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![Page 1: Neurological Recovery After Traumatic SCI Ralph J. Marino, MD, MS Associate Professor, Rehabilitation Medicine Thomas Jefferson University Philadelphia,](https://reader033.fdocuments.in/reader033/viewer/2022051614/551a8a41550346761a8b54d5/html5/thumbnails/1.jpg)
Neurological Recovery After Traumatic SCI
Ralph J. Marino, MD, MSAssociate Professor, Rehabilitation
MedicineThomas Jefferson University
Philadelphia, PA, USA
November 24, 2007
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Regional Spinal Cord Injury Center of the Delaware Valley
Affiliated institutions of
Jefferson University Hospital
Magee Rehabilitation Hospital
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Objectives
• Describe recovery after SCI based on initial severity of injury.
• Compare and contrast upper extremity recovery after complete and incomplete cervical SCI.
• Identify factors predictive of ambulation after traumatic SCI.
• Highlight areas where further research is needed to predict recovery after SCI.
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International Standards for the Neurological Classification of Spinal Cord Injury
http://www.asia-spinalinjury.org/publications/2001_Classif_worksheet.pdf
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Sensory Examination
• Test 28 dermatomes on each side of body.
• Light touch and pinprick.• Three-point scale (0-2).• Establish normal sensation on
face or other non-involved area.
• Also test for deep anal sensation.
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Motor Examination:Key Muscles
UPPER EXTC5 = Elbow
FlexorsC6 = Wrist
ExtensorsC7 = Elbow
ExtensorsC8 = Finger
Flexor (FDP-3)
T1 = Finger Abductor
(ADM)
LOWER EXTL2 = Hip
FlexorsL3 = Knee
ExtensorsL4 = Ankle
DorsiflexorsL5 = Extensor
Hallucis Longus
S1 = Ankle Plantar-
flexors
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Sensory Level
• The sensory level is the most caudal segment of the spinal cord with normal sensory function.
• Right and left sides are evaluated separately.
• Both pin prick and light touch sensation must be normal in this dermatome.
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Motor Level
• The motor level on each side is the most caudal segment of the spinal cord with normal motor function.
• Normal motor function refers to the myotome of the spinal cord, not to the key muscle being tested.
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The ASIA Impairment Scale
A. Complete. No motor or sensory function in sacral segments S4-S5.
B. Motor complete, sensory incomplete. Sensory sparing but no motor function below the zone of injury. Includes the sacral segments S4-5.
C. Motor incomplete. Motor function preserved below the injury and less than half of key muscles have a muscle grade > 3.
D. Motor incomplete. Motor function preserved below the neurological level and at least half of key muscles have a muscle grade > 3.
E. Normal. Motor and sensory function are normal.
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Timing of Baseline Exam
“Short term motor recovery in the zone of injury of motor complete quadriplegia is better predicted by the 72-hr MMT than the 24-hr MMT”
Brown et al. 1991
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Reliability of Early Designation of Complete (Burns et al; 2003)
Retrospective study of SCI patients at RSCICDV (Jefferson)
Factors affecting reliability:• mechanical ventilation• intoxication/sedation • Closed head injury• Cerebral palsy • psychiatric illness • language • severe pain
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Reliability of Early Designation of Complete (Burns et al; 2003)
• Initial exam within 48 hrs• Overall, 6.2% (5/81) convert A
to B within the first week
• By one year,If NO factor, 1/38 (2.6%) convert – to AIS B
If + factor, 4/43 (9.3%) convert – to AIS B = 1, C = 2, D = 1
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Neurological Recovery After SCI: Model Systems (Marino et al., 1999)
• Subject selection:−Admitted to System 1/1/88-
12/31/97−Within one week of traumatic
SCI• Exclude if:
−Minimal deficit on admission−Died within first year−Incomplete data
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Neurological Recovery After SCI: Model Systems
Subjects: 4365 admitted
|--------------- 391 died3974 alive at one year
||----- 65, minimal
deficit|------ 324, incomplete
data|
3585 retained
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Neurological Recovery After SCI: Model Systems
Ethnicity %Non-Hisp. White
53.2African American
28.9Hispanic 15.0Other 2.9
Sex %Male 82.2Female 17.8
Etiology %Vehicle crash
36.9Violence
29.3Falls
21.9Sports 7.8Pedestrian
2.2Med/Surg
1.5Other
0.4
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Neurologic Impairment Group
28.4%
21.8%
19.8%30.0%
Tetra Comp
Tetra Inc
Para Inc
Para Comp
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Initial to Discharge AIS Grade
N=1560 Discharge AIS Grade
Admit AIS Grade
A
B
C
D
E
A (n=808) 89.0 5.8 3.6 1.6 0.0
B (n=242) 2.9 42.5 36.8 17.8 0.0
C (n=295) 1.0 1.0 43.4 54.6 0.0
D (n=215) 0.0 0.5 0.0 96.7 2.8
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Initial to One-year AIS Grade
N=842 One-year AIS Grade
Admit AIS Grade
A
B
C
D
E
A (n=482) 84.6 7.3 5.8 2.3 0.0
B (n=129) 7.8 19.4 38.0 33.3 1.5
C (n=159) 3.1 1.3 25.1 66.7 3.8
D (n=72) 0 0 1.4 94.4 4.2
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Tetraplegia Recovery
0
20
40
60
80
100
A B C D
Frankel/AIS Grade
Mot
or S
core
Initial Discharge One Year
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Paraplegia Recovery
40
50
60
70
80
90
100
A B C D
Frankel/AIS Grade
Mot
or S
core
Initial Discharge One Year
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Recovery at the Zone of Injury
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Upper Extremity Key Muscles
• C5 - Elbow flexors• C6 - Wrist extensors• C7 - Elbow extensors• C8 - Flexor dig profundus (digit
3)• T1 - Abductor digiti minimi
• Motor Score (UE) = 0-50
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Change in UE Motor Score
• Blaustein 1993 (72-hrs to 6 months) Complete : 5.4 pts
• Waters 1993, 1994 (1 month to 1 year)Complete: 8.6 pts Incomplete: 10.6 pts
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UE recovery in Tetraplegia(Waters et al., 1993)
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Upper Extremity Recovery(by level of Injury)
Initial Motor Level
MotorComplete
MotorIncomplete
C4 70 90*
C5 75 90*
C6 85 90
Percent recovering next level to antigravity strength (Ditunno et al. 2000)
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Percent Motor Compete Tetraplegic Patients Recovering Next Motor Level
0
20
40
60
80
100
0 1 3 6 12 18 24
Months post-injury
Per
cen
t
SMP NMP
Ditunno et al. 1992
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Upper Extremity Recovery(≥ 3/5) by distance below level
0
10
20
30
40
50
60
70
80
1st 2nd 3rd
Level below original motor level
Perc
ent
Impro
ve
Graziani 1992 Fisher 2005
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Prognosis for Ambulation
50
3
75 95
0
20
40
60
80
100
A B* C# D
Initial ASIA Impairment Scale
Per
cent
Am
bula
tory
* influenced by type of sensation # influenced by age at injury
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Ambulation Potential (for AIS B)
NDon’tWalk Walk
B1 (No pin) 18 16 2
B2 (Pin) 9 1 8
Total 27 17 10
Crozier et al. 1991
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Sacral Pin Prick and Ambulation (Oleson et al., 2005)
Initial PP
010203040506070
Walk Don'tWalk
Perc
ent
PP - yes PP - no
4 Week PP
0
2040
60
80100
120
Walk Don'tWalk
Perc
ent
PP - yes PP - no
P=.32 P=.01
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Prognosis for Ambulation
50
3
75 95
0
20
40
60
80
100
A B* C# D
Initial ASIA Impairment Scale
Per
cent
Am
bula
tory
* influenced by type of sensation # influenced by age at injury
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Potential for Ambulation(based on age – initial AIS C)
30
13
3
18
0
5
10
15
20
25
30
35
Age < 50 Age 50+
Ambulatory Non-ambulatory
(Burns et al. 1997)
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Prognosis for Ambulation(based on LE strength)
Initial LEMS
Para Comp
Para Inc
Tetra Inc
0 <1% 33% 0 1-9 45% 70% 21%
10-19 100% 63% 20+ 100% 100%
Based on Waters et al., 1992, 1994
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Controversies and
Questions
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Conversions from AIS B
Fawcett JR et al. Spinal Cord (2007) 45, 190–205.
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Convert from Complete to Incomplete
Fawcett JR et al. Spinal Cord (2007) 45, 190–205.
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Late conversions to incomplete
Fawcett JR et al. Spinal Cord (2007) 45, 190–205.
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Are they unrecognized factors that influence motor recovery?
Early Treatment
0
10
20
30
40
50
0 20 40 60
Weeks
Perc
ent
Reco
very
Placebo Drug
Late Treatment
10
20
30
40
50
0 20 40 60
Weeks
Perc
ent
Reco
very
Placebo Drug