|SYMPOSIUM: CERVICAL SPINE TRAUMA
|Year : 2022 | Volume
| Issue : 1 | Page : 69-81
Predicting outcomes following cervical spine trauma
Spinal Cord Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
|Date of Submission||06-Apr-2021|
|Date of Decision||20-May-2021|
|Date of Acceptance||13-Sep-2021|
|Date of Web Publication||02-Feb-2022|
Spinal Cord Unit, IRCCS Fondazione Santa Lucia, via Ardeatina 306, 00179 Rome.
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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. 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. 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.,,,,,, 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., 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
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. 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. 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. 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. For example, in the first few days following SCI, management strategies are formulated, which often include very early surgical decompression of the spinal cord. 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.
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. Prognostic data are essential to correctly evaluate the efficacy of these new drugs and therapies and to accurately design clinical trials.
| Materials and Methods|| |
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|| |
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], 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)|
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|Figure 2: Explanations for classification (Reproduced and adapted with permission)|
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It is recommended that this examination take place 72 h after neurological injury because examination within 24 h can be unreliable., However, another common baseline examination is at 1 month following injury,,,, 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., 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.
| Neurological Improvement|| |
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.,, 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,, [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,, [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. 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. 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%). 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., 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.,,, 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.
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. 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.
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,, [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), which could explain why these patients have a greater deficit in self-care activities than in walking. 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.
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. 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, [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%) [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.,,,, The most important factor associated with upper extremity recovery is the presence/absence of any movement at the level of injury [Table 1]. The presence of motor strength at a determinate level is also predictive of recovery at the next level [Table 1]. Finally, the presence/absence of pinprick sensation at the level of injury is also associated with recovery. 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|| |
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].
|Table 2: Expected functional outcomes for patients with complete lesion at different cervical levels|
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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.,,
Patients with SCI, especially those with incomplete lesions, consider walking as a primary recovery goal. Therefore, a precise evaluation of the natural recovery of walking and of the prognostic factors influencing this function is required. Walking recovery could be defined as the ability to walk independently in the community, with or without the use of devices or braces.
AIS grade at initial examination is considered the basis for predicting functional walking recovery. Patients with AIS grade A at their first examination have very few chances of achieving ambulation, especially those with tetraplegia,, [Table 3].
|Table 3: Prediction of functional walking according to AIS impairment and other features|
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The overall walking recovery of patients with grade B at the initial examination is approximately 33%.,,, 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,, [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.
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%,,,, [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., 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.
Finally, patients with AIS grade D at admission had a very good ambulation prognosis at discharge from rehabilitation and at 1-year post-injury,,, [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. Overall, 33% of patients with SCI recover normal bladder control.
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., 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.
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, 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.
| Algorithms and Prediction Rules|| |
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. 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.
Zorner 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.
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. 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.
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.
| Factors Affecting Neurological and Functional Recovery|| |
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. 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,,,,,, it is still to be decided if age may also affect neurologic recovery. Previously, increased age was considered to negatively affect neurological improvement, [Table 4], as it has been hypothesized that decreased neural plasticity associated with age is the basis for these differences in neurologic recovery., However, other studies failed to identify an age-related effect on neurologic recovery following SCI,,, [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 [Table 4].
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.
The ISNCSCI allows the recognition of several incomplete spinal cord syndromes with different prognostic values., At the cervical level, the most common is central cord syndrome (CCS), which represents approximately 9% of the total SCIs 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. 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,, [Table 4].
Brown-Sèquard syndrome (BSS) is also relatively frequent at the cervical level and is usually due to stab-wound injuries. It is due to spinal hemisection and therefore is characterized by ipsilateral hemiplegia or contralateral hemianalgesia., BSS accounts for 2% to 4% of all traumatic SCIs. 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 [Table 4].
Both syndromes are characterized by a good prognosis for bladder control recovery.
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). 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. In the clinical field, Sipski 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,, [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.,, 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 [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, [Table 5].
The advent of MRI provided a rapid noninvasive evaluation of the amount of spinal cord compression as well as the spinal cord parenchyma and extent of spinal cord damage. 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,,,,,, [Table 5].
| Conclusion|| |
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
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.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]