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:
  admitted
|  391 died
3974 alive at one year |
|----- , minimal deficit
|------ 324, incomplete data
3585 retained

15. Neurological Recovery After SCI: Model Systems
Ethnicity %
Non-Hisp. White
African American 28.9
Hispanic
Other
Sex %
Male
Female
Etiology %
Vehicle crash 36.9
Violence 29.3
Falls
Sports
Pedestrian
Med/Surg
Other

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 (72-hrs to 6 months) Complete : 5.4 pts
Waters 1993, (1 month to 1 year)
Complete: pts Incomplete: 10.6 pts

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

25. 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

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)
Don’t Walk
Walk
B1 (No pin) 18 16 2
B2 (Pin) 9 1 8
Total 27 17 10
Crozier et al. 1991

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

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?