Zone Of Partial Preservation Research Articles

The revised zone of partial preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury: ZPP applicability in incomplete injuries

Study designConsensus process.ObjectivesTo provide a reference for the Zone(s) of Partial Preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and analyze the initial impact of applicability of the revised ZPPs. Revisions include the use of ZPPs in selected incomplete injuries (in addition to prior use in sensorimotor complete injuries). Specifically, the revised motor ZPPs are applicable bilaterally in injuries with absent voluntary anal contraction (VAC) and the revised sensory ZPP for a given side is applicable if deep anal pressure (DAP), light touch and pin prick sensation in S4-5 are absent on that side.SettingCommittee with 16 ISNCSCI experts and datasets from the European Multicenter Study about Spinal Cord Injury (EMSCI).MethodsOccurrence frequencies of applicable ZPPs were determined in an EMSCI cohort consisting of two ISNCSCI examinations from 665 individuals with traumatic SCI.ResultsMotor ZPPs were derived in 35.2% of all datasets of incomplete injuries, while sensory ZPPs are much less frequent (1.0%). Motor ZPPs are applicable in all American Spinal Injury Association Impairment Scale (AIS) B datasets (mean ZPP length: 0.9 ± 1.0 segments), in 55.4% of all AIS C datasets (ZPP length: 11.8 ± 8.2 segments) and in 9.9% of the AIS D datasets (ZPP length: 15.4 ± 7.9 segments).ConclusionsThe revised ZPP allows for determining motor ZPPs in approximately 1/3 of all incomplete injuries. The broadened applicability enables the use of ZPPs beyond complete injuries for complementary description of residual functions in more individuals.SponsorshipN/A

Spontaneous Neurological Recovery of Patients with Acute Traumatic Spinal Cord Injuries (ATSCI) without Intervention the Injured Cord”

Acute traumatic spinal cord injuries (ATSCI) are life threatening and life changing events. With good Active Physiological Conservative Management (APCM) of the injured spine and the systemic effects of cord damage to prevent further mechanical and non-mechanical damage of the cord the majority of patients make some spontaneous neurological recovery (SNR). The magnitude and extent of this recovery depends on the initial degree and topographical sparing of sensory and sensory-motor tracts functions at and below the Zone of Partial Preservation (ZPP).

The feasibility of training with FES-assisted cycling: Psychological, physical and physiological consideration

Objective The literature contains considerable data showing that such programs are crucial to reduce the consequences of physical inactivity of people with SCI. The objective of the study was to assess the physical, psychological, functional and financial feasibility of training a paraplegic subject on a FES-assisted recumbent bike – initially fixed on a stationary stand and then over open terrain. At the end of a 12-month training, the patient was invited to participate in an international competition (Cybathlon 2016). Material/Patients and methods Feasibility indicators related to physical, psychological, functional and financial tolerance. Physical, psychological and functional indicators of training impact. Results Mr. J.P., 47-years-old was paraplegic for 21 years, T3, AIS-A with no zone of partial preservation. Feasibility indicators: no osteoarticular, cutaneous, or cardiorespiratory morbidity was noted. The acceptability score of the training constraints increased from 51 to 59/65 and satisfaction was high around 8/10 and peaked at 10/10 the day after the competition. The pedaling duration increased from 1 to 26 on the recumbent bike and from 1 to 15 on open terrain. The total cost of the bike + the stimulation was estimated at 7650 D. Impact indicators: no significant changes were found with BMD and the body mass. Thigh circumference did not significantly increase. Cardiorespiratory measures during exercise tests did not show any improvement. SF 36 showed significant improvement of more than 10% and score on the Rosenberg Self-Esteem Scale rapidly improve from 36 to 39/40 and remained at a level of 40/40 up to the competition. Mr. J.P. distinguished himself during Cybathlon 2016, by reaching the objective of covering 750 m in under 8 minutes, at an average speed of 5.80 km.hr and a maximal speed of 6.14 km.hr. He finished 6th out of 12. Discussion/Conclusion A person who has been paraplegic for many years (more than 20) with a high lesion level (T3 AIS-A) can undertake this type of challenge if the prerequisites are met; this type of training is without danger if the safety precautions are respected; the training itself, the challenge of participating in a competition, and the sheer pleasure of cycling outdoors without attracting stigmatizing attention all had a powerful impact on JP's self-esteem and perceived quality of life.

Achieving assessor accuracy on the International Standards for Neurological Classification of Spinal Cord Injury.

A retrospective audit of assessor accuracy using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in three multicentre randomised controlled trials (SCIPA: Spinal Cord Injury and Physical Activity) spanning 2010-2014 with standards revised in 2011. To investigate assessor accuracy of neurological classification after spinal cord injury. Australia and New Zealand. ISNCSCI examinations were undertaken by trained clinicians prior to randomisation. Data were recorded manually and ISNCSCI worksheets circulated to panels, consensus reached and worksheets corrected. An audit team used a 2014 computerised ISNCSCI algorithm to check manual worksheets. A second audit team assessed whether the 2014 computerised algorithm accurately reflected pre- and post-2011 ISNCSCI standards. Of the 208 ISNCSCI worksheets, 24 were excluded. Of the remaining 184 worksheets, 47 (25.5%) were consistent with the 2014 computerised algorithm and 137 (74.5%) contained one or more errors. Errors were in motor (30.1%) or sensory (12.4%) levels, zone of partial preservation (24.0%), motor/sensory scoring (21.5%), ASIA Impairment Scale (AIS, 8.3%) and complete/incomplete classification (0.8%). Other difficulties included classification when anal contraction/sensation was omitted, incorrect neurological levels and violation of the 'motor follows sensory rule in non-testable myotomes' (7.4%). Panel errors comprised corrections that were incorrect or missed or incorrect changes to correct worksheets. Given inaccuracies in the manual ISNCSCI worksheets in this long-term clinical trial setting, continued training and a computerised algorithm are essential to ensure accurate scoring, scaling and classification of the ISNCSCI and confidence in clinical trials.

International standards for neurological classification of spinal cord injury: classification skills of clinicians versus computational algorithms.

This is a retrospective analysis. The objective of this study was to describe and quantify the discrepancy in the classification of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by clinicians versus a validated computational algorithm. European Multicenter Study on Human Spinal Cord Injury (EMSCI). Fully documented ISNCSCI data sets from EMSCI's first years (2003-2005) classified by clinicians (mostly spinal cord medicine residents, who received in-house ISNCSCI training by senior SCI physicians) were computationally reclassified. Any differences in the scoring of sensory and motor levels, American Spinal Injury Association Impairment Scale (AIS) or the zone of partial preservation (ZPP) were quantified. Four hundred and twenty ISNCSCI data sets were evaluated. The lowest agreement was found in motor levels (right: 62.1%, P=0.002; left: 61.8%, P=0.003), followed by motor ZPP (right: 81.6%, P=0.74; left 80.0%, P=0.27) and then AIS (83.4%, P=0.001). Sensory levels and sensory ZPP showed the best concordance (right sensory level: 90.8%, P=0.66; left sensory level: 90.0%, P=0.30; right sensory ZPP: 91.0%, P=0.18; left sensory ZPP: 92.2%, P=0.03). AIS B was most often misinterpreted as AIS C and vice versa (AIS B as C: 29.4% and AIS C as B: 38.6%). Most difficult classification tasks were the correct determination of motor levels and the differentiation between AIS B and AIS C/D. These issues should be addressed in upcoming ISNCSCI revisions. Training is strongly recommended to improve classification skills for clinical practice, as well as for clinical investigators conducting spinal cord studies. This study is partially funded by the International Foundation for Research in Paraplegia, Zurich, Switzerland.

Feasibility of using training cases from International Spinal Cord Injury Core Data Set for testing of International Standards for Neurological Classification of Spinal Cord Injury items.

Descriptive comparison analysis. To evaluate whether five training cases of International Spinal Cord Injury Core Data Set (ISCICDS) are appropriate for testing the facts within the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and could thus be used for testing its training effectiveness. The authors reviewed the five training cases from the ISCICDS and determined the sensory level (SL), motor level (ML) and American Spinal Injury Association Impairment Scale (AIS) for the training cases. The key points from the training cases were compared with our interpretation of the key aspects of the ISNCSCI. For determining SL, three principles of ML, sacral sparing, complete injury, classification of AIS A, B, C and D, determining motor incomplete status through sparing of motor function more than three levels below the ML, there are corresponding case scenarios in ISCICDS. However, no case scenario shows classification of AIS E and the use of voluntary anal sphincter contraction for determination of motor incomplete status. Neurological level of injury could be deduced from the SL and ML. Finally, none of the cases include information about zone of partial preservation, sensory score or motor score. Majority of the facts related to SL, ML and AIS are included in the five training cases of ISCICDS. Thus, using these training cases, it is feasible to test the above facts within the ISNCSCI. It is suggested that the missing fact should be included in an update of the training cases.

Changes in electrical perceptual threshold in the first 6 months following spinal cord injury

ObjectivesTo investigate the use of electrical perceptual threshold (EPT) testing to follow the natural history of sensory progression after complete and incomplete acute spinal cord injury (SCI) and to compare EPT changes with the American Spinal Injuries Association (ASIA) Impairment Scale (AIS).Study DesignProspective descriptive study.MethodsASIA examination and EPT testing was performed on 17 patients (7 AIS A, 10 AIS B–D), within 1, 3, and 6 months after acute SCI. EPT assessment was carried out bilaterally at ASIA sensory points from 2 levels above the neurological level to all levels below, including the sacral segments. Comparisons of EPT values above, at, and below the SCI were made at the three time points as well as comparisons of EPT data to ASIA assessment.ResultsThere was poor agreement between lowest normal level on EPT and ASIA assessment. Over time, EPTs tended to deteriorate above and at the ASIA level in AIS A patients with modest changes below the neurological level of injury (NLI), mainly where EPTs correlated with the zone of partial preservation. Sacral sparing was detected in one patient with EPT testing, but not with ASIA assessment. AIS B–D patients showed improvement at the ASIA level and extensive changes, both improvement and deterioration, below the NLI.ConclusionEPT testing has sufficient sensitivity to detect subclinical changes in sensory function as early as the first month post–SCI, which is not apparent in ASIA examination. In particular, the testing is able to show abnormalities at and around the injury site for both complete and incomplete SCI. In addition, EPT allows for the detection and monitoring of alterations, both improvements and deterioration, in the abnormal range of sensation.

Characterization of neurological recovery following traumatic sensorimotor complete thoracic spinal cord injury

Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI). To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI. A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI. AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion. The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.

ASIA-A Patients With Partial Preservation Versus Partial Recovery

Objective To prospectively investigate changes in the zone of partial preservation (ZPP) and outside the extent of these zones in patients with complete [American Spinal Injury Association (ASIA-A)] spinal cord injury. Methods Patients were examined and evaluated according to the ASIA revised 2000 criteria. Main outcome measure was the determination of partially innervated zones on early and late stages; we also examined sensory and motor recovery, neurologic level of injury, and ASIA classification. All the examinations were performed at admission to the rehabilitation unit and at months 6 and 12. Results A total of 27 patients with ASIA-A complete spinal cord injury were included in the study. Fifteen patients completed the study. In 10 of 15 patients, zones that could not in the beginning be considered as ZPP according to the definition in ASIA 2000 Standards booklet turned out to be complete and/or partially recovered zones (sensory and/or motor—though not functional in most of the cases) in the follow-up period. Conclusions Lately recovered zones that terminologically cannot be considered as ZPP on initial examinations (according to ASIA standards) may be called as “zone of partial recovery” at some time after the injury. The term ZPP may be used during a limited time period to be clearly distinguished from zones that were not preserved but recovered neurologically. In other words: “When ‘zone of partial preservation’?” and “When ‘zone of partial recovery’?”

2007 SAE-P: Spinal Cord Injury Medicine

published by the AmericanSpinal Injury Association (ASIA)(a) shoulder abductors are 1 of the 5 key upper-extremitymuscle groups.(b) the zone of partial preservation is only pertinent incomplete spinal cord injury.(c) if half the key muscles below the neurologic level ofinjury have a muscle grade less than 3, the ASIAgrade is D.(d) the patient should be examined in a seated position.

Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials

The International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP) supported an international panel tasked with reviewing the methodology for clinical trials in spinal cord injury (SCI), and making recommendations on the conduct of future trials. This is the first of four papers. Here, we examine the spontaneous rate of recovery after SCI and resulting consequences for achieving statistically significant results in clinical trials. We have reanalysed data from the Sygen trial to provide some of this information. Almost all people living with SCI show some recovery of motor function below the initial spinal injury level. While the spontaneous recovery of motor function in patients with motor-complete SCI is fairly limited and predictable, recovery in incomplete SCI patients (American spinal injury Association impairment scale (AIS) C and AIS D) is both more substantial and highly variable. With motor complete lesions (AIS A/AIS B) the majority of functional return is within the zone of partial preservation, and may be sufficient to reclassify the injury level to a lower spinal level. The vast majority of recovery occurs in the first 3 months, but a small amount can persist for up to 18 months or longer. Some sensory recovery occurs after SCI, on roughly the same time course as motor recovery. Based on previous data of the magnitude of spontaneous recovery after SCI, as measured by changes in ASIA motor scores, power calculations suggest that the number of subjects required to achieve a significant result from a trial declines considerably as the start of the study is delayed after SCI. Trials of treatments that are most efficacious when given soon after injury will therefore, require larger patient numbers than trials of treatments that are effective at later time points. As AIS B patients show greater spontaneous recovery than AIS A patients, the number of AIS A patients requiring to be enrolled into a trial is lower. This factor will have to be balanced against the possibility that some treatments will be more effective in incomplete patients. Trials involving motor incomplete SCI patients, or trials where an accurate assessment of AIS grade cannot be made before the start of the trial, will require large subject numbers and/or better objective assessment methods.

Perceptual threshold to cutaneous electrical stimulation in patients with spinal cord injury

Prospective experimental. The aim of this study was to develop a quantitative sensory test (QST) that could be used for assessing the level and the density (degree of impairment) of spinal cord injury (SCI) and for monitoring neurological changes in patients with SCI. National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK. Perceptual threshold to 3 Hz cutaneous electrical stimulation was measured in 30 control subjects and in 45 patients with SCI at American Spinal Injuries Association (ASIA) sensory key points for selected dermatomes between C3 and S2 bilaterally. Electrical perceptual threshold (EPT) was recorded as the lowest ascending stimulus intensity out of three tests at which the subject reported sensation. The level of SCI according to EPT results was established for right and left sides as the most caudal spinal segment at which patient's EPT was within the control range (mean +/- 2 standard deviation (SD)). The level of SCI, according to EPT, was then compared with clinical sensory level derived according to ASIA classification. In the control group, EPT depended on the dermatome tested and was lowest for T1 (1.01 +/- 0.23 mA, mean +/- SD) and highest for L5 (3.32 +/- 1.14 mA). There was strong correlation between corresponding right and left dermatomes and between repeated assessments. In the SCI group, the level of lesion according to EPT and clinical testing was the same in 43 of the 90 tests (48%). In 37 cases (41%), the EPT level was higher than the clinical level, and in 10 cases (11%), it was lower. Below the level of lesion in incomplete SCI and in the zone of partial preservation in complete SCI, the EPT values in most dermatomes were raised compared with the control group. EPT is a simple, reproducible QST that can assess both the level and the density of SCI. It seems to add sensitivity and resolution to the standard clinical testing and could be a useful adjunct in longitudinal monitoring of patients with SCI for research purposes during natural recovery and therapeutic interventions. International Spinal Research Trust (ISRT), UK, Grant CLI001.

Thermal perception thresholds: assessing the level of human spinal cord injury

Controlled, cross-sectional, observational. To investigate whether quantitative sensory testing (QST) is able to reveal subclinical deficits at the neurological level of lesion in subjects with chronic spinal cord injury (SCI). National Spinal Injuries Centre, Stoke Mandeville Hospital and Imperial College London, UK. QST and clinical assessments were carried out on 18 subjects with complete SCI (American Spinal Injury Association (ASIA) grade A) and 10 subjects with incomplete SCI (ASIA grades B, C or D). A total of 10 healthy subjects acted as controls. At the level of lesion perceptual thresholds to monofilaments, cold pain and heat pain were similar to values in control subjects but cool and warm thresholds were significantly raised. A correlation between cool and warm thresholds was observed at the level of lesion in complete SCI and between heat and cold pain thresholds at the level of lesion in complete SCI, incomplete SCI and in control subjects. In the zone of partial preservation in complete SCI and below the level of lesion in incomplete SCI, thresholds for all modalities were all different compared to controls. QST reveals impaired thermal sensation in dermatomes clinically defined as normal with ASIA standards. Quantitative thermal testing therefore permits a discriminating assessment of preserved sensation and subclinical deficit and has the potential to improve upon the clinical detection of natural recovery or changes in level of injury following interventions designed to repair SCI.

Motor Recovery, Functional Status, and Health-Related Quality of Life in Patients With Complete Spinal Cord Injuries

A retrospective cohort with cross- sectional follow-up. The primary objective was to determine motor recovery in patients with complete traumatic spinal cord injury (SCI). Secondary objectives included: 1) determining which factors predict local recovery, 2) assessing functional status using the Functional Independence Measure (FIM), and 3) assessing generic health-related quality of life using the Short Form-36 (SF-36). Motor recovery following complete SCI has been documented in the literature; however, it has been difficult to interpret: 1) spinal shock is often not addressed; 2) the definition of complete SCI has changed over the last 10 years; and 3) few studies differentiate between local neurologic recovery in the zone of partial preservation and neurologic recovery caudal to the lesion. All patients admitted to Vancouver Hospital with a complete SCI between 1994 and 2001 were identified and included in the study if they remained complete following the resolution of spinal shock. Minimum 2-year follow-up consisted of an ASIA motor score, an FIM, and the SF-36. Of 133 patients identified, 94 were eligible and 70 completed follow-up. For the tetraplegic patients, the average ASIA motor score was 11.9 +/- 10.7 on admission and 20.1 +/- 10.8 at follow-up, a change reflecting local recovery only. For the paraplegic patients, the average ASIA motor score was 49.3 +/- 2.4 on admission and 50.6 +/- 1.7 at follow-up. Motor recovery does not occur below the zone of injury for patients with complete SCI. Varying degrees of local recovery can be expected in tetraplegic individuals.

Neuroprotective effects of basic fibroblast growth factor following spinal cord contusion injury in the rat.

Cytokines and neurotrophic factors have been implicated in the pathophysiology of injury to the central nervous system. While some cytokines are considered pro-inflammatory, other factors promote neuronal growth and survival. The present study investigated the neuroprotective effects of interleukins 1 (IL-1), 4 (IL-4), and 6 (IL-6), nerve growth factor (NGF), ciliary neurotrophic factor (CNTF), and basic fibroblast growth factor (bFGF) in a contusion model of spinal cord injury. Female Sprague-Dawley rats (n = 55) sustained a 10-g weight-drop injury to the lower thoracic spinal cord (T10) from a height of 12.5 mm using the NYU impactor. A micro-infusion system (Alzet minipump) was used to continuously deliver drugs or vehicle directly into the epicenter of the contused spinal cord starting 1 or three h postinjury. At the end of 7 days, animals were perfused and the cords removed for histopathological analysis. Longitudinal serial sections were cut on a freezing microtome and stained with cresyl violet. Areas of central necrosis, partial preservation, and total zone of tissue injury were identified and traced by an independent reviewer using a computer based imaging system. The mean total zone of injury in five animals receiving vehicle infusion was 18.04+/-4.20 mm3. The mean zone of partial preservation in these animals was 16.46+/-3.32 mm. Basic fibroblast growth factor reduced the total zone of injury by 33% [p<0.01, least significant difference (LSD) of Fisher] in five animals and the zone of partial preservation by 32% (p<0.01, LSD of Fisher) when compared to controls. There were trends toward reduction in total zone of injury and zone of partial preservation in rats treated with IL-4, CNTF, and NGF versus vehicle; however, none of these reached statistical significance. No significant differences were observed between animals receiving vehicle versus bFGF treatment commencing 3 h after injury. These data demonstrate that the continuous intramedullary infusion of bFGF initiated one hour after moderate contusion injury of the spinal cord significantly reduces the total zone of injury and the zone of partial preservation. These results support the further investigation and possible future clinical application of bFGF in the treatment of acute spinal cord contusion injury.

A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury.

This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent 'correct' (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.

Pin sensation as a predictor of extensor carpi radialis recovery in spinal cord injury.

The purpose of this prospective study was to determine if initial preservation of C5 pin sensation could predict extensor carpi radialis (ECR) motor recovery in the zone of partial preservation after spinal cord injury (SCI). The study compared initial C5 pin sensation and initial ECR strength as predictors of ECR motor recovery after C4 and C5 SCI. The initial motor and sensory evaluation was done less than seven days after injury. Motor power was graded from absent (0/5) to normal strength (5/5). Pin sensation was graded as absent (0/2) decreased (1/2) or normal (2/2). The manual muscle test was performed weekly to four weeks and than at three, six, and 12 months after injury. An ECR muscle grade of > or = 3/5 was defined as recovery. C5 pin sensation at the lateral antecubital fossa significantly correlated with ECR recovery to > or = 3/5 (p < 0.001). Only two of nine subjects with absent C5 pin sensation recovered ECR to > or = 3/5, whereas 14 of 15 subjects with 1/2 or 2/2 C5 pin sensation had ECR motor recovery to > or = 3/5. All ten subjects with 1/5 or 2/5 initial ECR strength had ECR motor recovery. Five of six subjects with 0/5 initial ECR strength and subsequent ECR recovery to > or = 3/5 were found to have C5 pin preservation. In conclusion the presence of 1/5 to 2/5 initial ECR strength or 1/2 or 2/2 C5 pin sensation were highly significant predictors of ECR motor recovery to > or = 3/5 in C4 and C5 motor complete quadriplegic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Course of motor recovery in the zone of partial preservation in spinal cord injury.

Thirty-nine C4 to C6 motor complete Frankel A or B spinal cord injured subjects were included in this prospective study to determine the course of recovery in the zone of partial preservation (ZPP) during the first 6 months postinjury. Subjects had initial manual muscle testing and neurologic examination between 3 and 7 days postinjury. Subjects whose most rostral key muscle in the ZPP had a motor power of grade 1 or 1+/5 (group 1, n = 22) were compared with subjects whose most rostral key muscle had a motor power of grade 2 or 2+/5 (group 2, n = 17). Subjects had manual muscle testing weekly for 1 month and then monthly for 6 months postinjury. Comparisons were made for recovery to: (1) grade 3/5; (2) grade 4/5; (3) an increase of one grade; and (4) an increase of two grades. Analyses were made at monthly intervals by the Fisher Exact test and between median times of recovery by the Kruskal-Wallis Ranking test. There was earlier recovery to grade 3/5 for group 2. At one month 11 of 17 (65%) group 2 subjects had reached grade 3/5 compared with 4 of 22 (18%) group 1 subjects (p less than 0.01). At 2 months postinjury, 14 of 17 (82%) group 2 subjects versus 10 of 22 (45%) group 1 subjects had reached grade 3/5 strength (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of zero-grade muscles in the zone of partial preservation in motor complete quadriplegia.

This prospective study was designed to demonstrate root level recovery in the zone of preservation by examining muscles with an initial strength of grade 0/5 in 32 motor complete (Frankel A and B) patients who had cervical spinal cord injury at the C4 through C7 levels. The biceps (C5), extensor carpi radialis (C6), triceps (C7), and flexor digitorum profundus (C8) muscles were used as key muscles when their strength at the initial manual muscle test, which was performed between three and seven days postinjury, was grade 0/5 and the muscle innervated by the cord segment directly rostral to that innervating the key muscle (grade 0/5) was grade greater than or equal to 3/5. If the biceps muscle was used, C4 pin sensation was required to be normal. Further manual muscle tests were performed weekly for four weeks, and then at 2, 3, 6, and 12 months postinjury. None, 6%, 17%, 35%, and 43% of the patients recovered to grade greater than or equal to 3/5 by 1, 2, 3, 6, and 12 months postinjury, respectively. It was also noted that in 86% of our patients, improving to grade greater than or equal to 1/5 by one month postinjury was a predictor of recovering to grade greater than or equal to 3/5 by 12 months postinjury (p less than .002). Similarly, in 100% of our patients, improving to grade greater than or equal to 2/5 by three months postinjury was a predictor of recovering to grade greater than or equal to 3/5 by 12 months postinjury (p less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)