Traumatic Spinal Cord Injury: Long-Term Motor, Sensory, and Urinary Outcomes
Traumatic Spinal Cord Injury: Long-Term Motor, Sensory, and Urinary Outcomes
Clinical
412 Rouzbeh Study et al.
Motiei-Langroudi Asian Spine J 2017;11(3):412-418
Asian Spine J 2017;11(3):412-418 https://doi.org/10.4184/asj.2017.11.3.412
Keywords: Treatment outcome; Spinal cord injuries; Surgery; Treatment; Spinal fracture
Received Aug 17, 2016; Revised Sep 29, 2016; Accepted Oct 18, 2016
Corresponding author: Rouzbeh Motiei-Langroudi
Division of Neurosurgery, Department of Surgery, Pastor Hospital, Bam University of Medical Sciences, Bam, Iran
Tel: +98-344439401, Fax: +98-3442510847, E-mail: [email protected]
ASJ
Copyright 2017 by Korean Society of Spine Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
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Asian Spine Journal Traumatic spinal cord injury 413
surgical reconstruction and instrumented fusion with or disabilities, including those with SCI. A thorough his-
without decompression [1,2]. tory regarding sensory, motor, and urinary complaints
In the long term, SCI is associated with multiple medi- was taken. The patients then underwent a thorough
cal (pressure ulcers, pneumonia, atelectasis, and others), neurological examination (including motor, sensory, and
urinary (autonomic dysreflexia, neurogenic bladder, and urinary status) prior to reviewing the medical records.
others), and neurological complications in addition to Finally, all medical records of the patients, including
pain. The chances of neurological recovery and improve- their neurological state after trauma, trauma mechanism,
ment are different in different patients and depend on var- treatment protocol, surgical protocol (if performed), and
ious factors, including primary neurological state, trauma imaging findings were evaluated. Patients with an intact
mechanism, vertebral fracture type and location, and age. neurological state after trauma, no evidence of vertebral
Complete SCI, older age, thoracic fractures, and fractures fracture, or missing data were excluded from the study. In
accompanied by dislocations generally follow a more dis- patients with multiple contiguous vertebral fractures, the
mal prognosis [3-7]. Among all these factors, the extent level with the highest imaging indicators of instability that
of neurological deficits (mostly based on the American was also consistent with the motor and sensory deficit
Spinal Injury Association [ASIA] classification [8]) has level was considered as the level of fracture to be incorpo-
been considered the most important predictive factor for rated in statistical analysis. Age, sex, trauma mechanism,
functional outcome and prognosis [4]. Of patients with preoperative and follow-up ASIA scores, preoperative
complete SCI early after injury, 5%20% will experience and follow-up urinary status, preoperative and follow-up
improvement to some extent [3]; the figure is higher in sensory examinations, level of fractures, and surgical pro-
incomplete lesions, albeit possibly over a very prolonged cedure performed were then recorded in a computerized
period after injury [6]. database. The primary outcome measure was the change
Although it has been shown that there is a better chance in motor force, sensory examination, and urinary func-
of neurological recovery in SCI patients undergoing sur- tion. The reexamination, final follow-up evaluations, and
gery for vertebral fractures, compared with conservative data analysis were performed by a neurosurgeon (R.M.L.)
management [5], most studies have not evaluated or have who was not involved in the treatment of any of the pa-
failed to show the influence of different surgical approach- tients. To reduce any potential bias, data analysis was
es and other parameters on neurological recovery. Here, also performed by the other author (H.S.) who was not
we conducted a retrospective analysis of patients suffering involved in any patient examination.
from SCI (and cauda equine injury in patients with mid All analyses were performed with PASW ver. 18 pack-
to lower lumbar fractures) after vertebral fracture and age (SPSS Inc., Chicago, IL, USA). Univariate analysis of
assessed their recent urinary and neurological state. The data was performed by t-test for quantitative measures
majority of these patients were survivors of a major earth- and chi-square test for qualitative measures. Logistic re-
quake in December 2003. The objective of this study was gression was used for multivariate analysis of the effect of
to evaluate how the motor, sensory, and urinary outcomes studied parameters on outcome. For all analyses, p-values
of these patients had been influenced in the long term by less than 0.05 were considered statistically significant.
treatment type, surgical procedure, and other factors. All the patients had provided their consent to partici-
pate in the study. The study design was approved by the
Materials and Methods Ethical Committee of Medical University, and the study
was performed with adherence to the statements of the
The study was conducted in a retrospective cohort de- Declaration of Helsinki and regulations of Institutional
sign to evaluate the predictor effects of multiple past Review Board.
risk factors on the motor, sensory, or urinary outcomes
of patients with SCI. Patients with documented medi- Results
cal records indicating spinal cord or cauda equine injury
due to vertebral fracture were visited in July 2014. All the 1. Patient data
patients were registered in the Welfare Organization of
Bam, Iran, an organization with a record of patients with In total, 103 patients were enrolled in the present study.
414 Rouzbeh Motiei-Langroudi et al. Asian Spine J 2017;11(3):412-418
There were 57 females and 46 males, with the mean (Fig. 3).
standard deviation age at the time of trauma being
28.310.5 years (range, 1155 years). The mean and me- 2. Treatment data
dian time passed since trauma (the follow-up period) was
10.32.7 and 11 years, respectively (range, 219 years). After the trauma, all the patients were transferred or re-
Most patients (76, 73.8%) were survivors of a major earth- ferred to other cities due to the lack of surgical facilities
quake that had devastated the region in December 2003, in the primary earthquake town at the time of trauma; 95
while the other 27 (26.2%) were victims of motor vehicle patients (92.2%) were surgically treated and eight (7.8%)
accidents (MVA). The median ASIA score at the time of underwent conservative management (including complete
injury was A (Fig. 1). Fig. 2 displays the fracture levels, bed rest for at least 1 month and immobilization with
the most common being T12 and L1 (29 and 25 patients, orthoses). Surgery was performed in eight surrounding
respectively), comprising more than half of the patients cities, all with major academic referral centers. No surgery
(52.4%). Although L2, L3, and L4 fractures were observed was performed within the 48 h after the trauma. All the
in six, seven, and seven patients, respectively, there were patients underwent multiple sessions of limb physical
no L5 fractures. For the ease of statistical analysis, C1C7, therapy, as recorded in their medical records.
T1T10, T11L2, and L3L5 fractures were classified as The surgical procedures included posterior spinal fu-
cervical (C), thoracic (T), thoracolumbar (TL), and lum- sion with pedicular screws (PS) in 75 patients and Har-
bar (L), respectively, and specified as such in the analysis rington rods (HR) in 14 and anterior cervical fusion with
70 66 70 65
60 57 60
50 50
40 40
30 30
24
20 18 19 20 18
Injury 14
11 11 F/U
10 10 11
0 0
0 0
A B C D E C T TL L
Fig. 1. American Spinal Injury Association scores at the time of injury Fig. 3. Number of patients within each fracture level category. C, cer-
and follow-up (F/U) visit. vical; T, thoracic (T1T10); TL, thoracolumbar (T11L2); L, lumbar (L3
L5).
35
30 29
25
25
20
15
10
7 7
6
5
5 4
3 3 3
2 2 2
0 1 0 1 0 1 1 1 0
0
C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5
20 18
13 14
3. Follow-up visit data 9
10 7 6
0
In the follow-up visits, 69 patients (67.0%) showed no Motor Sensory Urination
change in their motor force, 13 (12.6%) showed partial
No Partial Substantial Complete
recovery (less than 5/5 muscle force) in both proximal
Fig. 4. Motor, sensory, and urinary improvement at the time of follow-
and distal muscle groups (defined here as partial improve- up.
ment), 14 (13.6%) showed complete (5/5) proximal but
partial distal recovery (substantial improvement), and
seven (6.8%) showed complete recovery (complete im- 120
ment (p=0.35, p=0.56, p=0.92, and p=0.97, respectively); mild SCI) or E (neurologically intact) groups. The mean
in addition, fracture level, performance of laminectomy, follow-up duration of the patients was more than 10 years,
and NSCT had no effect (p=0.82, p=0.69, and p=0.99, one of the longest periods for SCI patients reported in
respectively). Only better postinjury ASIA scores signifi- the literature. None of the patients with grade A impair-
cantly improved sensory outcome (p<0.001). ments after trauma showed motor improvement, while
all patients with grade B and C impairments showed im-
6. Effect of study variables on urinary outcome provement by atleast one grade. In addition, the extent of
motor improvement was greater in grade C patients. In
Sex, age at injury time, follow-up time duration, trauma contrast, patients with grade A and B impairments had an
mechanism, fracture level, performance of laminectomy, identical poor prognosis in terms of sensory and urinary
and NSCT had no effect on urinary improvement (p=0.51, improvement, patients with grade C impairments showed
p=0.70, p=0.64, p=0.26, p=0.63, p=0.28, and p=0.83, re- a much more positive outcome (more than 85% chance of
spectively). However, both preinjury and postinjury ASIA improvement). This was supported by the finding that the
scores were related to improved urinary outcome, with the postinjury ASIA score, in other words, the neurological
initial ASIA score showing A greater influence (p<0.001 state after trauma, is the most important prognostic factor
and p=0.005, respectively). for motor, sensory, and urinary outcomes, a finding show-
ing clear agreement with previous results.
Discussion Performing laminectomy at the time of surgery was
another factor positively influencing motor improvement.
SCI is a potentially disabling and devastating neurological Although it has been shown that in SCI patients with
outcome of spinal column fractures that is associated with vertebral fractures, there is a better chance of neurologi-
a high social and economic burden for the patient, family, cal recovery in those undergoing surgery than in those
and healthcare system. Moreover, it most often involves receiving conservative management [5,10], most studies
the patients in their most productive period of life. The have not evaluated or have failed to show the influence
burden of the disease is highly related to the extension of different surgical approaches and other parameters on
(number of limbs involved), severity (partial vs. com- neurological recovery. The role of decompression at the
plete), and total duration of paralysis. time of surgery also remains controversial. For instance,
Different values have been reported for the recovery in a series of 23 patients with SCI after TL fractures who
rate, and the extent of recovery has been shown to differ did not undergo decompression at the time of fusion,
depending on each patients condition. The most im- Miyashita et al. showed imaging evidence of canal remod-
portant factors predicting the extent of recovery are the eling in all the patients. However, their series lacked a
primary neurological state, location of injury within the control group with decompression to compare the results
spinal cord, trauma mechanism, vertebral fracture type [11]. In contrast, some other studies have favored a role
and location, and patient age [3-7]. of laminectomy in fusion procedures in patients with dif-
The ASIA score early after trauma is reported to be the ferent degrees of SCI [2,12]. The latter studies also include
most important factor predicting the chance of motor re- case series without nondecompression control groups.
covery [4]. It is one of the most accepted and used classifi- The results of the present study, however, have provided
cations for the extent of neurological deficits after SCI and evidence of better long-term motor outcomes with lami-
classifies patients from A (complete motor and sensory nectomy or decompression.
injury) to E (normal neurological state) [8]. In general, the Another factor that influenced long-term motor out-
rate of neurological recovery in patients with grade A im- come but not sensory and urinary outcomes in this study
pairment has been reported to be around 25%45%, while was fracture and injury locations. The best outcome was
the value has been reported to be as high as 65%75% for observed for lumbar (L3 and below) fractures, and the
patients with incomplete injuries (grade C and D) [3,4,9]. worst outcome was observed for thoracic fractures (T1
This study included 103 patients with spinal fractures T10). Moreover, none of the patients had a L5 fracture,
complicated by different grades of SCI (ASIA A to C). which may indicate a low potential for neurological
None of the patients belonged to grade D (relatively compromise at this level. These results are in accordance
Asian Spine Journal Traumatic spinal cord injury 417
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