• Users Online: 219
  • Print this page
  • Email this page

 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 69-81

Predicting outcomes following cervical spine trauma

Spinal Cord Unit, IRCCS Fondazione Santa Lucia, Rome, Italy

Date of Submission06-Apr-2021
Date of Decision20-May-2021
Date of Acceptance13-Sep-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Giorgio Scivoletto
Spinal Cord Unit, IRCCS Fondazione Santa Lucia, via Ardeatina 306, 00179 Rome.
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_29_21

Rights and Permissions

Outcome prediction is fundamental for patients with spinal cord injury (SCI) to allow correct counselling of patients and their families and to determine resource allocation during and after rehabilitation immediately after the lesion. Furthermore, knowledge of the natural history of SCI is mandatory to project and assess the results of clinical trials.Thus, the aim of this narrative review was to provide a clear picture of the neurological and functional outcomes of subjects with cervical SCI.This review was based on MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Central Register of Controlled Trials databases. The following search terms were used: prognosis prediction, SCI, tetraplegia/quadriplegia, neurologic recovery, and ambulation/gait/walking recovery. All article types of the manuscript were included with the exception of animal studies and studies in languages other than English.Both neurological and functional recovery could be prognosticated by the severity of the lesion as assessed by radiological findings and the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). The effect of other factors (such as age, gender and presence of specific syndromes) is also discussed in relation to neurologic and walking recovery.

Keywords: Evaluation, International Standards for Neurological Classification of Spinal Cord Injury, outcomes, prognosis, spinal cord injury

How to cite this article:
Scivoletto G. Predicting outcomes following cervical spine trauma. Indian Spine J 2022;5:69-81

How to cite this URL:
Scivoletto G. Predicting outcomes following cervical spine trauma. Indian Spine J [serial online] 2022 [cited 2022 May 25];5:69-81. Available from: https://www.isjonline.com/text.asp?2022/5/1/69/337140

  Introduction Top

The incidence of traumatic spinal cord injury (SCI) is still a matter of debate and may range from 3.6 to 195.4 patients per million worldwide.[1] Recently, the World Health Organization reported a global incidence of 40–80 new cases per million population per year; this means that between 250,000 and 500,000 people become spinal cord injured every year.[2] The epidemiology of traumatic SCI in Western countries has been changing over the last decades, with an increase in the average age of patients in recent decades.[3],[4],[5],[6],[7],[8],[9] The etiology of trauma has also changed, at least in the Western world, with a reduction in SCI due to traffic accidents and an increase in SCI due to falls. Falls, low-level ones in particular, represent the main cause of SCI among people over the age of 55.[6],[9] Most importantly to the aims of this review, in the last few decades a change in the neurological level of injury (NLI) and severity of SCIs was observed, with a progressive increase of incomplete cervical spinal cord injuries[3]

Despite these changes and advancements in care during the acute phase, SCI remains an event that, depending on the level and severity, can disrupt the motor and sensory pathways of the upper and/or lower extremities, thus resulting in life-lasting disabling consequences. These consequences may affect several functions (motor and sensory function, bladder and bowel control, sexual function). As a result, SCI may have a great impact on patients’ independence and quality of life (QoL).

For subjects with SCI, the goal of rehabilitative interventions is to regain independence and thus a good QoL.[10] From the patients’ perspective, this is achieved by targeting recovery of bladder and bowel function and by focusing on upper limb function in tetraplegic subjects.[11] However, recovery of locomotor ability is also of high priority for SCI subjects independent of the severity, time after injury and age at the time of injury.[11] Unfortunately, despite the expectations of patients with SCI, the recovery of these functions is not always possible.

Therefore, a correct outcome prognosis is mandatory for both patients and professionals.[12] For example, in the first few days following SCI, management strategies are formulated, which often include very early surgical decompression of the spinal cord.[13] This time is exceedingly difficult for injured patients and their families, as they face significant prognostic uncertainty. A precise prognosis may allow clinicians to address questions more accurately regarding a patient’s functional outcomes. In addition, health care systems that are based on insurance require justification for the allocation of resources and treatment options by rehabilitation professionals.[14]

Finally, to enhance neurological recovery following SCI, we require better knowledge of its course, as well as a better understanding of its mechanisms, to develop effective treatment options. There are many interventions, therapies, and devices that have been developed to improve SCI functional outcomes, several of which will undergo clinical trials in the near future. Although some early-stage SCI treatment options go through clinical trials, overall, there is limited evidence of the efficacy of these treatments.[15] Prognostic data are essential to correctly evaluate the efficacy of these new drugs and therapies and to accurately design clinical trials.[15]

  Materials and Methods Top

A systematic search was performed of all papers and websites mentioning SCI and neurological and walking recovery. The literature search was conducted without time limits to identify all papers examining these two aspects in patients with SCI. Databases included PubMed, Ovid MEDLINE, CINAHL, PsychINFO, Cochrane Central Register of Controlled Trials, and Scopus, which includes Embase citations. All study designs, excluding case reports, were included, with no restrictions on the ages of participants. Non-English articles and animal studies were excluded. The following search terms were used: “prognosis” OR “outcomes prediction” AND “SCI” AND “tetraplegia” OR “quadriplegia,” AND “neurologic recovery,” AND “ambulation” OR “gait” OR “walking recovery.” In addition, other databases, such as Google, a hand search of Spinal Cord and an examination of the references of the retrieved articles, yielded other citations not identified by the above strategy.

  Assessing Injury Severity Top

The initial neurological status following injury, as standardized in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) [Figure 1] and [Figure 2],[16] seems to be the best prognostic indicator of SCI functional recovery. This examination establishes a level of neurological injury and severity of the lesion (impairment) according to the ASIA Impairment Scale (AIS). Components of the examination determine voluntary anal contraction and anal sensation for proper diagnosis. Patients who lack sensory or motor function at the lowest sacral segments are considered to have a complete lesion (AIS A). Patients with sensation and/or motor function below the level of neurological injury, particularly within the lowest sacral segments (anal sensation, including deep anal pressure and voluntary external anal sphincter contraction), are considered to have incomplete lesions.
Figure 1: Scoring sheet for the International Standards for Neurological Classification of Spinal Cord Injury (Reproduced and adapted with permission)

Click here to view
Figure 2: Explanations for classification (Reproduced and adapted with permission)

Click here to view

It is recommended that this examination take place 72 h after neurological injury[17] because examination within 24 h can be unreliable.[18],[19] However, another common baseline examination is at 1 month following injury,[20],[21],[22],[23] which historically corresponds to admission to a rehabilitation facility. Regardless, clinicians should be aware of the baseline time points used in the medical literature when establishing a prognosis.[24],[25] Communication barriers, such as mechanical ventilation, intoxication, chemical sedation, paralysis, closed head injury, psychiatric illness, language, severe pain, or cerebral palsy, can reduce the reliability of the results from this examination.[26]

  Neurological Improvement Top

Neurologic recovery is particularly important to patients, as the completeness or incompleteness of a lesion is one of the most relevant determinants of functional outcome.

ASIA Impairment Scale grade conversion and motor score improvement

Several studies have assessed AIS grade conversion.[15],[27],[28] Overall, approximately 50% of patients with traumatic SCI show a conversion of the AIS grade. The chance of conversion varies based on the initial AIS grade, with patients with AIS B and C improving more than those with AIS A and D[15],[27],[28] [Table 1]. Furthermore, the rate of recovery seems to be higher for tetraplegic patients (with up to 30% of AIS A patients improving their AIS grade) than for paraplegic patients[15],[29],[30] [Table 1]. Two possible explanations have been suggested for this difference. First, tetraplegic patients may be given an incorrect initial classification due to communication barriers.[31] Alternatively, it is possible that the mechanical forces necessary to cause trauma to the cervical spine are lower than those needed to cause injury to the thoracic spine, thus being associated with less complete injuries.[24] The rate of conversion in tetraplegic patients may depend on the lesion level, being higher for those with C7 lesions (59%) than for those with C4 lesions (15%).[30] Regarding the time of recovery, approximately 60% of conversions occur in the first 2 months following injury, and 77% occur within the first 3 months; however, some recovery continues throughout the first year after injury.[27],[30] Therefore, if the initial examination is performed later, the rate of AIS grade conversion can be much lower because baseline assessments will not capture any conversion occurring between 0 and 30 days post-injury. This can comprise improvement rates between 4% and 16% for AIS grade A patients, between 26% and 48% for AIS grade B patients, and between 51% and 54% for AIS grade C patients.[21],[23],[32],[33] Furthermore, it is also possible for patients with complete injury to experience recovery more than one year later. Of 571 patients with SCI, 5.6% of complete injuries converted between 1 and 5 years post-injury; however, very few patients converted to AIS grade D, and many could have been incorrectly assessed.[34]
Table 1: Neurological improvement after SCI

Click here to view

An important prognostic factor for recovery is the presence and extent of a sensory zone of partial preservation (ZPP). Sensory ZPPs are defined as spinal cord segments below the sensory level with preserved sensory function.[30] A baseline sensory ZPP of three or more segments correlated with a higher chance of AIS grade conversion: AIS A patients with a ZPP of more than three segments are three times more likely to convert to motor incomplete than patients with a smaller ZPP.[28]

The motor score improvement varied based on the initial AIS grade being greater for AIS B and C subjects than for AIS A and D subjects[29],[30],[31] [Table 1]. However, motor incomplete tetraplegic patients may continue to have a noticeable loss of strength in the upper limbs, with a residual deficit of 30% (15 of 50 points),[30] which could explain why these patients have a greater deficit in self-care activities than in walking.[35] It is also important to consider the distribution of upper extremity motor score recovery rather than the total recovery. If the recovery is distributed over all ten key muscles of the upper extremity (with low motor improvement per muscle), this has little meaning. However, if the same amount of recovery occurs in a few muscles, the improvement could be measured as an improvement of 1 or 2 levels.[36]

With regard to lower extremity recovery, patients with complete tetraplegia have a very low probability of motor recovery in the lower extremities (<5%), especially if they remain clinically complete for more than 1-month post-injury.[23] Furthermore, any recovered lower extremity motor function is usually nonfunctional.

The descent in the level of lesions in complete tetraplegic patients is of fundamental importance, particularly for those with complete lesions, as lesions at lower levels correspond with higher levels of function. According to different studies, most AIS grade A tetraplegic patients recovered at least 1 level, but fewer recovered 2 or more levels[31],[32] [Table 1].

The rate of motor level descent was higher for those with initial injuries at levels C5 (75%) and C6 (85%) than for those with a C4 level injury (70%)[37] [Table 1].

Several articles have been dedicated to the prognosis of recovery at or below the level of lesions in tetraplegic patients. In these studies, recovery to a grade of 3/5 was a positive outcome, as this is considered a motor power suitable for daily activities.[21],[22],[37],[38],[39] The most important factor associated with upper extremity recovery is the presence/absence of any movement at the level of injury[38] [Table 1]. The presence of motor strength at a determinate level is also predictive of recovery at the next level[39] [Table 1]. Finally, the presence/absence of pinprick sensation at the level of injury is also associated with recovery.[40] Patients with pinprick sensation (1/2 or 2/2) at the level of injury are more likely to recover a strength of 3/5 in the next caudal level (93%) than patients without pinprick sensations (22%).

  Functional Outcomes and Walking Recovery Top

Functional outcome in patients with complete lesions

Functional outcome prognosis is an important part of helping patients with SCI, relatives, and professionals to understand functional capacity at the time of discharge from rehabilitation. There is a close relationship between the level of lesion and the level of independence in the activities of daily life (ADL) in patients with motor complete lesions, which is particularly important for those with cervical lesions. This relationship between injury level and function has been excellently summarized in the clinical practice guidelines published by the Consortium for Spinal Cord Medicine [Table 2].[41]
Table 2: Expected functional outcomes for patients with complete lesion at different cervical levels

Click here to view

The outcomes as described by the abovementioned clinical practice guidelines generally apply to younger, physically fit patients with complete lesions. Therefore, older patients with comorbidities may not reach these results. Furthermore, functional outcomes can be positively or negatively influenced by several demographic (age, see below), clinical (presence of pain and spasticity), and psychological (motivation and depression) factors.[42],[43],[44]

Walking recovery

Patients with SCI, especially those with incomplete lesions, consider walking as a primary recovery goal.[45] Therefore, a precise evaluation of the natural recovery of walking and of the prognostic factors influencing this function is required.[46] Walking recovery could be defined as the ability to walk independently in the community, with or without the use of devices or braces.[47]

AIS grade at initial examination is considered the basis for predicting functional walking recovery.[48] Patients with AIS grade A at their first examination have very few chances of achieving ambulation, especially those with tetraplegia[27],[32],[48] [Table 3].
Table 3: Prediction of functional walking according to AIS impairment and other features

Click here to view

The overall walking recovery of patients with grade B at the initial examination is approximately 33%.[20],[48],[49],[50] This percentage varies depending on the modality of the sensation spared at the lowest sacral segments, with patients with light touch and pinprick preservation having a better walking recovery than those with light touch only[20],[49],[50] [Table 3]. Preservation of the pinprick and light touch sensations indicates the integrity of the spinothalamic and posterior column tracts. These structures are relatively close to the corticospinal tracts; therefore, their preservation could indicate possible sparing of the motor pathways.[50]

AIS grade C patients have a better prognosis for walking recovery than sensory incomplete, motor complete patients, with an overall recovery rate of approximately 75%[21],[46],[48],[49],[50] [Table 3]. Several characteristics are of prognostic value for walking recovery in these patients: lower extremity strength and upper extremity strength in tetraplegic patients and age and timing of strength recovery.[21],[46] For patients with incomplete tetraplegia, there is an important relationship between upper extremity strength and ambulation recovery, with patients who are community or household ambulators having significantly higher motor scores. This is probably due to the importance of upper extremity strength for device use during walking.[21]

Finally, patients with AIS grade D at admission had a very good ambulation prognosis at discharge from rehabilitation and at 1-year post-injury[18],[42],[48],[51] [Table 3].

Bladder function recovery

An important sequela of SCI is the loss of bladder and bowel control. Little is known about bladder recovery after spinal lesions, although bladder control is of major importance to patients with SCI and their families to enable function in the workplace or classroom.[52] Overall, 33% of patients with SCI recover normal bladder control.[53]

The main predictive factor for bladder recovery (normal voiding) seems to be the neurological status at the moment of the first examination, particularly with regard to AIS grade: none of the patients with AIS grade A at admission recover volitional micturition, whereas 17% of AIS grade B patients, 63% of AIS grade C patients, and 67% of AIS grade D patients do.[53],[54] An important prognostic factor for bladder recovery is the preservation of the pinprick sensation together with the light touch sensation, rather than the light touch sensation alone. No patient with an absent pinprick sensation at the first examination voids was unassisted, compared to 65%–70% of those with a pinprick sensation.[55]

The level of the lesion is associated with bladder recovery. Patients with thoracic lesions have a lower probability of recovering volitional voiding than patients with cervical lesions,[53] probably because patients with thoracic lesions more often show complete injuries. However, patients with cervical lesions undergoing clean intermittent catheterization to void their bladder experience difficulties in the maneuver depending on the level of hand function compromise.[56]

  Algorithms and Prediction Rules Top

In recent times, algorithms have been developed to predict functional outcomes and to identify patients in the subacute phase who could achieve walking.

A formula based on acute clinical and radiologic data was recently produced to prognosticate the probability of independence in ADLs.[57] The formula incorporates four predictor variables: AIS, dichotomized ASIA motor score, age, and MRI intramedullary signal characteristics. The results of the model indicate that better functional status is predicted by a sequentially less severe initial AIS grade and an AMS greater than 50 at hospital admission.[57]

Zorner[58] reported a clinical algorithm to predict independent walking (as assessed by the Walking Index for Spinal Cord Injury). In incomplete tetraplegia, the presence of lower extremity motor scores >25 and the presence of tibial somatosensory evoked potential (SSEP), either delayed but with normal amplitude or normal, correctly predicted independent walking in 92% of cases.[58]

Another clinical prediction rule for walking recovery is based on the combination of age (<65 vs. ≥65 years), motor scores of the quadriceps femoris (L3), gastrosoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1.[59] Each factor received a weighted coefficient that produced a minimum and a maximum score when multiplied by the score of each factor. The sum of these scores was used to predict independent walking at one year after injury. This rule showed an excellent discrimination capacity in recognizing patients who achieved independent ambulation at follow-up.[59]

Finally, Pavese recently showed that normal bladder function may be reliably predicted by a simple model based on lower extremity motor scores at initial (within 40 days after the lesion) evaluation.[60]

  Factors Affecting Neurological and Functional Recovery Top


The effect of age on the recovery of patients with SCI is of particular relevance, as the average age of patients with SCI is constantly increasing.[61] Despite several studies dedicated to this issue, the effect of age on SCI recovery is still controversial. Although the negative effect of advanced age on the functional recovery of patients with SCI is quite well established,[62],[63],[64],[65],[66],[67] it is still to be decided if age may also affect neurologic recovery. Previously, increased age was considered to negatively affect neurological improvement[62],[63] [Table 4], as it has been hypothesized that decreased neural plasticity associated with age is the basis for these differences in neurologic recovery.[68],[69] However, other studies failed to identify an age-related effect on neurologic recovery following SCI[66],[67],[68],[69] [Table 4]. Furthermore, in a recent postmortem examination of the spinal cord from patients with SCI, elderly and younger individuals did not show differences in the extent of myelin degeneration or the number of intact axons within spinal cord tracts[67] [Table 4].
Table 4: Factors influencing neurological and functional outcomes

Click here to view

Younger patients also have better outcomes in bladder management. Specifically, patients under 50 years of age achieve bladder-voiding independence more frequently than their older counterparts. Interestingly, this difference includes the ability to perform clean intermittent catheterization and to void spontaneously.[63]


The ISNCSCI allows the recognition of several incomplete spinal cord syndromes with different prognostic values.[15],[70] At the cervical level, the most common is central cord syndrome (CCS), which represents approximately 9% of the total SCIs[70] and is characterized by a disproportionate impairment in the upper and lower limbs, with more pronounced muscle strength loss and reduced function in the upper extremities, neurogenic bladder dysfunction and different degrees of sensation loss.[71] As the lower extremities are less affected than the upper extremities, CCS patients have a good prognosis for walking recovery but lower independence in daily life activities, particularly with regard to self-care[72],[73],[74] [Table 4].

Brown-Sèquard syndrome (BSS) is also relatively frequent at the cervical level and is usually due to stab-wound injuries.[75] It is due to spinal hemisection and therefore is characterized by ipsilateral hemiplegia or contralateral hemianalgesia.[76],[77] BSS accounts for 2% to 4% of all traumatic SCIs.[70] Similar to CCS, BSS is characterized by a good functional prognosis, particularly regarding walking recovery, with approximately 75% of patients regaining independent walking at discharge from rehabilitation[77] [Table 4].

Both syndromes are characterized by a good prognosis for bladder control recovery.[70]


Epidemiological data indicate that women are less likely to sustain traumatic injury than men and have a higher frequency of incomplete lesions (probably due to nontraumatic etiology).[78] Therefore, male and female patient comparisons require special matching to control for the covariant effects of age and injury features. The effect of sex on neurological recovery is still a matter of debate. The results from experimental studies suggested that a sex-related difference in neurological recovery exists in favor of female sex and appears to be related to the positive effects of estrogen and progesterone.[79] In the clinical field, Sipski[80] reported that women had higher changes in ASIA total motor scores from admission to one year after the lesion [Table 4]. However, other articles indicated that sex has no effect on neurological status at admission or on neurological improvement[78],[81],[82] [Table 4].

Etiology of the lesion

The impact of the etiology of the lesion (either traumatic or nontraumatic) deserves attention, as nontraumatic lesions are increasing with the ageing of the population. Patients with nontraumatic lesions show several clinical and epidemiological characteristics: they are older and more often have an incomplete lesion. However, when the confounding effects of age and lesion completeness were considered, the neurological and functional outcomes of the two populations were comparable.[83],[84],[85] One noticeable exception is represented by patients with traumatic cervical SCI, in which the neurological recovery seems to be lower than that of their nontraumatic counterparts[86] [Table 4].

Severity of the lesion as assessed by radiological examinations

Before the advent of magnetic resonance imaging (MRI), there were no imaging methods to assess the severity of traumatic SCI. At that time, important features related to the severity of lesions were considered the amount of canal compromise and the amount of spinal cord compression at radiographic or computed tomography examination[87],[88] [Table 5].
Table 5: Radiological prognostic factors

Click here to view

The advent of MRI provided a rapid noninvasive evaluation of the amount of spinal cord compression[89] as well as the spinal cord parenchyma and extent of spinal cord damage.[90] A damaged spinal cord usually shows two main features, intramedullary hemorrhage and edema, that together with the amount of affected spinal cord tissue are directly correlated with the initial neurologic deficit and prognosis[91],[92],[93],[94],[95],[96],[97] [Table 5].

  Conclusion Top

The neurological and functional recovery of subjects with cervical SCI could be reliably predicted based on the level and severity of the injury. Age and possibly other demographic and clinical features (sex, etiology) may affect recovery after SCI.

Ethical policy and institutional review board statement

Not applicable.

Financial support and sponsorship

This study was supported by the ERANET-NEURON grant to Giorgio Scivoletto.

Conflicts of interest

There are no conflicts of interest.

  References Top

Jazayeri SB, Beygi S, Shokraneh F, Hagen EM, Rahimi-Movaghar V Incidence of traumatic spinal cord injury worldwide: A systematic review. Eur Spine J 2015;24:905-18.  Back to cited text no. 1
Bickenbach J, Boldt I, Brinkhof M, Chamberlain J, Cripps R, Fitzharris M, et al. A global picture of spinal cord injury. In: Bickenbach J, editor. International Spinal Cord Society, W. H. O. in International Perspectives on Spinal Cord Injury. Geneva: World Health Organization; 2013.p.11-32.  Back to cited text no. 2
Nijendijk JHB, Post MWM, van Asbeck FWA Epidemiology of traumatic spinal cord injuries in the Netherlands in 2010. Spinal Cord 2014;52:258-63.  Back to cited text no. 3
McCaughey EJ, Purcell M, McLean AN, Fraser MH, Bewick A, Borotkanics RJ, et al. Changing demographics of spinal cord injury over a 20-year period: A longitudinal population-based study in Scotland. Spinal Cord 2016;54:270-6.  Back to cited text no. 4
Ferro S, Cecconi L, Bonavita J, Pagliacci MC, Biggeri A, Franceschini M Incidence of traumatic spinal cord injury in Italy during 2013-2014: A population-based study. Spinal Cord 2017;55:1103-7.  Back to cited text no. 5
Montoto-Marqués A, Ferreiro-Velasco ME, Salvador- de la Barrera S, Balboa-Barreiro V, Rodriguez-Sotillo A, Meijide-Failde R Epidemiology of traumatic spinal cord injury in Galicia, Spain: Trends over a 20-year period. Spinal Cord 2017;55:588-94.  Back to cited text no. 6
Pagliacci MC, Celani MG, Zampolini M, Spizzichino L, Franceschini M, Baratta S, et al; Gruppo Italiano Studio Epidemiologico Mielolesioni. An Italian survey of traumatic spinal cord injury. The Gruppo Italiano Studio Epidemiologico Mielolesioni study. Arch Phys Med Rehabil 2003;84: 1266-75.  Back to cited text no. 7
Chamberlain JD, Deriaz O, Hund-Georgiadis M, Meier S, Scheel-Sailer A, Schubert M, et al. Epidemiology and contemporary risk profile of traumatic spinal cord injury in Switzerland. Inj Epidemiol 2015;2:28.  Back to cited text no. 8
Geisler FH, Coleman WP, Grieco G, Poonian D; Sygen Study Group. Measurements and recovery patterns in a multicenter study of acute spinal cord injury. Spine (Phila Pa 1976) 2001;26: S68-86.  Back to cited text no. 9
Hubli M, Dietz V The physiological basis of neurorehabilitation–locomotor training after spinal cord injury. J Neuroeng Rehabil 2013;10:5.  Back to cited text no. 10
Adriaansen JJ, Ruijs LE, van Koppenhagen CF, van Asbeck FW, Snoek GJ, van Kuppevelt D, et al. Secondary health conditions and quality of life in persons living with spinal cord injury for at least ten years. J Rehabil Med 2016;48:853-60.  Back to cited text no. 11
Chay W, Kirshblum S Predicting outcomes after spinal cord injury. Phys Med Rehabil Clin N Am 2020;31:331-43.  Back to cited text no. 12
Wilson JR, Grossman RG, Frankowski RF, Kiss A, Davis AM, Kulkarni AV, et al. A clinical prediction model for long-term functional outcome after traumatic spinal cord injury based on acute clinical and imaging factors. J Neurotrauma 2012;29:2263-71.  Back to cited text no. 13
Jongbloed L, Wendland T The impact of reimbursement systems on occupational therapy practice in Canada and the United States of America. Can J Occup Ther 2002;69:143-52.  Back to cited text no. 14
Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: Spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord 2007;45:190-205.  Back to cited text no. 15
Kirshblum S, Snider B, Rupp R, Read MS; International Standards Committee of ASIA and ISCoS. Updates of the international standards for neurologic classification of spinal cord injury: 2015 and 2019. Phys Med Rehabil Clin N Am 2020;31:319-30.  Back to cited text no. 16
Whiteneck G, Adler C, Bidddle AK, et al. Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-care Professionals. Washington, DC: Paralyzed Veterans of America; 1999.  Back to cited text no. 17
Maynard FM, Reynolds GG, Fountain S, Wilmot C, Hamilton R Neurological prognosis after traumatic quadriplegia. Three-year experience of California regional spinal cord injury care system. J Neurosurg 1979;50:611-6.  Back to cited text no. 18
Brown PJ, Marino RJ, Herbison GJ, Ditunno JF Jr. The 72-hour examination as a predictor of recovery in motor complete quadriplegia. Arch Phys Med Rehabil 1991;72:546-8.  Back to cited text no. 19
Waters RL, Yakura JS, Adkins RH, Sie I Recovery following complete paraplegia. Arch Phys Med Rehabil 1992;73:784-9.  Back to cited text no. 20
Waters RL, Adkins RH, Yakura JS, Sie I Motor and sensory recovery following complete tetraplegia. Arch Phys Med Rehabil 1993;74:242-7.  Back to cited text no. 21
Waters RL, Adkins RH, Yakura JS, Sie I Motor and sensory recovery following incomplete tetraplegia. Arch Phys Med Rehabil 1994;75:306-11.  Back to cited text no. 22
Waters RL, Adkins RH, Yakura JS, Sie I Motor and sensory recovery following incomplete paraplegia. Arch Phys Med Rehabil 1994;75:67-72.  Back to cited text no. 23
Kirshblum SC, O’Connor KC Predicting neurologic recovery in traumatic cervical spinal cord injury. Arch Phys Med Rehabil 1998;79:1456-66.  Back to cited text no. 24
Burns AS, Ditunno JF Establishing prognosis and maximizing functional outcomes after spinal cord injury: A review of current and future directions in rehabilitation management. Spine (Phila Pa 1976) 2001;26:S137-45.  Back to cited text no. 25
Burns AS, Lee BS, Ditunno JF Jr, Tessler A Patient selection for clinical trials: The reliability of the early spinal cord injury examination. J Neurotrauma 2003;20:477-82.  Back to cited text no. 26
Spiess MR, Müller RM, Rupp R, Schuld C, van Hedel HJ; EM-SCI Study Group. Conversion in ASIA Impairment Scale during the first year after traumatic spinal cord injury. J Neurotrauma 2009;26:2027-36.  Back to cited text no. 27
Marino RJ, Ditunno JF Jr, Donovan WH, Maynard F Jr. Neurologic recovery after traumatic spinal cord injury: Data from the model spinal cord injury systems. Arch Phys Med Rehabil 1999;80:1391-6.  Back to cited text no. 28
Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: An update from the national spinal cord injury database. Arch Phys Med Rehabil 2011;92:369-75.  Back to cited text no. 29
Steeves JD, Kramer JK, Fawcett JW, Cragg J, Lammertse DP, Blight AR, et al; EMSCI Study Group. Extent of spontaneous motor recovery after traumatic cervical sensorimotor complete spinal cord injury. Spinal Cord 2011;49:257-65.  Back to cited text no. 30
Burns AS, Marino RJ, Flanders AE, Flett H Clinical diagnosis and prognosis following spinal cord injury. Handb Clin Neurol 2012;109:47-62.  Back to cited text no. 31
Catz A, Goldin D, Fishel B, Ronen J, Bluvshtein V, Gelernter I Recovery of neurologic function following nontraumatic spinal cord lesions in Israel. Spine (Phila Pa 1976) 2004;29:2278-82; discussion 2283.  Back to cited text no. 32
Scivoletto G, Morganti B, Molinari M Neurologic recovery of spinal cord injury patients in Italy. Arch Phys Med Rehabil 2004;85:485-9.  Back to cited text no. 33
Kirshblum S, Millis S, McKinley W, Tulsky D Late neurologic recovery after traumatic spinal cord injury. Arch Phys Med Rehabil 2004;85:1811-7.  Back to cited text no. 34
Penrod LE, Hegde SK, Ditunno JF Jr. Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehabil 1990;71:963-8.  Back to cited text no. 35
Kramer JL, Lammertse DP, Schubert M, Curt A, Steeves JD Relationship between motor recovery and independence after sensorimotor-complete cervical spinal cord injury. Neurorehabil Neural Repair 2012;26:1064-71.  Back to cited text no. 36
Ditunno JF Jr, Cohen ME, Hauck WW, Jackson AB, Sipski ML Recovery of upper-extremity strength in complete and incomplete tetraplegia: A multicenter study. Arch Phys Med Rehabil 2000;81:389-93.  Back to cited text no. 37
Ditunno JF Jr, Stover SL, Freed MM, Ahn JH Motor recovery of the upper extremities in traumatic quadriplegia: A multicenter study. Arch Phys Med Rehabil 1992;73:431-6.  Back to cited text no. 38
Ditunno JF Jr, Sipski ML, Posuniak EA, Chen YT, Staas WE Jr, Herbison GJ Wrist extensor recovery in traumatic quadriplegia. Arch Phys Med Rehabil 1987;68:287-90.  Back to cited text no. 39
Browne BJ, Jacobs SR, Herbison GJ, Ditunno JF Jr. Pin sensation as a predictor of extensor carpi radialis recovery in spinal cord injury. Arch Phys Med Rehabil 1993;74:14-8.  Back to cited text no. 40
Consortium for Spinal Cord Medicine. Outcomes following traumatic spinal cord injury: Clinical practice guidelines for health-care professionals. J Spinal Cord Med 2000;23:289-316.  Back to cited text no. 41
Saebu M, Sørensen M Factors associated with physical activity among young adults with a disability. Scand J Med Sci Sports 2011;21:730-8.  Back to cited text no. 42
Bravo-Esteban E, Taylor J, Abián-Vicén J, Albu S, Simón-Martínez C, Torricelli D, et al. Impact of specific symptoms of spasticity on voluntary lower limb muscle function, gait and daily activities during subacute and chronic spinal cord injury. Neurorehabilitation 2013;33:531-43.  Back to cited text no. 43
Tawashy AE, Eng JJ, Lin KH, Tang PF, Hung C Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: A correlational study. Spinal Cord 2009;47:301-6.  Back to cited text no. 44
Ditunno PL, Patrick M, Stineman M, Ditunno JF Who wants to walk? Preferences for recovery after SCI: A longitudinal and cross-sectional study. Spinal Cord 2008;46:500-6.  Back to cited text no. 45
Crozier KS, Cheng LL, Graziani V, Zorn G, Herbison G, Ditunno JF Jr. Spinal cord injury: Prognosis for ambulation based on quadriceps recovery. Paraplegia 1992;30:762-7.  Back to cited text no. 46
Hussey RW, Stauffer ES Spinal cord injury: Requirements for ambulation. Arch Phys Med Rehabil 1973;54:544-7.  Back to cited text no. 47
van Middendorp JJ, Hosman AJ, Pouw MH, Van de Meent H; EM-SCI Study Group. ASIA Impairment Scale conversion in traumatic SCI: Is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 2009;47:555-60.  Back to cited text no. 48
Katoh S, el Masry WS Motor recovery of patients presenting with motor paralysis and sensory sparing following cervical spinal cord injuries. Paraplegia 1995;33:506-9.  Back to cited text no. 49
Oleson CV, Burns AS, Ditunno JF, Geisler FH, Coleman WP Prognostic value of pinprick preservation in motor complete, sensory incomplete spinal cord injury. Arch Phys Med Rehabil 2005;86:988-92.  Back to cited text no. 50
Burns SP, Golding DG, Rolle WA Jr, Graziani V, Ditunno JF Jr. Recovery of ambulation in motor-incomplete tetraplegia. Arch Phys Med Rehabil 1997;78:1169-72.  Back to cited text no. 51
Patrick M, Ditunno P, Ditunno JF, et al. A comparison of spinal cord injury (SCI) consumers/staff preference for walking: A pilot study. J Spinal Cord Med 2003;26:541.  Back to cited text no. 52
Scivoletto G, Cosentino E, Morganti B, Farchi S, Molinari M Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions. Disabil Rehabil 2008;30:330-7.  Back to cited text no. 53
Maynard FM Assessment and prognosis in spinal cord lesions. Annual readapatation Med Phys 1992;35:44-7.  Back to cited text no. 54
Weiss DJ, Fried GW, Chancellor MB, Herbison GJ, Ditunno JF Jr, Staas WE Jr. Spinal cord injury and bladder recovery. Arch Phys Med Rehabil 1996;77:1133-5.  Back to cited text no. 55
Elliott CS, Stoffel JT, Myers JB, Lenherr SM, Welk B, Elliott SP, et al. Validation of upper extremity motor function as a key predictor of bladder management after spinal cord injury. Arch Phys Med Rehabil 2019;100:1939-44.  Back to cited text no. 56
Kaminski L, Cordemans V, Cernat E, M’Bra KI, Mac-Thiong JM Functional outcome prediction after traumatic spinal cord injury based on acute clinical factors. J Neurotrauma 2017;34:2027-33.  Back to cited text no. 57
Zörner B, Blanckenhorn WU, Dietz V, Curt A; EM-SCI Study Group. Clinical algorithm for improved prediction of ambulation and patient stratification after incomplete spinal cord injury. J Neurotrauma 2010;27:241-52.  Back to cited text no. 58
van Middendorp JJ, Hosman AJ, Donders AR, Pouw MH, Ditunno JF Jr, Curt A, et al; EM-SCI Study Group. A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: A longitudinal cohort study. Lancet 2011;377:1004-10.  Back to cited text no. 59
Pavese C, Schneider MP, Schubert M, Curt A, Scivoletto G, Finazzi-Agrò E, et al. Prediction of bladder outcomes after traumatic spinal cord injury: A longitudinal cohort study. PLOS Med 2016;13:e1002041.  Back to cited text no. 60
Wirz M, Dietz V Concepts of aging with paralysis: Implications for recovery and treatment. Handb Clin Neurol 2012;109:77-84.  Back to cited text no. 61
Cifu DX, Seel RT, Kreutzer JS, McKinley WO A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample. Arch Phys Med Rehabil 1999;80:733-40.  Back to cited text no. 62
Scivoletto G, Morganti B, Ditunno P, Ditunno JF, Molinari M Effects on age on spinal cord lesion patients’ rehabilitation. Spinal Cord 2003;41:457-64.  Back to cited text no. 63
von Leden RE, Khayrullina G, Moritz KE, Byrnes KR Age exacerbates microglial activation, oxidative stress, inflammatory and NOX2 gene expression, and delays functional recovery in a middle-aged rodent model of spinal cord injury. J Neuroinflammation 2017;14:161.  Back to cited text no. 64
Kempermann G, Gast D, Gage FH Neuroplasticity in old age: Sustained fivefold induction of hippocampal neurogenesis by long-term environmental enrichment. Ann Neurol 2002;52:135-43.  Back to cited text no. 65
Furlan JC, Fehlings MG The impact of age on mortality, impairment, and disability among adults with acute traumatic spinal cord injury. J Neurotrauma 2009;26:1707-17.  Back to cited text no. 66
Furlan JC, Bracken MB, Fehlings MG Is age a key determinant of mortality and neurological outcome after acute traumatic spinal cord injury? Neurobiol Aging 2010;31:434-46.  Back to cited text no. 67
Wilson JR, Davis AM, Kulkarni AV, Kiss A, Frankowski RF, Grossman RG, et al. Defining age-related differences in outcome after traumatic spinal cord injury: Analysis of a combined, multicenter dataset. Spine J 2014;14:1192-8.  Back to cited text no. 68
Wirz M, Dietz V; European Multicenter Study of Spinal Cord Injury (EMSCI) Network. Recovery of sensorimotor function and activities of daily living after cervical spinal cord injury: The influence of age. J Neurotrauma 2015;32:194-9.  Back to cited text no. 69
McKinley W, Santos K, Meade M, Brooke K Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med 2007;30:215-24.  Back to cited text no. 70
Wirz M, Zörner B, Rupp R, Dietz V Outcome after incomplete spinal cord injury: Central cord versus Brown-Sequard syndrome. Spinal Cord 2010;48:407-14.  Back to cited text no. 71
Aito S, D’Andrea M, Werhagen L, Farsetti L, Cappelli S, Bandini B, et al. Neurological and functional outcome in traumatic central cord syndrome. Spinal Cord 2007;45:292-7.  Back to cited text no. 72
Blasetti G, Pavese C, Maier DD, Weidner N, Rupp R, Abel R, et al. Comparison of outcomes between people with and without central cord syndrome. Spinal Cord 2020;58:1263-73.  Back to cited text no. 73
Newey ML, Sen PK, Fraser RD The long-term outcome after central cord syndrome: A study of the natural history. J Bone Joint Surg Br 2000;82:851-5.  Back to cited text no. 74
Gentleman D, Harrington M Penetrating injury of the spinal cord. Injury 1984;16:7-8.  Back to cited text no. 75
Brown-Sequard CE Lectures on the physiology and pathology of the central nervous system and the treatment of organic nervous affections. Lancet 1868;2:593-5.  Back to cited text no. 76
Roth EJ, Park T, Pang T, Yarkony GM, Lee MY Traumatic cervical brown-sequard and brown-sequard-plus syndromes: The spectrum of presentations and outcomes. Paraplegia 1991;29:582-9.  Back to cited text no. 77
Scivoletto G, Morganti B, Molinari M Sex-related differences of rehabilitation outcomes of spinal cord lesion patients. Clin Rehabil 2004;18:709-13.  Back to cited text no. 78
Stewart AN, MacLean SM, Stromberg AJ, Whelan JP, Bailey WM, Gensel JC, et al. Corrigendum: Considerations for studying sex as a biological variable in spinal cord injury. Front Neurol 2020;11: 597689.  Back to cited text no. 79
Sipski ML, Jackson AB, Gómez-Marín O, Estores I, Stein A Effects of gender on neurologic and functional recovery after spinal cord injury. Arch Phys Med Rehabil 2004;85:1826-36.  Back to cited text no. 80
Furlan JC, Krassioukov AV, Fehlings MG The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury. J Neurotrauma 2005;22:368-81.  Back to cited text no. 81
McKinley WO, Seel RT, Gadi RK, Tewksbury MA Nontraumatic vs. traumatic spinal cord injury: A rehabilitation outcome comparison. Am J Phys Med Rehabil 2001;80:693-9; quiz 700, 716.  Back to cited text no. 82
Scivoletto G, Farchi S, Laurenza L, Molinari M Traumatic and non-traumatic spinal cord lesions: An Italian comparison of neurological and functional outcomes. Spinal Cord 2011;49:391-6.  Back to cited text no. 83
Gedde MH, Lilleberg HS, Aßmus J, Gilhus NE, Rekand T Traumatic vs non-traumatic spinal cord injury: A comparison of primary rehabilitation outcomes and complications during hospitalization. J Spinal Cord Med 2019;42:695-701.  Back to cited text no. 84
Machino M, Ando K, Kobayashi K, Morozumi M, Tanaka S, Ito K, et al. Differences in clinical outcomes between traumatic cervical myelopathy and degenerative cervical myelopathy: A comparative study of cervical spinal cord injury without major bone injury and cervical spondylotic myelopathy. J Clin Neurosci 2019;70:127-31.  Back to cited text no. 85
Kang JD, Figgie MP, Bohlman HH Sagittal measurements of the cervical spine in subaxial fractures and dislocations. An analysis of two hundred and eighty-eight patients with and without neurological deficits. J Bone Joint Surg Am 1994;76:1617-28.  Back to cited text no. 86
Hayashi K, Yone K, Ito H, Yanase M, Sakou T MRI findings in patients with a cervical spinal cord injury who do not show radiographic evidence of a fracture or dislocation. Paraplegia 1995;33:212-5.  Back to cited text no. 87
Fehlings MG, Rao SC, Tator CH, Skaf G, Arnold P, Benzel E, et al. The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part II: Results of a multicenter study. Spine (Phila Pa 1976) 1999;24:605-13.  Back to cited text no. 88
Yamashita Y, Takahashi M, Matsuno Y, Kojima R, Sakamoto Y, Oguni T, et al. Acute spinal cord injury: Magnetic resonance imaging correlated with myelopathy. Br J Radiol 1991;64:201-9.  Back to cited text no. 89
Bondurant FJ, Cotler HB, Kulkarni MV, McArdle CB, Harris JH Jr. Acute spinal cord injury. A study using physical examination and magnetic resonance imaging. Spine (Phila Pa 1976) 1990;15:161-8.  Back to cited text no. 90
Flanders AE, Schaefer DM, Doan HT, Mishkin MM, Gonzalez CF, Northrup BE Acute cervical spine trauma: Correlation of MR imaging findings with degree of neurologic deficit. Radiology 1990;177:25-33.  Back to cited text no. 91
Flanders AE, Spettell CM, Tartaglino LM, Friedman DP, Herbison GJ Forecasting motor recovery after cervical spinal cord injury: Value of MR imaging. Radiology 1996;201:649-55.  Back to cited text no. 92
Boldin C, Raith J, Fankhauser F, Haunschmid C, Schwantzer G, Schweighofer F Predicting neurologic recovery in cervical spinal cord injury with postoperative MR imaging. Spine (Phila Pa 1976) 2006;31:554-9.  Back to cited text no. 93
Sato T, Kokubun S, Rijal KP, Ojima T, Moriai N, Hashimoto M, et al. Prognosis of cervical spinal cord injury in correlation with magnetic resonance imaging. Paraplegia 1994;32:81-5.  Back to cited text no. 94
Schaefer DM, Flanders AE, Osterholm JL, Northrup BE Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury. J Neurosurg 1992;76:218-23.  Back to cited text no. 95
Marciello MA, Flanders AE, Herbison GJ, Schaefer DM, Friedman DP, Lane JI Magnetic resonance imaging related to neurologic outcome in cervical spinal cord injury. Arch Phys Med Rehabil 1993;74:940-6.  Back to cited text no. 96
Ramón S, Domínguez R, Ramírez L, Paraira M, Olona M, Castelló T, et al. Clinical and magnetic resonance imaging correlation in acute spinal cord injury. Spinal Cord 1997;35:664-73.  Back to cited text no. 97


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Assessing Injury...
Neurological Imp...
Functional Outco...
Algorithms and P...
Factors Affectin...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded55    
    Comments [Add]    

Recommend this journal