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regardlessoftheinitialNLI.
SpecialFeaturesofZoneofInjuryRecoveryinCompleteParaplegia
Inthe overwhelmingmajority ofpatientswith completeparaplegia at1month
post-injury, neurologic classification will remain complete (4,11).Recoveryof
motor function in paraplegia is related to the level of injury. In 1992, when
WatersperformedastudyonmotorrecoveryusingtheFrankelscale,nopatients
withanNLIaboveT9regainedmotorfunction1yearfollowinginjury(14).At
the more caudal levels of injury, greater recovery of motor functions occurs
throughrecoveredfunctioninthezoneofpartialpreservation.
Recovery of “functional” strength (3/5 or greater) is minimal in lower
extremity(LE)keymuscleswithagradeof0/5at1month(11).Onlyabout5%
of these muscles will regain functional strength 1 year following injury. In
contrast,64%ofmuscleswitheither 1/5 or 2/5 strength at 1 month will have
grade 3/5 strength at 1 year. Typically, muscles with motor strength of this
magnitude occur in the zone ofpartial preservation. Improvement in this area
mayultimatelyresultinachangeintheNLItoamorecaudallevel,eventhough
theoverallgradeofinjurymayremaincomplete.Fawcett’sconversiondatafor
bothcomplete andincompletelevels ofSCIalso found similarresults (21).In
studies by Waters, of patients 1 year after injury, only 5% of complete
paraplegics(11)recoveredadequatestrengthtoambulate(Table9.2).
FactorsDeterminingOutcomeinCompleteSCI
AgeisasignificantfactorinmotorrecoveryatcertainlevelsofSCI.Potentially,
itisamongthelimitingfactorsinobtaininganaccurateearlyexamination,but
age also plays a role in the likelihood of functional if not motor recovery,
particularlyamongthosewithAISBandCinjuries.Wilsonetal.(30)examined
376patientsyoungerthan65versus65andolder.Theauthorsfoundthatwhile
motorrecovery was similarinAIS AandD,possiblydue to ceilingandfloor
effects,functionalindependencemeasures(FIM)scoresweresignificantlylower
inolderindividuals,particularlyamongthosewithAISBandC.
With regard to the timing of surgery, Vaccaro et al. (31) observed that a
numberofretrospectivestudiespriorto1997reported varyingopinions onthe
appropriatetimingofsurgicaldecompressionandstabilizationforcervicalspinal
cordtrauma. Intheir randomized,prospective,controlled studyofearly versus
late surgery, they found no statistical difference and no significant neurologic
benefit when surgery is performed less than 72 hours after injury (mean: 1.8
days) compared with treatment administered longer than 5 days post-injury
(mean:16.8days).However,in2012,alarge(n=313),prospectivecohortstudy
by Fehlings et al. (32) demonstrated the benefits of early surgery, defined as
priorto24hoursafterSCI.Itconcludedthatdecompressivesurgerypriorto24
hours after SCI could be performed safely and was associated with improved
neurologic outcome defined as at least a two-grade AIS improvement at 6
monthsfollow-up.Itisnowpossibletosavetimeafterthepatientarrivesasa
resultofbettercoordinationofcarebetween local hospitals and larger level 1
traumacenters,aswellasimagesharingtoolssuchas“LifeImage”thatobviate
theneedtorepeatMRIandCTscansafterapatienttransferstoatraumacenter,
saving valuable time and resources and enabling earlier surgery. A 2017
systematic analysis covering studies subsequent to 2012 (33) confirms the
growingconsensusthatearlyspinaldecompressionssurgery,asopposedtolater
intervention, is associated with improved neurologic outcomes and low
prevalenceofpostsurgicalcomplications,withthegreatefficacyachievedwhen
surgery is performed within the first 12 hours of injury. See Chapter 13 for
furtherdetails.
Theroleofprotectivesteroidshasbeenpreviouslyexploredintheliterature
withinconclusiveresultsanddetailedinChapter12.Amongsubjectsinvolvedin
studies based on the U.S. Model System SCI Database, varying numbers of
patients received steroid treatment, particularly high-dose methylprednisolone
withavarietyofoutcomemeasures(34).Inthepast10years,therehasbeena
phasingoutofthistreatmentinfavorofearliersurgicalinterventionaswellas
concernsabouttherisksofsteroidtherapy(35).However,2017guidelineshave
recommended the use of methylprednisolone for patients stabilized within 8
hours(36).Atpresent,thisremainsapointofdebate.
IncompleteSCI:ASIAImpairmentScaleB
Thecategoryofmotorcomplete,sensoryincompleteSCIrepresentsonly11%of
initialSCIcases(1).Personsinthiscategoryhavesomesensorypreservationin
thelowestsacralsegmentsbutlackvolitionalmotorfunctionbelowthezoneof
injury(threelevelsbelowthemotorleveloneithersideofthebody).Twoearly
studiesbyFoo(37)andWaters(13,14)demonstratedbetteroutcomesformotor
recoveryamong those withinitialpinprick sensation below thezoneof injury,
butthesearelimitedbysmallnumbersofsubjectsanduseoftheearlierFrankel
scale.
InareviewofModelSCISystemdatafrom1994to2009(38),Marinoetal.
demonstratedthatamongcervicalAISBpatients,24.8%remainedAISB,8.8%
regressedtoAISA;and29.6%becameAISCand36%AISD.Thefindingsby
Marinoetal.reliedonModelSystemdatathatwascollectedbyexaminerswith
varying degrees of training and expertise in SCI classification. To verify the
accuracy to the extent possible in a retrospective database study, a computer
algorithm was applied to check reported scores against a calculated model
crosschecked by SCI clinicians. Despite this safeguard, findings from large
databasestudies shouldbe interpretedwithcaution incomparisonwith studies
where testing has been more formalized and examiners specifically trained in
consistentevaluationstandards.
Incomparisontootherinvestigations,theEMSCIdatabasestudyfoundthat
at1year,22.5%ofinitialAISBsubjectsremainedAISB,10%regressedtoAIS
A,35%improvedtoAISC,and32.5% toAISD(39).IntheKirshblumetal.
2016 review of Model System data from 2011 to 2015, 35.7% of patients,
initiallyAISB,remainedAISB;10.7%declinedtoAISA;32.2%improvedto
AISC,and24.4%toAISD(4).Thisstudyalsoprovidedfindingsatdischarge
fromrehab, but in 2017 versus earliercyclesinthe SCI Model System, rehab
dischargeoutcomesarebecomingincreasinglydifficulttocomparebecausethe
lengthofstaysinbothacutecareandrehabareincreasinglyshorterandagreater
percentage of rehab therapy time is expected to take place in the outpatient
setting. This difference can make interpreting neurologic outcome during
inpatient rehabilitation in recent years challenging in comparison to historical
studies.
InastudyofpatientswithonlythoracicSCI,34personswithAISBreturned
for1-yearfollow-up,ofwhom20.8%hadregressedtoAISA,anequalnumber
remainedAIS B,and theremaining31% improvedto motorincompletestatus
(nearlyevenlydividedbetweenAISCandD)(24).Thiswasahigherpercentage
ofdecline fromAIS Bto Athanhadbeenseen inpersons withtetraplegia, as
reported by Marino et al. (38), illustrating the importance of differences seen
amongcervicalinjuriesandthoracicandlowerlevels(4,38).
TheImportanceofPinprickandLocationofSparing
Theroleofthemodalityofsensorysparinginprognosishasbeenexamined.Ina
small study, Crozieretal. (40) found that among 27 motor complete, sensory
incomplete subjects assessed at 72 hours postinjury, only 2 of 18 (11%)
ambulatedatdischargefromrehabiftheylackedevenpartialPPbelowthezone
of injury at 72 hours. Conversely,8 of 9 (89%) with a few dermatomes with
preservedPPbelowthezoneofinjuryachievedcommunityambulation,defined
asmorethan200feet,ifPPbelowtheinjurywasobservedatinitialevaluation.
Itisimportanttorecognizethatthissensoryfindingwasnotsacralsparing,but
utilizing the previous definition of incomplete injury (i.e., using the Frankel
scale).
In a subsequent study, using the 72-hour ASIAexamination, Oleson et al.
(41)foundthatamong131subjectswithAISB,ratesofambulationwere48%at
thelevel of atleastBenzel V(ableto ambulate 25feetassisted or unassisted)
and 24% for Benzel VI (able to walk 150 feet without a helper). However,
successrates forthe individualpatientlargelydepended onpreservationof PP
sensation. Significant differenceswere observed for recovery of ambulation 1
year post-injury at level Benzel V or better in 36% of persons with PP
preservationinthelowestsacralsegments4weekspost-injuryversusjust4.4%
forthosewithoutPPatS4–5.Howevernosignificantdifferenceinhigher-level
ambulatory function (Benzel VI and above) at 1 year was observed for those
with versus without S4–5 PP preservation at the 72-hour examination. In
contrast,lower-extremityPPpreservationingreaterthan50%ofLEdermatomes
L2–S1,observedatthe72-hourexamination,waspredictiveofambulationat6
monthsor1yearatalevelof≥BenzelVandforambulation≥BenzelVI.This
wastruebothforambulatoryfunction atthe6-month post-injurydateand at1
year. Overall, 66% of those with initial PP at L2–S1 recovered ambulation
≥BenzelV1yearafterSCI,and40%recoveredtoalevel≥BenzelVI.However,
40.3% of those lacking the threshold of 50% dermatomes L2–S1 with PP
preservation achieved ambulation at least equal to Benzel V but only 16.4%
ambulationofBenzelVIorbetter.
Atthe sametime, manyindividuals withPPdonotseemto recovermotor
function,so thequestionarises astowhat otherfactorsmight influencemotor
recovery.Itappearsthatthepresenceofmultipleinjuriesprolongsrehabilitation
butdoesnotultimatelychangeneurologicaloutcomeattheendofrehabilitation.
Comorbiditiesandseverityofconcomitantinjurieshavebeenshowntoprolong
lengthofstay.Scivolettoetal.(42)consideredthisquestionandconcludedthat
those with multiple injuries required a longer length of time during inpatient
rehabilitationandthosewereadmittedtotherehabhospitalwithgreaterdegrees
ofimpairment.However,theyleftwithanoutcomethatwasstatisticallysimilar
tothosewithmonotraumaticinjuriesandshorterlengthsofstay.
The influence of age on recovery of ambulation in AIS B patients was
recently examined by Oleson et al. (43), and found that patients aged 50 and
above had a decreased likelihood of recovering walking ability 1 year postinjury, relative topatientsunder age 50. Whenthepreservation of PPin more
than 50% of LE dermatomes L2–S1 was present, youngerpatients (underage
50) demonstrated improved walking ability, relative to the similarly aged
patientswithoutPPpreservation.However,thebenefitofpinprickpreservation
hadnoeffectonoutcomeinolderAISBpatients,whocontinuedtodemonstrate
verylow ratesof successfulambulation1 yearfollowing acuteSCI (seeTable
9.3).Inanotherstudy,Wilsonetal.foundthat,whileunivariateanalysisfound
noage-relateddifferencesinmotorrecoveryorinAISgradeconversion,future
functionalindependencewasmarkedlylowerinolderpatients(asmeasuredby
FIMscores).Moreover,multivariateanalysisrevealedthatolderagenegatively
influencedthe relationship of AIS grade to function, particularly among those
withAISBandCinjuries(30).
ThedefinitionofAISBallowsforanumberofwaystohavesensorysacral
sparing including: LT only, PP only, deep anal pressure (DAP) only, or a
combinationofthese.In2016studybyKirshblumetal.,attaininganoutcomeof
AISDat1yearwasmorelikelyinthosewithsacralsparinginacombinationof
modalities(LT,PP,andDAP)spared(4).Furtherinvestigationoftheseissuesis
needed.
MotorIncomplete(AISCandD)
Age has been shown to play a significant rolein therecovery ofLE function
following both incomplete tetraplegia and paraplegia. For those with AIS C,
personsunderage50 have a 91% chance of obtaining community ambulation
upondischargefromrehabilitation,relativetoonly42%ofpersonsagedover50
(46).ThepreviouslydescribedstudybyBurnsandcolleagues(46)examineda
varietyofmotorincompletesubtypes(centralcord,Brown-Séquard,andmixed),
butAISCandDwereseparatelyanalyzed.InastudybyPenrod(45)limitedto
thosewithcentralcordsyndrome,outcomesforambulationdifferedsignificantly
dependingontheageoftheparticipant.Ninety-sevenpercentofthoseunderage
50,but only41% ofthose age50or older,wereabletoambulate atdischarge
frominpatient rehabilitation. However,the authorsdidnot separate those with
AISCfromthosewithAISD.Kayetal.(47) did not find a similar trend of
olderagewithlesserambulationintheirevaluationofAISDpatients,although
they did show a trend to lesser likelihood to ambulate at the time of rehab
dischargeforoldersubjects(55%vs.79%).Incontrast,findingsbyBurnsetal.
showed that, regardless of age, all those with AIS D ambulated following
rehabilitation(46).
Both of the studies mentioned earlier (45,46) examined ambulation at
dischargefromrehabilitation, withlengthsofstayranging from3 to6months
after injury in the period from the early to mid-1990s. With limitations in
insurance coverage, discharge from both acute care and rehabilitation for
incompletetetraplegiain2007occurredinashortertimeaccordedtopatientsin
the1990s.Today,thetrendisevenmore dramaticinterms ofsendingpatients
homeafterjustafewweeksbutatlowerfunctionallevelofrecovery(1),often
deferring long-term goals such as community ambulation to be met in an
outpatientsetting.
IntheinvestigationbyKirshblumetal.(4)examiningtheinfluenceofsacral
sparing on prediction of motor and sensoryrecovery, for those withAIS C at
admission,96.2% eitherremained AISC(44%)orimproved toAIS D(52%).
Persons with initial AIS C with voluntary anal contraction (VAC)as the only
measureofmotorfunctionbelowtheNLIhadthepoorestprognosis;nopatients
progressed to AIS D status, with 0% of patients reaching AIS D at both
dischargetimefromrehaband1yearpost-injury.Incontrast,thosewithVAC,
DAP,andeitherlighttouchorpinprickinthelowestsacralsegmentsprogressed
toAISD60%to87%ofthetime.
TABLE9.3AmbulationAccordingtoASIAGrade
ASIAGRADE BASELINE
EXAM
RATESOFAMBULATION
ASIAImpairmentA
tetraplegia(7) ≤30days 0%communityat1year
paraplegia(6) ≤30days 5%communityat1year(no
subjectsaboveT9level)
FrankelB(earlierscale)
withlighttouchbutabsenceofpinappreciationbelow
zoneofinjury(40)
≤72hours 11%attimeofd/cfrominpatient
rehab
withlighttouchandpresenceofpartialorfullpin
appreciationbelowzoneofinjury(40)
≤72hours 89%attimeofd/cfrom
inpatientrehab
withtouchsensation,withpartialorcompletepin
appreciationbelowlevelofinjury(37)
1–42days 67%attimeofd/cfrom
inpatientrehab
withtouchsensation,butabsenceofanypin
appreciationbelowlevelofinjury(37)
1–42days 14%attimeofd/cfrom
inpatientrehab
ASIAImpairmentB
withPPin>50%LEdermatomes(41) ≤72hours 40%communityambulationat1
year
67%onlyhouseholdambulation
at1year
withPPin<50%LEdermatomes ≤72hours 16%communityambulationat1
year
40%onlyhouseholdambulation
at1year
withatleastpartialPPinlowestsacralsegmentsS45
(41)
4weeks 36%householdambulation
withabsenceofPPinlowestsacralsegmentsS45 4weeks 4.4%householdambulation
ageunder50(43) ≤72hours 15.8%ambulationat1year
age50orolder ≤72hours 7.9%ambulationat1year
underage50withPPin<50%LEdermatomes(43) ≤72hours 10.9%ambulationat1yearpost-
injury
age50orolderwithPPin<50%LEdermatomes ≤72hours 0.0%ambulationat1yearpost-
injury
underage50withPPin≥50%LEdermatomes(43) ≤72hours 50.0%ambulationat1yearpost-
injury
age50orolderwithPPin≥50%LEdermatomes ≤72hours 25.0%ambulationat1yearpost-
injury
ASIAImpairmentC
underage50(46) ≤72hours 91%atleasthouseholdatrehab
d/c
age50orolder ≤72hours 42%atleasthouseholdatrehab
d/c
underage50(47)[NS] ≤72hours 33%,withambulationscore≥3
atrehabd/c
age50orolder ≤72hours 25%,withambulationscore≥3
atrehabd/c
ASIAImpairmentD
allages(46) ≤72hours >95%communityrehabd/c
underage50(47) ≤72hours 79%,withambulationscore≥3
atrehabd/c
age50orolder ≤72hours 55%,withambulationscore≥3
atrehabd/c
ASIA,AmericanSpinalInjuryAssociation;LE,lowerextremity;NS,nonsignificant;PP,pinprick.
FavorablerecoverytoAISDfunctionmaybebetterintermsofLErecovery
than upper-extremity function. Many individuals withboth AIS C andAIS D
SCI continue to demonstrate upper-extremity weakness that leaves them
dependent on others for aspects of self-care activities, particularly if a task
involvesfinemotorfunction(45).
LocalRecoveryattheInitialNeurologicLevelof
Injury
Independent of changes in the AIS grade, improvementsatthe zone of injury
occur in incomplete tetraplegia as well as paraplegia, with outcomes highly
dependentontheinitial(takenasanaverageof30days)motorstrengthofthe
muscle being studied for recovery. Waters published two studies in the 1990s
(13,14)andfoundthatamongthosepatientswithaninitialmotorscoreof0/5in
anygiven upper-extremitymuscle, recovery ofthat muscle to“functional”3/5
strengthat1yearpost-injurywas only5%;in paraplegia55%recovered some
motorfunction, butonly 26%(55/212)achieved thenecessary 3/5tomeetthe
definition of functional motor recovery in that myotome. If a muscle had an
initialscoreof1/5,90%ofpatientswithtetraplegiaachieved3/5by1yearandif
thestartingmotorstrengthwas2/5,thenallsubjectsrecoveredfunctionaluseof
thatmuscleby1yearafterinjury.Personswithparaplegiahavesimilaroutcomes
forachieving3/5strengthat1-yearfollow-upbasedoninitialmotorstrengthof
1/5or2/5.
SpecificSyndromesinMotorIncompleteSCI
Central cord syndrome (CCS) is the most common of incomplete syndromes.
Widelyseenintheelderly,thisconditionhasa profoundeffectonactivitiesof
dailylivingandself-care.Recoveryoccursearlierandtoagreaterextentinthe
legs.Earlierstudiessuggestthat57%to86%ofpatientswiththissyndromewill
ambulateindependently(48,49).Penrod’sstudyofthoseolderandyoungerthan
age50demonstratedasignificantdifferenceinambulationofolder(41%)versus
younger(97%) individualswith CCS(45).Intrinsic handfunction,essential to
maintainingindependence,isoftenthelastimpairmenttoimproveandrecovery
maynotequalthatofthelowerextremities(50).
The anterior cord syndrome is characterized by the absence of volitional
motor function and pinprick versus light touch differentiation, but relative
sparingofproprioceptionandgenerallighttouch exists(37).Thissyndromeis
believedtoaffectspinalcordtractsintheanteriortwo-thirdsofthespinalcord,
specifically the corticospinal tract that controls pain and temperature and the
spinothalamic tract that controls motor function. The anterior cord syndrome,
however,sparesfunctionintheposteriorspinalcordintheregionofthedorsal
columnswherelighttouchandproprioceptionareprocessed.Motorrecoveryfor
ambulationispoorinpatientswiththiscondition(13,37,40).
The Brown-Séquard syndrome constitutes only 2% to 4% of all traumatic
spinal cord injuries but has among the best prognoses of all incomplete
syndromes, with approximately 75% ultimately achieving community
ambulation.Thisconditioninvolvescontralaterallossofpain andtemperature,
with ipsilateral loss of vibratory and proprioception function in addition to
ipsilateralmotorloss.Thispatternofcrossedsensoryandmotorfindingsresults
from the hemisection of the spinal cord. Brown-Séquard syndrome is also
associated with an 80%to 90% recovery ofbowel and bladder function(51).
Moreover, approximately 70% of patients achieve independence or modified
independence with activities of daily living (51). It has been proposed that
uncrossedaxonsinthecontralateralcordfacilitaterecovery(52).
TimingofMotorRecovery:EarlyVersusLate
Theprocess ofplottinga graphofthe annualizedrates of changeagainst time
since injury reveals the course of motor recovery. Regardless of the level or
completeness of injury,the majority of recovery occurs in the first 6 months
followinginjury.Therateofchangeplateausatapproximately9months,butit
doesnotequalzero(Figure9.1).Although somemotorrecoverymaycontinue
for 2 or more yearsafter injury, the degree is generally small and unlikely to
significantlyimprovefunction.Mangeandassociatesexaminedmotorrecovery
in the zone of injury and compared recovery of motor-complete and motorincomplete subjects. Their results suggest that patients with motor-incomplete
injuriesrecoverearlier(9).
In studies by Waters,findings demonstrate that inthe 4% of patients who
undergo“late conversion” (defined as conversionafter30days)to incomplete
status, motor recovery is limited. Late conversion is significant, however, for
recovery of sacral functions. Approximately halfof patientswho undergolate
conversionswillregainvolitionalbowelandbladderfunction(11).Kirshblumet
al.(25)examinedratesofneurologicrecoveryatalatertimeperiod;betweenthe
first and fifth year post-injury. Among 539 subjects with AIS grade A 1 year
post-injury,3.5%improvedtoAISgradeBand1.05%toeachofgradesCand
D.Theremaining94.4%remainedatAISgradeA.
ALTERNATIVEMETHODSOFPREDICTING
PROGNOSIS
PrognosisBasedonReflexRecovery
ImmediatelyfollowinganSCI,allreflexactivitymaybelost,resultinginwhat
is known as “spinal shock.” Recognized by clinicians for over two centuries,
spinalshockinvolvestheloss(areflexia)ortemporarydepression(hyporeflexia)
ofcutaneousanddeeptensionreflexes(DTRs)belowthelevelofinjury;itcan
beaccompaniedbyhypotensionresultingfromalossofsympathetictone.The
underlyingcauseofspinalshockisthelossofconductivityofelectricalsignals
in the spinal cord, preventing the transmission of nerve impulses that control
automatic reflexes below the site of injury. Reflexes above the site of SCI
(rostralreflexes)are generally unaffected bySCI.Staufferhad warned against
predictingoutcomesofSCIpatientsduringtheperiodofspinalshock(52). He
andothersdefinedspinalshockasanabsenceofallreflexes,ascenariorarely
observedeveninthosewithcompleteSCI.
PatternofReflexRecovery
Thereturnof reflexesand theendofspinalshockoccursin aspecificpattern,
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