incomplete Spinal Cord Injury Based on Potential for Recovery: A Group-Based Trajectory Analysis.

The outcomes of cervical incomplete spinal cord injury (SCI) are heterogeneous. This study sought to dissociate subgroups of cervical incomplete SCI patients with distinct longitudinal temporal profiles of recovery in upper limb motor function. Patients with cervical incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] B-D; C1-C8) were identified from four prospective, multi-center SCI datasets. A group-based trajectory model was fit to longitudinal upper extremity motor scores out to 1 year. Multi-variable multinomial logistic regression was performed to identify features that characterize each trajectory group. A classification system for predicting trajectory group at baseline was developed by recursive partitioning. In total, 801 patients were eligible. Four distinct trajectory groups were identified: 1) "Poor outcome": Severe injury, very minimal recovery; 2) "Moderate recovery": Moderate-to-severe injury, moderate recovery; most recovery occurs by 6 months, with mild, gradual recovery continuing thereafter; 3) "Good recovery": Moderate injury, good recovery; most recovery occurs by 3 months, with mild, gradual recovery continuing thereafter; and 4) "Excellent outcome": Mild injury, recovery to normal/near-normal by 3 months. On adjusted analyses, older age was associated with lower likelihood of "excellent outcome" (p = 0.020). AIS C and D injuries were associated with "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001). Mid-cervical injuries occurred more frequently in "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001) groups. Early surgical decompression (< 24 h) was associated with increased propensity for "good recovery" (p = 0.039) and "excellent outcome" (p = 0.048). A classification model based on recursive partitioning could predict trajectory group using age, AIS grade, and neurological level with an area under the curve of 0.81. Patients with cervical incomplete SCI demonstrate distinct temporal profiles of recovery in upper limb motor function. The trajectory a patient is likely to follow may be predicted at baseline with fair accuracy.

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.