Original article
Upper- and Lower-Extremity Motor Recovery After Traumatic Cervical Spinal Cord Injury: An Update From the National Spinal Cord Injury Database

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Abstract

Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database.

Objective

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

Design

Longitudinal cohort; follow-up to 1 year.

Setting

U.S. SCIMS.

Participants

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

Interventions

Not applicable.

Main Outcome Measures

Change in AIS, UEMS, LEMS, and motor levels.

Results

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2–3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2–7.8; P<.001).

Conclusions

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.

Section snippets

Methods

We extracted demographic and neurologic data from 1994 to 2009 from the NSCISC database. To be included, subjects had to be at least 16 years of age at the time of injury, have a complete neurologic examination recorded within 1 week of injury, and have at least 1 other complete neurologic examination more than 30 days after injury. We excluded children younger than 16 years because the reliability of motor scores may be reduced in these subjects.8 All centers participating in the NSCISC

Results

The 1436 subjects included in the analyses were recruited from 21 different centers. The number of subjects from a single center ranged from 3 to 196. Mean ± SD age at injury was 41±17 years. Thirty-four percent of the sample was 30 years or younger and 14% were older than 60 years at the time of injury. Men made up 80% of the sample. Whites made up 61% of the sample; blacks, 27%; Hispanics, 9%; and other racial groups, 3% (table 1). The most common causes of injury were vehicular collisions

Discussion

Our understanding of the “natural recovery” of neurologic function after SCI has evolved with analyses of the NSCISC, EM-SCI, Sygen, and other databases that have tracked key outcomes over time. The knowledge gained from such analyses has served to inform the design of interventional clinical trials, as well as the discussion of prognosis with patients and clinicians. In this report, we have updated neurologic outcomes from the NSCISC database by using data from patients injured between 1994

Conclusions

Motor recovery of traumatic tetraplegic SCI in the NSCISC database is similar to other published data in terms of AIS grade conversion and motor score improvement. Separating motor scores in upper- and lower-limb components shows different patterns of motor recovery based on AIS grade. Deficits in UEMS persist at 1 year in most motor incomplete patients. Motor level recovery of 2 or more levels in those with cervical complete SCI occurs in only 23.5% of patients. Motor level recovery in those

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    Supported by the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, Department of Education (grant no. H133N060011).

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

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