I ORAL PRESENTATIONS

Topic 2: Prognostication of Physical Outcome
Chair: Gordana Savic, John Ditunno

Introduction Lecture:
PROGNOSTICATION OF PHYSICAL OUTCOME FOLLOWING SPINAL CORD INJURY
Gordana Savic
National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK

Some neurological recovery and functional improvement occur after traumatic spinal
cord injury (SCI) during standard treatment and rehabilitation, as part of the natural
recovery process. The degree of recovery depends on the type, level and severity of
injury, as shown in the two large retrospective studies (Frankel et al. 1969 and Mar-ino
et al. 1999)1,2. Prognostic factors for recovery have been examined in many retrospective
and a few prospective studies, especially over the last two decades, all very
comprehensively summarized by Burns and Ditunno (2001)3. Even though dif-ferent
methodologies were used for data collection and analysis, most studies agree that
results of an early neurological assessment according to the ASIA standards are the
best prognostic factor in cooperative patients. Patients with incomplete injuries
according to the ASIA classification seem to show more recovery that those with
complete injuries: motor incomplete do better than sensory incomplete and sensory
incomplete with preserved pin prick sensation better than those with light touch only.
Overall, incomplete cervical injuries tend to show the most recovery and complete
thoracic the least.

Predicting the final neurological and functional outcome is of great importance in
planning the treatment, rehabilitation and discharge of patients with SCI. In addition,
knowing the time and magnitude of a possible natural recovery is very important in
designing future clinical trials, especially trials of early interventions in the acute phase
of SCI before the natural recovery plateau is reached.

7/2 Neurologic Outcome in surgically treated patients with incomplete
closed traumatic cervical spinal cord injuries.

B. Singhal, A. Mohammed, P. Kluger
National Spinal Injuries centre, Stoke Mandeville Hospital, Mandeville Road,
Aylesbury UK HP21 8AL

Background:
This study is based on referenced (Reference1) paper, which looked into neurological
outcome in patients with conservatively managed incomplete closed traumatic spinal
cord injuries using the ASIA motor scoring system and the Frankel Classification. We
base our study with the same parameters in cervical SCI patients who were treated
Surgically.

Method:
Retrospective study looking into patients with incomplete cervical injuries who were
admitted to the hospital within 2 days after injury were included. All patients were
treated surgically and mobilised within 7 days post operatively. Patients who had solely
anterior fixation were mobilised with Philadelphia collar for 4 weeks. Patients who had
both anterior and posterior fixation were mobilised without any orthosis.

Results:
2 patients had neurological deterioration post surgery but all regained the pre fixation
level of neurological function within 12-16 weeks of their hospital stay. The patients
who were followed up for 12 months or more concurred with the finding in the
referenced paper that preservation of pinprick sensation below the level of injury was
indicator of good prognosis. We also saw an improvement in a Frankel grading from B
to C and C to D in majority of our patients. Sacral sparing remained the best prognostic
indicator of motor recovery .

Conclusion:
Surgical management of the closed cervical spine injury is an equally effective way of
managing the above patient group. Mean operation to mobilisation time was 5 days,
which in comparison to referenced paper was much less.

Reference:
(1) Katoh Shinsuke ,Masry-El Wagih ; Spine,1996 Vol 21(20),2345-2351

8/2 Late Onset of Innervated Zones in Complete Spinal Cord Injury:
When Zone of Partial Preservation? When Zone of Partial Recovery?
A Preliminary Report

H Unalan, M Uludag, M Akyüz, B Erhan, SS Karamehmetoglu, A Dinç,
J Majlesi, S Gündüz
Istanbul University, Cerrahpasa Medical Faculty, PMR Dept. Istanbul, Turkey

Objective: To follow-up, for one year, the possible neurological changes in zones of
partial preservation in patients with complete (ASIA A-2000) SCI.

Methods: Fifteen patients with complete SCI were followed-up for 12 months.
Evaluation was performed by only physical examination to determine the neurological
level of injury and ZPP areas in the initial examination (i.e., at admission to the
rehabilitation department) and during the follow-up period. Initial detailed neurological
examination was performed according to ASIA revised 2000 standarts on admission to
the rehabilitation unit and was repeated at months 6 and 12. The same physiatrist (the
first author) with 10 years of experience in SCI medicine performed all neurological
examinations and decided for the classification of the injuries. The patients were
recruited consecutively as they were admitted to the rehabilitation unit for
hospitalization after discharge from the acute care and/or neurosurgery department.
Results: In 10 of 15 patients, zones that could not be considered as ZPP according to
the definition in ASIA 2000 Standarts booklet, at the beginning, turned to be
neurologically recovered zones in the follow-up (though not functional at all times). In
14 of 15 patients the initial neurological level changed. Some sensory and/or motor
recovery occurred in areas initially examined as 0/2 (sensory) and 0/5 (motor) and also
more than 3 levels below the initial level. These areas were not classified as ZPP
considering the definition in ASIA booklet.

Conclusion: According to the authors ‘zone of partial preservation’ should be more
clarified in the booklet. Late recovered zones that can not be considered as ZPP in
initial examinations (according to ASIA standarts) may be called as ‘zone of partial
recovery’ at some time after the injury, if one also takes into account some proposed
mechanisms of recovery in complete (A) injuries such as ‘sprouting’. The term ZPP
may be used in a limited ‘time period’ to be clearly distinguished from zones that were
not preserved but recovered neurologically. In other words, when ‘zone of partial
preservation’ and when ‘zone of partial recovery’?

9/2 Functional independence among young adults with spina bifida, in
relation to hydrocephalus and level of lesion

F.W.A. van Asbeck, M. Verhoef, R.H.J.M. Gooskens, M.W.M. Post
Rehabilitation Centre De Hoogstraat; Utrecht; The Netherlands

Knowledge about the level of functional independence that can be expected at adult
age might support decisions on the treatment of newborns with spina bifida (SB). This
study determined functional independence among young adults with SB and its
relationships with pathological characteristics known from birth (hydrocephalus, level of
lesion). Data were collected from medical files and by physical examination. Functional
independence was assessed on six domains (self-care, sphincter control, transfers,
locomotion, communication and social cognition) using the Functional Independence
Measure (FIM).

Subjects were 165 SB patients (69 men, age range 16–25 years, mean 20:9 (Y:M), 117
with hydrocephalus). Patients without hydrocephalus were independent for all FIM
domains except sphincter control, as were patients with hydrocephalus with a lesion
level below L2. Most patients with hydrocephalus and a lesion at L2 or above were
dependent as regards sphincter control (98%), locomotion (79%) and self-care (54%),
and quite a few needed support in transfers (38%), social cognition (29%) and
communication (15%).

Our study shows that patients without hydrocephalus were independent for all FIM
categories except sphincter control. Within the group of patients with hydrocephalus,
independence was closely related to level of lesion.

10/2 Outcomes in Patients Admitted for Rehabilitation with Spinal Cord
Lesions Following Degenerative Spinal Stenosis

J Ronen, M Itzkovich, V Bluvshtein, A Catz,
1Loewenstein Rehabilitation Hospital, Raanana; 2Sackler Faculty of Medicine,
Tel Aviv University,Israel

The main problem: Little information is available about the survival, neurological
recovery, and length of stay in hospital (LOS) of patients with spinal stenosis (SS) and
Spinal Cord Lesion (SCL).

Method: To evaluate outcome measures and the factors affecting them, a retrospective
cohort study was carried out at Loewenstein Rehabilitation Hospital, the premier
referral center for rehabilitation medicine in Israel. The study included 262 patients with
SCL following degenerative spinal stenosis, treated between 1962 and 2000.
Data were collected retrospectively. Survival was assessed using the Kaplan-Meier
method, and the relative mortality risk by the Cox proportional hazard model.
Neurological recovery was evaluated by calculating the change in Frankel grades, and
factors that affect it were assessed by logistic regression. LOS associations were
analyzed with ANOVA.

Results: The median age at lesion onset was 61 years, and the median survival 17.6
years. Age at SCL onset was found the only factor with a significant effect on survival.
Fifty-eight percent of the 148 patients who had Frankel grades A, B, or C on admission
achieved useful recovery to grades D and E. Frankel grade at admission to
rehabilitation, age, and SCL level had a significant effect on recovery. The mean LOS
was 99.7 days, and only Frankel grade had a significant effect on LOS.

Conclusions: Patients with SS and disabling SCL can achieve significant neurological
recovery and survive for many years. They require adequate care in a specialist
rehabilitation system.

11/2 Traffic accident spinal cord injury, distribution and outcomes:
Croatian experience

Sasa Moslavac, Ivan Dzidic
Spinal Unit, Spec. Med. Rehab. Hosp., Varazdinske Toplice, Croatia

The aim of the study was to investigate neurological outcome of traffic accident spinal
cord injury (SCI) patients. We monitored level of injury in this study since it defines
neurological prognosis and implicates functional improvement in course of
rehabilitation. Hospital records of 154 traffic accident SCI patients rehabilitated in
Spinal Unit of Rehabilitation Hospital in Varazdinske Toplice, Croatia in years 1991 –
2001 were reviewed. Following 6 groups of patients were formed: car drivers, codrivers,
back seat passengers, motorcycle drivers, bicycle drivers and pedestrians.
Overall, 93% of initially complete SCI patients remained complete at discharge, while
72% previously non-ambulatory incomplete patients (ASIA B and ASIA C) achieved
ambulatory status (ASIA D and ASIA E) in course of rehabilitation. Motorcycle drivers
had complete injury at admission in 67% of patients, followed by 54% of car drivers,
and both groups had the lowest percentage of conversion to incomplete injury (0% and
3%, respectively), indicating vulnerable position in traffic. Ambulatory status at
admission was found most frequently in bicycle group (40%) and co-driver group
(35%), but with samples too small to be indicative. Similarly, it is difficult to compare
group patterns in achieving ambulation; however it is important that incomplete nonambulatory
patients from all groups improved to ambulatory status in range of 57%
(pedestrian group) to 100% (bicycle group), with average of 72%. It would be of further
interest to monitor outcomes of injury in these groups in traffic accidents, especially
with respect to preventive measures taken on them.

Key words: traffic spinal cord injury, rehabilitation, neurological outcome

12/2 The Comparison of the SF-36 Survey and Its One-Word Modified
Version in Patients with Spinal Cord Injury
H Unalan, B Celik, A Sahin, N Caglar, S Esen, SS Karamehmetoglu
Istanbul 70. Yil Physical Medicine & Rehabilitation Teaching and Rehabilitation
Hospital, Istanbul University Cerrahpasa Medical School PMR Dept.

Objective: The SF-36 is a well known instrument that purports to measure healthrelated
quality of life. The aim of this study was to compare the results of the SF-36
with the one word-modified form in patients with spinal cord injury (SCI) recruited from
the state rehabilitation hospital and the university hospital.

Methods: Forty-one patients with SCI (11 women, 30 men; mean age±SD,
38.39±13.99) who were discharged at least 6 months ago and a control group
consisting of 31 healthy individuals (10 women, 21 men; mean age±SD; 37.71±12.99)
were included in the study. The interviews were conducted by telephone. The words
“walking” and “climbing” were replaced with “going” in the one word-modified version of
the SF-36 survey by authors. Both the original SF-36 and its one-word modified version
were applied to the patient at each interview.

Results: Physical functioning domain scores were significantly higher in the one wordmodified
form than in the original SF-36 survey (p<0.000). All the test domains were
significantly lower in patients with SCI than in the healthy control group.

Conclusion: The use of the original SF-36 in patients with SCI could result in
underestimation of physical functioning in the activities of daily living in patients with
SCI.

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