If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MOVA St. Louis Healthcare System, St. Louis, MO
To help individuals make informed choices regarding the optimal type and timing of restorative surgical treatment for cervical spinal cord injury (SCI), more precise information is needed on their ability to perform activities of daily living. The goal of this work was to describe functional independence achieved by individuals with differing levels of cervical SCI.
Methods
Using the comprehensive European Multicenter Study of Spinal Cord Injury dataset, analysis was undertaken of individuals with traumatic SCI, motor-level C5–C8. Data on feeding, bladder management, and transfers (bed to wheelchair) were compared between individuals with different levels of injury. Subgroup analyses of symmetrical and asymmetrical SCI and between complete and incomplete SCI were performed. The impact of age, sex, and time postinjury on functional independence was ascertained.
Results
Data were available for individuals with symmetrical (n = 204) and asymmetrical (n = 95) patterns of SCI. Independence with feeding, urinary function, and transfer ability was increased in individuals with strong finger flexion. Unexpectedly, the presence of strong elbow extension did not uniformly result in the ability to transfer independently. There was no change in any of the analyzed activities between 6 and 12 months postinjury.
Conclusions
People with cervical SCI who gain finger flexion have greater independence with feeding, urinary, and transfer activities. Restoration of finger flexion should be a reconstructive priority for individuals with midcervical-level SCI.
Cervical-level spinal cord injury (SCI) causing tetraplegia has a profound impact on upper limb function, affecting activities of daily living (ADLs) and self-care, and it ultimately restricts community integration and quality of life. Approximately 50% of SCI occurs at the cervical level,
European Multicenter Study of Spinal Cord Injury (EMSCI) Network. Recovery of sensorimotor function and activities of daily living after cervical spinal cord injury: the influence of age.
Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series.
Hoben H, Varmun R, James A, et al. Nerve transfers to restore and function in cervical level spinal cord injury: a more appealing and accessible option for patients. Paper presented at: American Society for Peripheral Nerve Annual Meeting; January 23-25, 2015; Paradise Island, Bahamas. Abstract 113.
Candidacy for nerve transfers can be time-sensitive owing to peripheral axon and muscle degeneration from the varying degree of direct lower motor neuron destruction that occurs.
making timely and informed surgical decision making critically important.
Gains in motor levels and functional independence occur during rehabilitation, and individuals with motor-incomplete SCI may recover owing to the reorganization of preserved (undamaged) central neural pathways.
in: Frontera W.R. DeLisa J.A. Gans B.M. Robinson L.R. Bockeneck W. Chase J. DeLisa’s Physical Medicine and Rehabilitation, Principles and Practice. Lippincott Williams & Wilkins,
Philadelphia2005: 1715-1752
Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience.
Early decompression (< 8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by spinal cord independence measure after one year.
Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience.
Therefore, for a given motor level of injury, there is a range of possible functional independence. Overall, there are paucity of published data on the expected degree of ADLs independence for a given cervical spinal motor level.
The aim of this study was to define improvements in functional independence within the first year after SCI involving motor levels C5 to C8. The primary objective was to establish the relative degree of recovery in functional independence across different motor levels of cervical SCI. The secondary objectives were to determine how functional independence differs between symmetrical and asymmetrical and between complete and incomplete SCI as well as to assess the impact of age, sex, and time postinjury on functional independence. The ultimate goal of this research was to guide decision-making involving early restorative hand surgery, particularly for time-dependent nerve transfers.
Methods
European Multicenter Study of Spinal Cord Injury Database
This database includes deidentified prospectively collected data acquired by the SCI rehabilitation centers participating in the European Multicenter Study of Spinal Cord Injury (EMSCI) study group (www.emsci.org, ClinicalTrials.gov Identifier NCT01571531).
Institutional review board approval was obtained at the individual SCI centers participating in EMSCI. The database includes individuals’ neurological and functional independence measurements over time. Within the EMSCI network, trained examiners using a uniform protocol assess participants within 2 weeks of initial SCI and subsequently at 1, 3, 6, and 12 months. Neurological assessments are performed according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI),
and include motor and sensory scoring of individual spinal cord segments. Upper extremity motor scores are based on muscle strength scores (Medical Research Council [MRC] 0–5) derived from manual muscle testing of the following key functions deriving primary innervation from a specific spinal cord segment: (1) elbow flexion (C5), (2) wrist extension (C6), (3) elbow extension (C7), (4) finger flexion (C8), and (5) finger abduction (T1).
Functional assessments of ADLs (functional independence) are measured using the Spinal Cord Independence Measure (SCIM). This validated performance measure
requires direct observation and scoring of the individual performing activities such as feeding, accomplishing urinary function, and transferring from bed to wheelchair.
This study examined the relationship between upper extremity movement and the ability to independently perform feeding, urinary, and transfer activities as captured by the SCIM
survey. A query of the central EMSCI database was performed to identify specific data subsets from individuals at 6 months following injury with motor levels C5, C6, C7, or C8 (as determined later under Determining motor level). Age at time of injury, sex, mechanism of injury, and grade (A–D) from the American Spinal Injury Association (ASIA) Impairment Scale (AIS) were collected. For each level of injury, SCIM items 1 (Feeding), 6 (Sphincter Management—Bladder), and 10 (Transfers: Bed-Wheelchair) were recorded at 6 months and 12 months after injury (Fig. 1). The SCIM collects data on a broad range of functional activities including respiratory and other functions. We chose to collect data on activities that individuals with midcervical SCI specifically identified in a previous study
Nerve transfer surgery in cervical spinal cord injury: a qualitative study exploring surgical and caregiver participant experiences [published online ahead of print September 27, 2019]. Disabil Rehabil.
as relevant to gains in function that can be achieved with surgery. Individuals with incomplete data were excluded from the analysis.
Figure 1Spinal Cord Independence Measure (SCIM) items 1 (Feeding), 6 (Sphincter Management—Bladder), and 10 (Transfers: bed—wheelchair). One item from each domain (self-care, sphincter management, mobility) was chosen to widely reflect functional differences at various cervical spinal cord levels. Standardized SCIM answer choices were grouped into independent (green), partial assist (yellow), or full assist (red) as shown.
For this study, C5 motor-level SCI was defined as having elbow flexion MRC grade 3, 4, or 5 with caudal levels C6–T1 as having an MRC grade 0, 1, or 2. Similarly, C6 motor-level SCI was defined as having wrist extension of MRC grade 3, 4, or 5 with caudal levels C7–T1 of MRC grade 0, 1, or 2; C7 motor level was defined as having elbow extension of MRC grade 3, 4, or 5 with caudal levels C8–T1 of MRC grade 0, 1, or 2; and C8 motor level was defined as having finger flexion of MRC grade 3, 4, or 5 with T1 of MRC grade of 0, 1, or 2. All segments rostral to the motor level must have achieved an MRC grade of 4 or 5 or a normal sensory score at C4 where there is no testable motor score available; a normal segmental sensory score (2 of 2) infers a normal C4 segmental motor status. This purposely deviates from how motor level is typically defined by SCI clinicians using the ISNCSCI, in which the motor level is the first spinal segment (indexed by the key muscle group for that segment) having a muscle strength score of at least 3 of 5 (full range contraction against gravity alone), providing all rostral key muscle segmental motor scores are normal (5 of 5).
As surgeons, we deliberately chose a more inclusive and conservative approach to defining the surgically relevant motor level, where more rostral levels may have muscle strength scores of MRC 4 or 5. Injury patterns were categorized into symmetrical and asymmetrical SCI, with asymmetrical SCI defined as 1 or more motor level difference between sides. Asymmetrical patterns of injury were categorized according to the more caudal level (ie, a person with a C5 motor level on one side and a C7 motor level on the contralateral side was classified as a C7 level injury).
Range of SCIM activities
The range of performance for each of the 3 SCIM activity items was examined and correlated with the individual’s motor level. The SCIM item scores were condensed by the authors into independent, partial assist, and full assist as shown in Figure 1. Range of functional independence between 6 and 12 months was compared to see whether there were changes in functional activity with greater time following injury. Subgroup analyses were performed between symmetrical and asymmetrical injuries, as well as motor-complete (ASIA A, B) and motor-incomplete (ASIA C, D) injury patterns. The impact of age (categorized as <40, 40–60, or >60 years), sex, time since injury, and degree of asymmetry (for asymmetrical SCI, number of intervening levels) on independence was ascertained.
Statistical analysis
Descriptive statistics were used to summarize baseline characteristics. The SCIM item scores at each motor level were reported with 95% confidence intervals. The Fisher exact test was used to compare SCIM scores for a given motor level among the following groups: (1) 6 versus 12 months after SCI, (2) symmetrical versus asymmetrical SCI, and (3) motor-complete (ASIA A or B) versus motor-incomplete (ASIA C or D) patterns of injury. The impact of age, sex, and degree of asymmetry on SCIM scores was also evaluated using Fisher exact test.
Results
There were 299 individuals with motor level C5 to C8 spinal cord injury at 6 months included in this study; 204 (68%) had symmetrical SCI, and 95 (32%) had asymmetrical patterns of SCI. Demographic characteristics for the symmetrical and asymmetrical groups were similar (mean age, 42 ± 18 years; 81% male; Table 1). The most common cause of SCI was trauma (97%), followed by ischemia (3%). The AIS category was distributed as follows: AIS A 47%, AIS B 25%, AIS C 19%, and AIS D 9%. Motor level was distributed as follows: C5 28% (n = 85), C6 38% (n = 113), C7 23% (n = 68), and C8 11% (n = 33).
Asymmetrical pattern of injury was defined as 1 or more motor level difference between sides. AIS category is defined as A complete, B sensory incomplete, C motor-incomplete with > 50% of key muscles below the level graded as MRC < 3, and D motor-incomplete with > 50% of key muscles below the level graded as MRC ≥ 3. Motor levels were assigned based on the most cephalad level at which MRC was graded 3, 4, or 5 with all rostral levels 4 or 5 and all caudal levels 0, 1, or 2. Motor level is defined as the most caudal level at which the MRC grade is 3, 4, or 5.
AIS, American Spinal Injury Association Impairment Scale.
∗ Asymmetrical pattern of injury was defined as 1 or more motor level difference between sides. AIS category is defined as A complete, B sensory incomplete, C motor-incomplete with > 50% of key muscles below the level graded as MRC < 3, and D motor-incomplete with > 50% of key muscles below the level graded as MRC ≥ 3. Motor levels were assigned based on the most cephalad level at which MRC was graded 3, 4, or 5 with all rostral levels 4 or 5 and all caudal levels 0, 1, or 2. Motor level is defined as the most caudal level at which the MRC grade is 3, 4, or 5.
The range of functional independence in feeding (SCIM item 1) by motor level is shown in Figure 2 for symmetrical SCI and Figure E1 for asymmetrical SCI. Corresponding confidence intervals for all activities are shown in Table 2 and Table E1. Functional independence in feeding for symmetrical SCI is further broken down into motor-complete and motor-incomplete injury in Figure E2. Feeding requiring personal assistance or adaptive devices was found for the majority of patients with MRC 3 to 5 wrist extension (C6 motor level), which enables use of tenodesis-driven hand function. Feeding independently without need for assistance or adaptive devices was found for individuals with the added function of MRC grade 3 to 5 finger flexion (C8 motor level). Independence with feeding did not change between 6 and 12 months at any injury level. Subgroup analysis showed that individuals with C6 motor level were more independent in feeding if they were younger (<40 versus >60 years). No association of sex, AIS category, or magnitude of asymmetry with independence with feeding was found.
Figure 2Feeding (SCIM item 1) by motor level for symmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Feeding with assistance or adaptive devices was noted for the majority with strong (MRC 3–5) wrist extension (C6 function). Feeding independently without need for assistance or adaptive devices was noted only for individuals with strong (MRC 3–5) wrist flexion (C8 function). A trend toward greater independence with greater time postinjury was seen.
Table 2Distribution of Independence With Feeding, Bladder Management, and Transfers (Bed to Wheelchair) for Motor Levels C5–C8 Symmetrical SCI, 6 Months, and 12 Months After Injury, as Assessed by SCIM (Items 1, 6, 10, Respectively)
Data are presented as percentage of the total with 95% confidence intervals. Six-mo data for all patients are presented in addition to 6-mo data for only those with corresponding 12-mo data available (bold). Numbers in parentheses (n) correspond to SCIM scores.
Feeding
Motor Level
Time (mo)
n
Distribution of Level of Independence With 95% Confidence Intervals (%)
Full Assist (0)
Partial Assistance or Adaptive Device (1–2)
Independent (3)
C5
6
58
41 ± 13
59 ± 13
0
6
32
38±17
63±17
0
12
32
34 ± 16
66 ± 16
0
C6
6
83
12 ± 8
88 ± 8
0
6
56
13±9
88±9
0
12
56
4 ± 5
95 ± 6
2 ± 4
C7
6
44
2 ± 4
95 ± 6
2 ± 4
6
31
3±6
97±6
0
12
31
3 ± 6
90 ± 11
6 ± 8
C8
6
19
5 ± 10
53 ± 22
42 ± 22
6
11
9±17
36±28
55±29
12
11
0
45 ± 29
55 ± 29
Bladder Management
Motor Level
Time (mo)
n
Requires Assist (0, 3, 6)
Independent (9, 11, 13, 15)
C5
6
58
100
0
6
32
100
0
12
32
97 ± 6
3 ± 6
C6
6
83
93 ± 5
7 ± 5
6
56
93±7
7±7
12
56
86 ± 9
14 ± 9
C7
6
44
75 ± 13
25 ± 13
6
31
71±16
29±16
12
31
68 ± 16
32 ± 16
C8
6
19
47 ± 22
53 ± 22
6
11
27±26
73±26
12
11
27 ± 26
73 ± 26
Transfers
Motor Level
Time (mo)
n
Full Assist (0)
Partial Assistance or Adaptive Device (1)
Independent (2)
C5
6
58
91 ± 7
9 ± 7
0
6
32
88±11
12±11
0
12
32
88 ± 11
9 ± 10
3 ± 6
C6
6
83
76 ± 9
19 ± 8
5 ± 5
6
56
75±11
21±11
4±5
12
56
59 ± 13
29 ± 12
13 ± 9
C7
6
44
45 ± 15
34 ± 14
20 ± 12
6
31
45±18
35±17
19±14
12
41
35 ± 17
45 ± 18
19 ± 14
C8
6
19
16 ± 16
47 ± 22
37 ± 22
6
11
9±17
36±28
55±29
12
11
18 ± 23
18 ± 23
64 ± 28
∗ Data are presented as percentage of the total with 95% confidence intervals. Six-mo data for all patients are presented in addition to 6-mo data for only those with corresponding 12-mo data available (bold). Numbers in parentheses (n) correspond to SCIM scores.
Range of functional independence in bladder management (SCIM item 6) by motor level is shown in Figure 3 for symmetrical SCI and Figure E3 for asymmetrical SCI. Corresponding confidence intervals for all activities are shown in Table 2 and Table E1. Functional independence in bladder management for symmetrical SCI is further broken down into motor-complete and motor-incomplete injury in Figure E4. Independence with bladder management was found in those with MRC 3 to 5 finger flexion (C8 motor level). Independence with bladder management did not change between 6 and 12 months at any injury level. Subgroup analysis showed that individuals were more independent in bladder management at the C6 level if they had some trunk or lower extremity control (motor-incomplete injuries). No association of age, sex, or magnitude of asymmetry on independence with bladder management was found.
Figure 3Bladder management (SCIM item 6) by motor level for symmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Independence with bladder management was noted in those with strong (MRC 3–5) finger flexion (C8 function). A trend toward greater independence with greater time postinjury was seen.
Range of functional independence in transfers, bed to wheelchair (SCIM item 10) by motor level is shown in Figure 4 for symmetrical SCI and Figure E5 for asymmetrical SCI. Corresponding confidence intervals for all activities are shown in Table 2 and Table E1. Functional independence in transfers for symmetrical SCI is further broken down into motor-complete and motor-incomplete injury in Figure E6. The MRC 3- to 5 elbow extension (C7 motor level) did not uniformly result in the ability to transfer independently; only 54% to 64% of individuals with elbow extension were independent in transfers. Subgroup analysis showed that individuals with stronger elbow extension (MRC 5 > 4 > 3) had equivalent independence with transfers. The addition of MRC 3 to 5 finger flexion (C8 motor level), however, was associated with greater independence with transfers. Of note, a small subset of individuals (5%–13%) were able to transfer independently even without any elbow extension movement. Independence with transfers did not change between 6 and 12 months after injury. Subgroup analysis showed that individuals were more independent with transfers at the C6 level if they were younger or at the C5, C6, or C7 level if they had trunk or lower extremity control (motor-incomplete injuries). No association of sex or magnitude of asymmetry on independence with transfers was found.
Figure 4Transfers, bed to wheelchair (SCIM item 10), by motor level for symmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Strong (MRC 3–5) elbow extension (C7 function) did not uniformly result in the ability to transfer independently; only 20% of individuals with intact elbow extension were independent in transfers at 6 months. Strong (MRC 3–5) finger flexion (C8 function), however, was noted to be present in those who were independent with transfers. Notably, these data also show that a small subset of 5% to13% of individuals is able to transfer without any elbow extension present (C6 level). A trend toward greater independence with greater time postinjury was seen.
Nerve transfer surgery in cervical spinal cord injury: a qualitative study exploring surgical and caregiver participant experiences [published online ahead of print September 27, 2019]. Disabil Rehabil.
Our study provides some information on the functional independence levels for specific ADLs in individuals with cervical SCI at motor levels C5 to C8 at 6 and 12 months after injury. This knowledge can guide expectations on independence after SCI and can be used to inform individuals with SCI and clinicians on decision-making around early restorative upper limb surgery.
Individuals with acute SCI must process an overwhelming amount of information during rehabilitation to resume daily activities and maintain health. This includes modification of mobility, bladder and bowel function, pressure-offloading, and spasticity management. The transition from inpatient rehabilitation to home requires careful planning and coordinated care. Knowledge of the time course of expected functional recovery and attainable levels of independence is important to inform decisions about rehabilitation and participation in potential therapeutic interventions.
Previous studies have examined target values for SCIM scoring at various neurological levels
Published guidelines on expected independence 1 year after injury suggest that feeding with adaptive devices is possible with a C5 motor level and independence with feeding requires a C7 motor level.
By contrast, the results presented here suggest that feeding with assistive devices requires a strong wrist extension, and full independence requires strong finger flexion. Greater independence with bladder management also required strong finger flexion. Published guidelines suggest independence with transfers is possible for those with a C7 (elbow extension) motor level.
This study, by contrast, showed that strong C8 motor scores were better associated with independence in transfers. Physiologically, this makes sense as the addition of C8-driven grasp of the wheelchair arm-to-body support by use of elbow extension together contribute to transfer ability. Subgroup analyses showed the impact of age, sex, and degree of motor completeness (AIS category) on independence. Previous studies have also shown that lower functional independence is associated with increased age
Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience.
and nerve transfer surgery can restore a variety of upper limb functions including hand closing and opening, which this work shows is critical to independent feeding, urinary, and transfer function. Unfortunately, as few as 14% of eligible individuals receive upper limb surgery in the United States.
Depending on the level of injury and available intact donor nerves, nerve transfers have been used to restore a variety of functions. These include wrist extension,
Work on indications, selection, and long-term outcomes of nerve transfers is ongoing. Establishing a neurological plateau prior to nerve transfer is critical because nerve transfer would halt further spontaneous recovery in the recipient muscle(s); however, studies have shown that the results of nerve transfers diminish when surgery is done further from time of injury.
Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series.
Tendon transfers can similarly restore elbow extension, hand opening and closing, and other functions. Although from a physiological standpoint, tendon transfers may be completed at any time following SCI, some work suggests that people with SCIs may prefer having this surgery within a year of injury.
Our results showed that there was no change in independence with feeding, bladder management, or transfers between 6 and 12 months after SCI. Additional work by our group shows that few individuals recover additional motor movement between 6 and 12 months: only 3% of individuals without C7 motor function at 6 months gain strong C7 motor function at 12 months, and only 3% without C8 motor function gain strong C8 motor function by 12 months.
Fox I, Dengler J, Curt A, et al. Degree of upper extremity function recovery in cervical spinal cord injury: implications for peripheral nerve transfer surgery to restore upper limb function. Paper presented at: 58th ISCoS Annual Scientific Meeting; November 5-7, 2019; France.
This suggests that evaluation for surgical intervention as early as 6 months after SCI could be considered. Previous studies have shown that recovery beyond 12 months is limited (but greater in incomplete tetraplegia).
Database studies have inherent limitations. The sample size in this study was limited by the data available, missing SCIM scores, and a dropoff in follow-up between 6 and 12 months after SCI; it may have been underpowered. Although no improvements in function were seen, this does not preclude the individual possibility of this occurring. The insights gained from the study should be taken as 1 more data point in a complex decision algorithm for both the provider and the patient. We were also unable to assess other factors that are known to affect independence such as the presence of traumatic brain injury, autonomic dysreflexia, spasticity, and multiple comorbidities,
because these data were not included in the database.
In addition, the rehabilitation care received by individuals in the EMSCI database may not parallel that of individuals in the United States or other countries. Motor recovery is in part due to strengthening of existing function,
The EMSCI-derived results may overpredict gains in function that would be seen in more-disadvantaged populations with less access to comprehensive and no-cost rehabilitation care.
The SCIM is focused on observed gains in ability to perform a specific activity (such as feeding) and does not necessarily measure real-life behavior. Accomplishing an activity does not mean completing it as the individual desires. Thus, the SCIM may overestimate the satisfactory level of independence. Finally, the data presented here do not include improvements in functional independence beyond 12 months. In this study, single items from the SCIM were used to determine independence. Whereas the SCIM has been validated, the application of single items may not possess similar high-validity psychometrics. However, these items were chosen to be most relevant for surgeons who evaluate and treat individuals with midcervical SCI.
Overall, our study shows that spontaneous gains in functional independence start to plateau by 6 months after SCI, and improvements in strength after 6 months were not reflected in functional independence. This should influence decision-making for individuals with SCI and their clinicians when considering intervention to augment function such as nerve and/or tendon transfer.
Acknowledgments
The members of the Department of Defense (DOD) group are Catherine Curtin, MD, Palo Alto Veterans Healthcare System, Palo Alto, CA; Carie Kennedy, BSN, RN, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Amanda Miller, MD, Division of Physical Medicine and Rehabilitation, Washington University School of Medicine, St. Louis, MO; Christine Novak, PhD, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Doug Ota, MD, Palo Alto Veterans Healthcare System, Palo Alto, CA; and Katherine C. Stenson, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, and VA St. Louis Healthcare System, St. Louis, MO.
The members of the EMSCI group are Armin Curt, MD, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; Doris Maier, MD, BG-Trauma Center, Murnau, Germany; Rainer Abel, MD, PhD, Hohe Warte Bayreuth, Bayreuth, Germany; Norbert Weidner, MD, PhD, Rüdiger Rupp, MD, Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany; J. Vidal, MD, Institute Guttmann, Neurorehabilitation Hospital, Barcelona, Spain; Jesus Benito, MD, Institute Guttmann, Neurorehabilitation Hospital, Barcelona, Spain; and Yorck-Bernhard Kalke, MD, RKU Universitäts- und Rehabilitationskliniken Ulm, Ulm, Germany.
IKF grant funding support was provided by the U.S. Department of Defense—Project #W81XWH-17-1-0285 “Supporting Patient Decisions about Upper-Extremity Surgery in Cervical SCI.”
The contents of this work do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
Supplementary Data
Figure E1Feeding (SCIM item 1) by motor level for asymmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Feeding with assistance or adaptive devices was noted for the majority with strong (MRC 3–5) wrist extension (C6 function). Feeding independently without need for assistance or adaptive devices was noted only for individuals with strong (MRC 3–5) wrist flexion (C8 function). A trend toward greater independence with greater time postinjury was seen.
Figure E2Feeding (SCIM item 1) by motor level for symmetrical SCI, 6 months and 12 months after injury for motor-complete (ASIA A, B) and motor-incomplete (ASIA C, D; highlighted by blue square). Data are presented as percentage of the total. No difference in the change from 6 to 12 months was seen between the motor-complete and the motor-incomplete groups.
Figure E3Bladder management (SCIM item 6) by motor level for asymmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Independence with bladder management was noted in those with strong (MRC 3–5) finger flexion (C8 function). A trend toward greater independence with greater time postinjury was seen.
Figure E4Bladder management (SCIM item 6) by motor level for symmetrical SCI, 6 months and 12 months after injury for motor-complete (ASIA A, B) and motor-incomplete (ASIA C, D; highlighted by blue square). Data are presented as percentage of the total. No difference in the change from 6 to 12 months was seen between the motor-complete and the motor-incomplete groups.
Figure E5Transfers, bed to wheelchair (SCIM item 10), by motor level for asymmetrical SCI, 6 months and 12 months after injury. Data are presented as percentage of the total. Strong (MRC 3–5) elbow extension (C7 function) did not uniformly result in the ability to transfer independently; only 8% of individuals with intact elbow extension were independent in transfers at 6 months. Strong (MRC 3–5) finger flexion (C8 function), however, was noted to be present in those who were independent with transfers. Notably, there data also show that a small subset of 3% to 6% of individuals were able to transfer without any elbow extension present (C6 level). A trend toward greater independence with greater time postinjury was seen.
Figure E6Transfers, bed to wheelchair (SCIM item 10), by motor level for symmetrical SCI, 6 months and 12 months after injury for motor-complete (ASIA A, B) and motor-incomplete (ASIA C, D; highlighted by blue square). Data are presented as percentage of the total. No difference in the change from 6 to 12 months was seen between the motor-complete and the motor-incomplete groups.
Table E1Distribution of Independence With Feeding, Bladder Management, and Transfers (Bed to Wheelchair) for Motor Levels C5–C8 Symmetrical SCI, 6 Months And 12 Months After Injury, as Assessed by SCIM (Items 1, 6, 10, Respectively)
Data are presented as percentage of the total with 95% confidence intervals. Six-mo data for all patients are presented in addition to 6-mo data for only those with corresponding 12-mo data available (bold). Numbers in parentheses (n) correspond to SCIM scores.
Feeding
Motor Level
Time (mo)
n
Distribution of Level of Independence With 95% Confidence Intervals (%)
Full Assist (0)
Partial Assistance or Adaptive Device (1–2)
Independent (3)
C5
6
27
63 ± 18
37 ± 18
0
6
15
67±24
33 ± 24
0
12
15
67 ± 24
33 ± 24
0
C6
6
30
30 ± 16
70 ± 16
0
6
16
25±21
75±21
0
12
16
19 ± 19
81 ± 19
0
C7
6
24
4 ± 8
86 ± 8
0
6
14
7±13
93±13
0
12
14
0
100
0
C8
6
14
0
93 ± 13
7 ± 13
6
10
0
90±19
10±19
12
10
0
60 ± 30
40 ± 30
Bladder Management
Motor Level
Time (mo)
n
Requires Assist (0, 3, 6)
Independent (9, 11, 13, 15)
C5
6
27
100
0
6
15
100
0
12
15
100
0
C6
6
30
93 ± 9
7 ± 9
6
16
94±12
6±12
12
16
94 ± 12
6 ± 12
C7
6
24
100
0
6
14
100
0
12
14
86 ± 18
14 ± 18
C8
6
14
71 ± 24
29 ± 24
6
10
80±25 %
20±25 %
12
10
60 ± 30 %
40 ± 30 %
Transfers
Motor Level
Time (mo)
n
Full Assist (0)
Partial Assistance or Adaptive Device (1)
Independent (2)
C5
6
27
100
0
0
6
15
100
0
0
12
15
97 ± 9
3 ± 9
0
C6
6
30
97 ± 6
0
3 ± 6
6
16
94±12
0
6±12
12
16
88 ± 16
6 ± 12
6 ± 12
C7
6
24
67 ± 19
25 ± 17
8 ± 11
6
14
57±26
29±24
14±18
12
14
57 ± 26
14 ± 18
29 ± 24
C8
6
14
36 ± 25
36 ± 25
29 ± 24
6
10
40±30
20±25
40±30
12
10
30 ± 28
30 ± 28
40 ± 30
∗ Data are presented as percentage of the total with 95% confidence intervals. Six-mo data for all patients are presented in addition to 6-mo data for only those with corresponding 12-mo data available (bold). Numbers in parentheses (n) correspond to SCIM scores.
European Multicenter Study of Spinal Cord Injury (EMSCI) Network. Recovery of sensorimotor function and activities of daily living after cervical spinal cord injury: the influence of age.
Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series.
Hoben H, Varmun R, James A, et al. Nerve transfers to restore and function in cervical level spinal cord injury: a more appealing and accessible option for patients. Paper presented at: American Society for Peripheral Nerve Annual Meeting; January 23-25, 2015; Paradise Island, Bahamas. Abstract 113.
in: Frontera W.R. DeLisa J.A. Gans B.M. Robinson L.R. Bockeneck W. Chase J. DeLisa’s Physical Medicine and Rehabilitation, Principles and Practice. Lippincott Williams & Wilkins,
Philadelphia2005: 1715-1752
Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience.
Early decompression (< 8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by spinal cord independence measure after one year.
Nerve transfer surgery in cervical spinal cord injury: a qualitative study exploring surgical and caregiver participant experiences [published online ahead of print September 27, 2019]. Disabil Rehabil.
Fox I, Dengler J, Curt A, et al. Degree of upper extremity function recovery in cervical spinal cord injury: implications for peripheral nerve transfer surgery to restore upper limb function. Paper presented at: 58th ISCoS Annual Scientific Meeting; November 5-7, 2019; France.
30709-7&id=gr1.jpg){kind=link}
30709-7&id=gr2.jpg){kind=link}
30709-7&id=gr3.jpg){kind=link}
30709-7&id=gr4.jpg){kind=link}
30709-7&id=fx1.jpg){kind=link}
30709-7&id=fx2.jpg){kind=link}
30709-7&id=fx3.jpg){kind=link}
30709-7&id=fx4.jpg){kind=link}
30709-7&id=fx5.jpg){kind=link}
30709-7&id=fx6.jpg){kind=link}