Neurologic Improvement After Thoracic, Thoracolumbar, and Lumbar Spinal Cord (Conus Medullaris) Injuries

Department of Neurological Surgery, Thomas Jefferson University Hospital, 909 Walnut St, Philadelphia, PA 19107, USA.
Spine (Impact Factor: 2.3). 01/2011; 36(1):21-5. DOI: 10.1097/BRS.0b013e3181fd6b36
Source: PubMed


With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord.
Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients.
Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology.
A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P < 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury.
Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others.

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    • "But in some cases, this could mask the prognosis-worsening effect of the combined peripheral nerve injury in SCI. Harrop et al. [14] found that SCI at the thoracolumbar level, when combined with lower motor neuron lesions, such as cauda equina lesions, showed to be contrary to our result by having better outcomes than SCI at the upper-thoracic level. However, because most of the subjects in that study had mild injury (AIS D), it is possible that SCI itself is not obvious when combined with lower motor neuron lesions. "
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    ABSTRACT: Objective To delineate cervical radiculopathy that is found in combination with traumatic cervical spinal cord injury (SCI) and to determine whether attendant cervical radiculopathy affects the prognosis and functional outcome for SCI patients. Methods A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International Standards for the Neurological Classification of Spinal Cord Injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group). Results A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI. Conclusion Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit.
    Annals of Rehabilitation Medicine 08/2014; 38(4):443-9. DOI:10.5535/arm.2014.38.4.443
    • "Neurological status at admission is probably the most important factor related to patient's outcome. Harrop et al., 2011, published a series of 95 patients followed by at least 1 year with spinal cord injury.[44] They report that after 1 year, patients with lumbar (conus) impairment had up to 90% of chances in improvement of one or more ASIA level, compared to just 22.4% of thoracic (T4-9) and thoracolumbar (T10-12) injuries. "
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    ABSTRACT: Thoracolumbar spine trauma is the most common site of spinal cord injury, with clinical and epidemiological importance. We performed a comprehensive literature review on the management and treatment of TLST. Currently, computed tomography is frequently used as the primary diagnostic test in TLST, with magnetic resonance imaging used in addition to assess disc, ligamentous, and neurological injury. The Thoracolumbar Injury Classification System is a new injury severity score created to help the decision-making process between conservative versus surgical treatment. When decision for surgery is made, early procedures are feasible, safe, can improve outcomes, and reduce healthcare costs. Surgical treatment is individualized based on the injury characteristics and surgeon's experience, as there is no evidence-based for the superiority of one technique over the other. The correct management of TLST involves multiple steps, such as a precise diagnosis, classification, and treatment. The TLICS can improve care and communication between spine surgeons, resulting in a more standardized treatment.
    Journal of craniovertebral junction and spine 03/2013; 4(1):3-9. DOI:10.4103/0974-8237.121616
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    ABSTRACT: Spinal cord injury (SCI) is a debilitating condition that affects thousands of new individuals each year, the majority of which are males. Males with SCI tend to be injured at an earlier age, mostly during sports or motor vehicle accidents, whereas females tend be injured later in life, particularly in the age group 65 and older. In both experimental and clinical studies, the question as to whether gender affects outcome has been addressed in a variety of patient groups and animal models. Results from experimental paradigms have suggested that a gender bias in outcome exists that favors females and appears to involve the advantageous or disadvantageous effects of the gonadal sex hormones estrogen and progesterone or testosterone, respectively. However, other studies have shown an absence of gender differences in outcome in specific SCI models and work has also questioned the involvement of female sex hormones in the observed outcome improvements in females. Similar controversy exists clinically, in studies that have examined gender disparities in outcome after SCI. The current review examines the experimental and clinical evidence for a gender bias in outcome following SCI and discusses issues that have made it difficult to conclusively answer this question.
    08/2013; 4(4). DOI:10.1007/s12975-012-0249-7
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