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STUDY DESIGN: Multicenter retrospective study. OBJECTIVE: To examine whether posttraumatic cervical spinal canal compromise and spinal cord compression are responsive to changes in motor and sensory functions. SUMMARY OF BACKGROUND DATA: The maximum canal compromise (MCC) and maximum spinal cord compression (MSCC) were developed to quantitatively assess canal stenosis and spinal cord compression using computed tomographic (CT) scan and magnetic resonance imaging (MRI) in the setting of acute spine trauma. METHODS: We included 100 consecutive patients with acute spine trauma. Patients were classified into three groups as follows: patients with acute spine trauma without spinal cord injury (group 1), patients with incomplete spinal cord injury (group 2), and patients with complete spinal cord injury (group 3). We studied three quantitative imaging parameters given as follows: MCC using CT-based measurements, MCC using T1-MRI based measurements, and MSCC using T2-MRI based measurements. RESULTS: There were 78 male patients and 22 female patients with ages from 17 to 82 years (mean age = 45 years). In group 1, there were no significant differences regarding the mean MRI-MCC and MSCC among the spine levels. Although most spine levels were statistically comparable regarding the CT-MCC in patients of group 1, the C7 level significantly differed from the C3 level. Comparisons among all three patient groups showed significant differences regarding the mean MRI-MCC and MSCC, but no significant differences were observed in the mean CT-MCC between groups 1 and 2, and between groups 1 and 3. Data analyses using operating characteristics of each radiologic parameter indicated that only the MRI parameters had consistently optimal cutoff points to distinguish between groups 1 and 2, and between groups 2 and 3. CONCLUSION: Our results suggest that the MRI-based measurements of canal compromise and spinal cord compression are responsive to changes in motor and sensory functions. However, the MCC using CT-based measurements provides inconsistent results that can result in misdiagnosis in the clinical setting. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective cohort study supplemented by analysis of postmortem spinal cord tissue. OBJECTIVES: This study examines the frequency of hyponatremia in early stage (2 weeks) after cervical spinal cord injury (SCI), and the relationship between integrity of key autonomic pathways and hyponatremia. SUMMARY OF BACKGROUND DATA: Interruption of key circuits in the spinal cord can induce autonomic dysfunction with disordered metabolic and physiologic homeostasis. Given that hyponatremia may be a common electrolyte disorder during the acute stage post-SCI, we hypothesized that disconnection of descending sympathetic renal spinal cord tracts may be associated with hyponatremia after SCI. METHODS: Consecutive individuals with cervical spine trauma were included in our cohort of patients, which was divided into a SCI group and a control group (patients with spine trauma without SCI). Also, postmortem spinal cord sections from individuals with cervical, motor complete SCI, and control cases without CNS trauma were evaluated regarding the extent of axonal preservation within the descending vasomotor pathways, the descending renal sympathetic pathways (DRSPs), the corticospinal tracts, and the dorsal columns. RESULTS: There were 21 SCI individuals (6 women, 15 men; ages, 17-83 years; mean, 57.1) and 12 patients in the control spine trauma group who did not have SCI (4 women, 8 men; ages 18-90 years; mean, 45.9). Patients had either motor complete (7/21) or motor incomplete (14/21) tetraplegia. Hyponatremia occurred in 85.7% after SCI, which was significantly more frequent than the control group. Postmortem analysis included 5 control cases and 6 SCI individuals of whom 3 developed hyponatremia. The number of preserved axons within the DRSPs from normonatremic SCI patients was significantly lower than the number of axons within DRSPs from hyponatremic SCI patients, but development of hyponatremia was not associated with the integrity of the descending vasomotor pathways. Hyponatremic SCI individuals also showed greater evidence of neurogenic hypotension than normonatremic SCI individuals. CONCLUSION: Hyponatremia is common in the early stage post-SCI. Our results also suggest that hyponatremia is associated with the integrity of descending renal sympathetic circuits which mediate the renin-angiotensin response to neural injury, in the setting of neurogenic hypotension with cardiovascular dysfunction. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Reliability study. OBJECTIVE: To assess the intrarater and interrater reliability of a recently described technique to measure of maximum canal compromise (MCC) and maximum spinal cord compression (MSCC) using digitized and magnified images in the setting of traumatic cervical spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: The extent of MCC and MSCC is of clinical and prognostic value in the setting of traumatic cervical SCI. However, concerns remain regarding the accuracy of measurements based on hard copy images. We hypothesized that the interrater and intrarater reliability of these assessments would be enhanced using magnified digitized images and software-based measurement tools. METHODS: Midsagittal MRI and CT images of cervical spine were selected from 5 individuals with acute traumatic cervical SCI. Measurements of MCC using CT scan and T1-weighted MRI and measurements of MSCC based on T2-weighted MR images were independently estimated by 13 raters on 10 occasions. RESULTS: The intrarater reliability for CT-MCC, T1-weighted MRI-MCC and T2-weighted MRI-MSCC was high in the 10 rounds in each patient. In addition, the mean intrarater interclass correlation coefficient was 0.72 +/- 0.05 for the CT-MCC, 0.70 +/- 0.07 for the T1-weighted MRI-MCC, and 0.68 +/- 0.11 for the T2-weighted MRI-MSCC. The mean interrater interclass correlation coefficients were 0.43 +/- 0.02 for the CT-MCC, 0.61 +/- 0.03 for the T1-weighted MRI-MCC, and 0.55 +/- 0.05 for the evaluation of T2-weighted MRI-MSCC. CONCLUSION: Our study has demonstrated that the intrarater reliability for the instrument to assess MCC and MSCC in the setting of traumatic SCI was high. The interrater ICCs at a moderate level of reliability combined with our results using analysis of variance with post hoc tests indicate that the measurements of MCC and MSCC are reproducible, which supports the use of these radiologic parameters in the clinical and research settings. [ABSTRACT FROM AUTHOR]

Study Design. Systematic review.Objective. To examine the evidence to support practice guidelines for screening for DVT in asymptomatic adults with acute traumatic spinal cord injury (SCI) who undergo pharmacologic thromboprophylaxis.Summary of Background Data. Despite the fact that pharmacologic thromboprophylaxis has been widely used since the 1980s, deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) still account for approximately 10% of deaths during the first year following SCI.Methods. MEDLINE and EMBASE were searched from the earliest achievable date to December 2005. We only included clinical studies that used a screening test for DVT and the gold standard diagnostic tests for DVT (i.e., lower limb venography) and for PE (i.e., lung arteriogram) in adults with traumatic SCI who underwent drug thromboprophylaxis during the acute stage after SCI.Results. The search yielded 188 articles, of which 9 articles fulfilled the criteria to be included in our review. Screening for DVT was performed in 3 randomized clinical trials and 6 case series. The protocol of these studies included the use of D-Dimer (1 of 9),1251-labeled fibrinogen (2 of 9), ultrasound (1 of 9), impedance plethysmography (1 of 9), impedance plethysmography and Doppler in combination (1 of 9), Duplex (1 of 9) or venography (2 of 9) as screening test for DVT. Based on the pooled data of these studies, asymptomatic DVT was detected in 16.9% of SCI population. Only 4 studies reported the occurrence of PE in 4.4% of cases.Conclusion. There is insufficient evidence to support (or refute) a recommendation for routine screening for DVT in adults with acute traumatic SCI under thromboprophylaxis. However, there is level 11-2 evidence that screening could detect asymptomatic DVT in 22.7% of those individuals. Although additional investigation is needed, we hypothesize that weekly screening for DVT during the first 13 weeks post-SCI could detect most of the asymptomatic DVT events in this patient population. D-Dimer, ultrasound, and MR venography could be considered as potentially useful screening tests for DVT in the SCI population in future research studies. [ABSTRACT FROM AUTHOR]

Fine-needle aspiration biopsy (FNAB) is considered a safe, reliable and cost-effective means of selecting thyroid nodules with risk for malignancy. However, there are limitations of this method including false positive/negative and 'nondiagnostic' results that may be reduced by repeating FNAB. OBJECTIVE: To evaluate accuracy, sensitivity, specificity and costs of sequential FNAB in the management of thyroid nodular disease. METHODS: Charts of all patients who underwent thyroidectomy at a university teaching hospital in Toronto from 1998 to 2000 were reviewed. FNAB reports of 'suspicious for malignancy,' 'follicular lesion' and 'cellular atypia' were considered to be positive. Data were analyzed with chi2 and z tests. RESULTS: There were 268 patients (225 women and 43 men; age range 18-89 yr; mean age 47 yr) who underwent a total of 449 FNABs (mean 1.7 FNABs/patient) within a year before thyroidectomy. Accuracy (63.8%), sensitivity (73.8%) and specificity (69%) were determined for single FNABs. Sequential FNAB increased the accuracy of method by 22.6%, sensitivity by 13.8% and specificity by 6.2%, with reduction of false positive/negative results by 14.2% and 'nondiagnostic' results by 100%. However, the costs of sequential cytology per patient were 70% higher than single FNAB. CONCLUSIONS: Multiple FNABs are unpleasant for patients, but useful in the selection for treatment of patients with thyroid nodular diseases. Although sequential FNAB increases the costs of method, the improvement of precision of FNAB may imply a reduction in overall health-care costs. [ABSTRACT FROM AUTHOR]

Purpose: People with spinal cord injury (SCI) experience a considerable loss of bone after the injury. Lumbar spine (LS) bone mineral density (BMD) has been reported to be within the normal range, or even higher when assessed with DXA, in people with SCI; hence, it has been hypothesized that sources of error may spuriously increase LS BMD. The aim of this study was to describe the frequency of potential sources of error that may alter LS BMD measurement in a cohort of individuals with chronic SCI at baseline and over a 2-year period., Methods: We analyzed baseline and 2-year follow up DXA scans (Hologic Discovery QDR 4500, Hologic Inc., MA, USA) previously performed from a cohort of males and females with chronic SCI. Two physicians independently reviewed each scan, commented on whether the scan was appropriate for BMD analysis, should be re-analyzed, or be removed from the dataset, and reported on the presence of potential sources of error in LS BMD measurement., Results: We reviewed 115 lumbar spine DXA scans from 58 participants, and 107 (93.0 %) scans from 52 participants presented at least one potential source of error. At baseline, the average number of potential sources of error per scan was 5.5 ± 1.7 and 5.7 ± 1.5 according to rater 1 and rater 2, respectively. Follow-up scans presented an average of 5.6 ± 1.6 and 5.7 ± 1.4 potential sources of error according to rater 1 and rater 2, respectively. Facet sclerosis, osteophytes and difficulty in detecting bone edges were the most prevalent sources of error., Conclusion: The high frequency of potential sources of error is consistent with current recommendations against the use of LS BMD for fracture risk assessment in people with SCI., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: This research work was performed: (1) To assess the accessibility of in-laboratory polysomnography for individuals with spinal cord injury (SCI); (2) to evaluate the validity of four screening questionnaires for sleep-related breathing disorders (SRBDs); and (3) to assess the association between anthropometric features and apnea-hypopnea index (AHI)., Methods: An Environmental scan (E-scan) was performed in the province of Ontario, where all sleep clinics were invited to complete the E-scan survey. Furthermore, a cross-sectional study was performed at a rehabilitation hospital (Canada), where consecutive adults with subacute/chronic (>1 month) SCI were recruited. Using a home-based screening sleep test (HBSST), the validity of the Berlin, STOP, Medical Outcomes Study Sleep Scale [MOS-SS], and STOP-Bang screening questionnaires was assessed. The association between AHI and three features (i.e., neck circumference, body mass index [BMI] and oropharynx opening as assessed using the Modified Mallampati classification [MMC]) was evaluated., Results: According to the E-scan, access to polysomnography is limited for the SCI population in Ontario. Of the 28 participants with SCI (11 females, 17 males; mean age: 54.9 years) included in the cross-sectional study, 32.1 % were diagnosed with moderate-to-severe SRBD. The performance of the questionnaires was considered insufficient for screening of individuals living with SCI. AHI was not associated with neck circumference, BMI, or MMC., Conclusions: Those results suggest that the use of a HBSST could overcome the barriers for individuals with SCI to access diagnostic testing of SRBDs. The use of screening questionnaires and risk assessment for SRBDs in the SCI population is unreliable., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Julio C. Furlan reports financial support was provided by Praxis Spinal Cord Institute. Mark I. Boulos reports equipment, drugs, or supplies was provided by ResMed. Julio C. Furlan reports a relationship with Craig H. Neilsen Foundation that includes: a funding grant. Julio C. Furlan reports a relationship with Cervical Spine Research Society that includes: funding grants. Julio C. Furlan reports a relationship with Ministry of Health (Ontario) that includes: a funding grant. Julio C. Furlan reports a relationship with University of Toronto that includes: a funding grant. Mark I. Boulos reports a relationship with Heart and Stroke Foundation of Canada that includes: a funding grant. Julio C. Furlan reports a relationship with Ontario Neurotrauma Foundation that includes: a funding grant. If there are other authors, they 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 B.V. All rights reserved.)

Background: Degenerative cervical myelopathy (DCM) is a progressive chronic spinal cord injury estimated to affect 1 in 50 adults. Without standardised guidance, clinical research studies have selected outcomes at their discretion, often underrepresenting the disease and limiting comparability between studies. Utilising a standard minimum data set formed via multi-stakeholder consensus can address these issues. This combines processes to define a core outcome set (COS)-a list of key outcomes-and core data elements (CDEs), a list of key sampling characteristics required to interpret the outcomes. Further "how" these outcomes should be measured and/or reported is then defined in a core measurement set (CMS). This can include a recommendation of a standardised time point at which outcome data should be reported. This study defines a COS, CDE, and CMS for DCM research., Methods and Findings: A minimum data set was developed using a series of modified Delphi processes. Phase 1 involved the setup of an international DCM stakeholder group. Phase 2 involved the development of a longlist of outcomes, data elements, and formation into domains. Phase 3 prioritised the outcomes and CDEs using a two-stage Delphi process. Phase 4 determined the final DCM minimal data set using a consensus meeting. Using the COS, Phase 5 finalised definitions of the measurement construct for each outcome. In Phase 6, a systematic review of the literature was performed, to scope and define the psychometric properties of measurement tools. Phase 7 used a modified Delphi process to inform the short-listing of candidate measurement tools. The final measurement set was then formed through a consensus meeting (Phase 8). To support implementation, the data set was then integrated into template clinical research forms (CRFs) for use in future clinical trials (Phase 9). In total, 28 outcomes and 6 domains (Pain, Neurological Function, Life Impact, Radiology, Economic Impact, and Adverse Events) were entered into the final COS. Thirty two outcomes and 4 domains (Individual, Disease, Investigation, and Intervention) were entered into the final CDE. Finally, 4 outcome instruments (mJOA, NDI, SF-36v2, and SAVES2) were identified for the CMS, with a recommendation for trials evaluating outcomes after surgery, to include baseline measurement and at 6 months from surgery., Conclusions: The AO Spine RECODE-DCM has produced a minimum data set for use in DCM clinical trials today. These are available at https://myelopathy.org/minimum-dataset/. While it is anticipated the CDE and COS have strong and durable relevance, it is acknowledged that new measurement tools, alongside an increasing transition to study patients not undergoing surgery, may necessitate updates and adaptation, particularly with respect to the CMS., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Davies et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Although concomitant traumatic brain injury (TBI) is not infrequently associated with spinal cord injury (SCI), there is relatively scarce information about the effects of concomitant TBI on outcomes after SCI., Objective: To assess the impact of concomitant mild-to-moderate TBI on survival, and neurological and functional outcomes within the first year after acute traumatic SCI., Design: Retrospective cohort study., Setting: Acute spine trauma centers in the United States., Participants: This study includes all individuals who were enrolled into the Third National Spinal Cord Injury Study (NASCIS-3). The study population was classified into SCI + TBI group and SCI-alone group. TBI was defined as a Glasgow Coma Scale score <15 on admission., Intervention: Not applicable., Main Outcome Measures: Both groups were compared regarding their survival and neurological outcomes (ie, NASCIS motor, sensory and pain scores) and functional outcome (ie, Functional Independence Measure score) within the first year following SCI. Data analyses were adjusted for major potential confounders., Results: There were 413 individuals in the SCI-alone group and 86 individuals in the SCI + TBI group (17.2%). Both groups were comparable regarding gender distribution (p = .621). However, the SCI + TBI group was older (p < .001), had a higher proportion of complete (p = .006) and cervical SCI (p = .003), and had a higher blood alcohol level (p < .001) than the SCI-alone group. The SCI + TBI group did not significantly differ from the SCI-alone group regarding survival within the first year after SCI (p = .768). Among the survivors, concomitant mild-to-moderate TBI did not significantly affect neurological and functional outcomes at 1 year after SCI in the multiple regression analyses after adjusting for major potential confounders., Conclusions: The results of this study suggest that concomitant mild-to-moderate TBI did not have a significant impact on survival, neurological recovery, and functional outcomes at 1 year after SCI, even though there were some epidemiological differences between SCI-alone and SCI + TBI groups., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Study Design: Modified DELPHI Consensus Process., Objective: To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness., Method: AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings., Results: Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal., Conclusion: A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future., 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.

Objective . Spinal cord injury (SCI) can cause significant impairment and disability with an impact on the quality of life for individuals with SCI and their caregivers. Surface electromyography (sEMG) is a sensitive and non-invasive technique to measure muscle activity and has demonstrated great potential in capturing neuromuscular changes resulting from SCI. The mechanisms of the sEMG signal characteristic changes due to SCI are multi-faceted and difficult to study in vivo . In this study, we utilized well-established computational models to characterize changes in sEMG signal after SCI and identify sEMG features that are sensitive and specific to different aspects of the SCI. Approach . Starting from existing models for motor neuron pool organization and motor unit action potential generation for healthy neuromuscular systems, we implemented scenarios to model damages to upper motor neurons, lower motor neurons, and the number of muscle fibers within each motor unit. After simulating sEMG signals from each scenario, we extracted time and frequency domain features and investigated the impact of SCI disruptions on sEMG features using the Kendall Rank Correlation analysis. Main results . The commonly used amplitude-based sEMG features (such as mean absolute values and root mean square) cannot differentiate between injury scenarios, but a broader set of features (including autoregression and cepstrum coefficients) provides greater specificity to the type of damage present. Significance . We introduce a novel approach to mechanistically relate sEMG features (often underused in SCI research) to different types of neuromuscular alterations that may occur after SCI. This work contributes to the further understanding and utilization of sEMG in clinical applications, which will ultimately improve patient outcomes after SCI., (Creative Commons Attribution license.)

Background: Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this., Objective: The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes., Methods: Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders., Results: Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway., Conclusions: This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community., International Registered Report Identifier (irrid): DERR1-10.2196/46809., (©Irina Sangeorzan, Grazia Antonacci, Anne Martin, Ben Grodzinski, Carl M Zipser, Rory K J Murphy, Panoraia Andriopoulou, Chad E Cook, David B Anderson, James Guest, Julio C Furlan, Mark R N Kotter, Timothy F Boerger, Iwan Sadler, Elizabeth A Roberts, Helen Wood, Christine Fraser, Michael G Fehlings, Vishal Kumar, Josephine Jung, James Milligan, Aria Nouri, Allan R Martin, Tammy Blizzard, Luiz Roberto Vialle, Lindsay Tetreault, Sukhvinder Kalsi-Ryan, Anna MacDowall, Esther Martin-Moore, Martin Burwood, Lianne Wood, Abdul Lalkhen, Manabu Ito, Nicky Wilson, Caroline Treanor, Sheila Dugan, Benjamin M Davies. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.10.2023.)

To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Identify the most common trends and features of research studies on spinal cord rehabilitation, which were registered in the ClinicalTrials.gov Website between 2000 and 2022; (2) Discuss the main limitations of research on spinal cord rehabilitation, based on the protocols published on the ClinicalTrials.gov Website; and (3) Recognize important knowledge gaps in clinical studies on spinal cord rehabilitation that were registered in the ClinicalTrials.gov Website., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Little is known about the impact of race/ethnicity on the clinical and neurological outcomes after acute traumatic spinal cord injury (tSCI)., Objectives: This study examined the influence of race/ethnicity on the individuals' survival and neurological recovery within the first year after tSCI., Methods: The 306 cases enrolled in the First National Acute Spinal Cord Injury Study (NASCIS-1) were grouped as African American individuals ( n = 84), non-Hispanic White individuals ( n = 159), and other races/ethnicities that included Hispanic individuals ( n = 60) and Asian individuals ( n = 3). Outcome measures included survival and neurological recovery within the first year after tSCI. Data analyses were adjusted for major potential confounders., Results: There were 39 females and 267 males with mean age of 31 years who mostly sustained cervical severe tSCI after motor vehicle accidents or falls. The three groups were comparable regarding sex distribution, level and severity of tSCI, level of consciousness at admission, and total received dose of methylprednisolone. African American individuals were significantly older than non-Hispanic White individuals ( p = .0238). African American individuals and individuals of other races/ethnicities more often had a tSCI with open wound caused by missile and water-related accidents than non-Hispanic White individuals ( p < .0001). Survival rates within the first year after tSCI were comparable among the three groups ( p = .3191). Among the survivors, there were no significant differences among the three groups regarding motor and pinprick and light-touch sensory recovery ( p > .0500)., Conclusions: The results of this study suggest that, while there were few differences among the racial/ethnical groups regarding the epidemiology of tSCI, race/ethnicity did not influence survival rate or neurological recovery within the first year post-tSCI., (© 2023 American Spinal Injury Association.)

Introduction: Sleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction., Methods: This cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI., Discussion: To our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI., Trial Registration: The research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Furlan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To compare males and females who were stratified into subgroups corresponding to premenopausal, perimenopausal, and postmenopausal ages, regarding access to optimal care and their outcomes after traumatic spinal cord injury (tSCI)., Study Design: Retrospective cohort study., Setting: Eighteen acute care centers and 13 rehabilitation facilities across Canada., Participants: This study included 5571 individuals with tSCI at C1-L2 who were enrolled in the Rick Hansen Spinal Cord Injury Registry from July 2004 to September 2019 (N=5571). Females were compared with males in the younger (aged ≤40 years), middle-aged (ages 41-50), and older (aged >50 years) subgroups., Intervention: Not applicable., Main Outcome Measures: Females were compared with males in each subgroup with regard to their demographic data, pre-existing comorbidities, injury characteristics, management choices, access to optimal care, and clinical, neurologic, and functional outcomes after tSCI., Results: In the younger subgroups, females (n=408) were significantly younger, had a greater proportion of aboriginals and transportation-related tSCIs, underwent surgical treatment more often, and had a greater sensory score change than males (n=1613). In the middle-aged subgroups, females (n=174) had a greater proportion of high-thoracic tSCIs than males (n=666). In the older subgroups, females (n=660) were significantly older, had more fall-related and less severe tSCIs, had a shorter stay at the rehabilitation center, had less spasticity, and were discharged home less often than males (n=2050)., Conclusions: The results of this study suggest some sex-related differences in individuals' demographics and injury characteristics, but fewer discrepancies between females and males regarding their access to optimal care and outcomes after tSCI. Overall, future clinical trials could consider inclusion of males and females of all age groups to enhance recruitment and augment generalizability., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: This scoping review was undertaken to synthetize and appraise the literature on the potential mechanisms of action of functional electrical stimulation therapy in combination with task-specific training (FEST + TST) in the rehabilitation following stroke, spinal cord injury, traumatic brain injury, or multiple sclerosis., Materials and Methods: The literature search was performed using multiple databases (including APA, PsycInfo, Medline, PubMed, EMBASE, CCRCT, and Cochrane Database of Systematic Reviews) from 1946 to June 2020. The literature search used the following terms: (spinal cord injury, paraplegia, tetraplegia, quadriplegia, stroke, multiple sclerosis, traumatic brain injury, or acquired brain injury) AND (functional electrical stimulation or FES). The search included clinical and preclinical studies without limits to language., Results: Of the 8209 titles retrieved from the primary search, 57 publications fulfilled the inclusion and exclusion criteria for this scoping review. While most publications were clinical studies (n = 50), there were only seven preclinical studies using animal models. The results of this review suggest that FEST + TST can result in multiple effects on different elements from the muscle to the cerebral cortex. However, most studies were focused on the muscle changes after FEST + TST., Conclusions: The results of this scoping review suggest that FEST + TST can result in multiple effects on different elements of the neuromuscular system, while most research studies were focused on the muscle changes after FEST + TST. Despite the efficacy of the FEST + TST in the neurorehabilitation after CNS injury or disease, the results of this review underline an important knowledge gap with regards to the actual mechanism of action of FEST + TST., (Copyright © 2022 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Progress in degenerative cervical myelopathy (DCM) is hindered by inconsistent measurement and reporting. This impedes data aggregation and outcome comparison across studies. This limitation can be reversed by developing a core measurement set (CMS) for DCM research. Previously, the AO Spine Research Objectives and Common Data Elements for DCM (AO Spine RECODE-DCM) defined 'what' should be measured in DCM: the next step of this initiative is to determine 'how' to measure these features. This protocol outlines the steps necessary for the development of a CMS for DCM research and audit., Methods and Analysis: The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials and the Consensus-based Standards for the selection of health Measurement Instruments. The process involves five phases. In phase 1, the steering committee agreed on the constructs to be measured by sourcing consensus definitions from patients, professionals and the literature. In phases 2 and 3, systematic reviews were conducted to identify tools for each construct and aggregate their evidence. Constructs with and without tools were identified, and scoping reviews were conducted for constructs without tools. Evidence on measurement properties, as well as on timing of assessments, are currently being aggregated. These will be presented in phase 4: a consensus meeting where a multi-disciplinary panel of experts will select the instruments that will form the CMS. Following selection, guidance on the implementation of the CMS will be developed and disseminated (phase 5). A preliminary CMS review scheduled at 4 years from release., Ethics and Dissemination: Ethical approval was obtained from the University of Cambridge (HBREC2019.14). Dissemination strategies will include peer-reviewed scientific publications; conference presentations; podcasts; the identification of AO Spine RECODE-DCM ambassadors; and engagement with relevant journals, funders and the DCM community., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Literature Review (Narrative)., Objective: To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness., Methods: Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM., Results: DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness., Conclusion: Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

Study Design: Narrative review., Objective: Degenerative cervical myelopathy is one of the most frequent impairments of the spinal cord encountered internationally in adults. Currently, surgical decompression is the recommended treatment for people with DCM (PwCM) presenting with moderate to severe symptoms or neurological deficits. However, despite surgical intervention, not all patients make a complete recovery due to the irreversible tissue damage within the spinal cord. The objective of this review is to describe the state and gaps in the current literature on rehabilitation for PwCM and possible innovative rehabilitation strategies., Methods: Literature search., Results: In other neurological disorders such as stroke and acute traumatic spinal cord injury (SCI), timely and strategic rehabilitation has been shown to be indispensable for maximizing functional outcomes, and it is imperative that appropriate perioperative rehabilitative interventions accompany surgical approaches in order to enable the best outcomes. In this review, the current state of knowledge regarding rehabilitation for PwCM is described. Additionally, various therapies that have shown to improve outcomes in comparable neurological conditions such as stroke and SCI which may be translated to DCM will be reviewed., Conclusions: We conclude that locomotor training and arm/hand therapy may benefit PwCM. Further, we conclude that body weight support, robotic assistance, and virtual/augmented reality therapies may be beneficial therapeutic analogs to locomotor and hand therapies.

Study Design: Literature Review (Narrative)., Objective: To contextualize AO Spine RECODE-DCM research priority number 5: What is the socio-economic impact of DCM? (The financial impact of living with DCM to the individual, their supporters, and society as a whole)., Methods: In this review, we introduce the methodology of health-economic investigation, including potential techniques and approaches. We summarize the current health-economic evidence within DCM, so far focused on surgical treatment. We also cover the first national estimate, in partnership with Myelopathy.org from the United Kingdom, of the cost of DCM to society. We then demonstrate the significance of this question to advancing care and outcomes in the field., Results: DCM is a common and often disabling condition, with a significant lack of recognition. While evidence demonstrates the cost-effectives of surgery, even among higher income countries, health inequalities exist. Further the prevalent residual disability in myelopathy, despite treatment affects both the individual and society as a whole. A report from the United Kingdom provides the first cost-estimate to their society; an annual cost of ∼£681.6 million per year, but this is likely a significant underestimate., Conclusion: A clear quantification of the impact of DCM is needed to raise the profile of a common and disabling condition. Current evidence suggests this is likely to be globally substantial.

Abstract: This scoping review examined the current trends and characteristics of the clinical research initiatives on the management of acute spinal cord injury. This review included all clinical studies on the acute treatment of spinal cord injury that were registered in the ClinicalTrials.gov website from February 2000 to December 2020. The search strategy combined the terms "acute spinal cord injury" and "treatment." There has been a gradual increase in the number of registered clinical studies on acute treatment of spinal cord injury over the past two decades. Of the 116 studies, there were 103 interventional studies, 12 observational studies, and 1 registry. While 115 clinical studies recruited male and female participants, most of the registered clinical studies included only adults with an upper age limit after spinal cord injury. Most of the registered clinical studies were interventional studies led by single institutions in North America (n = 70), Europe (n = 29), and Asia (n = 15). Most of the research initiatives were interventional studies on new therapies for management of individuals with spinal cord injury (n = 91). In conclusion, the results of this scoping review suggest that although there has been an increase in the amount and diversity of the research initiatives on treatment of acute spinal cord injury over the past two decades, their generalizability remains relatively limited., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the measurement properties of outcome measures currently used in the assessment of degenerative cervical myelopathy (DCM) for clinical research., Design: Systematic review DATA SOURCES: MEDLINE and EMBASE were searched through 4 August 2020., Eligibility Criteria: Primary clinical research published in English and whose primary purpose was to evaluate the measurement properties or clinically important differences of instruments used in DCM., Data Extraction and Synthesis: Psychometric properties and clinically important differences were both extracted from each study, assessed for risk of bias and presented in accordance with the Consensus-based Standards for the selection of health Measurement Instruments criteria., Results: Twenty-nine outcome instruments were identified from 52 studies published between 1999 and 2020. They measured neuromuscular function (16 instruments), life impact (five instruments), pain (five instruments) and radiological scoring (five instruments). No instrument had evaluations for all 10 measurement properties and <50% had assessments for all three domains (ie, reliability, validity and responsiveness). There was a paucity of high-quality evidence. Notably, there were no studies that reported on structural validity and no high-quality evidence that discussed content validity. In this context, we identified nine instruments that are interpretable by clinicians: the arm and neck pain scores; the 12-item and 36-item short form health surveys; the Japanese Orthopaedic Association (JOA) score, modified JOA and JOA Cervical Myelopathy Evaluation Questionnaire; the neck disability index; and the visual analogue scale for pain. These include six scores with barriers to application and one score with insufficient criterion and construct validity., Conclusions: This review aggregates studies evaluating outcome measures used to assess patients with DCM. Overall, there is a need for a set of agreed tools to measure outcomes in DCM. These findings will be used to inform the development of a core measurement set as part of AO Spine RECODE-DCM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The field of spinal oncology has substantially evolved over the past decades. This review synthesizes and appraises what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms. This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February 2000 to December 2020. The terms "spinal cord tumor," "spinal metastasis," and "metastatic spinal cord compression" were used. Of the 174 registered clinical studies on primary spinal tumors and spinal metastasis, most of the clinical studies registered in this American registry were interventional studies led by single institutions in North America (n = 101), Europe (n = 43), Asia (n = 24), or other continents (n = 6). The registered clinical studies mainly focused on treatment strategies for spinal neoplasms (90.2%) that included investigating stereotactic radiosurgery (n = 33), radiotherapy (n = 21), chemotherapy (n = 20), and surgical technique (n = 11). Of the 69 completed studies, the results from 44 studies were published in the literature. In conclusion, this review highlights the key features of the 174 clinical studies on spinal neoplasms that were registered from 2000 to 2020. Clinical trials were heavily skewed toward the metastatic population as opposed to the primary tumors which likely reflects the rarity of the latter condition and associated challenges in undertaking prospective clinical studies in this population. This review serves to emphasize the need for a focused approach to enhancing translational research in spinal neoplasms with a particular emphasis on primary tumors., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Study Design: Retrospective cohort study., Objectives: To evaluate the effects of older age at the time of injury on the individuals' survival and neurological recovery within the first year after acute traumatic spinal cord injury (tSCI)., Setting: United States., Methods: This study included all participants enrolled into the First National Acute Spinal Cord Injury Study (NASCIS-1). Outcome measures included survival and neurological recovery (as assessed using the NASCIS motor and sensory scores) within the first year after tSCI. Data analyses of neurological recovery were adjusted for major potential confounders., Results: The study included 39 females and 267 males with overall mean age of 31 years who mostly sustained cervical severe tSCI after motor vehicle accidents or falls. Survival rates among older individuals are significantly lower than among younger individuals within the first year following tSCI (p < 0.0001). Among who survived the first year of tSCI, there were no statistically significant difference between older survivors and younger survivors regarding motor and sensory recovery in the multiple regression analyses adjusted for major potential confounders., Conclusions: The results of this retrospective study suggest that older age at the injury onset is associated with lower survival rate within the first year following tSCI. However, older individuals have similar potential to recover from their initial neurological impairment to younger individuals after tSCI. The results of this study combined to the recent literature underline the need for multidisciplinary team approach to the management of the elderly with acute SCI is essential to maximize their recovery., (© 2021. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objective: To comprehensively and critically appraise the clinical benefits and engineering designs of functional electrical stimulation (FES)-rowing for management of individuals with spinal cord injury (SCI)., Data Sources: Electronic database searches were conducted in Cumulative Index to Nursing & Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Excerpta Medica database, Emcare, Medline, PubMed, Scopus, and Web of Science databases from inception to May 12, 2020., Study Selection: Search terms used were synonyms of "spinal cord injury" for Population and "Electric Stimulation (Therapy)/ and rowing" for Intervention. Two reviewers independently assessed articles based on the following inclusion criteria: recruited individuals with SCI; had aerobic FES-rowing exercise as study intervention; reported cardiovascular, muscular, bone mineral density, or metabolic outcomes; and examined engineering design of FES-rowing systems. Of the 256 titles that were retrieved in the primary search, 24 were included in this study., Data Extraction: Study characteristics, quality, participants' characteristics, test descriptions, and results were independently extracted by 2 reviewers. The quality of studies was assessed with the Downs and Black checklist., Data Synthesis: Comparison of peak oxygen consumption (V̇ o2peak ) rates showed that V̇ o2peak during FES-rowing was significantly higher than arm-only exercise; FES-rowing training improved V̇ o2peak by 11.2% on average (95% confidence interval, 7.25-15.1), with a 4.1% (95% confidence interval, 2.23-5.97) increase in V̇ o2peak per month of training. FES-rowing training reduced bone density loss with increased time postinjury. The rowing ergometer used in 2 studies provided motor assistance during rowing. Studies preferred manual stimulation control (n=20) over automatic (n=4)., Conclusions: Our results suggest FES-rowing is a viable exercise for individuals with SCI that can improve cardiovascular performance and reduce bone density loss. Further randomized controlled trials are needed to better understand the optimal set-up for FES-rowing that maximizes the rehabilitation outcomes., (Copyright © 2021 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Traumatic spinal cord injury (SCI) disrupts spinal and supraspinal pathways, and this process is reflected in changes in surface electromyography (sEMG). sEMG is an informative complement to current clinical testing and can capture the residual motor command in great detail-including in muscles below the level of injury with seemingly absent motor activities. In this comprehensive review, we sought to describe how the sEMG properties are changed after SCI. We conducted a systematic literature search followed by a narrative review focusing on sEMG analysis techniques and signal properties post-SCI. We found that early reports were mostly focused on the qualitative analysis of sEMG patterns and evolved to semi-quantitative scores and a more detailed amplitude-based quantification. Nonetheless, recent studies are still constrained to an amplitude-based analysis of the sEMG, and there are opportunities to more broadly characterize the time- and frequency-domain properties of the signal as well as to take fuller advantage of high-density EMG techniques. We recommend the incorporation of a broader range of signal properties into the neurophysiological assessment post-SCI and the development of a greater understanding of the relation between these sEMG properties and underlying physiology. Enhanced sEMG analysis could contribute to a more complete description of the effects of SCI on upper and lower motor neuron function and their interactions, and also assist in understanding the mechanisms of change following neuromodulation or exercise therapy.

Traumatic cauda equina injury (TCEI) is usually caused by spine injury at or below L1 and can result in motor and/or sensory impairments and/or neurogenic bowel and bladder. We examined factors associated with recovery in motor strength, walking ability, and bowel and bladder function to aid in prognosis and establishing rehabilitation goals. The analysis cohort was comprised of persons with acute TCEI enrolled in the Rick Hansen Spinal Cord Injury Registry. Multi-variable regression analysis was used to determine predictors for lower-extremity motor score (LEMS) at discharge, walking ability at discharge as assessed by the walking subscores of either the Functional Independence Measure (FIM) or Spinal Cord Independence Measure (SCIM), and improvement in bowel and bladder function as assessed by FIM-relevant subscores. Age, sex, neurological level and severity of injury, time from injury to surgery, rehabilitation onset, and length of stay were examined as potential confounders. The cohort included 214 participants. Median improvement in LEMS was 4 points. Fifty-two percent of participants were able to walk, and >20% recovered bowel and bladder function by rehabilitation discharge. Multi-variable analyses revealed that shorter time from injury to rehabilitation admission (onset) was a significant predictor for both improvement in walking ability and bowel function. Longer rehabilitation stay and being an older female were associated with improved bladder function. Our results suggest that persons with TCEI have a reasonable chance of recovery in walking ability and bowel and bladder function. This study provides important information for rehabilitation goals setting and communication with patients and their families regarding prognosis.

Hyperglycemia has adverse effects on neuronal recovery after brain injury, but its effects after spinal cord injury (SCI) are understudied. This retrospective cohort study examined the potential effects on outcomes of hyperglycemia in the hyperacute stage after acute traumatic SCI. This study included all individuals enrolled in the National Acute Spinal Cord Injury Study 3 (NASCIS-3). Glycemic levels at 24 h, at 48 h, and at day 7 after acute SCI were examined as potential determinants of survival, neurological outcomes (using NASCIS motor, sensory, and pain scores), and functional outcome (using the Functional Independence Measure [FIM]) within the first year post-SCI. Hyperglycemia was defined using two thresholds (140 mg/dL and 180 mg/dL). Study subjects were 76 females and 423 males with an overall mean age of 36 years who sustained mostly cervical SCI due to motor vehicle accidents or falls. Hyperglycemia diagnosed at day 7 post-injury was associated with significantly greater mortality rates post-SCI. Among the survivors, hyperglycemia during the hyperacute stage was not significantly correlated with neurological recovery post-SCI. Hyperglycemia persistent until day 7 was significantly correlated with lower functional scores post-SCI. These results suggest that hyperglycemia at day 7 is correlated with greater mortality rates within the first year post-SCI. Although hyperglycemia during the hyperacute stage was not associated with neurological recovery, hyperglycemia at day 7 may adversely affect functional recovery within the first year post-SCI. Future investigations are needed to determine the optimal glycemic target in the management of patients with SCI., Competing Interests: No competing financial interests exist., (© Julio C. Furlan, 2021; Published by Mary Ann Liebert, Inc.)

Purpose: This study investigated the frequency and types of peripheral neuropathy in the lower limbs of patients undergoing rehabilitation after traumatic spinal cord injury or spinal cord disease., Methods: This study included consecutive patients with spinal cord injury/spinal cord disease who had electrophysiological assessments during their admission in a rehabilitation center from October 2015 to July 2019. Patients with traumatic spinal cord injury were compared with patients with nontraumatic spinal cord disease., Results: There were 67 patients (52 male patients, 15 female patients; mean age = 56.5 yrs) of whom 36 patients had spinal cord injury and 31 patients had spinal cord disease. Most of the patients were middle-aged men with at least one preexisting medical comorbidity, who were mostly admitted for rehabilitation of cervical, incomplete spinal cord injury/spinal cord disease. Most patients (86.6%) had abnormal electrophysiological studies representing 5.57% of all admissions. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions (n = 8). The group of patients with spinal cord injury was comparable with the group of patients with spinal cord disease regarding the other baseline data, clinical, and electrophysiological findings., Conclusions: Diseases of the peripheral nervous system were similarly found among patients undergoing rehabilitation for either spinal cord injury or spinal cord disease. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions. Timely diagnosis and proper treatment of the cause of peripheral neuropathies in the lower limbs in these patients may potentially influence rehabilitation protocols and improve patient outcomes., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Military personnel are exposed to mechanisms of bodily injuries that may differ from civilians. A retrospective cohort study (RCS) and a propensity score-matched cohort study (PSMCS) were undertaken to examine the potential differences in injury epidemiology, management and outcomes after spinal cord injury (SCI) between military personnel and civilians., Methods: Using a Canadian multicentre SCI database, data of all individuals with sufficient data from October 2013 to January 2017 were included in the RCS (n=1043). In the PSMCS, a group of 50 military personnel with SCI was compared with a group of 50 civilians with SCI who were matched regarding sex, age, and level, severity and mechanism of SCI., Results: In the RCS, military personnel with SCI (n=61) were significantly older and predominantl males when compared with civilians with SCI (n=982). However, the study groups were not statistically different with regards to their: level, severity and mechanisms of SCI; frequency of associated bodily injuries; and need for mechanical ventilation after SCI. In the PSMCS, the group of military individuals with SCI (n=50) was similar to the group of civilians with SCI (n=50) regarding pre-existing medical comorbidities, degree of motor impairment at admission, initial treatment for SCI and clinical and neurological outcomes after SCI., Conclusions: The results of these studies suggest that military SCI group has disproportionally older men at the time of injury compared with civilians with SCI. However, the military and civilian SCI groups had similar outcomes of alike initial treatment when both groups were matched regarding their demographic profile and injury characteristics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While many patients with mild traumatic brain injury (mTBI) or concussion recover completely, prolonged postconcussion symptoms remain a challenge for patients and an opportunity for clinical research. This has led to numerous research initiatives over the last 2 decades., Objective: To review the characteristics of clinical studies on management of mTBI/concussion; and to examine their definitions of mTBI/concussion., Methods: This scoping review included all clinical studies on diagnosis and management of patients with mTBI/concussion registered at www.clinicaltrials.gov from 2000 to June/2019. The terms "mild TBI/concussion" were used for the primary search. Definitions of mTBI/concussion were obtained from the protocols. When a definition was missing in the website, the study's investigators were contacted for clarification., Results: There were 225 interventional and 95 observational studies. Most of the studies are focused on treatment (54.7%) or diagnosis (37.5%), while 3.4% examined preventive measures, 2.8% evaluated prognostic instruments, and 1.6% developed registries. Most of the studies in this American database were single-center initiatives led by American and Canadian institutions. The definitions of mTBI/concussion differed widely among 109 studies., Conclusion: The results of this review suggest that most of the clinical studies are focused on diagnosis and non-pharmacological therapies for patients with mTBI/concussion. The large number of differing definitions of mTBI/concussion among the studies creates significant limitations when comparing studies. The requirements for registering research protocols on mTBI/concussion should include the necessity to state the definition being used. There is a need for consensus on a uniform definition of concussion., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Despite the shift in the demographics of traumatic spinal cord injury (SCI) with increased proportion of injuries in the elderly, little is known on the potential effects of old age on the pathobiology of SCI. Since there is an assumption that age adversely affects neural response to SCI, this study examines the clinically relevant question on whether age is a key determinant of inflammatory response, oligodendroglial apoptosis and axonal survival after traumatic SCI. This unique study includes post-mortem spinal cord tissue from 64 cases of SCI (at cervical or high-thoracic levels) and 38 control cases without CNS injury. Each group was subdivided into subgroups of younger and elderly individuals (65 years of age or older at the SCI onset). The results of this study indicate that age at the SCI onset does not adversely affect the cellular inflammatory response to, oligodendroglial apoptosis and axonal survival after SCI. These results support the conclusion that elderly individuals have similar neurobiological responses to SCI as younger people and, hence, treatment decisions should be based on an assessment of the individual patient and not an arbitrary assumption that "advanced age" should exclude patients with an acute SCI from access to advanced care and translational therapies., Competing Interests: Declaration of Competing Interest The authors declare no competing interests to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: West Nile virus (WNV) can have severe consequences, including encephalitis and paralysis. Purpose : To describe the benefits of intensive locomotor training (LT) for an individual with a previous WNV infection resulting in chronic paraplegia. Case Description : The patient, who became a wheelchair user following standard rehabilitation, began LT 3 years post infection. Her goals included standing and walking with an assistive device and transferring independently. The intervention consisted of bodyweight-supported treadmill training and overground training, which involved walking, balancing, strengthening, and transferring activities. Outcomes : Following 5 months of LT, the patient ambulated independently with a walker at a speed = 0.34m/s. She walked 110.1 metres in 6 minutes and increased her Berg Balance Scale score by 17 points. These improvements were either maintained or further increased 3 months post LT. The patient's perspectives on LT were collected through a semi-structured interview. A conventional content analysis, which uses data to drive themes, revealed three themes: (1) recalibrating goals, (2) outcomes (i.e. physical and psychological benefits, such as a sense of accomplishment), and (3) challenges of LT and effective coping strategies. Conclusions : The patient demonstrated improved balance and walking abilities. Intensive LT was feasible and effective for this individual with chronic paraplegia due to WNV infection.

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.

Study Design: Narrative review., Objectives: To discuss how electrophysiology may contribute to future clinical trials in spinal cord injury (SCI) in terms of: (1) improvement of SCI diagnosis, patient stratification and determination of exclusion criteria; (2) the assessment of adverse events; and (3) detection of therapeutic effects following an intervention., Methods: An international expert panel for electrophysiological measures in SCI searched and discussed the literature focused on the topic., Results: Electrophysiology represents a valid method to detect, track, and quantify readouts of nerve functions including signal conduction, e.g., evoked potentials testing long spinal tracts, and neural processing, e.g., reflex testing. Furthermore, electrophysiological measures can predict functional outcomes and thereby guide rehabilitation programs and therapeutic interventions for clinical studies., Conclusion: Objective and quantitative measures of sensory, motor, and autonomic function based on electrophysiological techniques are promising tools to inform and improve future SCI trials. Complementing clinical outcome measures, electrophysiological recordings can improve the SCI diagnosis and patient stratification, as well as the detection of both beneficial and adverse events. Specifically composed electrophysiological measures can be used to characterize the topography and completeness of SCI and reveal neuronal integrity below the lesion, a prerequisite for the success of any interventional trial. Further validation of electrophysiological tools with regard to their validity, reliability, and sensitivity are needed in order to become routinely applied in clinical SCI trials.

Context: Spinal cord injury or disease (SCI/D) leads to unchanged low-density lipoprotein and cholesterol, very low high-density lipoprotein a form of dyslipidemia and physical inactivity which combine to increase risk of morbidity and mortality from cardiometabolic disease. Herein, we describe the selection of structure, process and outcome indicators for adults in the first 18 months post-SCI/D rehabilitation admission. Methods: A Pan-Canadian Cardiometabolic Health Working Group was formed to develop a construct definition. Cardiometabolic risk factors were summarized in a Driver diagram. Release of the Paralyzed Veterans of America "Identification and Management of Cardiometabolic Risk after Spinal Cord Injury" and the International Scientific Exercise Guidelines: "Evidence-based scientific exercise guidelines for adults with spinal cord injury", informed the group's focus on prevention strategies to advance this Domain of rehabilitation admission. Results: The structure indicator identifies during rehabilitation the presence of appropriate time and resources for physical exercise prescription. Process indicators are lipid profile assessment at rehabilitation admission and documented exercise prescriptions prior to discharge. The outcome indicators track patient's knowledge retention regarding exercise prescription at discharge, current exercise adherence and lipid status 18 months after rehabilitation discharge. Conclusion: Routine national implementation of these indicators at the specified time points will enhance efforts to detect dyslipidemia and assure routine participation in endurance exercise. These indicators align with international initiatives to improve cardiometabolic health through interventions targeting modifiable risk factors specifically endurance exercising and optimal lipid profiles, crucial to augmenting cardiometabolic health after SCI/D.

Context/Objective: Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Design: Retrospective cohort study. Setting: Quaternary spine trauma center. Participants: This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Interventions: Spinal cord decompression. Outcome Measures: Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. Results: There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. Conclusion: The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.

Context/Objective: The potential effects of sex on injury severity and outcomes after acute spine trauma (AST) have been reported in pre-clinical and clinical studies, even though the data are conflicting. This study compared females and males regarding the epidemiology, injury characteristics, and clinical outcomes of AST. Design: Retrospective cohort study. Setting: Acute spine care quaternary center. Participants: All consecutive cases of AST admitted from January/1996 to December/2007 were included. Interventions: None. Outcome Measures: The potential effects of sex on the epidemiology, injury characteristics, and clinical outcomes of AST were studied. Results: There were 504 individuals with AST (161 females, 343 males; mean age of 49.44 ± 0.92 years). Sex was not associated with age or pre-existing co-morbidities as assessed using the Charlson Co-morbidity Index, however, females had a greater number of International Classifications of Diseases (ICD) codes at admission and higher Cumulative Illness Rating Scale (CIRS) than males. Over the 12-year period, the male-to-female ratio has not significantly changed. Although there were significant sex-related discrepancies regarding injury etiology, level and severity of AST, males and females had similar lengths of stay in the acute spine center, in-hospital survival post-AST, and need for mechanical ventilation and tracheostomy. Conclusion: This study suggests that females with AST present with a greater number of pre-existing co-morbidities, a higher frequency of thoraco-lumbar trauma, less severe neurological impairment and a greater proportion of MVA-related injuries. However, females and males have a similar length of stay in the acute spine center, and comparable in-hospital survival, need for mechanical ventilation, and tracheostomy after AST.

Study Design: Systematic review., Objectives: War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs., Methods: Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications., Results: The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force., Conclusions: The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Aging of the population has prompted an escalation of service utilization and costs in many jurisdictions including North America. However, relatively little is known on the economic impact of old age on the management of acute spine trauma (AST)., Objective: To examine the potential effects of age on the service utilization and costs of the management of patients with acute spine trauma., Methods: This retrospective cohort study included consecutive patients with AST admitted to an acute spine care unit of a Canadian quaternary university hospital between February, 2002 and September, 2007. The study population was grouped into elderly (≥65 yr) and younger individuals. All costing data were converted and updated to US dollars in June/2017., Results: There were 55 women and 91 men with AST (age range: 16-92 yr, mean age of 49.9 yr) of whom 37 were elderly. The mean total hospital costs for initial admission after AST in the elderly (USD $19 338 ± $4892) were significantly greater than among younger individuals (USD $13 775 ± $1344). However, elderly people had significantly lower per diem total, fixed, direct, and indirect costs for AST than younger individuals. Both groups were comparable regarding the proportion of services utilized in the acute care hospital., Conclusion: Given the escalating demand for surgical and nonsurgical spine treatment in the age of aging population, the timely results of this study underline key aspects of the economic impact of the spine care of the elderly. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for elderly with AST., (Copyright © 2018 by the Congress of Neurological Surgeons.)