Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries

Zariffa J, Curt A, for the EMSCI Study Group, Steeves JD. Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries.ObjectiveTo assess how frequently subjects with spinal cord injuries (SCIs) classified as American Spinal Injury Association Impairment Scale (AIS) grade A have substantial preserved motor function below the neurologic level of injury, despite having no preserved sensory or motor function at the S4-5 spinal cord segment.DesignAnalysis of the European Multicenter Study about Spinal Cord Injury database to determine how frequently subjects assessed as AIS A would have been AIS D based on motor scores alone (ie, had scores of ≥3 in at least half of the International Standards for Neurological Classification of Spinal Cord Injury [ISNCSCI] key muscles below the neurologic level of injury, despite having no sacral sparing).SettingEighteen European centers.ParticipantsIndividuals with traumatic SCI at any level (total of 2557 assessments).InterventionsNot applicable.Main Outcome MeasureISNCSCI assessments.ResultsOver the first year after SCI (with assessments at approximately 1, 4, 12, 24, and 48wk) and for all rostrocaudal levels of injury, only 3.2% of AIS A assessments were found to meet the AIS D motor score criteria. The percentage was highest for lumbar (16.3%) and lower thoracic (4.4%) SCI. No trends were observed across time points.ConclusionsThese results suggest that the low frequency of individuals with an AIS A classification and high levels of motor function are not a significant concern in subject recruitment for clinical trials, unless the level of SCI is within the lumbar cord.     

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.     

Late neurologic recovery after traumatic spinal cord injury

OBJECTIVE: To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI). DESIGN: Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury. SETTING: MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database. PARTICIPANTS: People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time. RESULTS: The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS. CONCLUSIONS: There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.     

Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia

ObjectiveTo determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.DesignRetrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SettingSCIMS centers.ParticipantsIndividuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.InterventionsNot applicable.Main Outcome MeasuresConversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.ResultsMean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.ConclusionsWhile UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.     

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

OBJECTIVE: To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24 h and 24-72 h) and late (>72 h) surgical spine intervention versus those treated nonsurgically. DESIGN: Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up. SETTING: Multicenter National Spinal Cord Injury Database. PARTICIPANTS: Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable. MAIN OUTCOME MEASURES: Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores). RESULTS: Subjects in the early surgery group were more likely ( P <.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P <.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P <.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P <.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency. CONCLUSIONS: ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.     

The impact of sacral sensory sparing in motor complete spinal cord injury

Kirshblum S, Botticello A, Lammertse DP, Marino RJ, Chiodo AE, Jha A. The impact of sacral sensory sparing in motor complete spinal cord injury.

Objective

To determine the effect of sensory sparing in motor complete persons with spinal cord injury (SCI) on completion of rehabilitation on neurologic, functional, and social outcomes reported at 1 year.

Design

Secondary analysis of longitudinal data collected by using prospective survey-based methods.

Setting

Data submitted to the National SCI Statistical Center Database.

Participants

Of persons (N=4106) enrolled in the model system with a motor complete injury (American Spinal Injury Association Impairment Scale [AIS] grade A or B) at the time of discharge between 1997 and 2007, a total of 2331 (56.8%) completed a 1-year follow-up interview (Form II) and 1284 (31.3%) had complete data for neurologic (eg, AIS grade, injury level) variables at 1 year.

Interventions

Not applicable.

Main Outcome Measures

AIS grade (A vs B) at 1 year, bladder management, hospitalizations, perceived health status, motor FIM items, Satisfaction With Life Scale, depressive symptoms, and social participation.

Results

Compared with persons with AIS grade A at discharge, persons with AIS grade B were less likely to require indwelling catheterization and be hospitalized and more likely to perceive better health, report greater functional independence (ie, self-care, sphincter control, mobility, locomotion), and report social participation in the first year postinjury. A greater portion of individuals with AIS grade B at discharge had improved neurologic recovery at 1 year postinjury than those with AIS grade A. Significant AIS group differences in 1-year outcomes related to physical health were maintained after excluding persons who improved to motor incomplete status for only bladder management and change in perceived health status. This recognition of differences between persons with motor complete injuries (AIS grade A vs B) has important ramifications for the field of SCI rehabilitation and research.     

Activity-Based Therapy for Recovery of Walking in Chronic Spinal Cord Injury: Results From a Secondary Analysis to Determine Responsiveness to Therapy

ObjectiveTo gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial.DesignSecondary analysis of results from a randomized controlled trial with delayed treatment design.SettingOutpatient program in a private, nonprofit rehabilitation hospital.ParticipantsVolunteer sample of adults (N=38; 27 men; 11 women; age, 22–63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI).InterventionsA total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.Main Outcome MeasuresWalking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test).ResultsThis secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program.ConclusionsABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.     

Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury

OBJECTIVE: To investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI). DESIGN: Retrospective study. SETTING: Comprehensive rehabilitation hospital. PARTICIPANTS: A total of 343 adult inpatients with traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM instrument walking rating of 3 (moderate assistance) or higher at discharge. RESULTS: Significantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. CONCLUSIONS: Admission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score > or = 3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.     

康复训练对脊髓损伤患者生活自理能力的影响

目的探讨脊髓损伤患者经过康复训练后生活自理能力与发病初期脊髓损伤程度之间的关系。方法回顾性分析30例脊髓损伤的患者,按照美国脊髓损伤学会脊髓损伤程度的分级(ASIA)进行分类,对他们进行相同的PT、OT、神经肌肉电刺激、针灸、按摩治疗,按照日常生活能力量表(见附表1)观察治疗前后日常生活能力的改善。对收集的资料进行相关性分析。结果相关性分析表明,ADL改善程度和ASIA级别密切相关(r=0.229),经过康复训练后,生活自理能力均有提高。而分级指数越高,生活自理能力改善的程度越明显。结论脊髓损伤患者进行ASIA分级是必要的,可以预测未来生活自理能力。而提高生活自理能力的关键是进行康复训练。     

Cut point determination in the measurement of pain and its relationship to psychosocial and functional measures after traumatic spinal cord injury: a retrospective model spinal cord injury system analysis

Forchheimer MB, Richards JS, Chiodo AE, Bryce TN, Dyson-Hudson TA. Cut point determination in the measurement of pain and its relationship to psychosocial and functional measures after traumatic spinal cord injury: a retrospective Model Spinal Cord Injury System analysis.

Objective

To evaluate potential pain cutoff scores reflecting mild, moderate, and severe pain in the spinal cord injury (SCI) population and determine the relationship between the derived cutoff scores and both psychosocial and functional outcome measures.

Design

Retrospective analysis.

Setting

SCI Model Systems.

Participants

Persons (N=6096; age >18y) with traumatic SCI (American Spinal Injury Association Impairment Scale [AIS] grades A–D; injured in 1973–2008).

Interventions

Not applicable.

Main Outcome Measures

Numeric rating scale (NRS) of pain severity (11 points), NRS of pain interference (5 points), Satisfaction With Life Scale, Patient Health Questionnaire-9, Craig Handicap Assessment and Reporting Technique Short-Form (CHART-SF), motor component of the FIM (M-FIM), and employment.

Results

The best set of pain severity cutoff points are 1 to 3, 4 to 6, and 7 to 10. This was validated by randomly assigning sample members to 2 groups and replicating. There were significant differences in all outcomes as a function of pain severity grouping, although they explained little of the variance in M-FIM and CHART-SF Physical Independence scale scores. Neurologic status differed significantly between pain groups, with incongruence between pain severity and interference in people in the AIS grade D group, who reported the greatest pain interference and least pain severity.

Conclusion

Pain severity can be categorized into groups that reflect pain interference. These groupings differentiate psychosocial well-being better than activity limitations. They do not provide a comprehensive pain assessment, for which pain type, location, and interference are likely to be necessary.     

Relationship Between ASIA Examination and Functional Outcomes in the NeuroRecovery Network Locomotor Training Program

Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program.ObjectiveTo determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI).DesignProspective observational cohort.SettingOutpatient rehabilitation centers in the NeuroRecovery Network (NRN).ParticipantsIndividuals (n=225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN.InterventionThe NRN Locomotor Training Program consists of manual-facilitated body weight–supported standing and stepping on a treadmill and overground.Main Outcome MeasuresAIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale.ResultsSignificant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.ConclusionsLocomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.     

Recovery of Sensory and Supraspinal Control of Leg Movement in People With Chronic Paraplegia: A Case Series

Objective

To report on unexpected findings in 4 patients with chronic paraplegia who underwent the laparoscopic implantation of neuroprosthesis procedure in the pelvic lumbosacral nerves.

Design

Observational case series.

Setting

Tertiary referral unit specialized in advanced gynecological surgery and neuropelveology.

Participants

Three patients with incomplete American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade B (n=2) and AIS grade C (n=1) spinal cord injury (SCI) and 1 patient with flaccid complete chronic SCI (AIS grade A) (n=1).

Intervention

Functional electrical stimulation (FES)-assisted locomotor training and continuous low-frequency pelvic-lumbosacral neuromodulation.

Main Outcome Measures

Change in ASIA Lower Extremity Motor Scores, ASIA sensory scores for light touch and pinprick sensation, and Walking Index for Spinal Cord Injury scores.

Results

All 4 patients developed progressive recovery of some sensory and voluntary motor functions below the lesions. Three are currently capable of voluntary weight-bearing standing and walking a few meters with a walker without FES. The first patient with the longest follow-up is even capable of electrically assisted standing/walking with 2 crutches without braces or assistance for a distance of about 900 meters, and of weight-bearing standing and walking for 30 meters with a walker without stimulation.

Conclusions

We report unexpected sensory and locomotor recovery in 4 people with paraplegia with SCI. Our findings suggest that FES-assisted locomotor training with continuous low-frequency pelvic nerve stimulation in patients with SCI may induce changes that affect the central pattern generator and allow supra- and infraspinal inputs to engage residual spinal pathways.     

Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury

Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.ObjectiveTo develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures.DesignProspective observational cohort with longitudinal follow-up.SettingSeven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).ParticipantsIndividuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.InterventionsIntensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.Main Outcome MeasuresBerg Balance Scale, six-minute walk test, and ten-meter walk test.ResultsIndividuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.ConclusionsAssessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.     

Cardiovascular Status of Individuals With Incomplete Spinal Cord Injury From 7 NeuroRecovery Network Rehabilitation Centers

Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers.ObjectiveTo examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score.DesignCross-sectional study.SettingSeven outpatient rehabilitation clinics.ParticipantsIndividuals (N=350) with incomplete AIS classification C and D were included in this analysis.InterventionsNot applicable.Main Outcome MeasuresHeart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge.ResultsCV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence.ConclusionsResting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.     

Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database

Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database.

Objective

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

Design

Longitudinal cohort; follow-up to 1 year.

Setting

U.S. SCIMS.

Participants

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

Interventions

Not applicable.

Main Outcome Measures

Change in AIS, UEMS, LEMS, and motor levels.

Results

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2–3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2–7.8; P<.001).

Conclusions

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.     

Spinal Epidural Abscess: A 5-Year Case-Controlled Review of Neurologic Outcomes After Rehabilitation

Koo DW, Townson AF, Dvorak MF, Fisher CG. Spinal epidural abscess: a 5-year case-controlled review of neurologic outcomes after rehabilitation.

Objective

To describe the neurologic outcomes of 29 spinal epidural abscess (SEA) patients after rehabilitation compared with a case-controlled traumatic spinal cord injury (TSCI) cohort.

Design

Five-year retrospective chart review.

Setting

University-affiliated surgical spine unit and inpatient rehabilitation program.

Participants

Patients (n=29; 19 men, 10 women) requiring inpatient rehabilitation after SEA and TSCI case controls (n=29) matched by level of injury, American Spinal Injury Association (ASIA) Impairment Scale (AIS), ASIA motor score (AMS), sex, and age.

Main Outcome Measure

The primary outcome was a change in AMS from acute admission to discharge from inpatient rehabilitation.

Results

Despite having lower admission motor scores, there was a significant trend toward greater neurologic recovery in the SEA group (P=.047). In contrast to what is known regarding recovery from complete TSCI, this study shows potential for dramatic recovery in SEA subjects presenting with AIS grade A deficit with a 73% conversion rate to incomplete status; out of 11 SEA subjects with initial AIS grade A, 2 improved to AIS grade B, 1 to AIS grade C, and 5 to AIS grade D.

Conclusions

This study shows the potential for a significant improvement in neurologic deficits related to SEA. Based on the results of our study, it is clearly inappropriate to generalize recovery patterns seen in the TSCI patient population to SEA-associated myelopathy because the latter appears to have more favorable outcomes.     

Gender-related differences in acute rehabilitation lengths of stay, charges, and functional outcomes for a matched sample with spinal cord injury: a multicenter investigation

OBJECTIVE: To examine the effects of gender on length of stay (LOS), treatment costs, and outcomes by using a matched sample of patients with spinal cord injury (SCI). DESIGN: A 2 x (15 x 3) mixed, block design was used retrospectively to analyze the impact of gender on subjects matched for age, American Spinal Injury Association (ASIA) motor impairment classification, and level of neurologic injury. SETTING: Twenty medical centers in the federally sponsored Spinal Cord Injury Model Systems project. PARTICIPANTS: One thousand seventy-four adult patients with SCI admitted between 1988 and 1998 were assessed at acute-care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA motor index and FIM instrument admission, discharge, and efficiency scores; rehabilitation LOS and medical care charges; and discharge disposition. RESULTS: Analysis revealed no gender-related differences in FIM motor scores on admission and discharge. No differences in FIM motor efficiencies or daily change were observed. No significant differences were found for ASIA motor scores on acute-care admission and rehabilitation discharge. No differences in acute rehabilitation LOS and charges were observed. No gender-related differences were seen in the likelihood of discharge to an institutional setting. CONCLUSION: Gender was not a significant factor in functional outcome of SCI patients after acute rehabilitation.     

Nontraumatic spinal cord injury: an Italian survey

OBJECTIVE: To describe the demographic and clinical characteristics and the clinical course of patients with nontraumatic spinal cord injury (SCI). DESIGN: A multicenter prospective study. SETTING: Thirty-two rehabilitation centers in several Italian regions. PARTICIPANTS: Patients with nontraumatic SCI (N=330) on first admission (February 1, 1997-January 31, 1999) to rehabilitation centers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Indicators of rehabilitation process quality were efficient bladder and bowel management. The indica-tor of neurologic recovery was improvement in American Spinal Injury Association Impairment Scale (AIS) level at discharge. The indicator of rehabilitation outcome was return home. Length of stay (LOS) was also measured as an indicator of the care process. RESULTS: Of the 330 patients, 30% exhibited an improvement in AIS classification at discharge, and 73% returned home. In multivariate analysis, a longer LOS was associated with vascular etiology, complete lesions, residence outside the district of the rehabilitation center, and presence of clinical complications. Neurologic improvement was related to incompleteness of the lesion and longer LOS. Factors predicting a return home were married status, incompleteness of lesion, clinical improvement, efficient bowel and bladder management, absence of pressure ulcers, and longer LOS. CONCLUSIONS: Patients showed long waiting times between diagnosis and initiation of rehabilitation, a good chance of improvement on the AIS, and low rates of home returns.     

Neurologic recovery of spinal cord injury patients in Italy

OBJECTIVE: To evaluate neurologic recovery of spinal cord lesion patients and its relationship to some lesion and patient features. DESIGN: Retrospective review of the charts. SETTING: Rehabilitation hospital in Italy. PARTICIPANTS: A total of 284 consecutive, newly injured patients were included with evaluation of lesion to admission time, etiology, lesion level, associated injury, medical complications and surgical intervention, length of stay, and American Spinal Injury Association (ASIA) impairment grade and motor scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA impairment grade and motor scores. RESULTS: Neurologic recovery was present in 27% of the patients. Most patients who improved and reached a functional status (ASIA class D) had an ASIA class C impairment at admission (71/129), versus ASIA class A (2/84) and ASIA class B (5/19). The lesion-to-admission interval was significantly longer in patients who did not improve (73+/-51.2d vs 47.2+/-38.4d, P=.006). CONCLUSIONS: ASIA impairment designations have prognostic value. Recovery from complete lesions was limited. Patients with ASIA class B impairment at admission had a better prognosis than those with ASIA class A. Patients with ASIA class C at admission had the best neurologic improvement. Finally, ASIA class D patients had lower ASIA grade improvement. Neurologic recovery was negatively associated with patients' age and delayed rehabilitation, but not by other lesion features.     

A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample.

OBJECTIVE: To examine the effects of age at injury on lengths of stay, treatment costs, and outcomes using a matched sample of tetraplegic spinal cord injury (SCI) patients. DESIGN: Differences were examined by separating the sample into three age categories (18 to 34, 35 to 64, and 65+ years old) matched for American Spinal Injury Association (ASIA) Motor Impairment Classification and level of neurologic preservation bilaterally. Analysis of variance was used to examine age group differences for lengths of stay, medical expenses, and functional outcome. SETTING: Sixteen medical centers in the federally sponsored Spinal Cord Injury Model Systems Project. PARTICIPANTS: Three hundred seventy-five adult patients with tetraplegic SCI admitted between 1988 and 1996 were assessed at acute care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. MAIN OUTCOME MEASURES: ASIA Motor Index and Functional Independence Measure (FIM) admission, discharge, and efficiency scores; acute care and rehabilitation lengths of stay and medical care charges; and discharge disposition. RESULTS: Analyses revealed equivalent lengths of stay and charges for all age groups. There were no age-related differences in ASIA and FIM Motor scores at acute care and inpatient rehabilitation admission. Younger patients' scores on the FIM Motor subscale improved significantly more than did middle and older patients'. The two younger groups of patients had a more significant improvement than did older patients, as indicated by ASIA Motor Index scores. When taking lengths of stay into account, the FIM motor scores of the youngest group of patients improved more quickly than those of the two older groups. Furthermore, the younger and middle age groups demonstrated greater treatment efficiency than the older patient group based on ASIA Motor Index score ratios. Younger patients were least likely to be discharged to institutional settings. CONCLUSIONS: Along with neurologic and functional status, age should be considered when formulating treatment plans and prognostic statements. For older patients, alternative rehabilitation settings with lower-intensity treatment and lower charges may prove to be a more efficacious use of resources.