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Neurological Recovery After Traumatic SCI Ralph J. Marino, MD, MS Associate Professor, Rehabilitation Medicine Thomas Jefferson University Philadelphia,

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Presentation on theme: "Neurological Recovery After Traumatic SCI Ralph J. Marino, MD, MS Associate Professor, Rehabilitation Medicine Thomas Jefferson University Philadelphia,"— Presentation transcript:

1 Neurological Recovery After Traumatic SCI Ralph J. Marino, MD, MS Associate Professor, Rehabilitation Medicine Thomas Jefferson University Philadelphia, PA, USA November 24, 2007

2 Regional Spinal Cord Injury Center of the Delaware Valley Affiliated institutions of Jefferson University Hospital Magee Rehabilitation Hospital

3 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.

4 International Standards for the Neurological Classification of Spinal Cord Injury

5 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.

6 Motor Examination: Key Muscles UPPER EXT C5 = Elbow Flexors C6 = Wrist Extensors C7 = Elbow Extensors C8 = Finger Flexor (FDP-3) T1 = Finger Abductor (ADM) LOWER EXT L2 = Hip Flexors L3 = Knee Extensors L4 = Ankle Dorsiflexors L5 = Extensor Hallucis Longus S1 = Ankle Plantar- flexors

7 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.

8 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.

9 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.

10 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

11 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

12 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

13 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

14 Neurological Recovery After SCI: Model Systems Subjects: 4365 admitted |  391 died 3974 alive at one year | |-----  65, minimal deficit |  324, incomplete data | 3585 retained

15 Neurological Recovery After SCI: Model Systems Ethnicity % Non-Hisp. White 53.2 African American 28.9 Hispanic 15.0 Other 2.9 Sex % Male 82.2 Female 17.8 Etiology % Vehicle crash36.9 Violence29.3 Falls21.9 Sports 7.8 Pedestrian 2.2 Med/Surg 1.5 Other 0.4

16 Neurologic Impairment Group

17 Initial to Discharge AIS Grade

18 Initial to One-year AIS Grade

19 Tetraplegia Recovery

20 Paraplegia Recovery

21 Recovery at the Zone of Injury

22 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

23 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

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

25 Upper Extremity Recovery (by level of Injury) Initial Motor Level Motor Complete Motor Incomplete C47090* C57590* C68590 Percent recovering next level to antigravity strength (Ditunno et al. 2000)

26 Percent Motor Compete Tetraplegic Patients Recovering Next Motor Level Ditunno et al. 1992

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

28 Prognosis for Ambulation * influenced by type of sensation # influenced by age at injury

29 Ambulation Potential (for AIS B) N Don’t WalkWalk B1 (No pin)18162 B2 (Pin)918 Total Crozier et al. 1991

30 Sacral Pin Prick and Ambulation (Oleson et al., 2005) P=.32 P=.01

31 Prognosis for Ambulation * influenced by type of sensation # influenced by age at injury

32 Potential for Ambulation (based on age – initial AIS C) (Burns et al. 1997)

33 Prognosis for Ambulation (based on LE strength) Based on Waters et al., 1992, 1994

34 Controversies and Questions

35 Conversions from AIS B Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

36 Convert from Complete to Incomplete Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

37 Late conversions to incomplete Fawcett JR et al. Spinal Cord (2007) 45, 190–205.

38 Are they unrecognized factors that influence motor recovery?


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