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Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis—The significance of anorectal evaluation

Published:November 02, 2022DOI:https://doi.org/10.1016/j.jos.2022.10.007

      Abstract

      Background

      Although the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients.

      Methods

      This study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings.

      Results

      Forty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (−), voluntary anal contraction (VAC) (−), anorectal tone (−), anal wink reflex (−), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up.

      Conclusions

      Incomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

      Keywords

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      References

        • Miyakoshi N.
        • Suda K.
        • Kudo D.
        • Sakai H.
        • Nakagawa Y.
        • Mikami Y.
        • et al.
        A nationwide survey on the incidence and characteristics of traumatic spinal cord injury in Japan in 2018.
        Spinal Cord. 2021 Jun; 59: 626-634
        • Shingu H.
        • Ohama M.
        • Ikata T.
        • Katoh S.
        • Akatsu T.
        A nationwide epidemiological survey of spinal cord injuries in Japan from January 1990 to December 1992.
        Paraplegia. 1995 Apr; 33: 183-188
        • Maynard Jr., F.M.
        • Bracken M.B.
        • Creasey G.
        • Ditunno Jr., J.F.
        • Donovan W.H.
        • Ducker T.B.
        • et al.
        International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association.
        Spinal Cord. 1997 May; 35: 266-274
        • Kirshblum S.C.
        • Burns S.P.
        • Biering-Sorensen F.
        • Donovan W.
        • Graves D.E.
        • Jha A.
        • et al.
        International standards for neurological classification of spinal cord injury (revised 2011).
        J Spinal Cord Med. 2011 Nov; 34: 535-546
        • Fawcett J.W.
        • Curt A.
        • Steeves J.D.
        • Coleman W.P.
        • Tuszynski M.H.
        • Lammertse D.
        • et al.
        Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials.
        Spinal Cord. 2007 Mar; 45: 190-205
        • Matsushita A.
        • Maeda T.
        • Mori E.
        • Yugue I.
        • Kawano O.
        • Ueta T.
        • et al.
        Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury.
        Spinal Cord. 2016 Jan; 54: 24-28
        • Crozier K.S.
        • Cheng L.L.
        • Graziani V.
        • Zorn G.
        • Herbison G.
        • Ditunno Jr., J.F.
        Spinal cord injury: prognosis for ambulation based on quadriceps recovery.
        Paraplegia. 1992 Nov; 30: 762-767
        • Frankel H.L.
        • Hancock D.O.
        • Hyslop G.
        • Melzak J.
        • Michaelis L.S.
        • Ungar G.H.
        • et al.
        The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I.
        Paraplegia. 1969 Nov; 7: 179-192
        • Hayashi T.
        • Kawano O.
        • Sakai H.
        • Ideta R.
        • Ueta T.
        • Maeda T.
        • et al.
        The potential for functional recovery of upper extremity function following cervical spinal cord injury without major bone injury.
        Spinal Cord. 2013 Nov; 51: 819-822
        • Nagoshi N.
        • Tsuji O.
        • Kitamura K.
        • Suda K.
        • Maeda T.
        • Yato Y.
        • et al.
        Phase I/II study of intrathecal administration of recombinant human hepatocyte growth factor in patients with acute spinal cord injury: a double-blind, randomized clinical trial of safety and efficacy.
        J Neurotrauma. 2020 May 22; 37: 1752-1758https://doi.org/10.1089/neu.2019.6854
        • Orkin B.A.
        • Sinykin S.B.
        • Lloyd P.C.
        The digital rectal examination scoring system (DRESS).
        Dis Colon Rectum. 2010 Dec; 53: 1656-1660
        • Resnick D.
        • Shaul S.R.
        • Robins J.M.
        Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations.
        Radiology. 1975 Jun; 115: 513-524
        • Taricco M.
        • Colombo C.
        • Adone R.
        • Chiesa G.
        • Di Carlo S.
        • Borsani M.
        • et al.
        The social and vocational outcome of spinal cord injury patients.
        Paraplegia. 1992 Mar; 30: 214-219
        • Kopp M.A.
        • Lubstorf T.
        • Blex C.
        • Schwab J.M.
        • Grittner U.
        • Auhuber T.
        • et al.
        Association of age with the timing of acute spine surgery-effects on neurological outcome after traumatic spinal cord injury.
        Eur Spine J. 2022 Jan; 31: 56-69
        • Kim D.I.
        • Tan C.O.
        Alterations in autonomic cerebrovascular control after spinal cord injury.
        Auton Neurosci. 2018 Jan; 209: 43-50https://doi.org/10.1016/j.autneu.2017.04.001
        • Dang G.
        • Chen X.
        • Chen Y.
        • Zhao Y.
        • Ouyang F.
        • Zeng J.
        Dynamic secondary degeneration in the spinal cord and ventral root after a focal cerebral infarction among hypertensive rats.
        Sci Rep. 2016 Mar 7; 622655https://doi.org/10.1038/srep22655
        • Holdsworth F.W.
        Neurological diagnosis and the indications for treatment of paraplegia and tetraplegia, associated with fractures of the spine.
        Manit Med Rev. 1968 Jan; 48: 16-18
        • Stauffer E.S.
        Diagnosis and prognosis of acute cervical spinal cord injury.
        Clin Orthop Relat Res. 1975 Oct; : 9-15
        • Previnaire J.G.
        The importance of the bulbocavernosus reflex.
        Spinal Cord Ser Cases. 2018; 42https://doi.org/10.1038/s41394-017-0012-0
        • Donovan W.H.
        The importance of the anal exam in neurologic classification of spinal cord injury.
        Spinal Cord Ser Cases. 2018; 44https://doi.org/10.1038/s41394-017-0014-y
        • Marino R.J.
        The anorectal exam is unnecessary.
        Spinal Cord Ser Cases. 2018; 43https://doi.org/10.1038/s41394-017-0013-z
        • Marino R.J.
        • Schmidt-Read M.
        • Kirshblum S.C.
        • Dyson-Hudson T.A.
        • Tansey K.
        • Morse L.R.
        • et al.
        Reliability and validity of S3 pressure sensation as an alternative to deep anal pressure in neurologic classification of persons with spinal cord injury.
        Arch Phys Med Rehabil. 2016 Oct; 97: 1642-1646
        • Samdani A.
        • Chafetz R.S.
        • Vogel L.C.
        • Betz R.R.
        • Gaughan J.P.
        • Mulcahey M.J.
        The international standards for neurological classification of spinal cord injury: relationship between S4-5 dermatome testing and anorectal testing.
        Spinal Cord. 2011 Mar; 49: 352-356
        • Kirshblum S.C.
        • Botticello A.L.
        • Dyson-Hudson T.A.
        • Byrne R.
        • Marino R.J.
        • Lammertse D.P.
        Patterns of sacral sparing components on neurologic recovery in newly injured persons with traumatic spinal cord injury.
        Arch Phys Med Rehabil. 2016 Oct; 97: 1647-1655
        • Inada T.
        • Takahashi H.
        • Yamazaki M.
        • Okawa A.
        • Sakuma T.
        • Kato K.
        • et al.
        Multicenter prospective nonrandomized controlled clinical trial to prove neurotherapeutic effects of granulocyte colony-stimulating factor for acute spinal cord injury: analyses of follow-up cases after at least 1 year.
        Spine (Phila Pa 1976). 2014 Feb 1; 39: 213-219
        • Jackson A.B.
        • 0043T Carnel
        • Ditunno J.F.
        • Read M.S.
        • Boninger M.L.
        • Schmeler M.R.
        • et al.
        Outcome measures for gait and ambulation in the spinal cord injury population.
        J Spinal Cord Med. 2008; 31: 487-499