Life expectancy and long-term survival after traumatic spinal cord injury: a systematic review.

INTRODUCTION: Spinal cord injuries have a considerable impact on healthcare in terms of mortality and morbidity. To address the difficulties faced by people affected by this condition and to raise awareness among stakeholders and policymakers, it is crucial to understand factors impacting survival. The purpose of this study is to systematically review the literature on life expectancy in people with traumatic spinal cord injury (tSCI), identifying key factors influencing mortality and survival. EVIDENCE ACQUISITION: We conducted a systematic review, searching the literature for articles published up to July 2023 in PubMed, Web of Science, Cochrane Library, Google Scholar, and PEDro. Study outcomes had to be one of survival rate, life expectancy, standardized mortality ratio, or mortality rate. Only original research articles published in English were included. The quality of evidence was evaluated with the MINORS scale. The level of evidence was categorized according to the OCEBM model. EVIDENCE SYNTHESIS: A comprehensive literature search yielded 102 articles, after the selection process 20 studies were included in our review. The main factors negatively influencing survival and life expectancy included higher neurological level of injury (NLI), completeness of the lesion, need for mechanical ventilation, increasing age, and male gender. The development of SCI-related comorbidities also negatively impacted survival as well as the lack of specialized care, especially in low-income countries. Additionally, pre-injury health status and personal income may affect survival. CONCLUSIONS: Current literature shows that people affected by tSCI have a shorter life expectancy compared to the general population, highlighting some factors as possible predictors. It is difficult to compare available evidence due to the methodological heterogeneity across studies, which makes it challenging to draw generalizable conclusions on life expectancy in people with tSCI. Further studies are required to address these issues and accurately estimate life expectancy accounting for gaps in the management of people affected by tSCI to improve their care.

Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury.

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

A multi-center international study on the spinal cord independence measure, version IV: Rasch psychometric validation.

CONTEXT: The Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL). OBJECTIVE: To validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods. STUDY DESIGN: Multi-center cohort study. SETTING: Nineteen SCL units in 11 countries. METHODS: SCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis. RESULTS: The study included inpatients aged 16-87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6-6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable. CONCLUSIONS: Rasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Causes and length of stay of readmission among individuals with traumatic spinal cord injury: a prospective observational cohort study.

BACKGROUND: Secondary conditions may reduce function and participation in individuals with chronic Spinal Cord Injury (SCI). The knowledge of reasons for readmission to the hospital may be enlightening to prevent them and remodel the health services. STUDY DESIGN: Multicenter prospective observational study of all consecutive readmissions of persons with SCI after rehabilitation completion. OBJECTIVES: To explore the characteristics of individuals with SCI readmitted to the hospital, the reasons for readmissions and the burden on hospitalization in terms of length of stay (LoS) for different conditions. SETTING: 31 Italian specialized SCI centers. METHODS: Data on people with traumatic SCI readmitted to SCI centers were recorded about: age, sex, SCI level and severity group, geographical origin, readmission causes, clinical interventions during hospitalization, LoS and discharge destination. Linear and multiple logistic regression analyses were performed considering LoS (days) as dependent variable for correlations with independent variables. All tests were two-sided. RESULTS: Among 1039 persons with traumatic SCI enrolled (mean age 46, males 85%, tetraplegia 43%), 59.09% of the readmissions were caused by urological problems, 39.74% by pressure injury and 35.41% by spasticity (68% readmitted for ≥2 causes, associated with longer LoS). The mean LoS was 48 days: pressure injury, rehabilitative needs, sexual, bowel, and pain problems were associated with longer and urological problems with shorter LoS. People from the South of the country were frequently (68%) readmitted to the northern centers. CONCLUSIONS: Urological problems, pressure injury and spasticity were the most frequent causes of re-hospitalization in individuals with traumatic SCI. The migration trend seeking SCI-specific treatments suggests geographic areas to which health care organizations need to pay more attention.

Dysphagia in multiple system atrophy consensus statement on diagnosis, prognosis and treatment.

Multiple system atrophy (MSA) is a neurodegenerative disorder characterized by a combination of autonomic failure plus cerebellar syndrome and/or parkinsonism. Dysphagia is a frequent and disabling symptom in MSA and its occurrence within 5 years of motor onset is an additional diagnostic feature. Dysphagia can lead to aspiration pneumonia, a recognized cause of death in MSA. Guidelines for diagnosis and management of dysphagia in MSA are lacking. An International Consensus Conference among experts with methodological support was convened in Bologna to reach consensus statements for the diagnosis, prognosis, and treatment of dysphagia in MSA. Abnormalities of the oral and pharyngeal phases of swallowing, esophageal dysfunction and aspiration occur in MSA and worsen as the disease progresses. According to the consensus, dysphagia should be investigated through available screening questionnaires and clinical and instrumental assessment (videofluoroscopic study or fiberoptic endoscopic evaluation of swallowing and manometry) at the time of MSA diagnosis and periodically thereafter. There is evidence that dysphagia is associated with poor survival in MSA, however effective treatments for dysphagia are lacking. Compensatory strategies like diet modification, swallowing maneuvers and head postures should be applied and botulinum toxin injection may be effective in specific conditions. Percutaneous endoscopic gastrostomy may be performed when there is a severe risk of malnutrition and pulmonary complications, but its impact on survival is undetermined. Several research gaps and unmet needs for research involving diagnosis, prognosis, and treatment were identified.

Traumatic spinal cord injury in Italy 20 years later: current epidemiological trend and early predictors of rehabilitation outcome.

STUDY DESIGN: Multicenter prospective observational study of people with acute traumatic spinal cord injury (TSCI) admitted to rehabilitation. OBJECTIVES: To update epidemiological characteristics of a TSCI Italian population and verify the impact of patient characteristics at admission on two outcomes: functional gain (SCIM III) and discharge destination. SETTING: Thirty-one SCI centers for comprehensive rehabilitation in 13 Italian regions. METHODS: All consecutive individuals admitted with acute TSCI were enrolled from October 1, 2013 to September 30, 2014; data were recorded on rehabilitation admission and discharge. Functional gain and discharge destination were identified as outcome measures and statistically analyzed with patient characteristics at admission to identify early outcome predictors. RESULTS: Five hundred and ten individuals with TSCI met inclusion criteria; falls represented the most frequent etiology (45%). On admission, AIS A-B-C tetraplegia was reported in 35% of cases; AIS A-B-C paraplegia in 40%; AIS D paraplegia/tetraplegia in 25%. The majority were discharged home (72%). The mean (SD) SCIM gain was 38 ± 26 points. A predictive model was found for discharge setting: individuals with fall-related injuries, severe SCI (AIS A-B-C tetraplegia), tracheal cannula or indwelling catheter on admission, were less likely to be discharged home (OR 95% CI 0.15 [0.06, 0.35]). A model with a lower predictive power was found for SCIM gain, with lower score expected for females, older age, higher severity of SCI, a longer onset of injury admission interval (OAI), and mechanical ventilation on admission. CONCLUSIONS: Prognostic factors in early rehabilitation are still hard to identify, making it difficult to correctly approach customized rehabilitation.

Possible Strategies to Optimize a Biomarker Discovery Approach to Correlate with Neurological Outcome in Patients with Spinal Cord Injury: A Pilot Study.

The lack of reliable diagnostic and prognostic markers for spinal cord injured (SCI) patients is a severe obstacle in development and testing of new therapies, and it also impairs appropriate rehabilitation care. The sparse available data on the biochemical composition of cerebrospinal fluid (CSF) during the acute and/or chronic phase of the lesion provide, up until now, inconsistent results. In this pilot study, we then explored the possibility of combining a multi-parametric and bioinformatic analysis of CSF for its biological properties tested on different cells types, suitable for investigating inflammation and re-myelination. The patient enrollment was based on stringent inclusion criteria; that is, cervical and thoracic SCI trauma, CSF collection within 24 h of trauma, type of surgical approach for spine stabilization, and absence of steroid therapy before CSF collection. Eleven SCI patients and four healthy controls were included, and in three patients, CSF was also collected at 3 months after lesion. We identified 19 proteins among the 60 investigated cytokines, chemokines, growth factors, and structural biomarkers, which are transiently regulated 24 h after SCI. A bioinformatic analysis indicated that interleukin (IL)-6 and IL-10 are in the core of the interconnected net of activated proteins. Cell-based experiments indicate that CSF from SCI patients stimulates astroglia derivation from neural precursor cells, and an inverse correlation between IL-8 CSF level and oligodendrocyte precursor cells generated from neural stem cells was also observed. Results from this pilot study suggest that using a combined bioanalytic and biological approach to analyze SCI CSF at different times after injury could be a useful approach for identifying reliable diagnostic and prognostic markers in SCI.

Stridor in multiple system atrophy: Consensus statement on diagnosis, prognosis, and treatment.

Multiple system atrophy (MSA) is a neurodegenerative disorder characterized by a combination of autonomic failure, cerebellar ataxia, and parkinsonism. Laryngeal stridor is an additional feature for MSA diagnosis, showing a high diagnostic positive predictive value, and its early occurrence might contribute to shorten survival. A consensus definition of stridor in MSA is lacking, and disagreement persists about its diagnosis, prognosis, and treatment. An International Consensus Conference among experts with methodological support was convened in Bologna in 2017 to define stridor in MSA and to reach consensus statements for the diagnosis, prognosis, and treatment. Stridor was defined as a strained, high-pitched, harsh respiratory sound, mainly inspiratory, occurring only during sleep or during both sleep and wakefulness, and caused by laryngeal dysfunction leading to narrowing of the rima glottidis. According to the consensus, stridor may be recognized clinically by the physician if present at the time of examination, with the help of a witness, or by listening to an audio recording. Laryngoscopy is suggested to exclude mechanical lesions or functional vocal cord abnormalities related to different neurologic conditions. If the suspicion of stridor needs confirmation, drug-induced sleep endoscopy or video polysomnography may be useful. The impact of stridor on survival and quality of life remains uncertain. Continuous positive airway pressure and tracheostomy are both suggested as symptomatic treatment of stridor, but whether they improve survival is uncertain. Several research gaps emerged involving diagnosis, prognosis, and treatment. Unmet needs for research were identified.

Proactive Cortical Control in Spinal Cord Injury Subjects with Paraplegia.

Preparatory cortical activities were investigated in subjects with paraplegia attributed to spinal cord injury (SCI). Electroencephalogram (EEG) and behavioral data were recorded simultaneously in a visual-motor discrimination go/no-go task performed with the right upper limb. Eighteen SCI subjects participated to one, two, or three experimental sessions (Go/No-Go task), according to their availability and willingness to participate. To evaluate the effects of SCI on cortical activities as a function of time, we considered three SCI groups (9 individuals each), based on different time from the injury onset (acute, 1-2 months; subacute, 3-5 months; chronic, 6-9 months), and a control group of 9 healthy participants matched for age and sex. Results indicate that response time (RT) was slower and percentage of omissions was higher in SCI subjects than healthy, independently from time from lesion (TFL). Also, the proactive motor preparation, indexed by the Bereitschafts potential (BP), and the pre-frontal cognitive control, indexed by the pre-frontal negativity component, showed reduced amplitude in SCI subjects, independently from TFL. Conversely, TFL effect was observed in the BP topography, which showed a more posterior focus in subacute and chronic groups than healthies. Interestingly, despite this posteriorization, BP amplitudes maintained the well-known correlation with RTs. Overall, SCI affects cortical reorganization independently from TFL, regarding proactive activities for action inhibition and reaction time; conversely, a TFL effect was observed in the topography changes related to the cortical areas involved in proactive motor activity. Present data are in line with growing evidence of brain changes after SCI, in particular focusing on cognitive effects and evidencing possible functional mechanisms related to motor and cognitive readiness processing, relevant for SCI rehabilitation programs.

The burden of colonization and infection by carbapenemase-producing Enterobacteriaceae in the neuro-rehabilitation setting: a prospective six-year experience.

We describe the high burden of carbapenemase-producing Enterobacteriaceae (CPE) colonization and infection in a neuro-rehabilitation hospital in Italy over a 6-year period. Overall, 9.3% of patients were found to be CPE carriers on admission; the rates of CPE in-hospital acquisition and CPE-BSI were 9.2 and 2.9 cases per 10,000 patient days, respectively.

What do spinal cord injury patients think of their improvement? A study of the minimal clinically important difference of the Spinal Cord Independence Measure III.

BACKGROUND: The Spinal Cord Independence Measure (SCIM III) is a scale of independence in the activities of daily life, specifically designed for spinal cord injury subjects. AIM: The aim of this study was to calculate the minimal clinically important difference (MCID) of the SCIM III according to distribution and anchor based approach. DESIGN: Prospective study. SETTING: Four Spinal Cord Units in Italy. POPULATION: Patients with acute/subacute spinal cord injury/lesion. METHODS: The scores of the total SCIM and of the four subscale was recorded at admission and discharge. Clinical significance was calculated according to anchor based methodology using a global rating of change questionnaire. The accuracy of MCID values in predicting a judgment of small improvement by the patients has been assessed by means of the area under the receiving operating curves (aROC). RESULTS: Total SCIM MCID values varied from 12 for patients with complete tetraplegia to 45.3 for those with incomplete thoracic lesions. The MCID of self-care varied from 3.3 to 8.5 and from 10 to 18 for respiration and sphincter management, depending on the level and severity of the lesion. With regard to mobility (room and toilet), the MCID varied from 1 to 3 and from 2.5 to 7.26 for mobility (indoors and outdoors). The aROC was between good and excellent for all these values. CONCLUSIONS: The results provide benchmarks for clinicians and researchers to interpret whether patients' change score on the SCIM III can be interpreted as true or clinically meaningful and to make clinical judgments about the patients' progress. CLINICAL REHABILITATION IMPACT: Our data could be useful for both clinicians and researchers. At the beginning of rehabilitation clinicians may have an idea of the minimal improvement of the patient (based on his neurological status) that could have an impact on patient's life. At the end of rehabilitation process, it is possible to control if the patient achieved an improvement that is true and significant. Researchers could also use these criteria to evaluate the clinical significance of an intervention by calculating the number of subjects in the treatment and control groups (or in two different treatment groups) who achieved a change calculated as the natural recovery plus the MCID.

Outcomes Following Ischemic Myelopathies and Traumatic Spinal Injury.

Background: As the general population ages, the rising prevalence of vascular lesions of the spinal cord will become significant. Purpose: The aim of this study was to compare the neurological and functional outcomes of patients with ischemic spinal cord injury (ISCI) and traumatic spinal cord injury (TSCI). Methods: We conducted a retrospective study in a spinal cord unit of 2 rehabilitation hospitals. We studied 168 patients with a TSCI and 72 with an ISCI. At admission and discharge, patients were evaluated by American Spinal Injury Association Impairment Scale (AIS) standards and Spinal Cord Independence Measure (SCIM). Length of stay, occurrence of complications, and discharge dispositions were also recorded. Linear and logistic regression models were used to analyze the effects of the etiology of the lesion, AIS level at admission, and level of the lesion. Results: Patients with an ISCI were older and experienced fewer cervical lesions and fewer complete lesions than patients with TSCI. By linear and logistic regression, etiology was a predictor (together with lesion features) of functional (SCIM improvement and SCIM at discharge) outcome, with traumatic patients having better outcome than ischemic ones. Age, AIS level, and lesion level were the chief predictors of length of stay, occurrence of complications, and discharge dispositions. Conclusions: A diagnosis of ischemia and trauma could be a determinant of functional recovery in SCI patients.