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Objective: Traumatic spinal cord injury (TSCI) stands as one of the most profoundly damaging and debilitating conditions. This study aims to explore the potential of magnetic resonance imaging (MRI) variables and peripheral inflammatory indicators as promising biomarkers. It aims to understand their significance in evaluating the severity and predicting the prognosis of TSCI. Furthermore, the study aims to ascertain whether combining these indicators could enhance the accuracy of injury assessment and predictive prognostic ability., Methods: A multicentre retrospective cohort study was conducted to assess the severity and prognostic value of MRI variables and peripheral inflammatory response biomarkers in patients with acute cervical TSCI. The study involved 374 patients with acute cervical TSCI drawn from the First Affiliated Hospital of Nanchang University and the Second Affiliated Hospital of Nanchang University. The severity and prognosis of patients with acute cervical TSCI were assessed using the American Spinal Injury Association Impairment Scale (AIS). The correlation between MRI variables, peripheral inflammatory response biomarkers, admission severity, and the 1-year follow-up prognosis was analysed., Results: After the initial assessment using the AIS grade system, 169 (49.2%) patients fell into the severe category for cervical TSCI (AIS A-B), while 205 (50.8%) patients were classified as non-severe cases (AIS C-E). The MRI variables (intramedullary lesion length [IMLL], Brain and Spinal Injury Centre [BASIC], maximum spinal cord compression [MSCC], and maximum canal compromise [MCC]) and inflammatory response biomarkers (white blood cells [WBCs], neutrophils, and C-reactive protein [CRP]) exhibited a consistent decrease correlating with the severity grades noted upon admission. Among the 374 patients assessed, 147 (39.3%) experienced a poor prognosis, as indicated by the AIS grade during the 1-year follow-up. MRI variables and peripheral inflammatory response biomarkers declined in correspondence with the follow-up AIS grades. Sex (p < 0.001), IMLL (p < 0.001), MSCC (p < 0.001), MCC (p < 0.001), BASIC (p < 0.001), WBC (p < 0.001), neutrophils (p < 0.001), and CRP (p < 0.001) were statistically significant in predicting poor outcomes. Through multivariate logistic regression analysis, BASIC score and CRP emerged as independent predictors of poor prognosis. Notably, the model combining the BASIC score and CRP yielded a larger area under the curve compared to models using only the BASIC score or CRP individually., Conclusions: The BASIC score and CRP are crucial biomarkers for evaluating the severity of cervical TSCI and predicting prognosis. Their combination proved to be a more robust determinant of injury severity and a better predictor of neurological recovery., Competing Interests: Declarations Ethics approval and consent to participate This study was approved by Ethics Review Committee of the First Affiliated Hospital of Nanchang University and the second Affiliated Hospital of Nanchang University. Informed consent was obtained from all individual participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Study Design: A narrative review., Objective: To summarize relevant data from representative studies investigating upper limb restorative therapies for cervical spinal cord injury., Summary of Background Data: Cervical spinal cord injury (SCI) is a debilitating condition resulting in tetraplegia, lifelong disability, and reduced quality of life. Given the dependence of all activities on hand function, patients with tetraplegia rank regaining hand function as one of their highest priorities. Recovery from cervical SCI is heterogeneous and often incomplete; currently, various novel therapies are under investigation to improve neurological function and eventually better quality of life in patients with tetraplegia., Methods: In this article, a narrative literature review was performed to identify treatment options targeting the restoration of function in patients with cervical SCI. Studies were included from available literature based on the availability of clinical data and whether they are applicable to restoration of arm and hand function in patients with cervical SCI., Results: We describe relevant studies including indications and outcomes with a focus on arm and hand function. Different treatment modalities described include nerve transfers, tendon transfers, spinal cord stimulation, functional electrical stimulation, non-invasive brain stimulation, brain-machine interfaces and neuroprosthetics, stem cell therapy, and immunotherapy. As the authors' institution leads one of the largest clinical trials on nerve transfers for cervical SCI, we also describe how patients undergoing nerve transfers are managed and followed at our center., Conclusions: While complete recovery from cervical spinal cord injury may not be possible, novel therapies aimed at the restoration of upper limb motor function have made significant progress toward the realization of complete recovery., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Cross-sectional Database Study., Objective: While the American Spinal Injury Association (ASIA) Impairment Scale is the standard for assessing spinal cord injuries (SCI), it has limitations due to subjectivity and impracticality. Advances in machine learning (ML) and image recognition have spurred research into their use for outcome prediction. This study aims to analyze deep learning techniques for identifying and classifying cervical SCI severity from MRI scans., Methods: The study included patients with traumatic and nontraumatic cervical SCI admitted from 2019 to 2022. MRI images were labeled by two senior resident physicians. A deep convolutional neural network was trained using axial and sagittal cervical MRI images from the dataset. Model performance was assessed using Dice Score and IoU to measure segmentation accuracy by comparing predicted and ground truth masks. Classification accuracy was evaluated with the F1 Score, balancing false positives and negatives., Result: In the axial spinal cord segmentation, we achieved a Dice score of 0.94 for and IoU score of 0.89. In the sagittal spinal cord segmentation, we obtained Dice score up to 0.9201 and IoU scores up to 0.8541. The model for axial image score classification gave a satisfactory result with an F1 score of 0.72 and AUC of 0.79., Conclusion: Our models successfully identified cervical SCI on T2-weighted MR images with satisfactory performance. Further research is needed to develop more advanced models for predicting patient outcomes in SCI cases., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To investigate the association between sufficient energy intake and improvement in activities of daily living (ADL) after hospitalization in patients with cervical spinal cord injury (CSCI) undergoing post-acute rehabilitation. Design: Retrospective cohort study. Setting: Post-acute care hospital from September 2013 to December 2020. Participants: Patients with CSCI admitted to a post-acute care hospital for rehabilitation. Intervention: Not applicable. Outcome measure(s): Multiple regression analysis was performed to investigate the relationship of sufficient energy intake to Motor Functional Independence Measure (mFIM) gain, mFIM score at discharge, and body weight change during hospitalization. Results: In total, 116 patients (104 men and 12 women), median age: 55 (interquartile range [IQR] 41-65) years were included in the analysis. Then, 68 (58.6%) were in the energy-sufficient group, and 48 (41.4%) patients were classified under the energy-deficient group. The two groups did not significantly differ in terms of mFIM gain and mFIM score at discharge. The energy-sufficient group maintained body weight change during hospitalization than the energy-deficient group (0.6 [-2.0-2.0] vs. -1.9 [-4.0--0.3], P  < 0.001). Multiple regression analysis showed no association between sufficient energy intake and outcomes. Conclusion: Sufficient energy intake within the first 3 days of admission did not affect ADL improvement during hospitalization in patients with a post-cute CSCI undergoing rehabilitation.

Background: Cardiac pacemaker implantation may be indicated in patients with refractory bradycardia following a cervical spinal cord injury (CSCI). However, evidence about the impact of this procedure on outcomes is lacking. We planned a study to assess whether the implantation of a pacemaker would decrease mortality and hospital resource utilization in patients with CSCI., Methods: Adult patients with CSCI in the Trauma Quality Improvement Program (TQIP) database between 2016 and 2019 were retrospectively analyzed. Patients were divided into "pacemaker" and "non-pacemaker" groups, and their baseline characteristics and clinical outcomes were analyzed., Results: A total of 6774 cases were analyzed. The pacemaker group showed higher in-hospital rates of cardiac arrest, myocardial infarction, and longer duration of mechanical ventilation and ICU stay than the non-pacemaker group. Nevertheless, pacemaker placement was associated with a significant decrease in mortality (4.2% vs 26.0%, P < .01)., Conclusions: Patients with CSCI requiring a pacemaker placement had better survival than those treated without a pacemaker. Pacemaker implantation should be highly considered in patients who develop refractory bradycardia after CSCI., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Cervical spinal cord injury usually results in cardiorespiratory dysfunctions due to interruptions of the bulbospinal pathways innervating the cervical phrenic motoneurons and thoracic sympathetic preganglionic neurons., Purpose: The present study aimed to evaluate the therapeutic effects of adrenergic agents on systemic and spinal hemodynamics during acute cervical spinal cord injury., Study Design: In vivo animal study., Methods: The cardiorespiratory function and spinal cord blood flow and oxygenation level were monitored in response to cervical spinal cord contusion and intravenous infusion of three types of adrenergic agents (phenylephrine, dobutamine, and norepinephrine)., Results: Cervical spinal cord contusion resulted in immediate reduction of respiratory airflow, arterial blood pressure, and spinal cord blood flow. The arterial blood pressure and spinal cord blood flow remained lower than the preinjury value in contused animals infused with saline at 60 min postinjury. Infusion of phenylephrine (500, 1000, and 2000 μg/kg) and norepinephrine (125, 250, and 500 μg/kg) significantly increased the arterial blood pressure, while only norepinephrine augmented the spinal cord blood flow. Conversely, dobutamine (1000 and 2000 μg/kg) reduced both arterial blood pressure and spinal cord blood flow. Notably, administration of adrenergic agents tended to increase spinal cord hemorrhage in contused animals., Conclusions: Infusion of norepinephrine can effectively maintain the blood pressure and improve spinal cord blood flow during acute spinal cord injury., Clinical Significance: Norepinephrine may be a superior medicine for hemodynamic management; however, the potential hemorrhage should be considered when utilizing the vasopressor to regulate systemic and spinal hemodynamics at the acute injured stage., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: We aimed to explore the prognostic significance of preoperative magnetic resonance imaging (MRI) variables and novel inflammatory indicators in predicting neurological recovery post-cervical traumatic spinal cord injury (TSCI) in the study., Methods: We enrolled a total of 244 patients diagnosed with acute cervical TSCI from 2 hospitals and evaluated the prognostic value of MRI variables (intramedullary hemorrhage, intramedullary lesion length [IMLL], maximum spinal cord compression, and maximum canal compromise [MCC]) and novel inflammatory indicators (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and systemic immune-inflammatory index) in patients with acute cervical TSCI., Results: Among the 244 patients, 140 (57.38%) exhibited improved AIS grade conversion at 1-year follow-up. The results revealed intramedullary hemorrhage, IMLL, MCC, neutrophils, and NLR were significantly different compared with follow-up AIS grade. Furthermore, IMLL, MCC, white blood cells, neutrophils, NLR, and lymphocyte-to-monocyte ratio correlated with the follow-up AIS grade by Spearman's correlation analysis. Multivariate analysis showed IMLL, intramedullary hemorrhage, NLR, and admission AIS grade emerged as independent predictors of AIS grade conversion. The receiver operating characteristic curve analysis showed that the novel model (combination of MRI variables, NLR, and admission AIS grade) produced a larger area under the curve compared with using only intramedullary hemorrhage, IMLL, NLR, or admission AIS grade individually., Conclusion: Intramedullary hemorrhage and IMLL and NLR are predictors of AIS grade conversion after cervical TSCI. Therefore, we suggest the combination of MRI variables and NLR for the prognostic prediction of AIS grade conversion in patients with cervical TSCI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the present study was to characterize the differences between respiration and swallowing in patients with dysphagia after cervical spinal cord injury (CSCI) and to explore the underlying physiological changes., Method: A total of 95 participants were recruited for bedside swallowing evaluation followed by a flexible endoscopic evaluation of swallowing and surface electromyography with a thermocouple nasal airflow sensor examination: 32 with dysphagia, 33 without dysphagia, and 30 healthy controls. The differences in respiratory patterns, swallowing apnea duration (SAD), inspiratory-expiratory ratio, and swallowing efficiency were observed among healthy adults, CSCI patients with and without dysphagia after CSCI., Results: Compared with those of healthy controls and patients without dysphagia after CSCI, the postswallow respiratory pattern of patients with dysphagia after CSCI was an inspiratory pattern, and the SAD was significantly shorter in patients with dysphagia after CSCI ( p < .001). Additionally, the expiratory time in patients with dysphagia was significantly shorter than the inspiratory time, and the swallowing efficiency was reduced, requiring multiple swallows. Moreover, the index of SAD was statistically significant for predicting the development of dysphagia in patients with CSCI ( p < .001)., Conclusion: Patients with CSCI have an inspiratory pattern after swallowing, and the SAD is significantly reduced; SAD can be used as the predictor of dysphagia in patients after CSCI; the pattern of coordination between respiration and swallowing in patients with dysphagia after CSCI is different from that of healthy controls and patients without dysphagia after CSCI., Supplemental Material: https://doi.org/10.23641/asha.26524717.

This retrospective study analyzed prognostic factors for neurological improvement and ambulation in 194 adult patients (≥ 15 years) with traumatic cervical spinal cord injuries treated at the neurological SCI unit (SCIU) at the Karolinska University Hospital Stockholm, Sweden, between 2010 and 2020. The primary outcome was American spinal injury association impairment scale (AIS) improvement, with secondary focus on ambulation restoration. Results showed 41% experienced AIS improvement, with 51% regaining ambulation over a median follow-up of 3.7 years. Significant AIS improvement (p < 0.001) and reduced bladder/bowel dysfunction (p < 0.001) were noted. Multivariable analysis identified initial AIS C-D (< 0.001), central cord syndrome (p = 0.016), and C0-C3 injury (p = 0.017) as positive AIS improvement predictors, while lower extremity motor score (LEMS) (p < 0.001) and longer ICU stays (p < 0.001) were negative predictors. Patients with initial AIS C-D (p < 0.001) and higher LEMS (p < 0.001) were more likely to regain ambulation. Finally, older age was a negative prognostic factor (p = 0.003). In conclusion, initial injury severity significantly predicted neurological improvement and ambulation. Recovery was observed even in severe cases, emphasizing the importance of tailored rehabilitation for improved outcomes., (© 2024. The Author(s).)

Study Design: Prospective observational study., Objectives: Classification of spinal-cord injury and prediction of independence in activities of daily living (ADL) based on performance evaluations such as upper-limb function have not been reported. Therefore, this study aimed to establish a severity classification and calculate cutoff values for independence in ADL using the Capabilities of Upper Extremity Test (CUE-T) for individuals with cervical spinal-cord injury (CSCI)., Setting: A spinal-cord injury rehabilitation center in Japan., Methods: This study included individuals with subacute CSCI. Collected data included the CUE-T and Spinal Cord Independence Measure III (SCIM III) scores. The severity classification was used for the hierarchical cluster analysis using the CUE-T. The cutoff values of CUE-T scores for independence in ADL were calculated using an adjustment model with logistic regression analysis. The dependent variable was binary (independent/non-independent) for each SCIM III Self-care item, and the independent variable was CUE-T., Results: A total of 71 participants were included in the analysis. The severity of upper-limb dysfunction was classified into four categories using CUE-T. Significant differences in upper-limb function and ADL were observed between clusters. The cutoff values for CUE-T score for independence in ADL ranged from 37 to 91 points. All cutoff values showed good results in the internal validation, sensitivity analysis., Conclusions: This study determined the severity of upper limb function in CSCI and the cutoff values of CUE-T scores for independence in ADL. These results may help set criteria and goals for interventions in the clinical and research fields., Sponsorship: None., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Cervical spinal cord injury (SCI) results in significant sensorimotor impairments below the injury level, notably in the upper extremities (UEs), impacting daily activities and quality of life. Regaining UE function remains the top priority for individuals post-cervical SCI. Recent advances in understanding adaptive plasticity within the sensorimotor system have led to the development of novel non-invasive neurostimulation strategies, such as spinal cord transcutaneous stimulation (scTS), to facilitate UE motor recovery after SCI. This comprehensive review investigates the neuromotor control of UE, the typical recovery trajectories following SCI, and the therapeutic potential of scTS to enhance UE motor function in individuals with cervical SCI. Although limited in number with smaller sample sizes, the included research articles consistently suggest that scTS, when combined with task-specific training, improves voluntary control of arm and hand function and sensation. Further, the reported improvements translate to the recovery of various UE functional tasks and positively impact the quality of life in individuals with cervical SCI. Several methodological limitations, including stimulation site selection and parameters, training strategies, and sensitive outcome measures, require further advancements to allow successful translation of scTS from research to clinical settings. This review also summarizes the current literature and proposes future directions to support establishing approaches for scTS as a viable neuro-rehabilitative tool.

We have previously demonstrated that machine learning-based video analysis, conducted via DeepLabCut, is more sensitive for detecting subtle deficits in hand grasping behavior than traditional end-point performance assessments. This superiority was observed in a nonhuman primate (NHP) model of cervical spinal cord injury, specifically a dorsal column lesion (DCL). The current study aims to further characterize the kinematic aspects of the deficits in hand reaching, grasping, and retrieving behavior from a 3D perspective following a DCL. Squirrel monkeys were trained to retrieve sugar pellets from eight wells, which were located either on a flat plate or a raised tube with varying well depths. This setup was designed to require coordinated finger movements during the task. Immediately after the DCL, the animals exhibited measurable behavioral deficits. These were characterized by significant increases in grasping speed squared and trial completion time, markedly widened movement trajectories of individual fingers, and abnormalities in inter-finger distance and orientation. Increased task difficulty was associated with more pronounced behavioral deficits. By three months post-DCL, video-based measurements indicated no significant recovery, even though global end-point performance had returned to baseline levels. Our findings demonstrate that deprivation of tactile information results in impaired dexterous hand behavior involving coordinated finger movements, and the impairment is sustained for 20 weeks. This spinal cord injury (SCI) model, along with DeepLapCut analysis, provides a valuable platform for separately evaluating sensory and motor functions and their contributions to dexterous hand behavior and may be used for evaluating therapeutic interventions using more sensitive behavioral outcome readouts., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Postoperative pulmonary infection (POI) of patients with cervical spinal cord injury (CSCI) is highly heterogeneous, while the potential endotypes and related risk factors remain unclear., Methods: A retrospective collection of 290 CSCI patients was conducted from January 2010 to July 2024 using 1:1 propensity score matching to compare POI (n = 145) and non-POI (n = 145) groups. We generated laboratory examination data from admission patients and identified endotypes using unsupervised consensus clustering and machine learning. CSCI patients were randomly assigned to the training set (n = 203) and internal validation set (n = 87). A separate cohort comprising 245 CSCI patients were used for external validation. Independent predictors for POI were identified using univariate and multivariate logistic regression. A nomogram and an online calculator were developed and validated, both internally and externally., Results: Two inflammation-related endotypes were identified: high inflammation endotype (endotype C1) and low inflammation endotype (endotype C2). Eight predictors for POI were identified (including age, operation duration, number of surgical segments, time between injury and surgery, preoperative steroid pulse, American Spinal Injury Association (ASIA) grade, smoking history, and inflammation-related endotype). A nomogram integrating the risk factors showed excellent discrimination in the training set (AUC, 0.976; 95% CI 0.956-0.996), internal validation set (AUC, 0.993; 95% CI 0.981-1.000), and external validation set (AUC, 0.799; 95%CI 0.744-0.854). Calibration curves demonstrated excellent fit, and decision curves highlighted its favorable clinical value. An online calculator (https://tjspine.shinyapps.io/dynnomapp/) was constructed to improve the convenience and efficiency of our prediction model., Conclusions: We identified inflammation-related endotype and constructed a web-based calculator for predicting POI in patients with CSCI, exhibiting excellent clinical utility., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The primary aim of this study is to assess the viability of employing multimodal radiomics techniques for distinguishing between cervical spinal cord injury and spinal cord concussion in cervical magnetic resonance imaging. This is a multicenter study involving 288 patients from a major medical center as the training group, and 75 patients from two other medical centers as the testing group. Data regarding the presence of spinal cord injury symptoms and their recovery status within 72 h were documented. These patients underwent sagittal T1-weighted and T2-weighted imaging using cervical magnetic resonance imaging. Radiomics techniques are used to help diagnose whether these patients have cervical spinal cord injury or spinal cord concussion. 1197 radiomics features were extracted for each modality of each patient. The accuracy of T1 modal in testing group is 0.773, AUC is 0.799. The accuracy of T2 modal in testing group is 0.707, AUC is 0.813. The accuracy of T1 + T2 modal in testing group is 0.800, AUC is 0.840. Our research indicates that multimodal radiomics techniques utilizing cervical magnetic resonance imaging can effectively diagnose the presence of cervical spinal cord injury or spinal cord concussion., (© 2024. The Author(s).)

Background: The accuracy of prognostication in patients with cervical spinal cord injury (SCI) needs to be improved. We aimed to explore the prognostic value of preserved spinal tissue bridges-injury-spared neural tissue adjacent to the lesion-for prediction of sensorimotor recovery in a large, multicentre cohort of people with SCI., Methods: For this longitudinal study, we included patients with acute cervical SCI (vertebrae C1-C7) admitted to one of three trauma or rehabilitation centres: Murnau, Germany (March 18, 2010-March 1, 2021); Zurich, Switzerland (May 12, 2002-March 2, 2019); and Denver, CO, USA (Jan 12, 2010-Feb 16, 2017). Patients were clinically assessed at admission (baseline), at discharge (3 months), and at 12 months post SCI. Midsagittal tissue bridges were quantified from T2-weighted images assessed at 3-4 weeks post SCI. Fractional regression and unbiased recursive partitioning models, adjusted for age, sex, centre, and neurological level of injury, were used to assess associations between tissue bridge width and baseline-adjusted total motor score, pinprick score, and light touch scores at 3 months and 12 months. Patients were stratified into subgroups according to whether they showed better or worse predicted recovery., Findings: The cohort included 227 patients: 93 patients from Murnau (22 [24%] female); 43 patients from Zurich (four [9%] female); and 91 patients from Denver (14 [15%] female). 136 of these participants (from Murnau and Zurich) were followed up for up to 12 months. At 3 months, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 9·3% (SD 0·9) of maximal total motor score (95% CI 7·5-11.2), 8·6% (0·8) of maximal pinprick score (7·0-10·1), and 10·9% (0·8) of maximal light touch score (9·4-12·5). At 12 months post SCI, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 10·9% (1·3) of maximal total motor score (8·4-13·4), 5·7% (1·3) of maximal pinprick score (3·3-8·2), and 6·9% (1·4) of maximal light touch score (4·1-9·7). Partitioning models identified a tissue bridge cutoff width of 2·0 mm to be indicative of higher or lower 3-month total motor, pinprick, and light touch scores, and a cutoff of 4·0 mm to be indicative of higher and lower 12-month scores. Compared with models that contained clinical predictors only, models additionally including tissue bridges had significantly improved prediction accuracy across all three centres., Interpretation: Tissue bridges, measured in the first few weeks after SCI, are associated with short-term and long-term clinical improvement. Thus, tissue bridges could potentially be used to guide rehabilitation decision making and to stratify patients into more homogeneous subgroups of recovery in regenerative and neuroprotective clinical trials., Funding: Wings for Life, International Foundation for Research in Paraplegia, EU project Horizon 2020 (NISCI grant), and ERA-NET NEURON., Competing Interests: Declaration of interests DP is supported by a Swiss National Science Foundation Postdoc Mobility Fellowship grant and the National Institutes of Health (NIH), and received best poster awards at the Stanford Bio-X Research Symposium and the Scientific Meeting of the International Spinal Cord Society. ACS is supported by NIH and Boettcher Foundation's Webb-Waring Biomedical Research Program. KAW is supported by grants from NIH and received honoraria for a lecture at the Massachusetts General Hospital Spinal Cord Workshop and grant review for the Norwegian Chiropractors' Research Foundation. OM declares provision of study datasets from BG Trauma Center Murnau. IL received a project grant from Wings for Life. JMS is the Scientific Director for Wings for Life Spinal Cord Research Foundation (a non-governmental organisation). AT received support for the present manuscript from the University College London (UCL)/UCL Hospitals NHS Foundation Trust National Institute for Health and Care Research Biomedical Research Centre; support from Eisai and German Aerospace Center Health Research (ERA-NET NEURON), paid to their institution; fees for work on the MSIS-29 Impact Scale to their institution; consulting fees from Sandoz Global Advisory and Novartis; honoraria from SAGE Publications for position as Editor-in-Chief and from Lancet Neurology for position as editorial board member; honoraria for lectures from Fundacio Privada Cemcat (November, 2023) and Inselspital MS Symposium (Bern; February, 2023); honorarium from the Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong (September, 2023) for academic review; fees for scientific review from the Health Research Board Ireland (January, 2024); fees for evaluation of research groups from Sant Pau Biomedical Research Institute (February, 2024); support for travel from the Clinical Trials Committee of the International Progressive MS Alliance, the National Multiple Sclerosis Society (USA) as member of the Research Programs Advisory Committee, Fundacio Privada Cemcat, European Committee for Treatment and Research in Multiple Sclerosis, European Charcot Foundation, Sobek Foundation SAB, BALCONE, MS Symposium (Bern), Annual MS Conference Poland, and Polish Neurological Society; is a guarantor of BRAIN; was a trustee of the National Brain Appeal, The National Hospital for Neurology and Neurosurgery (finished September, 2023); is Chair of Scientific Ambassadors for the Stop MS Appeal Board, MS Society UK; and is a board member of the European Charcot Foundation. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

High spinal cord injury (SCI) leads to persistent and debilitating compromise in respiratory function. Cervical SCI not only causes the death of phrenic motor neurons (PhMNs) that innervate the diaphragm, but also damages descending respiratory pathways originating in the rostral ventral respiratory group (rVRG) located in the brainstem, resulting in denervation and consequent silencing of spared PhMNs located caudal to injury. It is imperative to determine whether interventions targeting rVRG axon growth and respiratory neural circuit reconnection are efficacious in chronic cervical contusion SCI, given that the vast majority of individuals are chronically-injured and most cases of SCI involve contusion-type damage to the cervical region. We therefore employed a rat model of chronic cervical hemicontusion to test therapeutic manipulations aimed at reconstructing damaged rVRG-PhMN-diaphragm circuitry to achieve recovery of respiratory function. At a chronic time point post-injury, we systemically administered: an antagonist peptide directed against phosphatase and tensin homolog (PTEN), a central inhibitor of neuron-intrinsic axon growth potential; an antagonist peptide directed against receptor-type protein tyrosine phosphatase sigma (PTPσ), another important negative regulator of axon growth capacity; or a combination of these two peptides. PTEN antagonist peptide (PAP4) promoted partial recovery of diaphragm motor activity out to nine months post-injury (though this effect depended on the anesthetic regimen used during recording), while PTPσ peptide did not impact diaphragm function after cervical SCI. Furthermore, PAP4 promoted robust growth of descending bulbospinal rVRG axons caudal to the injury within the denervated portion of the PhMN pool, while PTPσ peptide did not affect rVRG axon growth at this location that is critical to control of diaphragmatic respiratory function. In conclusion, we find that, when PTEN inhibition is targeted at a chronic time point following cervical contusion, our non-invasive PAP4 strategy can successfully promote significant regrowth of damaged respiratory neural circuitry and also partial recovery of diaphragm motor function., Competing Interests: Declaration of competing interest The authors report no declarations of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Low-dose (< 2 h/day), acute intermittent hypoxia (AIH) elicits multiple forms of serotonin-dependent phrenic motor plasticity and is emerging as a promising therapeutic strategy to restore respiratory and non-respiratory motor function after spinal cord injury (SCI). In contrast, high-dose (> 8 h/day), chronic intermittent hypoxia (CIH) undermines some forms of serotonin-dependent phrenic motor plasticity and elicits pathology. CIH is a hallmark of sleep disordered breathing, which is highly prevalent in individuals with cervical SCI. Interestingly, AIH and CIH preconditioning differentially impact phrenic motor plasticity. Although mechanisms of AIH-induced plasticity in the phrenic motor system are well-described in naïve rats, we know little concerning how these mechanisms are affected by chronic SCI or intermittent hypoxia preconditioning. Thus, in a rat model of chronic, incomplete cervical SCI (lateral spinal hemisection at C2 (C2Hx), we assessed serotonin type 2A, 2B and 7 receptor expression in and near phrenic motor neurons and compared: 1) intact vs. chronically injured rats; and 2) the impact of preconditioning with varied "doses" of intermittent hypoxia (IH). While there were no effects of chronic injury or intermittent hypoxia alone, CIH affected multiple receptors in rats with chronic C2Hx. Specifically, CIH preconditioning (8 h/day; 28 days) increased serotonin 2A and 7 receptor expression exclusively in rats with chronic C2Hx. Understanding the complex, context-specific interactions between chronic SCI and CIH and how this ultimately impacts phrenic motor plasticity is important as we leverage AIH-induced motor plasticity to restore breathing and other non-respiratory motor functions in people with chronic SCI., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI., Methods: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation., Results: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest., Conclusion: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients., (© 2024. The Author(s).)

(1) Background: Restoring arm and hand function is one of the priorities of people with cervical spinal cord injury (cSCI). Noninvasive electromagnetic neuromodulation is a current approach that aims to improve upper-limb function in individuals with SCI. The aim of this study is to review updated information on the different applications of noninvasive electromagnetic neuromodulation techniques that focus on restoring upper-limb functionality and motor function in people with cSCI. (2) Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to structure the search protocol. A systematic review of the literature was performed in three databases: the Cochrane Library, PubMed, and Physiotherapy Evidence Database (PEDro). (3) Results: Twenty-five studies were included: four were on transcranial magnetic stimulation (TMS), four on transcranial direct current stimulation (tDCS), two on transcutaneous spinal cord stimulation (tSCS), ten on functional electrical stimulation (FES), four on transcutaneous electrical nerve stimulation (TENS), and one on neuromuscular stimulation (NMS). The meta-analysis could not be completed due to a lack of common motor or functional evaluations. Finally, we realized a narrative review of the results, which reported that noninvasive electromagnetic neuromodulation combined with rehabilitation at the cerebral or spinal cord level significantly improved upper-limb functionality and motor function in cSCI subjects. Results were significant compared with the control group when tSCS, FES, TENS, and NMS was applied. (4) Conclusions: To perform a meta-analysis and contribute to more evidence, randomized controlled trials with standardized outcome measures for the upper extremities in cSCI are needed, even though significant improvement was reported in each non-invasive electromagnetic neuromodulation study.

Respiratory deficits after C2 hemisection (C2Hx) have been well documented through single-sex investigations. Although ovarian sex hormones enable enhanced respiratory recovery observed in females 2 wk post-C2Hx, it remains unknown if sex impacts spontaneous respiratory recovery at chronic time points. We conducted a longitudinal study to provide a comprehensive sex-based characterization of respiratory neuromuscular recovery for 8 wk after C2Hx. We recorded ventilation and chronic diaphragm electromyography (EMG) output in awake, behaving animals, phrenic motor output in anesthetized animals, and performed diaphragm muscle histology in chronically injured male and female rodents. Our results show that females expressed a greater recovery of tidal volume and minute ventilation compared with males during subacute and chronic time points. Eupneic diaphragm EMG amplitude during wakefulness and phrenic motor amplitude are similar between sexes at all time points after injury. Our data also suggest that females have a greater reduction in ipsilateral diaphragm EMG amplitude during spontaneous deep breaths (e.g., sighs) compared with males. Finally, we show evidence for atrophy and remodeling of the fast, fatigable fibers ipsilateral to injury in females, but not in males. To our knowledge, the data presented here represent the first study to report sex-dependent differences in spontaneous respiratory recovery and diaphragm muscle morphology following chronic C2Hx. These data highlight the need to study both sexes to inform evidence-based therapeutic interventions in respiratory recovery after spinal cord injury (SCI). NEW & NOTEWORTHY In response to chronic C2 hemisection, female rodents display increased tidal volume during eupneic breathing compared with males. Females show a greater reduction in diaphragm electromyography (EMG) amplitude during spontaneous deep breaths (e.g., sighs) and atrophy and remodeling of fast, fatigable diaphragm fibers. Given that most rehabilitative interventions occur in the subacute to chronic stages of injury, these results highlight the importance of considering sex when developing and evaluating therapeutics after spinal cord injury.

Study Design: Cross-sectional study., Objectives: To study the relationship between the structural changes in the cervical spinal cord (C2/3 level) and the sensorimotor function of children with traumatic thoracolumbar spinal cord injury (TLSCI) and to discover objective imaging biomarkers to evaluate its functional status., Setting: Xuanwu Hospital, Capital Medical University, China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, China., Methods: 30 children (age range 5-13 years) with TLSCI and 11 typically developing (TD) children (age range 6-12 years) were recruited in this study. Based on whether there is preserved motor function below the neurological level of injury (NLI), the children with TLSCI are divided into the AIS A/B group (motor complete) and the AIS C/D group (motor incomplete). A Siemens Verio 3.0 T MR scanner was used to acquire 3D high-resolution anatomic scans covering the head and upper cervical spinal cord. Morphologic parameters of the spinal cord at the C2/3 level, including cross-sectional area (CSA), anterior-posterior width (APW), and left-right width (LRW) were obtained using the spinal cord toolbox (SCT; https://www.nitrc.org/projects/sct ). Correlation analyses were performed to compare the morphologic spinal cord parameters and clinical scores determined by the International Standard for Neurological Classification of Spinal Cord Injuries (ISNCSCI) examination., Results: CSA and LRW in the AIS A/B group were significantly lower than those in the TD group and the AIS C/D group. LRW was the most sensitive imaging biomarker to differentiate the AIS A/B group from the AIS C/D group. Both CSA and APW were positively correlated with ISNCSCI sensory scores., Conclusions: Quantitative measurement of the morphologic spinal cord parameters of the cervical spinal cord can be used as an objective imaging biomarker to evaluate the neurological function of children with TLSCI. Cervical spinal cord atrophy in children after TLSCI was correlated with clinical grading; CSA and APW can reflect sensory function. Meanwhile, LRW has the potential to be an objective imaging biomarker for evaluating motor function preservation., (© 2024. The Author(s).)

Following cSCI, activation of the DIAm can be impacted depending on the extent of the injury. The present manuscript describes a unilateral C2 hemisection (C2SH) model of cSCI that disrupts eupneic ipsilateral diaphragm (iDIAm) electromyographic (EMG) activity during breathing in rats. To evaluate recovery of DIAm motor control, the extent of deficit due to C2SH must first be clearly established. By verifying a complete initial loss of iDIAm EMG during breathing, subsequent recovery can be classified as either absent or present, and the extent of recovery can be estimated using the EMG amplitude. Additionally, by measuring the continued absence of iDIAm EMG activity during breathing after the acute spinal shock period following C2SH, the success of the initial C2SH may be validated. Measuring contralateral diaphragm (cDIAm) EMG activity can provide information about the compensatory effects of C2SH, which also reflects neuroplasticity. Moreover, DIAm EMG recordings from awake animals can provide vital physiological information about the motor control of the DIAm after C2SH. This article describes a method for a rigorous, reproducible, and reliable C2SH model of cSCI in rats, which is an excellent platform for studying respiratory neuroplasticity, compensatory cDIAm activity, and therapeutic strategies and pharmaceuticals.

Pneumonia after cervical spinal cord injury (CSCI) is a common and serious complication; however, its nutrition-related etiology has not yet been elucidated. This study aimed to elucidate the effects of nutritional factors on pneumonia after CSCI. Patients with acute traumatic CSCI who were admitted within 3 days after injury and followed up for at least 3 months were retrospectively examined. Occurrence of pneumonia, nutritional status, severity of dysphagia, vital capacity, use of respirators, and motor scores for paralysis were evaluated. Of 182 patients included in this study, 33 (18%) developed pneumonia. Multiple logistic regression analysis revealed that low nutritional status, severe paralysis, and low vital capacity were significant risk factors for pneumonia. The severity of paralysis, respiratory dysfunction, and poor nutritional status can affect the occurrence of pneumonia after CSCI. In addition to respiratory management, nutritional assessment and intervention may play key roles in preventing pneumonia associated with spinal cord injury-induced immune depression. Nutritional care should be provided as soon as possible when the nutritional status of a patient worsens after an injury., (© 2024. The Author(s).)

Importance: Spinal cord injury (SCI) causes drastic changes to an individual's physical health that may be associated with the ability to work., Objective: To estimate the association of SCI with individual earnings and employment status using national administrative health databases linked to income tax data., Design, Setting, and Participants: This was a retrospective, national, population-based cohort study of adults who were hospitalized with cervical SCI in Canada between January 2005 and December 2017. All acute care hospitalizations for SCI of adults ages 18 to 64 years were included. A comparison group was constructed by sampling from individuals in the injured cohort. Fiscal information from their preinjury years was used for comparison. The injured cohort was matched with the comparison group based on age, sex, marital status, province of residence, self-employment status, earnings, and employment status in the year prior to injury. Data were analyzed from August 2022 to January 2023., Main Outcomes and Measures: The first outcome was the change in individual annual earnings up to 5 years after injury. The change in mean yearly earnings was assessed using a linear mixed-effects differences-in-differences regression. Income values are reported in 2022 Canadian dollars (CAD $1.00 = US $0.73). The second outcome was the change in employment status up to 5 years after injury. A multivariable probit regression model was used to compare proportions of individuals employed among those who had experienced SCI and the paired comparison group of participants., Results: A total of 1630 patients with SCI (mean [SD] age, 47 [13] years; 1304 male [80.0%]) were matched to patients in a preinjury comparison group (resampled from the same 1630 patients in the SCI group). The mean (SD) of preinjury wage earnings was CAD $46 000 ($48 252). The annual decline in individual earnings was CAD $20 275 (95% CI, -$24 455 to -$16 095) in the first year after injury and CAD $20 348 (95% CI, -$24 710 to -$15 985) in the fifth year after injury. At 5 years after injury, 52% of individuals who had an injury were working compared with 79% individuals in the preinjury comparison group. SCI survivors had a decrease in employment of 17.1 percentage points (95% CI, 14.5 to 19.7 percentage points) in the first year after injury and 17.8 percentage points (14.5 to 21.1 percentage points) in the fifth year after injury., Conclusions and Relevance: In this study, SCI was associated with a decline in earnings and employment up to 5 years after injury for adults aged 18 to 64 years in Canada.

Background: Following spinal cord injury (SCI), gait function reaches a post-recovery plateau that depends on the paralysis severity. However, the plateau dynamics during the recovery period are not known. This study aimed to examine the gait function temporal dynamics after traumatic cervical SCI (CSCI) based on paralysis severity., Methods: This retrospective cohort study included 122 patients with traumatic CSCI admitted to a single specialized facility within 2 weeks after injury. The Walking Index for Spinal Cord Injury II (WISCI II) was estimated at 2 weeks and 2, 4, 6, and 8 months postinjury for each American Spinal Injury Association Impairment Scale (AIS) grade, as determined 2 weeks postinjury. Statistical analysis was performed at 2 weeks to 2 months, 2-4 months, 4-6 months, and 6-8 months, and the time at which no significant difference was observed was considered the time at which the gait function reached a plateau., Results: In the AIS grade A and B groups, no significant differences were observed at any time point, while in the AIS grade C group, the mean WISCI II values continued to significantly increase up to 6 months. In the AIS grade D group, the improvement in gait function was significant during the entire observation period., Conclusions: The plateau in gait function recovery was reached at 2 weeks postinjury in the AIS grade A and B groups and at 6 months in the AIS grade C group., (© 2024. The Author(s).)

Study Design: Retrospective study., Objectives: To investigate the risk factors of tracheostomy and decannulation after cervical spinal cord injury (CSCI) and their epidemiological changes over the past 8 years in Beijing Bo'ai Hospital, China Rehabilitation Research Center (CRRC), China., Setting: Beijing Bo'ai Hospital, CRRC., Methods: We reviewed 8 years of patient data (2013.1.1 to 2020.12.31) at CRRC, focusing on those hospitalized and diagnosed with CSCI. We analyzed changes in demographic and clinical data's trends. Logistic regression analysis was used to determine factors impacting tracheostomy and decannulation., Results: Finally, 1641 CSCI patients met the inclusion criteria. Over the past 8 years, the proportion of tracheostomized patients with CSCI was 16.3%, and the proportion of successfully decannulated of tracheostomized patients with TCSCI was 77.9%. We found that Traumatic (OR = 1.8, 95% CI = 1.06, 3.22; p = 0.046), Motor level of injury (C5-C8) (OR = 0.32, 95% CI = -1.91,-0.34; p = 0.005), AIS = A/B/C (OR = 22.7/11.1/4.2, 95% CI = 12.16,42.26/5.74,21.56/2.23,7.89; p < 0.001/p < 0.001/p < 0.001), age > 56 (OR = 1.6, 95% CI = 1.04, 2.32; p = 0.031) were the risk factors for tracheostomy. By analyzing the risk factors of decannulation failure in tracheostomized patients with TCSCI through multivariable logistic regression, statistically significant differences were found in age > 45 (OR = 4.1, 95% CI = 1.44, 11.81; p = 0.008), complete injury (OR = 2.7, 95% CI = 1.26, 5.95; p = 0.011), facet dislocation (OR = 2.8, 95% CI = 1.13,7.07; p = 0.027)., Conclusions: Recent years have witnessed shifts in the epidemiological characteristics of CSCI. Identifying the factors influencing tracheostomy and decannulation in CSCI can aid in improving patient prognosis., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Ampakines are positive allosteric modulators of AMPA receptors. We hypothesized that low-dose ampakine treatment increases diaphragm electromyogram (EMG) activity after mid-cervical contusion injury in rats. Adult male and female Sprague Dawley rats were implanted with in-dwelling bilateral diaphragm EMG electrodes. Rats received a 150 kDyn C4 unilateral contusion (C4Ct). At 4- and 14-days following C4Ct, rats were given an intravenous bolus of ampakine CX717 (5 mg/kg, n = 10) or vehicle (2-hydroxypropyl-beta-cyclodextrin; HPCD; n = 10). Diaphragm EMG was recorded while breathing was assessed using whole-body plethysmography. At 4-days, ampakine administration caused an immediate and sustained increase in bilateral peak inspiratory diaphragm EMG bursting and ventilation. The vehicle had no impact on EMG bursting. CX717 treated rats were able to increase EMG activity during a respiratory challenge to a greater extent vs. vehicle treated. Rats showed a considerable degree of spontaneous recovery of EMG bursting by 14 days, and the impact of CX717 delivery was blunted as compared to 4-days. Direct recordings from the phrenic nerve at 21-24 days following C4Ct confirmed that ampakines stimulated bilateral phrenic neural output in injured rats. We conclude that low-dose intravenous treatment with a low-impact ampakine can enhance diaphragm activation shortly following mid-cervical contusion injury, when deficits in diaphragm activation are prominent., Competing Interests: Declaration of competing interest Authors declare no competing financial interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI., Materials and Methods: In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3-C4 and C6-C7) and thoracic (T10-T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks., Results: All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20-70 mA and thoracic site = 25-190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS., Conclusions: We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS., Clinical Trial Registration: The Clinicaltrials.gov registration number for the study is NCT04032990., Competing Interests: Conflict of Interest Yury Gerasimenko has a shareholder interest in Onward and Cosyma. He holds certain inventorship rights on intellectual property licensed by the regents of the University of California to NeuroRecovery Technologies and its subsidiaries. The remaining authors report no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Study Design: Non-interventional, cross-sectional pilot study., Objectives: To establish the validity and reliability of the BioStamp nPoint biosensor (Medidata Solutions, New York, NY, USA [formerly MC10, Inc.]) for measuring electromyography in individuals with cervical spinal cord injury (SCI) by comparing the surface electromyography (sEMG) metrics with the Trigno wireless electromyography system (Delsys, Natick, MA, USA)., Setting: Participants were recruited from the Shirley Ryan AbilityLab registry., Methods: Individuals aged 18-70 years with cervical SCI were evaluated with the two biosensors to capture activity on upper-extremity muscles during two study sessions conducted over 2 days (day 1-consent alone; day 2-two data collections in same session). Time and frequency metrics were captured, and signal-to-noise ratio was determined for each muscle group. Test-retest reliability was determined using Pearson's correlation. Validation of the BioStamp nPoint system was based on Bland-Altmann analysis., Results: Among the 11 participants, 30.8% had subacute cervical injury at C5-C6; 53.8% were injured within 1 year of the study. Results from the test-retest reliability assessment revealed that most Pearson's correlations between the two sensory measurements were strong (≥0.50). The Bland-Altman analysis found values of the signal-to-noise ratio, frequency, and peak amplitude were within the level of agreement. Signal-to-noise ratios ranged from 7.06 to 22.1., Conclusions: In most instances, the performance of the BioStamp nPoint sensors was moderately to strongly correlated with that of the Trigno sensors in all muscle groups tested. The BioStamp nPoint system is a valid and reliable approach to assess sEMG measures in individuals with cervical SCI., Sponsorship: The present study was supported by AbbVie Inc., (© 2024. The Author(s).)

Objective: Corticospinal inhibitory mechanisms are relevant to functional recovery but remain poorly understood after spinal cord injury (SCI). Post-injury characteristics of contralateral silent period (CSP), a measure of corticospinal inhibition evaluated using transcranial magnetic stimulation (TMS), is inconsistent in literature. We envisioned that investigating CSP across muscles with varying degrees of weakness may be a reasonable approach to resolve inconsistencies and elucidate the relevance of corticospinal inhibition for upper extremity function following SCI., Methods: We studied 27 adults with chronic C1-C8 SCI (age 48.8 ± 16.1 years, 3 females) and 16 able-bodied participants (age 33.2 ± 11.8 years, 9 females). CSP characteristics were assessed across biceps (muscle power = 3-5) and triceps (muscle power = 1-3) representing stronger and weaker muscles, respectively. We assessed functional abilities using the Capabilities of the Upper Extremity Test (CUE-T)., Results: Participants with chronic SCI had prolonged CSPs for biceps but delayed and diminished CSPs for triceps compared to able-bodied participants. Early-onset CSPs for biceps and longer, deeper CSPs for triceps correlated with better CUE-T scores., Conclusions: Corticospinal inhibition is pronounced for stronger biceps but diminished for weaker triceps muscle in SCI indicating innervation relative to the level of injury matters in the study of CSP., Significance: Nevertheless, corticospinal inhibition or CSP holds relevance for upper extremity function following SCI., Competing Interests: Conflicts of Interest The authors report no potential conflict of interests., (Copyright © 2024 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Oropharyngeal dysphagia is common in moderate-severe traumatic brain injury (TBI) and cervical spinal cord injury (SCI) patients and can have serious consequences. Delaying feeding in these patients can also be detrimental. Nonetheless, the psychometric properties of screening tools that can promptly identify dysphagia have never been tested in these neurotrauma populations. This study aimed to: (1) adapt, translate, and validate the content of the French-Canadian version of the the Standardized Swallowing Assessment (SSA) tool to meet the needs of moderate-severe TBI and cervical SCI patients, (2) examine its inter-rater reliability and criterion-concurrent validation, and (3) evaluate its clinical utility from the perspectives of critical care nurses. The SSA tool was adapted and translated using an integrated method for the cultural adaptation and translation of tools. Eleven experts participated in the adaptation of the SSA tool, which led to the clarification of one item, as well as a new step and instructions for the screening procedure. Content validation (i.e., item and scale relevance) was evaluated by multidisciplinary team members ( n  = 17). The mean content validity index (CVI) score was 0.97 for the entire scale, while the mean CVI scores for individual items ranged from 0.82 to 1.0. A total of 60 neurotrauma patients were enrolled for inter-rater reliability and criterion-concurrent validation. Interrater reliability was determined by comparing two scores: one score from nurses responsible for the care of enrolled patients and one score from the research nurse. The weighted kappa coefficients for inter-rater reliability were 0.86 for moderate-severe TBI patients ( n  = 30) and 0.73 for cervical SCI patients ( n  = 30). A speech language therapist (SLT) also assessed dysphagia and results were used as the standard clinical reference criterion to determine concurrent validity (sensibility and specificity) of the adapted SSA tool. The sensitivity and specificity were 92% and 50% for moderate-severe TBI, and 77% and 75% for cervical SCI, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 65% and 87% in TBI patients, and 75% and 76% in SCI patients. Test accuracy was 71% and 77% for these same groups. The clinical utility of the tool was evaluated according to the following domains: appropriateness, accessibility of the required material, applicability, perceived effectiveness, and acceptability. Acceptability was the only domain with a level of agreement <80% (74%) among trauma critical care nurses ( n  = 49). Findings support the content validation and inter-rater reliability of the adapted French-Canadian version of the SSA tool in moderate-severe TBI and cervical SCI patients. Sensitivity was acceptable in both groups, but the specificity was lower, especially in moderate-severe TBI patients. Further validation of the adapted French-Canadian version of the SSA tool is needed in neurotrauma patients to confirm these results and to ensure safe dysphagia screening while avoiding oral feeding deferrals.

Cervical spinal cord injury (SCI) causes devastating loss of upper limb function and independence. Restoration of upper limb function can have a profound impact on independence and quality of life. In low-cervical SCI (level C5-C8), upper limb function can be restored via reinnervation strategies such as nerve transfer surgery. The translation of recovered upper limb motor function into functional independence in activities of daily living (ADLs), however, remains unknown in low cervical SCI (i.e., tetraplegia). The objective of this study was to evaluate the association of patterns in upper limb motor recovery with functional independence in ADLs. This will then inform prioritization of reinnervation strategies focused to maximize function in patients with tetraplegia. This retrospective study performed a secondary analysis of patients with low cervical (C5-C8) enrolled in the SCI Model Systems (SCIMS) database. Baseline neurological examinations and their association with functional independence in major ADLs-i.e., eating, bladder management, and transfers (bed/wheelchair/chair)-were evaluated. Motor functional recovery was defined as achieving motor strength, in modified research council (MRC) grade, of ≥ 3 /5 at one year from ≤ 2/5 at baseline. The association of motor function recovery with functional independence at one-year follow-up was compared in patients with recovered elbow flexion (C5), wrist extension (C6), elbow extension (C7), and finger flexion (C8). A multi-variable logistic regression analysis, adjusting for known factors influencing recovery after SCI, was performed to evaluate the impact of motor function at one year on a composite outcome of functional independence in major ADLs. Composite outcome was defined as functional independence measure score of 6 or higher (complete independence) in at least two domains among eating, bladder management, and transfers. Between 1992 and 2016, 1090 patients with low cervical SCI and complete neurological/functional measures were included. At baseline, 67% of patients had complete SCI and 33% had incomplete SCI. The majority of patients were dependent in eating, bladder management, and transfers. At one-year follow-up, the largest proportion of patients who recovered motor function in finger flexion (C8) and elbow extension (C7) gained independence in eating, bladder management, and transfers. In multi-variable analysis, patients who had recovered finger flexion (C8) or elbow extension (C7) had higher odds of gaining independence in a composite of major ADLs (odds ratio [OR] = 3.13 and OR = 2.87, respectively, p  < 0.001). Age 60 years (OR = 0.44, p  = 0.01), and complete SCI (OR = 0.43, p  = 0.002) were associated with reduced odds of gaining independence in ADLs. After cervical SCI, finger flexion (C8) and elbow extension (C7) recovery translate into greater independence in eating, bladder management, and transfers. These results can be used to design individualized reinnervation plans to reanimate upper limb function and maximize independence in patients with low cervical SCI.

Purpose: The purpose of this study was to collect preliminary data to assess whether participation in adaptive video gaming using a pneumatic sip-and-puff video game controller may provide respiratory or health benefits for individuals with cervical-level spinal cord injuries., Methods: A survey was anonymously distributed to potential participants and consisted of four sections: (1) General Information, (2) Gaming Habits, (3) Respiratory Quality of Life, and (4) Impact of Adaptive Video Gaming on Respiratory Health., Results: The study included 124 individuals with cervical-level spinal cord injuries. Participants had primarily positive self-rated health and good respiratory quality of life. Nearly half of the participants (47.6%) Agreed or Strongly Agreed that their breathing control has improved after using their sip-and-puff gaming controller and 45.2% Agreed or Strongly Agreed that their respiratory health has improved. Individuals who Agreed or Strongly Agreed that adaptive video gaming has improved their breathing control also reported a significantly higher level of exertion while gaming compared to those who did not Agree or Strongly Agree ( p  = 0.00029)., Conclusions: It is possible that there are respiratory benefits of using sip-and-puff video game controllers for individuals with cervical spinal cord injuries. The benefits reported by users were found to be dependent on their level of exertion while playing video games. Further exploration in this area is needed due to the positive benefits reported by participants.

While Wallerian degeneration (WD) is a crucial pathological process induced with spinal cord injury (SCI), its underlying mechanisms is still understudied. In this study, we aim to assess structural alterations and clinical significance of WD in the cervical cord following SCI using multi-modal magnetic resonance imaging (MRI), which combines T2*-weighted imaging and diffusion tensor imaging (DTI). T2*-weighted images allow segmentation of anatomical structures and the detection of WD on macrostructural level. DTI, on the other hand, can identify the reduction in neuroaxonal integrity by measuring the diffusion of water molecules on the microstructural level. In this prospective study, 35 SCI patients (19 paraplegic and 16 tetraplegic patients) and 12 healthy controls were recruited between July 2020 and May 2022. The hyperintensity voxels in the dorsal column was manually labeled as WD on T2*-weighted images. The mean cross-sectional area (CSA) and mean DTI indexes of WD at the C2 level were calculated and compared between groups. Correlation analysis was used to determine the associations of the magnitude of WD with lesion characteristics and clinical outcomes. Compared with controls, SCI patients showed evident hyperintensity (35/35) and decreased neuroaxonal integrity ( p  < 0.05) within the dorsal column at the C2 level. A higher neurological level of injury was associated with a larger mean CSA and reduction in neuroaxonal integrity within WD ( p  < 0.05). Smaller total and dorsal tissue bridges were related to greater mean CSA and lower fractional anisotropy values in WD ( p  < 0.05), respectively. Moreover, SCI participants with significantly larger CSAs and significantly lower microstructural integrity had worse sensory outcomes ( p  < 0.05). This comprehensive evaluation of WD can help us better understand the mechanisms of WD, monitor progression, and assess the effectiveness of therapeutic interventions after SCI.

Purpose: To explore accessibility challenges encountered by smartphone users with cervical spinal cord injuries (C1-C8). To investigate the suitability of current technology and make recommendations to help future technology meet user needs., Methods: The study uses a mixed-method approach combining an inductive thematic analysis of nine semi-structured interviews with a quantitative analysis of thirty-nine questionnaires., Results: The analysis generated four themes: 'the drive for independence and self-efficacy' ; 'trying to make it work' ; 'getting the right technology for me' ; 'using the phone as and when I want to' . These themes highlighted how unresolved access issues and situational barriers limited independence and created unwanted privacy compromises for effective communication. There was a lack of information or support on available smartphone accessibility features and assistive technology (AT). Smartphone AT was regarded as overpriced, poorly designed and lacking the voices of people with disabilities., Conclusions: The smartphone's potential to improve quality of life, participation, and well-being is limited by accessibility challenges hindering independent and private smartphone use. Future design work should focus on improving accessibility, investigating reasons for AT's poor quality and high cost, and removing barriers to end-user inclusion. To enhance user awareness of available technology, stakeholders should build and maintain an open platform to act as an information source for peer and professional support on assistive technology.

Study Design: Cross-Sectional Study., Objectives: To investigate the changes in the characteristics of cervical spinal cord injuries (CSCI) before and after the coronavirus disease 2019 (COVID-19) pandemic among patients transported to our hospital in Japan., Setting: Hospital with an emergency center in Chiba, Japan., Methods: Patients eligible for the study were those transported within 24 h of injury and diagnosed with cervical spinal cord injury between January 2018 and December 2021 at our hospital. Medical records were retrospectively examined to investigate the number and characteristics of patients with CSCI. The clinical variables of patients with CSCI were compared according to the time of admission as related to the COVID-19 pandemic: 2018-19 (before) or 2020-21 (after)., Results: The total number of patients with CSCI from 2018 to 2021 was 108, with 57 before the COVID-19 pandemic and 51 after the COVID-19 pandemic. The number of severe cases with an injury severity score (ISS) of >16 decreased after COVID-19 (p < 0.05). Falls on level surfaces were the most common cause of injury both before and after COVID-19. Although the ranking of traffic accidents decreased after COVID-19, among those, the number of bicycle injuries tended to increase., Conclusions: The number of serious cases with an ISS > 16 decreased, presumably because of the decline in high-energy trauma due to the background decrease in the number of traffic accidents., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objective: The objective of this study was to investigate the influence of blood pressure on the severity and functional recovery of patients with acute cervical spinal cord injury (SCI) without fracture and dislocation., Methods: A retrospective case control study analyzed the data of 40 patients admitted to our orthopedics department (Beijing Tiantan Hospital, Capital Medical University) from January 2013 to February 2021. They were diagnosed as acute cervical SCI without fracture and dislocation. Gender, age, height, weight, history of hypertension, postinjury American Spinal Injury Association grade, postinjury modified Japanese Orthopaedic Association (mJOA) score, postoperative mJOA score, 1-year follow-up mJOA score, preoperative mean arterial pressure (MAP), intramedullary T2 hyperintensity, and hyponatremia were collected. The patients were divided into groups and subgroups based on their history of hypertension and preoperative MAP. The effects of history of hypertension and preoperative MAP on the incidence of T2 hyperintensity, hyponatremia, the improvement rate of the postoperative mJOA and 1-year follow-up mJOA scores were analyzed., Results: Patients with history of hypertension had a lower incidence of intramedullary T2 hyperintensity than patients without history of hypertension (P < 0.05). Patients with history of hypertension and patients with a higher preoperative MAP had better neurological recovery at 1 year of follow-up (P < 0.05)., Conclusions: Blood pressure has great influence on acute cervical SCI without fracture and dislocation. Maintaining a higher preoperative MAP is advantageous for better recovery after SCI. Attention should be paid to the dynamic management of blood pressure to avoid the adverse effects of hypotension after SCI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Our previous research studies have demonstrated the role of microRNA133b (miR133b) in healing the contused spinal cord when administered either intranasally or intravenously 24 h following an injury. While our data showed beneficial effects of exogenous miR133b delivered within hours of a spinal cord injury (SCI), the kinetics of endogenous miR133b levels in the contused spinal cord and rostral/caudal segments of the injury were not fully investigated. In this study, we examined the miR133b dysregulation in a mouse model of moderate unilateral contusion injury at the fifth cervical (C5) level. Between 30 min and 7 days post-injury, mice were euthanized and tissues were collected from different areas of the spinal cord, ipsilateral and contralateral prefrontal motor cortices, and off-targets such as lung and spleen. The endogenous level of miR133b was determined by RT-qPCR. We found that after SCI, (a) most changes in miR133b level were restricted to the injured area with very limited alterations in the rostral and caudal parts relative to the injury site, (b) acute changes in the endogenous levels were predominantly specific to the lesion site with delayed miR133b changes in the motor cortex, and (c) ipsilateral and contralateral hemispheres responded differently to unilateral SCI. Our results suggest that the therapeutic window for exogenous miR133b therapy begins earlier than 24 h post-injury and potentially lasts longer than 7 days.

Background: Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury., Methods: In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery., Results: The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement., Conclusions: Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly., (Copyright © 2023 The Japanese Orthopaedic Association. All rights reserved.)

Background: Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients., Methods: A retrospective study was conducted on prospectively collected data from 2 academic institutions. Patients 18 years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis., Results: A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (P = 0.002), greater increases in ASIA motor scores at follow-up (P = 0.009), and a greater likelihood of clinically important improvement in ASIA motor score (P = 0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (P = 0.019) and clinically important improvement in ASIA motor score (P = 0.010), compared to AIS grade A or B injuries., Conclusions: The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury., (Copyright © 2023. Published by Elsevier Inc.)

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Magnetic resonance imaging plays an important role in characterizing microstructural changes and reorganization after traumatic injuries to the nervous system. In this study, we tested the feasibility of ex-vivo spinal cord diffusion tensor imaging (DTI) in combination with in vivo brain functional MRI to characterize spinal reorganization and its supraspinal association after a hemicontusion cervical spinal cord injury (SCI). DTI parameters (fractional anisotropy [FA], mean diffusion [MD]) and fiber orientation changes related to reorganization in the contused cervical spinal cord were compared to sham specimens. Altered fiber density and fiber directions occurred across the ipsilateral and contralateral hemicords but with only ipsilateral FA and MD changes. The hemicontusion SCI resulted in ipsilateral fiber breaks, voids and vivid fiber reorientations along the injury epicenter. Fiber directional changes below the injury level were primarily inter-hemispheric, indicating prominent below-level cross-hemispheric reorganization. In vivo resting state functional connectivity of the brain from the respective rats before obtaining the spinal cord samples indicated spatial expansion and increased connectivity strength across both the sensory and motor networks after SCI. The consistency of the neuroplastic changes along the neuraxis (both brain and spinal cord) at the single-subject level, indicates that distinctive reorganizational relationships exist between the spinal cord and the brain post-SCI., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Spinal cord injury is associated with spinal vascular disruptions that result in spinal ischemia and tissue hypoxia. This study evaluated the therapeutic efficacy of normobaric hyperoxia on spinal cord oxygenation and circulatory function at the acute stage of cervical spinal cord injury. Adult male Sprague Dawley rats underwent dorsal cervical laminectomy or cervical spinal cord contusion. At 1-2 days after spinal surgery, spinal cord oxygenation was monitored in anesthetized and spontaneously breathing rats through optical recording of oxygen sensor foils placed on the cervical spinal cord and pulse oximetry. The arterial blood pressure, heart rate, blood gases, and peripheral oxyhemoglobin saturation were also measured under hyperoxic (50% O2) and normoxic (21% O2) conditions. The results showed that contused animals had significantly lower spinal cord oxygenation levels than uninjured animals during normoxia. Peripheral oxyhemoglobin saturation, arterial oxygen partial pressure, and mean arterial blood pressure are significantly reduced following cervical spinal cord contusion. Notably, spinal oxygenation of contused rats could be improved to a level comparable to uninjured animals under hyperoxia. Furthermore, acute hyperoxia elevated blood pressure, arterial oxygen partial pressure, and peripheral oxyhemoglobin saturation. These results suggest that normobaric hyperoxia can significantly improve spinal cord oxygenation and circulatory function in the acute phase after cervical spinal cord injury. We propose that adjuvant normobaric hyperoxia combined with other hemodynamic optimization strategies may prevent secondary damage after spinal cord injury and improve functional recovery., (Copyright © 2024 Copyright: © 2024 Journal of Physiological Investigation.)

Study Design: Retrospective cohort study., Objective: To determine the risk factors associated with dysphagia in individuals with cervical spinal cord injury (CSCI) and analyze the differences between individuals with improved penetration-aspiration (PA) and persistent PA on follow-up., Setting: Tertiary inpatient rehabilitation facilities., Methods: Medical records of individuals with CSCI admitted between December 2009 and February 2023 who underwent a videofluoroscopic swallowing study (VFSS) were retrospectively reviewed. Multivariate logistic regression analysis was performed to assess risk factors for dysphagia. Differences between individuals with improved PA and persistent PA were analyzed using an independent t-test., Results: In total, 149 participants were enrolled. Age (odds ratio (OR) 1.08, 95% confidence interval (CI) 1.04-1.12), percentage of forced vital capacity to predicted normal (FVC (% predicted)) (OR 0.90, 95% CI 0.85-0.94), and skeletal muscle index (OR 0.89, 95% CI, 0.79-0.99) were significant factors associated with the risk of PA. Based on the receiver operating characteristic curve analysis, the cut-off values for age, FVC (% predicted), and skeletal muscle index were determined as 56.0, 45.7, and 41.0, respectively. A secondary analysis of the follow-up VFSS was conducted on 38 participants. The follow-up FVC (% predicted) and degree of weight loss differed significantly between the improved PA and persistent PA groups., Conclusions: Older age, low FVC (% predicted), and low skeletal muscle index can be predictors of dysphagia in patients with CSCI. On follow-up VFSS, individuals with improved PA demonstrated greater improvement in FVC (% predicted)., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Introduction: Postprandial hypotension is a type of autonomic dysfunction where there is a decrease in systolic blood pressure of >20 mm HG within 2 h after eating thought to be due to poor cardiovascular compensation for splanchnic blood pooling that occurs with meals. This form of autonomic dysfunction is underdiagnosed in patients with spinal cord injury, likely in part because it can be asymptomatic., Case Presentation: 26-year-old with complete cervical spinal cord injury (SCI) presented with neck pain described as severe 10/10 pain, which felt like "a rope around his neck." Pain came on during and after meals and was associated with a feeling of pressure behind his eyes, white spots in his vision along with feeling as if he was going to pass out. The caregiver noted a systolic blood pressure drop by about 30-40 points with meals and lost weight due to avoiding eating. A diagnosis of post-prandial hypotension (PPH) was made and Acarbose was started at a low dose 25 mg three times per day with meals. During follow up, the patient reported complete resolution of drops of blood pressure, neck pain, and all associated symptoms. The patient was able to eat comfortably and gained weight., Discussion: There are few case reports on PPH in SCI and none looking at acarbose on a young, nondiabetic person with SCI. Clinicians should be aware that PPH can occur in young otherwise healthy people with SCI. Further research is needed on PPH, including the use of acarbose, in the SCI population., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

This study aimed to clarify the association between swallowing disorder and prevertebral hyperintensity on magnetic resonance imaging (MRI) in patients with cervical spinal cord injury (CSCI) without a major fracture. This retrospective observational study included 30 patients who were diagnosed with acute CSCI without a major fracture (mean age: 69.3 years, 27 men). Swallowing disorder was defined as tube-dependent nutrition because of obvious aspiration 28 days after injury. The high-intensity area (HIA) and anteroposterior width (HIW) of the prevertebral space at C1-7 levels were measured using MRI short-TI inversion recovery midsagittal images. Receiver operating characteristic curve analysis was used to determine the optimal cutoff values of the HIA for predicting swallowing disorder. The incidence of swallowing disorder after CSCI was 16.7%. The HIA was significantly higher in the swallowing disorder group (median, 409.0 mm2) than in the non- swallowing disorder group (median, 159.1 mm2) (P = .04). There was no significant difference in HIW between the two groups. The optimal cutoff point of the HIA was measured at 203.2 mm2 with 80.0% and 20.0% sensitivity and specificity, respectively, with an area under the curve of 0.848 (95% confidence interval, 0.657-1.000, P = .01). The prevertebral hyperintensity area on MRI for swallowing disorder in patients after cervical cord injury without skeletal injury is associated with swallowing disorder. The optimal cutoff point of the area was determined to be 203.2 mm2., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Cervical spinal cord injury interrupts supraspinal pathways innervating thoracic sympathetic preganglionic neurons and results in cardiovascular dysfunction. Both respiratory and locomotor functions were also impaired due to damages of motoneuron pools controlling respiratory and forelimb muscles, respectively. However, no study has investigated autonomic and somatic motor functions in the same animal model. The present study aimed to establish a cervical spinal cord injury model to evaluate cardiorespiratory response and locomotor activity in unanesthetized rats. Cardiovascular response and respiratory behavior following laminectomy or cervical spinal contusion were measured using noninvasive blood pressure analyzer and plethysmography systems, respectively. Locomotor activity was evaluated by an open-field test and a locomotor rating scale. The results demonstrated that mean arterial blood pressure and heart rate were significantly reduced in contused rats compared with uninjured rats at the acute injured stage. Tidal volume was also significantly reduced during the acute and subchronic stages. Moreover, locomotor function was severely impaired, evidenced by decreasing moving ability and locomotor rating scores from the acute to chronic injured stages. Retrograde neurotracer results revealed that cervical spinal cord injury caused a reduction in number of phrenic and triceps motoneurons. Immunofluorescence staining revealed a significant attenuation of serotonergic, noradrenergic, glutamatergic, and GABAergic fibers innervating the thoracic sympathetic preganglionic neurons in chronically contused rats. These results revealed the pathological mechanism underlying the comorbidity of cardiorespiratory and locomotor dysfunction following cervical spinal cord injury. We proposed that this animal model can be used to evaluate the therapeutic efficacy of potential strategies to improve different physiological functions. NEW & NOTEWORTHY The present study establishes a preclinical rodent model to comprehensively investigate physiological functions under unanesthetized condition following cervical spinal cord contusion. The results demonstrated that cervical spinal cord contusion is associated with impairments in cardiovascular, respiratory, and locomotor function. Respiratory and forelimb motoneurons and neurochemical innervations of sympathetic preganglionic neurons were damaged following injury. This animal model can be used to evaluate the therapeutic efficacy of potential strategies to improve different physiological functions.

Purpose: To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures., Methods: We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups., Results: Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis., Conclusion: Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI)., Design: Retrospective cohort study. Setting: Spinal injuries center in Japan. Participants: Of 184 individuals who were admitted within 2 weeks after acute traumatic cervical spinal injuries, 167 individuals who met the criteria were included in this study. Interventions: The occurrence of pneumonia, degree of dysphagia using the Dysphagia Severity Scale, patient age, history of smoking, presence of tracheostomy, vital capacity, level of injury, and the American Spinal Injury Association Impairment Scale (AIS) 2 weeks after injury were assessed. Outcomes: Incidence of pneumonia were analyzed. Moreover, the risk factors of pneumonia were evaluated using logistic regression analysis., Results: From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI., Conclusions: It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.