Abstract
Study design
Cross-sectional survey.
Objectives
Most studies on neurological recovery after traumatic spinal cord injury (tSCI) assess treatment effects using the American Spinal Injury Association Impairment Scale (AIS grade) or motor points recovery. To what extent neurological recovery is considered clinically meaningful is unknown. This study investigated the perceived clinical benefit of various degrees of neurological recovery one year after C5 AIS-A tSCI.
Setting
The Netherlands.
Methods
By means of a web-based survey SCI patients and physicians evaluated the benefit of various scenarios of neurological recovery on a scale from 0 to 100% (0% no benefit to 100% major benefit). Recovery to AIS-C and D, was split into C/C+ and D/D+, which was defined by the lower and upper limit of recovery for each grade.
Results
A total of 79 patients and 77 physicians participated in the survey. Each AIS grade improvement from AIS-A was considered significant benefit (all p < 0.05), ranging from 47.8% (SD 26.1) for AIS-B to 86.8% (SD 24.3) for AIS-D+. Motor level lowering was also considered significant benefit (p < 0.05), ranging from 66.1% (SD 22.3) for C6 to 81.7% (SD 26.0) for C8.
Conclusions
Meaningful recovery can be achieved without improving in AIS grade, since the recovery of functional motor levels appears to be as important as improving in AIS grade by both patients and physicians. Moreover, minor neurological improvements within AIS-C and D are also considered clinically meaningful. Future studies should incorporate more detailed neurological outcomes to prevent potential underestimation of neurological recovery by only using the AIS grade.
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Data availability
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
References
Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, et al. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine. 2019:1–17. https://doi.org/10.3171/2018.10.SPINE18802.
El Tecle NE, Dahdaleh NS, Bydon M, Ray WZ, Torner JC, Hitchon PW. The natural history of complete spinal cord injury: a pooled analysis of 1162 patients and a meta-analysis of modern data. J Neurosurg Spine. 2018;28:436–43. https://doi.org/10.3171/2017.7.SPINE17107.
Brienza D, Krishnan S, Karg P, Sowa G, Allegretti AL. Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study. Spinal Cord. 2018;56:28–34. https://doi.org/10.1038/sc.2017.96.
van den Berg ME, Castellote JM, de Pedro-Cuesta J, Mahillo-Fernandez I. Survival after spinal cord injury: a systematic review. J Neurotrauma. 2018;27:1517–28. https://doi.org/10.1089/neu.2009.1138.
Jug M, Kejžar N, Vesel M, Al Mawed S, Dobravec M, Herman S, et al. Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience. J Neurotrauma. 2015;32:1385–92. https://doi.org/10.1089/neu.2014.3767.
ter Wengel PV, de Witt Hamer PC, Pauptit JC, Van der Gaag NA, Oner FC, Vandertop WP. Early surgical decompression improves neurological outcome after complete traumatic cervical spinal cord injury: a meta-analysis. J Neurotrauma. 2018. https://doi.org/10.1089/neu.2018.5974.
Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS). PLoS ONE. 2012;7. https://doi.org/10.1371/journal.pone.0032037.
Mattiassich G, Gollwitzer M, Gaderer F, Blocher M, Osti M, Lill M, et al. Functional outcomes in individuals undergoing very early (<5 h) and early (5–24 h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurological improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma. 2017;3371. https://doi.org/10.1089/neu.2017.5132.
Van Hedel HJA, Dokladal P, Hotz-Boendermaker S. Mismatch between investigator-determined and patient-reported independence after spinal cord injury: consequences for rehabilitation and trials. Neurorehabil Neural Repair. 2011;25:855–64. https://doi.org/10.1177/1545968311407518.
Anderson KD. Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma. 2004;21:1371–83. https://doi.org/10.1089/neu.2004.21.1371.
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. https://doi.org/10.1038/sj.sc.3102172.
van Hedel HJ, Curt A. Fighting for each segment: estimating the clinical value of cervical and thoracic segments in SCI. J Neurotrauma. 2006;23:1621–31.
Osterthun R, Tjalma TA, Spijkerman DCM, Faber WXM, van Asbeck FWA, Adriaansen JJE, et al. Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands. J Spinal Cord Med. 2018;1–8. https://doi.org/10.1080/10790268.2018.1504427.
Van Middendorp JJ, Hosman AJF, Pouw MH, Van De Meent H. 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. https://doi.org/10.1038/sc.2008.162.
Gündoğdu İ, Akyüz M, Öztürk EA, Cakcı FA. Can spinal cord injury patients show a worsening in ASIA impairment scale classification despite actually having neurological improvement the limitation of ASIA impairment scale classification. Spinal Cord. 2014;52:667–70. https://doi.org/10.1038/sc.2014.89.
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. https://doi.org/10.1038/sj.sc.3102007.
van Middendorp JJ. Letter to the editor regarding: “Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in Acute Spinal Cord Injury Study (STASCIS)”. Spine J. 2012;12:540. https://doi.org/10.1016/j.spinee.2012.06.007.
Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM—spinal cord independence measure: a new disability scale for patients with spinal cord lesions. Spinal Cord. 1997;35:850–6. https://doi.org/10.1038/sj.sc.3100504.
Scivoletto G, Tamburella F, Laurenza L, Molinari M. The spinal cord independence measure: How much change is clinically significant for spinal cord injury subjects. Disabil Rehabil. 2013;35:1808–13. https://doi.org/10.3109/09638288.2012.756942.
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 (Philos Pa 1976). 2001;26:S68–86. http://www.ncbi.nlm.nih.gov/pubmed/11805613.
Snoek GJ, Ijzerman MJ, Hermens HJ, Maxwell D, Biering-Sorensen F. Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics. Spinal Cord. 2004;42:526–32. https://doi.org/10.1038/sj.sc.3101638.
Lo C, Tran Y, Anderson K, Craig A, Middleton J. Functional priorities in persons with spinal cord injury: using discrete choice experiments to determine preferences. J Neurotrauma. 2016;33:1958–68. https://doi.org/10.1089/neu.2016.4423.
Cotler JM, Herbison GJ, Nasuti JF, Ditunno JF, An H, Wolff BE. Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine (Philos Pa 1976). 1993;18:386–90. https://doi.org/10.1097/00007632-199303000-00015.
Kramer JLK, 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. https://doi.org/10.1177/1545968312447306.
Levi L, Wolf A, Rigamonti D, Ragheb J, Mirvis S, Robinson W. Anterior decompression in cervical spine trauma: does the timing of surgery affect the outcome? Neurosurgery. 1991;29:216–22.
Fox IK, Miller AK, Curtin CM. Nerve and tendon transfer surgery in cervical spinal cord injury: Individualized choices to optimize function. Top Spinal Cord Inj Rehabil. 2018;24:275–87. https://doi.org/10.1310/sci2403-275.
Simpson LA, Eng JJ, Hsieh JTC, Wolfe DL. The health and life priorities of individuals with spinal cord injury: a systematiuc review. 2013;29:1548–55. https://doi.org/10.1089/neu.2011.2226.
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PVTW was responsible for the study conceptualization, survey creation, data acquisition, analysis and interpretation of data, writing of the paper, and final approval of the manuscript. MWMP contributed to study conceptualization, survey creation, interpretation of data, critical revision of the paper, and final approval of the manuscript. EM was responsible for survey creation, data acquisition, analysis and interpretation of the data, critical revision of the paper, and final approval of the manuscript. JSS contributed to study conceptualization, survey creation, interpretation of data, critical revision of the paper, and final approval of the manuscript. AJFH contributed to study conceptualization, interpretation of data, critical revision of the paper, and final approval of the manuscript. SS contributed to study conceptualization, interpretation of data, critical revision of the paper, and final approval of the manuscript. WPV contributed to study conceptualization, interpretation of data, critical revision of the paper, and final approval of the manuscript. FCO contributed to study conceptualization, interpretation of data, critical revision of the paper, final approval of the manuscript, and study supervision.
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ter Wengel, P.V., Post, M.W.M., Martin, E. et al. Neurological recovery after traumatic spinal cord injury: what is meaningful? A patients’ and physicians’ perspective. Spinal Cord 58, 865–872 (2020). https://doi.org/10.1038/s41393-020-0436-4
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DOI: https://doi.org/10.1038/s41393-020-0436-4
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