Citations

Abstract Background The T6 neurological level of spinal cord injury (SCI) is classically taught as differentiating who is and is not at risk for autonomic dysreflexia (AD); yet the reliability of this metric has rarely been tested. Objectives To determine how often individuals with SCI above and below the T6 neurological level of injury (NLI) experience symptomatic AD, quantify AD in the autonomic physiology laboratory, and describe underlying mechanisms that clinically manifest. Design Cross‐sectional. Setting Academic medical center. Participants 138 individuals with/without SCI. Interventions Not applicable. Main Outcome Measures Symptoms of AD were quantified using the validated Autonomic Dysfunction Following SCI‐AD survey. Deep autonomic physiology characterization was further completed ( n = 34 uninjured controls, n = 28 individuals with SCI) to identify underlying AD mechanisms. Continuous blood pressure, heart rate, regional vascular resistance in the arm/leg, and pre/posttest catecholamines were recorded. Vascular responsiveness and baroreflex sensitivity were assessed with intravenous phenylephrine boluses. Foot cold pressor and bladder pressor tests served as below level mild noxious stimuli to elicit controlled AD. Results AD symptoms were, as expected, significantly higher after SCI compared to uninjured controls ( p < .001). Symptomatic AD was identified in 77% of individuals with SCI at/above T6, compared to 38% with injuries below T6. McNemar's statistic indicated the T6 neurological level poorly differentiated who developed symptomatic AD ( p = .039). During laboratory testing, 57% of those with SCI at/above T6 experienced AD, as did 57% of those with injuries below T6 ( p = .33). Physiologically, AD in individuals with SCI below T6 can be due to heightened vascular responsiveness and poor baroreflex sensitivity, leading to minimal compensatory bradycardia. Conclusions Symptomatic and objective AD occurs in those with SCI above and below the T6 NLI threshold. As such, targeted autonomic testing must translate to the bedside to accurately quantify AD risk. In the interim, though the T6 threshold has become cannon in many patient and resident education materials regarding AD risk, evidence suggests clinical care should avoid using this strict cutoff.

ABSTRACT Introduction/Aims Patients with cervical spinal cord injury (SCI) prioritize recovery of upper extremity function. Upper extremity reconstruction can restore function in carefully selected individuals. Infralesional cord damage, observed below the neurological level of injury (NLI), may affect postoperative outcomes. We characterized the extent of infralesional lower motor neuron (LMN) injury in patients with traumatic cervical SCI. Methods Each patient underwent electromyography (EMG) of potential donor and recipient muscles based on preoperative clinical evaluation and specific candidacy for nerve and/or tendon transfers. The presence of infralesional pathologic insertional activity (IA), reduced motor unit potential (MUP) recruitment and/or neurogenic MUPs was assessed. The caudal‐most segment with infralesional LMN injury was determined. Inclusion criteria were patients with (1) traumatic cervical SCI; (2) injury ≥ 3 months duration; (3) preoperative planning EMG for nerve and/or tendon transfers. Results Forty‐eight upper extremity EMGs in 25 patients (68% male; mean age 39.5 years at injury) with traumatic cervical SCI were included. The NLI was at C7 or above in each patient, and 64% of SCIs were motor complete. Infralesional EMG abnormalities (median time from injury to EMG 466 days) were found a median of 3.0 (IQR 3.0–4.0) segments below the NLI. Three patients with an NLI as rostral as C1–C2 exhibited LMN injury seven segments below the NLI. Discussion In persons with traumatic cervical SCI, evidence of LMN injury may be observed several segments below the NLI. Defining the true extent of LMN involvement directly informs timing and selection of reconstructive procedures to maximize functional recovery.

Background: The National SCI Model Systems (SCIMS) Database was established in 1973 to study longitudinal data from persons with traumatic SCI (TSCI). The SCIMS provides an ideal platform to explore the feasibility of a parallel data collection effort to understand the characteristics of individuals with nontraumatic SCI (NTSCI). In the current data collection cycle (2021-2026), all SCIMS centers gathered data specific to NTSCI. Objectives: To (1) describe the demographic and injury-specific characteristics of participants with NTSCI and (2) assess neurological changes from admission to discharge. Methods: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination data of participants with NTSCI who were enrolled at an SCIMS center were extracted from the medical records at admission and discharge from inpatient rehabilitation. Data from 178 participants with NTSCI were analyzed. Results: Among the 93 participants who had adequate ISNCSCI data on admission, only 8.6% had neurological complete injuries. More participants had paraplegia ( n = 58, 62.4%) than tetraplegia ( n = 35, 37.6%). For participants with full ISNCSCI data at both admission and discharge ( n = 47), there were significant improvements in the lower extremity motor score and pinprick and light touch scores on discharge. Conclusion: On admission to acute rehabilitation, more people with NTSCI had paraplegia than tetraplegia, and neurological incomplete injuries were more common. People with NTSCI experienced significant improvement in ISNCSCI neurological variables by the time of discharge from rehabilitation.

Background: The Spinal Cord Injury Model Systems (SCIMS) began studying traumatic SCI (TSCI) in 1970. The National Institute of Disability, Independent Living and Rehabilitation Research (NIDILRR) provided pilot funding during the 2021-2026 SCIMS funding cycle to perform an initial study of individuals with nontraumatic spinal cord injury (NTSCI). Objectives: To describe the demographic and etiological profiles and inpatient rehabilitation outcomes of the SCIMS NTSCI pilot cohort. Methods: This was a descriptive study of adults with NTSCI admitted to SCIMS centers who consented to medical records abstraction and completed survey questionnaires near the completion of inpatient rehabilitation. Results: One hundred eighty-seven people with NTSCI consented to participate and provided data. The etiology of patients’ NTSCI was degenerative vertebral causes ( n = 67), tumor-malignant ( n = 29), tumor-benign/unknown ( n = 16), vascular ( n = 28), infection ( n = 26), and other NTSCI causes ( n = 21). The average age was 59.2 years. Over 40% of the population was age 60-74 years. The population was 35% female, 59.5% non-Hispanic White, 21.6% non-Hispanic Black, and 11.4% Hispanic. Age, sex, race, and ethnicity distributions did not differ significantly across etiology groups. Only symptom onset time ( P = .002) and marital status ( P = .005) were significantly different between groups. Vascular disorders onset was less than a day in 60% of cases. Greater than 60% of tumor-malignant, vascular, and other NTSCI individuals were married or living with a partner. Conclusion: The US SCIMS program can recruit a population of NTSCI research participants that is consistent with previously published results. Ongoing study of NTSCI through the US SCIMS could provide important data akin to that available regarding TSCI.

Background Successful utilization of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) requires a comprehensive understanding of its rules, terminology, and several complex concepts. There have been no studies investigating classification accuracy since the newest ISNCSCI revision (2019). Objectives To evaluate classification accuracy of SCI professionals using the 2019 ISNCSCI edition, identify common mistakes and areas of confusion, and assess associations between experience in ISNCSCI classification and performance. Methods Members of the International Spinal Cord Society (ISCoS) and attendees of the ISCoS Annual Scientific Meeting 2021 were invited to complete an online survey that included six ISNCSCI cases to classify. Results A total of 107 persons completed the survey, with overall classification accuracy of 74.6%. Accuracy was highest for injury completeness (95.3%) and sensory level (91.1%) and lowest for motor zone of partial preservation (ZPP; 54.7%) and ASIA Impairment Scale (AIS) grade (57.3%). Newer concepts, including the appropriate documentation of non-SCI conditions and classification of ZPP in incomplete injuries, contributed to several common errors. There was a significant association between overall classification accuracy and self-rated experience in the ISNCSCI classification ( p = .017). Experience with the ISNCSCI examination, experience in SCI medicine, and occupation were not found to be significantly associated with overall classification accuracy. Conclusion Classification accuracy of an international cohort of SCI professionals was modest but greater than previous reports. Knowledge deficits about the 2019 ISNCSCI updates are prevalent and contribute to common classification errors. Further training in the utilization of the ISNCSCI is needed.

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6–9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.