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9
PredictingOutcomesFollowingSpinal
CordInjury
ChristinaV.OlesonandAdamE.Flanders
INTRODUCTION
Spinal cord injury (SCI) remains one of the most devastating injuries any
individual can sustain. In the United States, the number of new SCI cases
annuallyisestimatedat17,000(1)withaprevalenceof282,000cases.Patients
and their families are primarily concerned with two outcomes: the expected
degreeofmotorandsensoryrecovery,andtheextentandtimingofhealingand
returntotheirpriorlifestyle.Formany,recoverywillbeminimaltonone,while
forothers,areturnofsubstantialneurologicalfunctioncanbeanticipated.Older
individualsarerapidlybecomingalargerpercentageofthosewithnewSCI,and
postinjuryplanningforpeoplewithpreexistingcomorbiditiescanbeevenmore
complex in terms of required physical assistance after discharge and home
modifications.Forthoseinjuredintheprimeoftheirlife,financialconcernsfor
long-termcarecanbeoverwhelming,thusanearlyunderstandingoffuturecare
needsiscrucial.Patientsandtheircaregiverswanttoknowiftheinjuredwillbe
able to walk, work, provide for their own self-care, and return to the same
intimaterelationshipstheyenjoyedpriortoinjury.
It is essential that patients and clinicians have a realistic expectation of
functional outcomes following SCI. Clinicians must be able to prognosticate
outcomes as the basis for planning an effective rehabilitation program.
Awareness of expected outcomes also helps to determine the effectiveness of
various treatment interventions (pharmacologic and rehabilitation protocols).
Finally, in the current healthcare system, characterized by declining resources
and a shift to managed care, recognition of expected outcomes is critical to
ensurethatthemostcost-effectiveprotocolsnecessarytoattainoptimalfunction
canbe implemented in theshortesttime possible. Justasitis inappropriate to
denyorfailtoprovideessentialandappropriaterehabilitationservices,itisalso
inappropriate to provide valuable rehabilitation services and resources that
would only minimally improve a patient’soverall function or would be more
effectivelyimplemented once barriers such as braces or pressure injuries have
been eliminated. Accurate prognostication following SCI will determine the
treatmentplanand minimizeunnecessaryinterventionswhilejustifying needed
careandresources.
Current and future efforts to advance SCI rehabilitation also require a
thoroughunderstandingof the nature and extent of natural recoveryfollowing
SCI. In the absence of such knowledge, it becomes difficult to differentiate
therapeutic effectsfrom natural recovery and, thereby,confirm the efficacyof
newinterventions.Forthesereasons,itisimperativethatwecontinuetoincrease
ourunderstandingofwhatdeterminesnaturalrecoveryfollowingSCI.
Thischapter reviewsthevarious factorsthatimpact the performanceof an
accurateneurologicalassessment,describetheextentandtimeframeofnatural
recovery following traumatic SCI, clarify the prospect for specific outcomes
such as ambulation, summarize the role of traditional imaging and new
modalities of viewing the injured spinal cord, and conclude with a brief
overviewoftheunderlyingmechanismsofrecovery.
FACTORSINDETERMININGNEUROLOGIC
RECOVERY
FeaturesoftheEarlyNeurologicalExaminationof
MotorandSensoryFunction
The determination of prognosis and expected outcome in SCI is founded on
results from an early and accurate neurological examination according to the
InternationalStandardsfortheClassificationofSpinalCord Injury(ISNCSCI)
(2) (see Chapter 5 for details). The most important determinant of long-term
prognosis is whether an injury is clinically complete or incomplete. The
InternationalStandardsdefineanSCIascompletewhenthereisatotalabsence
ofsensory and motor function in thelowestsacralsegment (“sacral sparing”).
Thishasbeenshowntobethemostreliableandclinicallyusefuldefinition(3).
A clinically complete injury does not imply a structural severing or complete
disruption of the cord, as this is relatively rare; but clinical completeness has
been noted in 38% of subjects in a recent report (4). In comparison, an
incompleteinjuryischaracterizedbythepresenceof “sacralsparing” (sensory
functionindermatomeS4-5orthepresenceofdeepanalpressureorvoluntary
anal sphincter activity). This definition is intuitive in the sense that for sacral
sparingtobepresent,somesignalsmusthavetraversedtheentirelengthofthe
spinalcordaswouldbeexpected with an incomplete block. After it has been
determined whether the injury is complete or incomplete, injury severity is
gradedusingtheAmericanSpinalInjuryAssociationImpairmentScale(AIS),as
describedinChapter5.
RelationshipBetweenTimingofAssessmentand
Prognosis
How early after injury can an accurate examination be performed such that
reasonable predictions of functional outcome can be developed? While
examinationsperformedintheemergencyroomcanbedifficultandmayleadto
error,theyshouldbecarriedoutassoonaspossiblefordocumentationpurposes
andforestablishingabaselinethatenablesmonitoringimprovementordecline
in neurological status. When performing an assessment in this context, the
assessorshould be aware of the elementsthatcanaffect the accuracyofearly
examinations.Burnsandcolleagues(5)assessedthefactorsthatarisewhenthe
initialassessmentisperformedwithin1to2daysofinjury,andfoundthatthere
wasahigherrateofconversion(completetoincomplete)atboth1weekand1
year after injury among patients who evidenced oneormore of the following
factors: (a) mechanical ventilation, (b) intoxication, chemical sedation, or
paralysis,(c)closedheadinjury,(d)psychiatricillness,(e)languagebarrier,(f)
severe pain, or (g) cerebral palsy. None of the clinically complete patients
withoutthesefactorsconvertedtomotorincompleteby1year,while13%(3/23)
of patients with at least one factor did. The results suggest that the risk of
misclassificationishigherwhenthevariableslimitreliablecommunicationand
participationbythesubject.
The 72-hour examination has been shown to have superior accuracy
compared with the 24-hour examination (6–9) due to not only the previously
mentioned limiting factors but also the presence of postinjury swelling and
spinal cord edema that may increase between 24 and 72 hours after injury.
Marinoand colleaguesfound thataneurologic examinationperformed1 week
following injury had prognostic value for determining recovery (10). These
investigators used the ASIA Impairment Scale (AIS) and the Frankel scale to
predictneurologicrecovery.TheFrankelscalepredatesthecurrentInternational
Standards and differsin that the latter requires the presenceof sacralsparing.
Some of the early studies of both complete and incomplete patients provide
valuabledata,buttheymustbeinterpretedincomparisonwithcurrentstandards,
accounting for the differences in the Frankel and AIS testing. Given the
increasing emphasis on shorter length of stays in both acute care and
rehabilitationsettings,predictingoutcomeat1monthpost-injury,aswasdonein
anumberofearlyanalyses(11–14),isnowgenerallyundertakenearlierthanthis
timeframe.Assuch,the1-monthdataareusedtosupplementearlierdiscussions
onprognosis.
Currently, the most consistently used method for evaluating changes in
classification, including worsening of an acute SCI during the immediate
postinjuryperiod,isrepeated clinicalexaminationsusingthe ISNCSCI(15). It
shouldbe noted that serial examination isunableto detect occult neurological
injury as opposed to ongoing compression or ischemia (16). The Subaxial
CervicalSpinalInjuryClassificationScale(SLIC)(17)wasdevelopedtoaddress
cervical injuries and identify those patients most at risk of progressive
neurologic deterioration. Despite the uncertainty of accurate classification by
clinical assessments alone (16,18,19) and the fact that this system has shown
considerableeffectiveness,ithasnotbeenwidelyadapted.Onesurveyofspinal
injuryexpertscitedlimitedattentionoftheSLICtothelevelofinjury,relative
complexity,inadequatereliability,andgeneralinabilitytopredictnaturalhistory,
indicatingtheircontinuedpreferencefortraditionalandsimplersystems(20).
RECOVERYBASEDONNEUROLOGICALLEVEL
OFINJURY
CompleteSCI:ASIAImpairmentScale(AIS)A
ThemajorityofneurologicrecoveryafterSCIisgenerallybelievedtooccurin
thefirstyearfollowinginjury.Fawcettetal.(21)summarizedfindingsofseveral
studiesthatexaminedconversionfromcomplete(AISA)toincomplete(AISB,
C, and D) injury classifications. Their analysis demonstrated that 80% of
subjects,initiallyclassifiedasAISA,3to28dayspost-SCI,remainedAISAat
1 year after injury and 20% became incomplete, of which approximately half
converted to AIS B and the other half to either AIS C or D. These statistics,
which include both persons with paraplegia and tetraplegia, represent study
findingsfrombeforeandafterthe2000RevisionoftheInternationalStandards
definitionof“motor incomplete”lesions.Priortotheyear2000, conversionof
completetoincompletestatuscouldbeobservedinpersonswithimprovementof
motororsensoryfindingsnearthezoneofinjury.
After2000,a requirement of sacral sparing (sensation in S4-5dermatome,
deep anal sensation [later referred to as deep anal pressure], or volitional
sphincteractivity)wasadoptedinorderforapatienttobeconsideredclinically
incomplete.Moreover,for AIS C orD,the patient must have either (1) some
degreeofanalsensationalongwithmotorfunctionmorethanthreelevelsbelow
the motor level or (2) voluntary anal contraction with or without deep anal
pressureorS45sensation(22).Ineithercase,thedistinctionbetweenAISCand
Dis based onthespecific motorscoresbelow the neurologicallevelof injury
(NLI)(2).Whilesome earlystudiesthat includedpersons withtetraplegiaand
paraplegiaestimateda20%conversionratefromcompletetoincompletestatus,
only 2% to 3% improve to an AIS D classification (10). In addition, many
amongthat small group of AISDpatients may not beambulatory(10).Other
studiesestimateconversionratesfromAISAtoB,C,orDat4%to13%(10–
12).
The data provided by Burns (5)demonstrated that in a group of 103 U.S.
ModelSystempatients,upto9.3%ofsubjectsinitiallyconsideredtobeAISAat
the72-hourexaminationwerereclassifiedasAISBwithinthefirstweek,dueto
challenges affecting the reliability of the early ISNCSCI examination. In
contrast,only2.6%ofsubjectswithoutfactorsimpedingtheaccuracyofanearly
examination were reclassified. Among those with reliable early examinations
indicating complete injuries at the 72-hour examination, only 2 of 30 (6.7%)
convertedtomotorcomplete,sensoryincomplete(AISB),butnoneconvertedto
motorand sensory incomplete(AISC or D).Muchhigher rates ofconversion
wereseeninthesubjectsexaminedatalatertimeandinthosewithoutcognitive
barriers.ThisfindingmayexplainwhyanearlierstudybyMaynard(7)founda
19%1-yearconversionrateofcompletetoincompletepatientsamongagroup
thatincluded10%ofsevereheadinjurypatients.
Zariffa et al. (23) conducted a retrospective analysis of 399 patients with
thoracic SCI using the European Multicenter Study about Spinal Cord Injury
(EMSCI)database,comprisingdatacollectedfrom18centers.Conversionfrom
completetoincompleteSCIatthefinaloutcomepointof48weekswasseenin
18.2%ofpatients:7.7%improvedfromAISAtoAISB,while5.7%converted
toAISCand4.8%to AISD.Conversionfromcompletetoincompleteduring
theinitialyearafterinjurywasdependentontheinitiallevelofthoracicSCI:
9.46%ofthoseT2-5convertedtosensoryormotorincomplete;15.56%ofthose
T6-9;29.17%ofthoseT10-12.
Lee et al. (24) studied 482 patients with complete injuries also focusing
between T2 and T12, specifically the percentage of patients who achieved a
score of AIS D, because future ambulators would be drawn from this group.
HigherconversionratestoAISDwereseeninT10-12levelinjuries(7.2%),but
only1.9%convertedtothesamelevelforpatientsintheT2-5levels.Duetothe
natureoftheretrospectivedata,noevaluationwasconductedofthoseamongthe
AISDpatientswhoachievedvariousdegreesoffunctionalmobility.Thoseover
age 50 demonstrated lower FIM scores in comparison to younger individuals
withthesameNLI.
Recently,Kirshblumetal.completedareviewofoutcomesfromtheModel
SCISystemdatabaseovera5-yearperiod,includingcervicalandthoraciclevels
ofinjury(4).Theauthorsusedtwooutcometimepoints:(1)betweenadmission
to rehabilitation and discharge, with admission occurring within 30 days of
injuryandwithdurationofrehabilitationvariable,and(2)at1yearpostinjury.
For changes between admission and dischargefrom rehabilitation, the authors
observed a 20% conversion rate from AIS A to incomplete status: 13.1%
improvedtoAISB,6.2%toAISC,and0.5%toAISD(4).Thosewithcervicallevel injuries had a higherrate of conversion to AISB and C compared with
higherparaplegic levelsofinjury (T1-9)andlower paraplegic levels(T10 and
below). The 3/662 subjects (0.5%) who converted from AIS A to AIS D
originallyhadlevelsofT10andbelow.At1year,therewasareportedoverall
neurological conversion from AIS A toincomplete status of 27.8%;10.7% to
AISB,13.9%toAISC,andto3.2%AISD(4).Conversionrateswerehigher
amongthosewithcervicallesionsandlowthoraciclesions,whileupperthoracic
lesions demonstrated lower rates of conversion to motor and/or sensory
incompleteSCI.
SpecialFeaturesofZoneofInjuryRecoveryinCompleteTetraplegia
Analysis of individual muscle recovery in relation to functional strength will
help in determining independent functioning. Recovery of functional strength
(definedasmotorscore≥3/5)isminimalinmuscleswithgrade0/5at1month
(25).Mostpatients(~80%)withneurologicalcompleteinjury(AISA)regainat
leastonelevelofmotorfunction(25–28)(Table9.1).Forexample,Fisheretal.
(27)reportedthat67%ofsubjectsregainedfunctioninonemotorlevel;16%in
two motor levels, and 3% in three motor levels. Steeves et al. (28) examined
upper extremity spontaneous recovery from the Sygen trial and European
Multisystem study databases, and reported slightly more favorable outcomes
with 28.8% to 40.7% of cervical level (C5-7 subjects) recovering one motor
leveland28.8%to32.5%recoveringtwoormorelevels.Inlookingatindividual
neurological levels, with the exception of the triceps, all upper-extremity
muscleswithaninitialstrengthgradeofatleast1/5recovertoatleast3/5by1
year(12,25,29).
TABLE9.1PredictionofUpper-ExtremityMotorRecovery
PERCENTAGEWITHFUNCTIONALSTRENGTH>3/5AT1
YEAR
MANUALMUSCLESTRENGTHAT1
MONTH*
COMPLETETETRAPLEGIA INCOMPLETETETRAPLEGIA
0/5 20% 24%
1/5 90% 73%
2/5 100% 100%
*ASIAkeymuscles
ASIA,AmericanSpinalInjuryAssociation
Source:WatersRL,AdkinsRH,YakuraJS,etal.Motorandsensoryrecoveryfollowingcomplete
tetraplegia.ArchPhysMedRehabil.1993;74:242–247;WatersRL,AdkinsRH,YakuraJS,etal.Motorand
sensoryrecoveryfollowingincompletetetraplegia.ArchPhysMedRehabil.1994;75:306–311.
doi:10.1016/0003-9993(94)90034-5.
Thereisdebateregardingwhethertherearedifferencesinrecoverybyinitial
NLI.Ditunnoetal.foundthatthosewithC4injurieswerelesslikelytoregain
one level of recovery (to C5) as lower cervical levels were able. Of those
individualswithinitialC4NLI,70%ofsubjectsregainedtotheC5motorlevel,
whereasforC5toC6,75%attainedthatlevel,andforC6toC7,85%(26). In
contrast, Steeves et al. (28) found a similar number of motor points gained
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