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

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 died 3974 alive at one year | |----- 65, minimal deficit |------ 324, incomplete data 3585 retained

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 crash 36.9 Violence 29.3 Falls 21.9 Sports 7.8 Pedestrian 2.2 Med/Surg 1.5 Other 0.4

Neurologic Impairment Group

Initial to Discharge AIS Grade

Initial to One-year AIS Grade

Tetraplegia Recovery

Paraplegia Recovery

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) Percent recovering next level to antigravity strength (Ditunno et al. 2000) Initial Motor Level Motor Complete Motor Incomplete C4 70 90* C5 75 C6 85 90

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

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

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

Ambulation Potential (for AIS B) Don’t Walk 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)

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

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

Prognosis for Ambulation (based on LE strength) 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?