Predicting neurologic recovery in traumatic cervical spinal cord injury

doi:10.1016/S0003-9993(98)90244-1

Archives of Physical Medicine and Rehabilitation

Volume 79, Issue 11, November 1998, Pages 1456-1466

https://doi.org/10.1016/S0003-9993(98)90244-1 Get rights and content

Abstract

Objective: Traumatic spinal cord injury (SCI) affects 8,000 to 10,000 individuals per year in the United States. One of the most difficult tasks confronting the clinician is the discussion of neurologic recovery and prognosis with the patient and/or family. Our objective is to provide a guide for practitioners to accurately predict neurologic outcome in acute traumatic cervical SCI (tetraplegia).

Data Source: Published reports obtained through MEDLINE search, texts, and studies presented at national conferences.

Study Selection: Peer reviewed studies, in English language, that discussed prognosis after traumatic SCI.

Conclusion: A comprehensive physical examination of the acute SCI patient is essential in determining the initial level and classification of the injury and is the most accurate method to predict neurologic recovery. Other diagnostic tests, including somatosensory evoked potentials, magnetic resonance imaging, and transcranial magnetic stimulation, may be helpful in further determining outcome when used in association with the clinical examination. The understanding of neurologic recovery should help predict ultimate functional capability and potential needs.

References (132)

The National SCI Statistical Center
Spinal cord injury: facts and figures at a glance
(1998)
BK Go et al.
The epidemiology of spinal cord injury
SL Stover
Benefits of the model spinal cord injury system of care
FM Maynard et al.
International standards for neurological and functional classification of spinal cord injury patients
Spinal Cord
(1997)
L Daniels et al.
CII Long et al.
Functional significance of spinal cord lesion level
Arch Phys Med Rehabil
(1955)
RO Welch et al.
Functional independence in quadraplegia critical levels
Arch Phys Med Rehabil
(1986)
HL Frankel et al.
The value of postural reduction in initial management of closed injuries of the spine with paraplegia and tetraplegia
Paraplegia
(1969)
Spinal Injury Association/International Medical Society of American et al.
International standards for neurological and functional classification of spinal cord injury patients
(1992)
RJ Marino et al.
Superiority of motor level over single neurological level in categorizing patients
Paraplegia
(1995)

CH Tator et al.

Sunnybrook cord injury scales for assessing neurological injury and neurological recovery in early management of acute spinal cord injury

JF Ditunno

American spinal injury standards for neurologic and functional classification of spinal cord injury: past, present, and future

J Am Para Soc

(1994)

RL Waters et al.

Definition of complete spinal cord injury

Paraplegia

(1991)

S Stover et al.

Spinal cord injury: clinical outcomes from the model systems

(1995)

PJ Brown et al.

The 72 hour examination as a predictor of recovery in motor complete quadriplegia

Arch Phys Med Rehabil

(1991)

FM Maynard et al.

Neurological prognosis after traumatic quadriplegia

J Neurosurg

(1979)

L Tominaga

Periodic neurological-functional assessment for cervical cord injury

Paraplegia

(1989)

GJ Herbison et al.

Motor power difference within the first two weeks post-SCI in cervical spinal cord quadriplegic subjects

J Neurotrauma

(1991)

FW Meinecke

Some thoughts about neurological recovery in spinal cord injuries: A philosophical review

Paraplegia

(1985)

DM Blaustein et al.

Predicting recovery of motor complete quadriplegic patients: 24-hour v 72-hour motor index scores

Am J Phys Med Rehabil

(1993)

P Bravo et al.

An assessment of factors affecting neurological recovery after spinal cord injury with vertebral fractures

Paraplegia

(1996)

RL Waters et al.

Firearm versus motor vehicle related spinal cord injury: Preinjury factors, injury characteristics, and initial outcome comparisons among ethnically diverse groups

Arch Phys Med Rehabil

(1997)

MJ Devivo et al.

The influence of age at time of spinal cord injury on rehabilitation outcome

Arch Neurol

(1990)

GM Yarkony et al.

Spinal cord injury rehabilitation outcome: impact of age

J Clin Epidemiol

(1988)

MB Bracken et al.

A randomized, controlled trial of Methylprednisolone or Naloxone in the treatment of acute spinal-cord injury: Results of the second national acute spinal cord injury study

N Engl J Med

(1990)

KA Greene et al.

Pharmacological management of spinal cord injury: Current status of drugs designed to augment functional recovery of the injured human spinal cord

J Spinal Disorder

(1996)

MB Bracken et al.

Administration of methylprednisolone for 24 or 48 hours or tirilizad mesylate for 48 hours in the treatment of acute spinal cord injury: results of the third national acute spinal cord injury randomized controlled trial

JAMA

(1997)

FH Geisler et al.

Recovery of motor function after spinal cord injury—a randomized, placebo controlled trial with GM- 1 ganglioside

N Engl J Med

(1991)

AI Faden

Therapeutic approaches to spinal cord injury

Adv Neurol

(1997)

SM Zeidman et al.

Clinical applications of pharmacologic therapies for spinal cord injury

J Spinal Disorder

(1996)

M Murray

Strategies and mechanisms of recovery after spinal cord injury

Adv Neurol

(1977)

BS Bregman et al.

Intervention strategies to enhance anatomical plasticity and recovery of function after spinal cord injury

Adv Neurol

(1997)

M Silberstein et al.

Suggested MRI criteria for surgical decompression in acute spinal cord injury. Preliminary Observations

Paraplegia

(1992)

MS Duh et al.

The effectiveness of surgery on the treatment of acute spinal cord injury and its relation to the pharmacological treatment

Neurosurgery

(1994)

GL Clifton et al.

Omental transposition in chronic spinal cord injury

Spinal Cord

(1996)

RL Waters et al.

Effect of surgery on motor recovery following traumatic spinal cord injury

Spinal Cord

(1996)

WF Collins

Surgery in the acute treatment of spinal cord injury: a review of the past forty years

J Spinal Cord Med

(1995)

AR Vaccarro et al.

Neurologic outcome of early versus late surgery for cervical spinal cord injury

Spine

(1997)

LN Kornsgold et al.

Biceps vs. extensor carpi radialis recovery in Frankel A & B in spinal cord patients

Paraplegia

(1994)

JF Ditunno et al.

Wrist extensor recovery in traumatic quadriplegia

Arch Phys Med Rehabil

(1987)

ES Stauffer

Neurologic recovery following injuries to the cervical spinal cord and nerve roots

Spine

(1984)

KS Eschbach et al.

Sensory root level recovery in patients with Frankel A quadriplegia

Arch Phys Med Rehabil

(1992)

JF Ditunno et al.

Functional outcomes

JF Ditunno et al.

Motor recovery of the upper extremities in traumatic quadriplegia: a multicenter study

Arch Phys Med Rehabil

(1992)

RL Waters et al.

Motor and sensory recovery following complete tetraplegia

Arch Phys Med Rehabil

(1993)

L Wu et al.

Recovery of zero grade muscles in the zone of partial preservation in motor complete quadriplegia

Arch Phys Med Rehabil

(1992)

JS Young et al.

Neurological recovery distal to the zone of injury in 172 cases of closed, traumatic spinal cord injury

Paraplegia

(1978)

BJ Browne et al.

Pin sensation as a predictor of extensor carpi radialis recovery in spinal cord injury

Arch Phys Med Rehabil

(1993)

KC Mange et al.

The course of motor recovery at the zone of injury in complete spinal cord injury

Arch Phys Med Rehabil

(1992)

GM Bedbrook et al.

A review of cervical spine injuries with neurological dysfunction

Paraplegia

(1982)

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^☆: Supported by a grant from the Eastern Paralyzed Veterans Association.

^☆☆: No commercial party having a direct or indirect interest in the subject matter of this article has or will confer a benefit upon the author or upon any organization with which the authors are associated.

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Review articlePredicting neurologic recovery in traumatic cervical spinal cord injury☆,☆☆

Abstract

Spinal cord injury: facts and figures at a glance

The epidemiology of spinal cord injury

Benefits of the model spinal cord injury system of care

International standards for neurological and functional classification of spinal cord injury patients

Spinal Cord

Functional significance of spinal cord lesion level

Arch Phys Med Rehabil

Functional independence in quadraplegia critical levels

Arch Phys Med Rehabil

The value of postural reduction in initial management of closed injuries of the spine with paraplegia and tetraplegia

Paraplegia

International standards for neurological and functional classification of spinal cord injury patients

Superiority of motor level over single neurological level in categorizing patients

Paraplegia

Sunnybrook cord injury scales for assessing neurological injury and neurological recovery in early management of acute spinal cord injury

American spinal injury standards for neurologic and functional classification of spinal cord injury: past, present, and future

J Am Para Soc

Definition of complete spinal cord injury

Paraplegia

Spinal cord injury: clinical outcomes from the model systems

The 72 hour examination as a predictor of recovery in motor complete quadriplegia

Arch Phys Med Rehabil

Neurological prognosis after traumatic quadriplegia

J Neurosurg

Periodic neurological-functional assessment for cervical cord injury

Paraplegia

Motor power difference within the first two weeks post-SCI in cervical spinal cord quadriplegic subjects

J Neurotrauma

Some thoughts about neurological recovery in spinal cord injuries: A philosophical review

Paraplegia

Predicting recovery of motor complete quadriplegic patients: 24-hour v 72-hour motor index scores

Am J Phys Med Rehabil

An assessment of factors affecting neurological recovery after spinal cord injury with vertebral fractures

Paraplegia

Firearm versus motor vehicle related spinal cord injury: Preinjury factors, injury characteristics, and initial outcome comparisons among ethnically diverse groups

Arch Phys Med Rehabil

The influence of age at time of spinal cord injury on rehabilitation outcome

Arch Neurol

Spinal cord injury rehabilitation outcome: impact of age

J Clin Epidemiol

A randomized, controlled trial of Methylprednisolone or Naloxone in the treatment of acute spinal-cord injury: Results of the second national acute spinal cord injury study

N Engl J Med

Pharmacological management of spinal cord injury: Current status of drugs designed to augment functional recovery of the injured human spinal cord

J Spinal Disorder

Administration of methylprednisolone for 24 or 48 hours or tirilizad mesylate for 48 hours in the treatment of acute spinal cord injury: results of the third national acute spinal cord injury randomized controlled trial

JAMA

Recovery of motor function after spinal cord injury—a randomized, placebo controlled trial with GM- 1 ganglioside

N Engl J Med

Therapeutic approaches to spinal cord injury

Adv Neurol

Clinical applications of pharmacologic therapies for spinal cord injury

J Spinal Disorder

Strategies and mechanisms of recovery after spinal cord injury

Adv Neurol

Intervention strategies to enhance anatomical plasticity and recovery of function after spinal cord injury

Adv Neurol

Suggested MRI criteria for surgical decompression in acute spinal cord injury. Preliminary Observations

Paraplegia

The effectiveness of surgery on the treatment of acute spinal cord injury and its relation to the pharmacological treatment

Neurosurgery

Omental transposition in chronic spinal cord injury

Spinal Cord

Effect of surgery on motor recovery following traumatic spinal cord injury

Spinal Cord

Surgery in the acute treatment of spinal cord injury: a review of the past forty years

J Spinal Cord Med

Neurologic outcome of early versus late surgery for cervical spinal cord injury

Spine

Biceps vs. extensor carpi radialis recovery in Frankel A & B in spinal cord patients

Paraplegia

Wrist extensor recovery in traumatic quadriplegia

Arch Phys Med Rehabil

Neurologic recovery following injuries to the cervical spinal cord and nerve roots

Spine

Sensory root level recovery in patients with Frankel A quadriplegia

Arch Phys Med Rehabil

Functional outcomes

Motor recovery of the upper extremities in traumatic quadriplegia: a multicenter study

Review article
Predicting neurologic recovery in traumatic cervical spinal cord injury☆,☆☆