M.H. Pouw

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

BACKGROUND Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to counsel patients and to plan rehabilitation. We developed a reliable, validated prediction rule to assess a patients chances of walking independently after such injury. METHODS We undertook a longitudinal cohort study of adult patients with traumatic spinal cord injury, with early (within the first 15 days after injury) and late (1-year follow-up) clinical examinations, who were admitted to one of 19 European centres between July, 2001, and June, 2008. A clinical prediction rule based on age and neurological variables was derived from the international standards for neurological classification of spinal cord injury with a multivariate logistic regression model. Primary outcome measure 1 year after injury was independent indoor walking based on the Spinal Cord Independence Measure. Model performances were quantified with respect to discrimination (area under receiver-operating-characteristics curve [AUC]). Temporal validation was done in a second group of patients from July, 2008, to December, 2009. FINDINGS Of 1442 patients with spinal cord injury, 492 had available outcome measures. A combination of age (<65 vs ≥65 years), motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1 showed excellent discrimination in distinguishing independent walkers from dependent walkers and non-walkers (AUC 0·956, 95% CI 0·936-0·976, p<0·0001). Temporal validation in 99 patients confirmed excellent discriminating ability of the prediction rule (AUC 0·967, 0·939-0·995, p<0·0001). INTERPRETATION Our prediction rule, including age and four neurological tests, can give an early prognosis of an individuals ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might improve the ability to stratify patients in interventional trials. FUNDING Internationale Stiftung für Forschung in Paraplegie.

Is determination between complete and incomplete traumatic spinal cord injury clinically relevant? Validation of the ASIA sacral sparing criteria in a prospective cohort of 432 patients.

Study design:Prospective multicenter longitudinal cohort study.Objective:To validate the prognostic value of the acute phase sacral sparing measurements with regard to chronic phase-independent ambulation in patients with traumatic spinal cord injury (SCI).Setting:European Multicenter Study of Human Spinal Cord Injury (EM-SCI).Methods:In 432 patients, acute phase (0–15 days) American Spinal Injury Association (ASIA)/International Spinal Cord Society neurological standard scale (AIS) grades, ASIA sacral sparing measurements, which are S4–5 light touch (LT), S4–5 pin prick (PP), anal sensation and voluntary anal contraction; and chronic phase (6 or 12 months) indoor mobility Spinal Cord Independence Measure (SCIM) measurements were analyzed. Calculations of positive and negative predictive values (PPV/NPV) as well as univariate and multivariate logistic regressions were performed in all four sacral sparing criteria. The area under the receiver-operating characteristic curve (AUC) ratios of all regression equations was calculated.Results:To achieve independent ambulation 1-year post injury, a normal S4–5 PP score showed the best PPV (96.5%, P<0.001, 95% confidence interval (95% CI): 87.9–99.6). Best NPV was reported in the S4–5 LT score (91.7%, P<0.001, 95% CI: 81.6–97.2). The use of the combination of only voluntary anal contraction and the S4–5 LT and PP sensory scores (AUC: 0.906, P<0.001, 95% CI: 0.871–0.941) showed significantly better (P<0.001, 95% CI: 0.038–0.128) discriminating results in prognosticating 1-year independent ambulation than with the use of currently used distinction between complete and incomplete SCI (AUC: 0.823, P<0.001, 95% CI: 0.781–0.864).Conclusions:Out of the four sacral sparing criteria, the acute phase anal sensory score measurements do not contribute significantly to the prognosis of independent ambulation. The combination of the acute phase voluntary anal contraction and the S4–5 LT and PP scores, predicts significantly better chronic phase-independent ambulation outcomes than the currently used distinction between complete and incomplete SCI.Sponsorship:This study was granted by ‘Acute Zorgregio Oost’ and the ‘Internationale Stiftung für Forschung in Paraplegie (IFP)’.

Structural biomarkers in the cerebrospinal fluid within 24 h after a traumatic spinal cord injury: a descriptive analysis of 16 subjects

Study design:Prospective cohort study.Objectives:To characterize the cerebrospinal fluid (CSF) concentrations of glial fibrillary acidic protein, neuron specific enolase (NSE), S-100β, tau and neurofilament heavy chain (NFH) within 24 h of an acute traumatic spinal cord injury (SCI), and to correlate these concentrations with the baseline severity of neurologic impairment as graded by the American Spinal Injury Association impairment scale (AIS).Methods:A lumbar puncture was performed to obtain CSF from 16 acute traumatic SCI patients within 24 h post injury. Neurological examinations were performed within 24 h of injury and again at 6 or 12 months post injury. The correlations between the CSF concentrations and initial AIS were calculated by using Pearson correlation coefficients. In addition, an independent Student’s t-test was used to test for differences in CSF concentrations between patients of different AIS grades.Results:The CSF NSE concentrations were significantly correlated with the baseline neurologic impairment being either ‘motor complete’ (AIS A, B) or ‘motor incomplete’ (AIS C, D) (r=0.520, P<0.05). The mean S-100β concentration in motor complete patients was significantly higher compared with motor incomplete patients; 377.2 μg l−1 (s.d.±523 μg l−1) vs 57.1 μg l−1 (s.d.±56 μg l−1) (P<0.05), respectively. Lastly, the mean NFH concentration in motor complete patients was significantly higher compared with motor incomplete patient, 11 813 ng l−1 (s.d.±16 195 ng l−1) vs 1446.8 ng l−1 (s.d.±1533 ng l−1), (P<0.05), respectively.Conclusion:In this study we identified differences in the structural CSF biomarkers NSE, S-100β and NFH between motor complete and motor incomplete SCI patients. Our data showed no clear differences in any of the protein concentrations between the different AIS grades.

Diagnostic criteria of traumatic central cord syndrome. Part 1: a systematic review of clinical descriptors and scores.

Study design:Systematic review.Background:The applied definition of traumatic central cord syndrome (TCCS) lacks specific quantified diagnostic criteria.Objective:To review currently applied TCCS diagnostic criteria and quantitative data regarding the ‘disproportionate weakness’ between the upper and lower extremities described in original studies reporting on TCCS subjects.Methods:A MEDLINE (1966 to 2008) literature search was conducted. The descriptors applied to define TCCS were extracted from all included articles. We included original studies that reported on the differences in motor score (based on the Medical Research Council scale) between the total upper extremity motor score (UEMS) and the total lower extremity motor score (LEMS), in a minimum of five TCCS patients at the time of hospital admission. The mean difference between the total UEMS and the total LEMS of the patients included in each study was calculated. Case reports were excluded.Results:None of the identified studies on TCCS patients reported inclusion and/or exclusion criteria using a quantified difference between the UEMS and LEMS. Out of 30 retrieved studies, we identified seven different clinical descriptors that have been applied as TCCS diagnostic criteria. Nine studies reporting on a total of 312 TCCS patients were eligible for analysis. The mean total UEMS was 10.5 motor points lower than the mean total LEMS.Conclusions:There is no consensus on the diagnostic criteria for TCCS. Nevertheless, this review revealed an average of 10 motor points between the UEMS and LEMS as a possible TCCS diagnostic criterion. However, further discussion by an expert panel will be required to establish definitive diagnostic criteria.

How does knowledge about spinal cord injury-related complications develop in subjects with spinal cord injury? A descriptive analysis in 214 patients.

Study design:Monocentric cohort study.Objective:To investigate the acquisition of knowledge about spinal cord injury (SCI)-related complications in SCI patients.Setting:Level 1 trauma center.Methods:All patients with a traumatic or non-traumatic SCI were included in the study. Data were collected at admission, post-admission at 1 and 3 months and post-discharge at 6, 18 and 30 months. The discharge of all patients was between 3 and 6 months post-admission. Knowledge about pressure ulcers and bladder management was tested using the ‘Knowledge’ score. This score has a minimum and maximum of 0 and 20 points. To detect differences across the multiple time intervals, the Friedman test was used. Differences in the number of patients with poor (0–8), average (9–12) and good knowledge (13–20) between the different age classifications (age at injury) were calculated using a χ 2-test.Results:A total of 214 patients were included. At discharge subjects had increased their knowledge score to 11.2 compared with 5.4 on admission (P<0.001). After 30 months, however, the mean score decreased to 10.8 points. At the time of discharge, the number of patients who achieved poor, average or good knowledge were 48 (22.4%), 65 (30.4%) and 101 (47.2%), respectively. Subjects of ∼50 years old and tetraplegics had better (P<0.001) knowledge compared with subjects of ∼50 years old and paraplegics, respectively.Conclusion:In this study, less than 50% of SCI patients had good knowledge about bladder management and pressure ulcers after being discharged.

Is the outcome in acute spinal cord ischaemia different from that in traumatic spinal cord injury? A cross-sectional analysis of the neurological and functional outcome in a cohort of 93 paraplegics

Study design:Retrospective cohort study.Objectives:To compare the neurological outcome between paraplegic patients with acute spinal cord ischaemia syndrome (ASCIS) or traumatic spinal cord injury (tSCI) and to investigate the influence of SCI aetiology on the total Spinal Cord Independence Measure (SCIM)-II score.Setting:Level 1 trauma centre.Methods:Initial (0–40 days) and chronic-phase (6–12 months) American Spinal Injury Association (ASIA) sensory scores, lower extremity motor score (LEMS) and chronic-phase total SCIM-II scores were analysed. Differences between ASCIS and tSCI patients were calculated using Students t-tests and Wilcoxon signed-rank tests. To assess which variables give rise to the prediction of total SCIM-II score, a multiple linear regression analysis was used. These predictor variables included complete (ASIA impairment scale A) or incomplete SCI (AIS B, C, and D), aetiology, age and gender.Results:Out of 93 included patients, 20 ASCIS and 73 tSCI patients were identified. In the complete SCI group, the initial pinprick scores were higher (P<0.05) in ASCIS patients compared with tSCI patients, 37.9 (95% Confidence Interval (CI), 23.3–52.5) and 27.3 (95% CI, 24.1–30.4), respectively. No other relevant differences in neurological outcome were identified between ASCIS and tSCI patients; however, the total SCIM-II scores were higher (P<0.05) in tSCI patients after 12 months. Using the linear regression analysis, we were able to predict 31.4% of the variability. The aetiology was not significant in this model.Conclusion:The neurological outcome was independent of the diagnosis ASCIS or tSCI. Furthermore, the diagnosis ASCIS or tSCI was not a significant predictor for total SCIM II scores after 12 months.Sponsorship:This study was granted by the ’Internationale Stiftung für Forschung in Paraplegie‘ (IFP), Zürich, Switzerland.

Malignant cord compression: A critical appraisal of prognostic factors predicting functional outcome after surgical treatment

Objectives: Advanced tumor disease and metastatic spinal cord compression (MSCC) are two entities with a high impact on patients’ quality of life. However, prognostic factors on the outcome after primary decompressive surgery are less well-defined and not yet standardized. The aim of this review was to identify prognostic variables that predict functional or ambulatory outcomes in surgically treated patients with symptomatic MSCC. Materials and Methods: We conducted MEDLINE database searches using relevant keywords in order to identify abstracts referring to prognostic factors on ambulatory outcomes in surgically treated MSCC patients. Details of all selected articles were assembled and the rates of ambulation were stratified. Results: Evidence from five retrospective comparative trials and one observational prospective study summarizes different prognostic factors with a positive or negative influence on postoperative ambulatory status. Ambulatory patients maintaining ambulation status after decompression of the spinal cord constituted 62.1%. The overall rate of MSCC patients losing the ability to ambulate was 7.5% compared to 23.5 % who regained ambulation. Preoperative ambulation status, time to surgery, compression fracture and individual health status seem to be the most relevant prognostic factors for ambulatory outcome. Conclusions: There is a lack of standardized prognostic tools which allow predicting outcome in surgically treated patients. A quantitative score consisting of reliable prognostic tools is essential to predict loss and/or regain of ambulation and requires validation in future prospective clinical trials.

Relevance of the diagnosis traumatic cervical Brown-Sequard-plus syndrome: an analysis based on the neurological and functional recovery in a prospective cohort of 148 patients.

Study design:Prospective multi-center cohort study.Objectives:To compare the neurological and functional recovery between tetraplegic Brown-Séquard-plus syndrome (BSPS) and incomplete tetraplegia (non-BSPS).Setting:European Multicenter Study of Human Spinal Cord Injury (EM-SCI).Methods:BSPS was defined as a traumatic incomplete spinal cord injury (SCI) with ipsilateral weakness and contralateral loss of pinprick sensation at neurologic levels C2–T1. Acute (0–15 days) and chronic phase (6 or 12 months) were assessed for the American Spinal Injury Association (ASIA) sensory scores, upper extremity motor scores and lower extremity motor scores. Furthermore, chronic phase scores of all Spinal Cord Independence Measure (SCIM) II items were analyzed. Differences in neurological and functional outcome between BSPS patients and non-BSPS patients were calculated using Students t-tests and Wilcoxon signed rank tests.Results:Out of 148 tetraplegic patients, 30 were diagnosed with BSPS. Patients with an ASIA impairment scale (AIS) B were significantly (P<0.001) more identified in non-BSPS patients (25%) compared with BSPS patients (3%), respectively. After 12 months, the median scores for sphincter management of the bladder for both BSPS and non-BSPS patients were 15. Both 25 and 75% quartile median scores were 15 for BSPS patients and 12 and 15 for non-BSPS patients (P<0.02). Except for the difference in bladder function, no significant differences were identified in other SCIM II subitems and ASIA motor or sensory scores between BSPS and non-BSPS patients when stratified for injury severity by excluding AIS B patients.Conclusion:Compared with incomplete tetraplegic patients, patients with cervical BSPS have a similar neurological and functional recovery when matched for the AIS.

Diagnostic criteria of traumatic central cord syndrome. Part 3: Descriptive analyses of neurological and functional outcomes in a prospective cohort of traumatic motor incomplete tetraplegics

Study design:Prospective multicenter cohort study.Objectives:To compare the neurological recovery and functional outcomes between traumatic central cord syndrome (TCCS) patients and motor incomplete tetraplegic patients.Setting:European Multicenter Study of human spinal cord injury.Methods:In 248 traumatic motor incomplete tetraplegics, initial phase (0–15 days) American Spinal Injury Association (ASIA) impairment grading, upper and lower extremity motor scores (UEMS and LEMS), upper and lower sensory scores and chronic phase (6 or 12 months) neurological outcomes were analyzed. In addition, chronic phase self-care and indoor mobility Spinal Cord Independence Measure (SCIM) items were studied. Tetraplegics were subdivided into three groups: (1) non-TCCS group (UEMS⩾LEMS), (2) intermediate-TCCS group (UEMS=(1–9 points)<LEMS) and (3) TCCS group (UEMS=(⩾10 points)<LEMS). Students t-tests and χ2-tests were applied.Results:A total of 89 non-TCCS subjects (AIS D, n=28), 62 int-TCCS (AIS D, n=43) and 97 TCCS (AIS D, n=80) subjects were analysed. Although minimal significant differences in chronic phase LEMS and UEMS outcomes were identified between TCCS and non-TCCS patients after stratification by the AIS grade, our data showed no significant differences in functional upper and lower extremity outcomes at 6 or 12 months post-injury.Conclusion:The AIS grading system, and not the diagnosis TCCS, continues to be the best available prognostic parameter for neurological and functional outcomes in motor incomplete tetraplegics. The authors recommend that for future outcome studies in motor incomplete tetraplegia, patients should not be selected based on, or stratified by, the diagnosis TCCS.

Diffusion-weighted MR imaging within 24 h post-injury after traumatic spinal cord injury: a qualitative meta-analysis between T2-weighted imaging and diffusion-weighted MR imaging in 18 patients

Study design:Only few studies have been published about diffusion-weighted imaging (DWI) within 24 h of traumatic spinal cord injury (tSCI).Objectives:The purpose of this study was to compare the imaging findings from conventional magnetic resonance imaging (MRI) and DWI in seven tSCI patients with findings in the existing literature.Methods:Seven patients with tSCI at neurologic levels C2–T10 were examined with conventional MRI and DWI within 24 h post-injury. DWI was obtained with a b-factor of 1000 s mm–2. American Spinal Injury Association (ASIA) scores and Spinal Cord Independence Measurement (SCIM) II item 12 after 12 months were collected. In addition, MEDLINE was searched from 1995 to 2010 to identify clinical tSCI studies reporting on MRI, DWI and apparent diffusion coefficient maps within 24 h post-injury to perform a meta-analysis. Images obtained with a b-factor of 1000 s mm–2 were compared with lower b-factors. Differences were calculated using χ 2 tests.Results:No associations were identified between the images of the seven tSCI patients and ASIA or SCIM II scores. Eighteen SCI patients (11 from the retrieved publications) were included in the meta-analysis. The detection rates of hyperintense signals on T2-weighted and DW imaging did not show significant differences at 94 and 72%, respectively. In addition, there were no significant differences in detection rates or diffusion abnormalities between subjects in whom DW images were obtained with a maximum b-factor of 1000 or <1000 s mm–2.Conclusion:Our analysis suggests that T2-weighted and DW imaging have comparable detection rates for spinal cord damage in tSCI patients within 24 h post-injury.