Introduction to Spinal Cord Injury Medicine

1
Introduction to Spinal Cord Injury Medicine

• Suzanne L Groah, MD, MSPH

2
Background
3
Spinal Cord Injury Model System

• Originated in 1970
• Federally funded (NIDRR)
• The most comprehensive database on individuals
  with SCI
• Captures approximately 12-15 of new SCIs in US

4
Spinal Cord Injury Model Systems
5
Comprehensive Neurological ExamASIA will have
new meaning from this day forward
6
Importance of Comprehensive Neurological Exam -
ASIA

• Evidence-based
• Valid, reliable, consistent
• Allows for prognosis
• Neurological
• Functional (Rehabilitation goals)
• Allows study of interventions
• Rehabilitation
• Drugs

7
ASIA Sensory Exam

• Sensory Exam
• 28 sensory points
• Test light touch pin/pain
• Importance of sacral pin testing
• 3 point scale (0,1,2)
• optional proprioception deep pressure to
  index and great toe (present vs absent)
• deep anal sensation recorded present vs absent

8
ASIA Motor Exam

• 10 key muscles
• C5 - Biceps L2 - Iliopsoas
• C6 - ECRL L3 - Quads
• C7 - Triceps L4 Tib ant
• C8 FDP (3rd) L5 - EHL
• T1 ADM S1 - Gastrocsoleus
• Sacral exam voluntary anal contraction
  (present/absent)
• optional ms diaphragm (VC), abdominal (Beevors
  test) , hip adductors

9
ASIA Motor Grading

• Motor Grading Scale
• 6 point scale (0-5) ..(avoid /-s)
• 0 no active movement
• 1 muscle contraction
• 2 movement thru ROM w/o gravity
• 3 movement thru ROM against gravity
• 4 movement against some resistance
• 5 movement against full resistance

10
ASIA Exam for Completeness

• A Complete No Sacral Motor / Sensory
• B Incomplete Sacral sensory sparing
• C Incomplete Motor Sparing (lt3)
• D Incomplete Motor Sparing (gt3)
• E Normal Motor Sensory

11
Spinal Cord Injury Epidemiology

• Incidence
• 40/million
• 10,000 new cases per year
• Does not include those who die at scene
• 4/million or 1,000 per year
• Prevalence
• 200,000 400,000 in US

12
Spinal Cord Injury Epidemiology

• Age at injury increasing
• Mean 32 years
• More people 60 years at time of injury
• 80 male
• Etiology
• 34 MVC, 19 falls, 17 GSW, 7 diving
• MVC 1 cause if lt45 years
• Falls 1 cause if gt45 years

13
Spinal Cord Injury Epidemiology

• Neurologic level and completeness (ASIA)
• Cervical 50.7
• Thoracic 35.1
• Lumbosacral 11
• C5 gt C4 gt C6 gt T12 gt C7 gt L1

14
Spinal Cord Injury Epidemiology

• ASIA
• A 49
• B 10.3
• C 11.2
• D 29.1
• E 0.8
• Thoracic usually complete
• Lumbosacral usually A or D
• Cervical A-D

15
Prognosis for Recovery After SCI
16
Prognosis for Recovery

• ASIA testing at 72h 1 week superior to earlier
  testing
• Repeat testing within 72 h 1 wk window
• Sensory exam better for predicting motor recovery
  in LE than UE

17
Prognosis for Recovery

• 50-67 of total 1-year recovery occurs in first 2
  months
• Slower recovery during 3-6 mos
• Motor recovery documented up to 2 yrs

18
Prognosis for Recovery

• Motor completes plateau at 12-18 mos
• Motor incompletes plateau at 9-12 mos

19
Summary of Recovery in Complete Tetraplegia

• Most regain 1 motor level
• At 72 hours 1 week,
• 50 chance of recovery 1st 0/5 muscle
• Nearly 100 recovery of 1st 1-2/5 muscle
• Sensation improves likelihood of recovery
• Greater recovery for C4 than C5 or C6

20
Summary of Recovery in Complete Tetraplegia

• Initial motor significant predictor of long-term
  motor and rate of recovery
• Faster an initial 0/5 muscle starts to recover,
  the better the prognosis
• Most UE recovery in first 6 months
• Most with some initial motor plateau earlier than
  those with no motor

21
Summary of Recovery in Complete Tetraplegia
22
Summary of Recovery in Incomplete Tetraplegia

• At 48h, if 0/5 motor but preserved PP
• 77 completes gain to at least 3/5
• 92 incompletes gain to at least 3/5
• At 48 h, of 0/5 motor but no preserved PP
• 1.3 completes gain to at least 3/5
• 3.9 incompletes gain to at least 3/5