Fok et al. Corrigendum.

Diagnostic and Predictive Value of Novel Inflammatory Markers of the Severity of Acute Traumatic Spinal Cord Injury: A Retrospective Study

Functional Motor Preservation Below the Level of Injury in Subjects With American Spinal Injury Association Impairment Scale Grade A Spinal Cord Injuries

To describe the kinematic gait characteristics of individuals with incomplete chronic spinal cord injury in a water environment and to compare these characteristics with those of healthy individuals. Cross-sectional study. Nineteen adults divided into 2 groups: individuals (n = 9) with incomplete chronic spinal cord injury (> 1 year), American Spinal Injury Association Impairment Scale (AIS) C or D; and a second group (n = 10) of healthy young adults. The groups were paired up according to body mass and height. Participants walked at a self-selected speed in a heated pool with water at the level of the xiphoid process. Participants with spinal cord injury were allowed to hold the researcher's hands. The body segment and joint angle coordinates in the sagittal plane were retrieved with SIMI Motion software. Temporal-spatial variables and joint ranges of motion were compared between groups. Duration of stance phase, stride length and speed differed significantly (p < 0.05) between groups. The ranges of joint motion were not significantly different (p > 0.05), and the joint angle patterns were qualitatively similar between groups. The physical properties of water provided the required time for reorganization of gait phases and allowed all individuals with spinal cord injury to walk in the water environment.

Case report. To report on the respiratory and kinematic changes associated with body weight supported treadmill training (BWSTT) in an individual with an incomplete cervical spinal cord injury (SCI). Human Locomotion Research Laboratory, Vancouver, BC, Canada. A 38-year-old man with an incomplete SCI at the C1/C2 level, graded on the American Spinal Injury Association Impairment Scale (AIS) as AIS D, participated in this case study. He performed three BWSTT sessions (45 min) per week for 12 weeks. Before and after training, respiration was measured at the mouth using a pneumotachograph while treadmill walking at 1.6 km h(-1). Completion of 12 weeks of BWSTT resulted in a lowering of minute ventilation during treadmill exercise. A coupling of locomotion and respiration was observed during treadmill walking after the training program, whereas the relationship was initially absent. This case illustrates that BWSTT can result in a reduced ventilatory demand and promote locomotor-respiratory coupling during walking in an individual with an incomplete cervical SCI.

Cross-sectional retrospective study of a neurophysiological method of voluntary motor control characterization. This study was undertaken to validate the surface electromyography (sEMG)-based voluntary response index (VRI) as an objective, quantitative, laboratory measure of spinal cord injury severity in terms of voluntary motor control disruption. VA Medical Centers in Houston and Dallas Texas, USA. A total of 67 subjects with incomplete spinal cord injury (iSCI), American Spinal Injury Association Impairment Scale (AIS)-C (n = 32) and -D (n = 35) were studied. sEMG recorded during a standardized protocol including eight lower-limb voluntary motor tasks was analyzed using the VRI method that relates multi-muscle activation patterns of SCI persons to those of healthy-subject prototypes (n = 15). The VRI is composed of a measure of the amount of the sEMG activity (magnitude) and the distribution of activity across muscle groups compared to that of healthy subjects for each motor task (similarity index, SI). These resulting VRI components, normalized magnitude and SI, were compared to AIS clinical findings in this study. Receiver operating characteristic analysis was performed to determine the SI values best separating AIS-C and AIS-D subjects. Magnitude and SI for AIS-C subjects had mean values of 0.27 +/- 0.32 and 0.65 +/- 0.21, respectively. Both parameters were significantly larger in the AIS-D subjects (0.78 +/- 0.43 and 0.93 +/- 0.06), respectively (P < 0.01). An SI value of 0.85 was found to separate AIS-C and AIS-D groups with a sensitivity of 0.89 and a specificity of 0.81. Further, the VRI of each leg strongly correlated with the respective AIS motor score (0.80, r < 0.01). In the domains of voluntary motor control, the sEMG-based VRI demonstrated adequate face validity and sensitivity to injury severity as currently measured by the AIS. Veterans Affairs Medical Center.

Introduction:Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients’ neurological status.Methods:A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).Results:Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients’ neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).Conclusion:Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities than of the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Often, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: full CCS, unilateral CCS, and borderline CCS. Of the 1490 participants in our sample, 17.5% had full, 25.6% had unilateral, and 9% had borderline CCS, together encompassing >50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared with existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of American Spinal Injury Association (ASIA) Impairment Scale (AIS) D grade than those with motor incomplete tetraplegia without CCS. Upper Extremity Motor Score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, whereas their Lower Extremity Motor Score (LEMS) consistently remained higher than for those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar, with some differences observed within those with AIS D grade. The AIS grade, rather than the diagnosis of CCS, remains the foremost determinant influencing neurological and functional outcomes. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. Although there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

Retrospective cohort study. Investigate the association between rehabilitation length of stay (LOS) and motor FIM® (mFIM) between rehabilitation admission and discharge among patients with traumatic spinal cord injury (SCI). Seventeen SCI Model Systems (SCIMS) centers in the United States. A total of 3386 patients with traumatic SCI enrolled in the SCIMS Database from 2011 to 2018. The main outcome measure was the mean change in mFIM (12 items) between rehabilitation admission and discharge by twelve neurological categories (C1-C4 American Spinal Injury Association impairment scale (AIS) A-B, AIS C, AIS D, and C5-C8 AIS A-B, AIS C, AIS D, and T1-T10 AIS A-B, AIS C, AIS D, and T11-S3 AIS A-B, C, D). Linear regression models were applied to estimate changes across rehabilitation LOS groups (shortest LOS, quarter2, quarter3, and longest LOS) after adjusting for covariables for each neurological category. The mean age of study patients was 44.5 years. Patients were predominantly men (78.5%), non-Hispanic white (64.8%), and had private insurance (57.1%). The median LOS was 42 days across the entire sample. Longer LOS was associated with a higher mFIM score compared to the shortest LOS among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D after adjusting for demographics and clinical characteristics. Among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D injuries, those with longer rehabilitation stays tended to have more motor function improvement.

To the Editor: In this letter, I would like to address the significance for physical therapy of a recent study by Dobkin et al.1 This randomized clinical trial investigated the effectiveness of a combination of body-weight–supported treadmill training (BWSTT) and over-ground mobility training versus solely over-ground mobility therapy in subjects with an incomplete spinal cord injury (iSCI). A large number of the subjects with iSCI regained walking ability independent of the group to which they were assigned. Compared with historic data, an unexpectedly high percentage (92%) of patients with an American Spinal Injury Association Impairment Scale (ASIA) classification C regained an independent walking ability. In addition, the walking speed of the subjects classified as ASIA C and D did not differ between the groups. The authors …

The purpose of this study was to evaluate the effect of body weight-supported (BWS) gait training on restoration of walking, activities of daily living (ADL) and quality of life (QoL) in persons with an incomplete spinal cord injury (SCI). Datasources: Cochrane, MEDLINE, EMBASE, CINAHL, PEDro and DocOnline. Studies were assessed for methodological quality and described regarding population, training protocol and effects on walking ability, ADL and QoL. A descriptive and quantitative synthesis was conducted. 18 articles/17 studies were included. Two randomized controlled trials (RCTs) showed that subjects with American Spinal Injury Association Impairment Scale (AIS) C or D of less than one year duration reached higher scores on the locomotor item of the Functional Independence Measure (FIM-L, range 1-7) in the over-ground training group than in the BWS treadmill training group at the end of training, mean difference 0.80 (0.04-1.56). There were no differences regarding walking velocity and hardly data on ADL or QoL. Concluded was that subjects with subacute SCIs classified AIS C or D reached a higher level of independent walking after over-ground training compared to BWS treadmill training. More RCTs are needed to clarify the effectiveness of BWS gait training on walking, ADL and QoL for subgroups of persons with incomplete SCIs.

Literature examining magnetic resonance imaging (MRI) in acute spinal cord injury (SCI) has focused on cervical SCI. Reproducible systems have been developed for MRI-based grading; however, it is unclear how they apply to thoracic SCI. Our hypothesis is that MRI measures will group as coherent multivariate principal component (PC) ensembles, and that distinct PCs and individual variables will show discriminant validity for predicting early impairment in thoracic SCI. We undertook a retrospective cohort study of 25 patients with acute thoracic SCI who underwent MRI on admission and had American Spinal Injury Association Impairment Scale (AIS) assessment at hospital discharge. Imaging variables of axial grade, sagittal grade, length of injury, thoracolumbar injury classification system (TLICS), maximum canal compromise (MCC), and maximum spinal cord compression (MSCC) were collected. We performed an analytical workflow to detect multivariate PC patterns followed by explicit hypothesis testing to predict AIS at discharge. All imaging variables loaded positively on PC1 (64.3% of variance), which was highly related to AIS at discharge. MCC, MSCC, and TLICS also loaded positively on PC2 (22.7% of variance), while variables concerning cord signal abnormality loaded negatively on PC2. PC2 was highly related to the patient undergoing surgical decompression. Variables of signal abnormality were all negatively correlated with AIS at discharge with the highest level of correlation for axial grade as assessed with the Brain and Spinal Injury Center (BASIC) score. A multiple variable model identified BASIC as the only statistically significant predictor of AIS at discharge, signifying that BASIC best captured the variance in AIS within our study population. Our study provides evidence of convergent validity, construct validity, and clinical predictive validity for the sampled MRI measures of SCI when applied in acute thoracic and thoracolumbar SCI.

Longitudinal Patterns of Functional Recovery in Patients With Incomplete Spinal Cord Injury Receiving Activity-Based Rehabilitation

INTRODUCTION Patients with cervical spinal cord injury (SCI) show different clinical outcomes. There is a significant association between the acute magnetic resonance (MR) imaging of cervical SCI and neurological recovery of cervical SCI. We speculated that principal component analysis (PCA), a dimension reduction procedure, would detect clinically predictive patterns in complex MR imaging and predict neurological improvements assessed by the American Spinal Injury Association Impairment Scale (AIS) and Japanese Orthopaedic Association (JOA) score. METHODS We performed a retrospective analysis of 50 patients with cervical SCI who underwent early surgical decompression less than 48 h after the trauma. We analyzed 7 types of MR imaging assessments: axial grade assessed by the Brain and Spinal Injury Center score (BASIC), longitudinal intramedurallry lesion length, spinal cord signal intensity on T1 and T2 weighted image, maximum canal compromise, maximum spinal cord compression, Subaxial Cervical Spine Injury Classification System. PCA was applied on these multivariate data to identify factors that contribute to recovery after cervical SCI following surgery. AIS conversion was evaluated at 6 mo. RESULTS Nonlinear principal component (PC) evaluation detected 2 features of MR imaging. PCA revealed PC 1 (40.6%) explaining the intramedullary signal abnormalities that were negatively associated with postoperative AIS conversion. PC2 (18.5%) suggested extrinsic morphological variables, but did not predict outcomes. The BASIC score revealed the significant overall predictive value for AIS conversion at six months (AUC 0.86). This result suggested that the intramedullary signal abnormalities reflect delayed neurological improvements even after early surgical decompressions in patients with cervical SCI. CONCLUSION PCA could be a useful data-mining tool to show the complex relationships between acute MR imaging findings in cervical SCI. This study emphasized the importance of multivariable intramedullary MR imaging as clinical outcome predictors.

The aim of the present study was to investigate the effects of high-frequency rTMS on motor function in individuals with iSCI, so as to explore the clinical utility of rTMS in this population. This prospective trial enrolled 15 individuals who were at least six months post incomplete SCI (aged 18–60 years), recruited through referral by medical practitioners or therapists. The study design involved both rTMS-sham and rTMS-active protocols. The protocol included five sessions (one session daily) of high-frequency rTMS (5 Hz) over the bilateral lower limb motor area positioned at the primary motor cortex (M1). In the sham condition, the coil was disconnected from the rTMS device so as to ensure the interruption of the magnetic field. American Spinal Injury Association Impairment Scale (ASIA) motor scores were assessed at baseline (before intervention), after rTMS-sham and after rTMS-active, and the changes from baseline motor values provided by the ASIA score were used to assess the effects of both rTMS-sham and rTMS-active on the motor performance of individuals with iSCI. rTMS active was associated with significantly larger changes in ASIA motor scores as compared to rTMS-sham (T(1, 14) = 5,359, P < 0.001, ES = 0.67). We conclude that rTMS has produced positive results in improving participants’ motor function, thereby indicating that rTMS might be used as an effective clinical tool in the rehabilitation of individuals with SCI.

Context: To investigate the feasibility of combining the lower-limb exoskeleton and body weight unweighing technology for assisted walking in tetraplegia following spinal cord injury (SCI).Findings: A 66-year-old participant with a complete SCI at the C7 level, graded on the American Spinal Injury Association Impairment Scale (AIS) as AIS A, participated in nine sessions of overground walking with the assistance from exoskeleton and body weight unweighing system. The participant could tolerate the intensity and ambulate with exoskeleton assistance for a short distance with acceptable and appropriate gait kinematics after training.Conclusion: This report showed that using technology can assist non-ambulatory individuals following SCI to stand and ambulate with assistance which may promote general physical and psychological health if used in the long term.