Future ambulation prognosis as predicted by somatosensory evoked potentials in motor complete and incomplete quadriplegia

doi:10.1016/S0003-9993(95)80632-6

Archives of Physical Medicine and Rehabilitation

Volume 76, Issue 7, July 1995, Pages 635-641

https://doi.org/10.1016/S0003-9993(95)80632-6 Get rights and content

Abstract

Objective: The purpose of this prospective study was to determine the efficacy of tibial somatosensory evoked potentials (SEPs) in predicting ambulation in tetraplegic individuals. Design: This was a prospective study of a cohort of cervical spinal cord—injured patients who had SEPs recorded within 72 hours to 2 weeks post-SCI and whose ambulation outcome was followed up to 2 years post-SCI. Setting: Regional Spinal Cord Injury (SCI) Center. Patients: All male and female subjects admitted to the center from 1988 to 1991 between the ages of 15 and 60 years who demonstrated C₄ through T₁ complete and incomplete acute SCIs were asked to participate in this study. Measurements: The tibial nerve cortical SEPs were graded as either present or absent. The waveforms were also graded as less than 0.5μV or ≥0.5μV. Quadriceps strength plus touch and pin sensation were tested within 72 hours to 2 weeks post-SCI. Ambulation was rated as absent, exercise, household, or community. The ambulatory and clinical status were assessed monthly for 3 months, and then at 6, 12, 18, and 24 months post-SCI. Statistical analysis using the two-tailed Fisher's exact test was performed relating the initial clinical and SEP data to ambulation outcome up to 24 months post-SCI. Results: All 13 subjects with a right and/or left quadriceps manual muscle test (MMT) greater than 0/5 became ambulatory. Of the 9 subjects with an initial bilateral quadriceps MMT = 0/5, only 1 recovered enough lower limb function to ambulate (p = .0001). One of the 7 subjects with absent touch sensation in the lower limbs became ambulatory, whereas 14 of the 15 subjects with touch sensation present became ambulatory (p = .002). All 7 subjects with absent pin sensation in the lower limbs were nonambulatory, and 14 of 15 subjects with pin sensation present became ambulatory (p < .0001). Of the 9 subjects with bilaterally absent cortical SEP waveforms, 2 became ambulatory. Twelve of the 13 subjects with a cortical SEP wave present became ambulatory (p = .0015). Of the 10 subjects with a cortical SEP wave amplitude less than 0.5μV, only two became ambulatory, whereas all 12 subjects with an amplitude ≥0.5μV became ambulatory (p = .00014). In no subject did the SEP predict future ambulation where the clinical examination did not also predict recovery of ambulation. Conclusion: Both the early postinjury clinical evaluation and the SEP predicted ambulation outcome to a significant degree, but the SEP offered no additional prognostic accuracy over that provided by the clinical examination.

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Cited by (33)

Outcome Prediction in Spinal Cord Injury: Myth or Reality
2020, World Neurosurgery
Citation Excerpt :
All patients with eligible MEPs at initial examination recovered a muscle strength of more than 3/5. Although a strong relation between somatosensory evoked potentials and ambulation outcomes has been shown, this technique has no additional prognostic accuracy over the clinical neurologic examination.10-12 Various studies have been conducted on the cardiopulmonary management of SCIs and its effect on outcome of SCI (Tables 1 and 2).
To identify the prognostic factors affecting the outcome of acute traumatic spinal cord injury (tSCI) and to provide updated recommendations on improving outcomes.
PubMed and Google Scholar search on experimental and clinical studies looking at the effect of various prognostic factors in tSCI.
A total of 76 articles were selected and retrieved. As per various systematic reviews and prospective studies, the initial neurologic examination determines the prognosis in SCI. The chance of walking after SCI can be accurately predicted on the basis of demographic data and clinical examination. There is level III evidence that keeping mean arterial pressure (MAP) >85 for 7 days in patients with spinal cord injury improves neurologic outcome. T2-weighted magnetic resonance imaging can rapidly screen patients with a cervical injury (class 2 evidence) and has significant predictive value (class 3 evidence). The Spine Trauma Study Group showed that at 6 months after injury, early surgical decompression was associated with 2.8-fold increased odds of a 2-grade American Spinal Injury Association Impairment Scale improvement. The STASCIS trial documented that surgical decompression within 6 hours of injury leads to an improvement in about 70% of patients by ≥1 American Spinal Injury Association grade. Biomarkers in the cerebrospinal fluid seem to correspond significantly to the outcome of the neurologic injury.
Prognostic data in tSCI are fundamental to assess the value of new therapies and to undertake clinical trials. The increasing knowledge of new and emerging prognostic factors may assist us to direct our efforts toward focused therapeutic interventions, which may present a promising result.
Clinical neurophysiology in the prognosis and monitoring of traumatic spinal cord injury
2012, Handbook of Clinical Neurology
Citation Excerpt :
They reflect the underlying disruption and demyelination of spared longitudinal axons traversing the location of the injury. Pathologically delayed and completely abolished SSEPs have been correlated with impaired and absent sensation to vibration and light touch examined during clinical neurological examination (Jacobs et al., 1995; Curt and Dietz, 1997, 1999; Iseli et al., 1999; Hayes et al., 2002), again pointing to severed transmission via the dorsal column pathway. Early SSEP recordings after trauma in the acute stage of SCI provide important diagnostic findings that are complementary to the assessment of the completeness of injury provided by ASIA sensory and motor scores.
Preclinical studies for the repair of spinal cord injury (SCI) and potential therapies for accessing the inherent plasticity of the central nervous system (CNS) to promote recovery of function are currently moving into the translational stage. These emerging clinical trials of therapeutic interventions for the repair of SCI require improved assessment techniques and quantitative outcome measures to supplement the American Spinal Injuries Association (ASIA) Impairment Scales. This chapter attempts to identify those electrophysiological techniques that show the most promise for provision of objective and quantitative measures of sensory, motor, and autonomic function in SCI. Reviewed are: (1) somatosensory evoked potentials, including dermatomal somatosensory evoked potentials, and the electrical perceptual threshold as tests of the dorsal (posterior) column pathway; (2) laser evoked potentials and contact heat evoked potentials as tests of the anterior spinothalamic tract; (3) motor evoked potentials in limb muscles, in response to transcranial magnetic stimulation of the motor cortex as tests of the corticospinal tract, and the application of the technique to assessment of trunk and sphincter muscles; and (4) the sympathetic skin response as a test of spinal cord access to the sympathetic chain.
Prediction of walking recovery after spinal cord injury
2009, Brain Research Bulletin
Citation Excerpt :
Women with SCI may have more natural neurologic recovery than men, but, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation [102]. SSEPs are used for clinical diagnosis in patients with neurologic disease, and many studies have been performed to determine the value of SSEPs in the evaluation and prediction of walking recovery in SCI patients [1,29,57,60,62,89,118,119,120]. Most of these studies assert that early SSEPs predict motor improvement and ambulation outcome.
The recovery of walking function is considered of extreme relevance both by patients and physicians. Consequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Society is making demands for treatment before adequate trials have been conducted, but the scientific community has emphasized the need for rigorous guidelines and studies. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affecting the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones. The prognostic value of some instrumental examinations and of the more diffuse pharmacological and surgical interventions has also been reviewed.
Levels of spinal cord injury and predictors of neurologic recovery
2000, Physical Medicine and Rehabilitation Clinics of North America
Predicting neurologic recovery in traumatic cervical spinal cord injury
1998, Archives of Physical Medicine and Rehabilitation
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.
Ambulatory capacity in spinal cord injury: Significance of somatosensory evoked potentials and ASIA protocol in predicting outcome
1997, Archives of Physical Medicine and Rehabilitation
Objective: Prediction of outcome of ambulatory capacity in patients with acute spinal cord injury (SCI) by the American Spinal Injury Association (ASIA) protocol and somatosensory evoked potentials (SSEP).
Design: Correlational study on a prospective cohort.
Setting: Spinal cord injury center, university hospital.
Patients: Consecutively sampled, 70 acute and 34 chronic SCI patients.
Main outcome measures: (1) ASIA motor and sensory scores; (2) tibial and pudendal SSEP graded in 5 categories, from normal to absent; (3) ambulatory capacity rated as no, therapeutic, functional, or full. The outcome of the ambulatory capacity was assessed after discharge from the rehabilitation program, at least 6 months after trauma.
Results: In acute SCI both the initial ASIA scores and the SSEP recordings are related (p < .001) to the outcome of ambulatory capacity. In acute tetraplegia the pudendal SSEP (spearman corr. coeff. .92; p < .001) and in acute paraplegia the ASIA motor score (spearman corr. coeff. .90; p < .001) were best related to the outcome of ambulatory capacity. In the early stage of acute SCI, ASIA scores and SSEP recordings can help to assess the outcome of ambulatory capacity and, therefore, can contribute to the selection of the appropriate therapeutic approaches during the rehabilitation program. In patients with acute SCI the ASIA motor score significantly increased (p < .05) in the 6 months after trauma, whereas the ASIA sensory scores and SSEP recordings did not change significantly during this same period.
Conclusion: ASIA scores and SSEP are related to the outcome of ambulatory capacity in patients with acute spinal cord injury; in noncomprehensive or uncooperative patients the SSEP are of supplemental value to the clinical examination. Therefore, the combination of clinical and electrophysiological examinations can be of additional diagnostic value in the assessment of acute spinal cord injury.

View all citing articles on Scopus

: Supported in part by awards from the National Institute on Disability and Rehabilitation Research to the Regional Spinal Cord Injury Center of Delaware Valley (G008535135) and the National Rehabilitation Research and Training Center in Spinal Cord Injury (H133B80017).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

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ArticleFuture ambulation prognosis as predicted by somatosensory evoked potentials in motor complete and incomplete quadriplegia

Abstract

Electroenceph Clin Neurophysiol

Neuroscience

Electroenceph Clin Neurophysiol

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

Arch Phys Med Rehabil

Spinal cord injury: prognosis for ambulation based on sensory examination in patients who are initially motor complete

Arch Phys Med Rehabil

Spinal cord injury: prognosis for ambulation based on quadriceps recovery

Paraplegia

Recovery following complete paraplegia

Arch Phys Med Rehabil

Somatosensory-evoked and dermatomal-evoked potentials are not clinically useful in the prognostication of acute spinal cord injury

Spine

Somatosensory evoked potentials and neurological grades as predictors of outcome in acute spinal cord injury

J Neurosurgery

Somatosensory evoked potentials (SEPs) in spinal cord injury

Functional evaluation: the Barthel Index

MD Med Journal

Standards for neurological classification of spinal injury patients

Effect of valium on the somatosensory evoked potentials

Motor power differences within the first two weeks post-SCI in cervical spinal cord injured subjects

J Neurotrauma

Article
Future ambulation prognosis as predicted by somatosensory evoked potentials in motor complete and incomplete quadriplegia