Neurological Recovery After Traumatic SCI

Ralph J. Marino, MD, MSAssociate Professor, Rehabilitation

MedicineThomas Jefferson University

Philadelphia, PA, USA

ralph.marino@jefferson.edu

November 24, 2007

Regional Spinal Cord Injury Center of the Delaware Valley

Affiliated institutions of

Jefferson University Hospital

Magee Rehabilitation Hospital

Objectives

• Describe recovery after SCI based on initial severity of injury.

• Compare and contrast upper extremity recovery after complete and incomplete cervical SCI.

• Identify factors predictive of ambulation after traumatic SCI.

• Highlight areas where further research is needed to predict recovery after SCI.

International Standards for the Neurological Classification of Spinal Cord Injury

http://www.asia-spinalinjury.org/publications/2001_Classif_worksheet.pdf

Sensory Examination

• Test 28 dermatomes on each side of body.

• Light touch and pinprick.• Three-point scale (0-2).• Establish normal sensation on

face or other non-involved area.

• Also test for deep anal sensation.

Motor Examination:Key Muscles

UPPER EXTC5 = Elbow

FlexorsC6 = Wrist

ExtensorsC7 = Elbow

ExtensorsC8 = Finger

Flexor (FDP-3)

T1 = Finger Abductor

(ADM)

LOWER EXTL2 = Hip

FlexorsL3 = Knee

ExtensorsL4 = Ankle

DorsiflexorsL5 = Extensor

Hallucis Longus

S1 = Ankle Plantar-

flexors

Sensory Level

• The sensory level is the most caudal segment of the spinal cord with normal sensory function.

• Right and left sides are evaluated separately.

• Both pin prick and light touch sensation must be normal in this dermatome.

Motor Level

• The motor level on each side is the most caudal segment of the spinal cord with normal motor function.

• Normal motor function refers to the myotome of the spinal cord, not to the key muscle being tested.

The ASIA Impairment Scale

A. Complete. No motor or sensory function in sacral segments S4-S5.

B. Motor complete, sensory incomplete. Sensory sparing but no motor function below the zone of injury. Includes the sacral segments S4-5.

C. Motor incomplete. Motor function preserved below the injury and less than half of key muscles have a muscle grade > 3.

D. Motor incomplete. Motor function preserved below the neurological level and at least half of key muscles have a muscle grade > 3.

E. Normal. Motor and sensory function are normal.

Timing of Baseline Exam

“Short term motor recovery in the zone of injury of motor complete quadriplegia is better predicted by the 72-hr MMT than the 24-hr MMT”

Brown et al. 1991

Reliability of Early Designation of Complete (Burns et al; 2003)

Retrospective study of SCI patients at RSCICDV (Jefferson)

Factors affecting reliability:• mechanical ventilation• intoxication/sedation • Closed head injury• Cerebral palsy • psychiatric illness • language • severe pain

Reliability of Early Designation of Complete (Burns et al; 2003)

• Initial exam within 48 hrs• Overall, 6.2% (5/81) convert A

to B within the first week

• By one year,If NO factor, 1/38 (2.6%) convert – to AIS B

If + factor, 4/43 (9.3%) convert – to AIS B = 1, C = 2, D = 1

Neurological Recovery After SCI: Model Systems (Marino et al., 1999)

• Subject selection:−Admitted to System 1/1/88-

12/31/97−Within one week of traumatic

SCI•  Exclude if:

−Minimal deficit on admission−Died within first year−Incomplete data

Neurological Recovery After SCI: Model Systems

 Subjects:  4365 admitted

|--------------- 391 died3974 alive at one year

||----- 65, minimal

deficit|------ 324, incomplete

data|

3585 retained

Neurological Recovery After SCI: Model Systems

Ethnicity %Non-Hisp. White

53.2African American

28.9Hispanic 15.0Other 2.9

Sex %Male 82.2Female 17.8

Etiology %Vehicle crash

36.9Violence

29.3Falls

21.9Sports 7.8Pedestrian

2.2Med/Surg

1.5Other

0.4

Neurologic Impairment Group

28.4%

21.8%

19.8%30.0%

Tetra Comp

Tetra Inc

Para Inc

Para Comp

Initial to Discharge AIS Grade

N=1560 Discharge AIS Grade

Admit AIS Grade

A

B

C

D

E

A (n=808) 89.0 5.8 3.6 1.6 0.0

B (n=242) 2.9 42.5 36.8 17.8 0.0

C (n=295) 1.0 1.0 43.4 54.6 0.0

D (n=215) 0.0 0.5 0.0 96.7 2.8

Initial to One-year AIS Grade

N=842 One-year AIS Grade

Admit AIS Grade

A

B

C

D

E

A (n=482) 84.6 7.3 5.8 2.3 0.0

B (n=129) 7.8 19.4 38.0 33.3 1.5

C (n=159) 3.1 1.3 25.1 66.7 3.8

D (n=72) 0 0 1.4 94.4 4.2

Tetraplegia Recovery

0

20

40

60

80

100

A B C D

Frankel/AIS Grade

Mot

or S

core

Initial Discharge One Year

Paraplegia Recovery

40

50

60

70

80

90

100

A B C D

Frankel/AIS Grade

Mot

or S

core

Initial Discharge One Year

Recovery at the Zone of Injury

Upper Extremity Key Muscles

• C5 - Elbow flexors• C6 - Wrist extensors• C7 - Elbow extensors• C8 - Flexor dig profundus (digit

3)• T1 - Abductor digiti minimi

• Motor Score (UE) = 0-50

Change in UE Motor Score

• Blaustein 1993 (72-hrs to 6 months) Complete : 5.4 pts

• Waters 1993, 1994 (1 month to 1 year)Complete: 8.6 pts Incomplete: 10.6 pts

UE recovery in Tetraplegia(Waters et al., 1993)

Upper Extremity Recovery(by level of Injury)

Initial Motor Level

MotorComplete

MotorIncomplete

C4 70 90*

C5 75 90*

C6 85 90

Percent recovering next level to antigravity strength (Ditunno et al. 2000)

Percent Motor Compete Tetraplegic Patients Recovering Next Motor Level

0

20

40

60

80

100

0 1 3 6 12 18 24

Months post-injury

Per

cen

t

SMP NMP

Ditunno et al. 1992

Upper Extremity Recovery(≥ 3/5) by distance below level

0

10

20

30

40

50

60

70

80

1st 2nd 3rd

Level below original motor level

Perc

ent

Impro

ve

Graziani 1992 Fisher 2005

Prognosis for Ambulation

50

3

75 95

0

20

40

60

80

100

A B* C# D

Initial ASIA Impairment Scale

Per

cent

Am

bula

tory

* influenced by type of sensation # influenced by age at injury

Ambulation Potential (for AIS B)

NDon’tWalk Walk

B1 (No pin) 18 16 2

B2 (Pin) 9 1 8

Total 27 17 10

Crozier et al. 1991

Sacral Pin Prick and Ambulation (Oleson et al., 2005)

Initial PP

010203040506070

Walk Don'tWalk

Perc

ent

PP - yes PP - no

4 Week PP

0

2040

60

80100

120

Walk Don'tWalk

Perc

ent

PP - yes PP - no

P=.32 P=.01

Prognosis for Ambulation

50

3

75 95

0

20

40

60

80

100

A B* C# D

Initial ASIA Impairment Scale

Per

cent

Am

bula

tory

* influenced by type of sensation # influenced by age at injury

Potential for Ambulation(based on age – initial AIS C)

30

13

3

18

0

5

10

15

20

25

30

35

Age < 50 Age 50+

Ambulatory Non-ambulatory

(Burns et al. 1997)

Prognosis for Ambulation(based on LE strength)

Initial LEMS

Para Comp

Para Inc

Tetra Inc

0 <1% 33% 0 1-9 45% 70% 21%

10-19 100% 63% 20+ 100% 100%

Based on Waters et al., 1992, 1994

Controversies and

Questions

Conversions from AIS B

Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

Convert from Complete to Incomplete

Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

Late conversions to incomplete

Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

Are they unrecognized factors that influence motor recovery?

Early Treatment

0

10

20

30

40

50

0 20 40 60

Weeks

Perc

ent

Reco

very

Placebo Drug

Late Treatment

10

20

30

40

50

0 20 40 60

Weeks

Perc

ent

Reco

very

Placebo Drug