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Background: The Trunk Assessment Scale for Spinal Cord Injury (TASS) and the Trunk Control Test for individuals with a Spinal Cord Injury (TCT-SCI) are highly reliable assessment tools for evaluating the trunk function of individuals with SCIs. However, the potential differences in the validity of these two scales are unclear. Objectives: To evaluate the criterion validity of the TASS and the construct validity of the TASS and TCT-SCI. Participants and Methods: We evaluated 30 individuals with SCIs (age 63.8 ± 10.7 yrs, 17 with tetraplegia). To evaluate criterion validity, we calculated Spearman's rho between the TASS and the gold standard (the TCT-SCI). To determine construct validity, we used the following hypothesis testing approaches: ( i ) calculating Spearman's rho between each scale and the upper and lower extremity motor scores (UEMS, LEMS), the Walking Index for SCI-II (WISCI-II), and the motor score of the Functional Independence Measure (mFIM); and ( ii ) determining the cut-off point for identifying ambulators with SCIs (≥ 3 points on item 12 of Spinal Cord Independent Measure III) by a receiver operating characteristics analysis. Results: A moderate correlation was confirmed between the TASS and the TCT-SCI ( r  = 0.68). Construct validity was supported by six of the eight prior hypotheses. The cut-off points for identifying ambulators with SCIs were 26 points (TASS) and 18 points (TCT-SCI). Conclusion: Our results indicate that the contents of the TASS and the TCT-SCI might reflect the epidemiological characteristics of the populations in which they were developed.

Spinal cord injury (SCI) is a serious neurological injury that is currently extremely difficult to cure clinically. SCI involves numerous pathophysiological processes, and microRNAs (miRNAs) play an important role in these processes. Meanwhile, miRNAs have received a lot of attention for their role in other diseases as well. Therefore, the detection of disease-related miRNAs is important for the study of disease development, treatment, and prognosis. With the rapid development of molecular biology, the traditional detection methods of miRNA can no longer meet the needs of experiments. Electrochemical detection methods are widely used because of their excellent detection performance. Here, we designed an electrochemical sensor prepared using borosilicate glass microneedle electrodes for real-time monitoring of miR-21-5p expression in vivo after SCI. The sensor showed a good linear relationship between the oxidation peak current value and the concentration of miR-21-5p in the concentration range 0-2 fM ( Y = 12.025 X + 90.396, R 2 = 0.98). The limit of detection (LOD) of the sensor was 0.3667 fM. The experimental results showed that the borosilicate glass microneedle electrochemical sensor achieved fast, accurate, highly sensitive, highly specific, highly stable, and reproducible monitoring of miR-21-5p. More importantly, the electrochemical sensor has a better clinical translation prospect, which is important for the research of clinical diseases.

Introduction: The revised international standards for neurological classification of spinal cord injury (ISNCSCI) have facilitated the documentation of non-spinal cord injury-related impairments, such as chronic peripheral nerve injuries and muscle weakness due to immobility. This advancement addresses potential biases in muscle strength examinations. Utilizing electrically evoked contractions from paralyzed muscles, enhanced by electrodiagnosis, holds promise in identifying false-negative diagnoses of non-responsiveness to neuromuscular electrical stimulation. This concept prompts the exploration of polyneuromyopathy arising from nonuse in paralyzed muscles., Case Series Presentation: To substantiate our hypothesis, we recruited nine participants for a case series aimed at elucidating the potential benefits of incorporating the stimulus electrodiagnostic test (SET) to mitigate non-responsiveness during preparation for functional electrical stimulation (FES)-assisted cycling. In our convenience sample (n = 5), we conducted neurological mapping based on ISNCSCI and applied SET on the quadriceps. The SET guided optimal dosimetry for evoking contractions and revealed responses similar to those observed in peripheral neuropathies, with α coefficients equal to or lower than 2.00. This observation is likely attributable to nonuse of paralyzed muscles, indicative of an ongoing polyneuropathy in individuals with chronic spinal cord injury (SCI)., Discussion: Among the nine initially recruited subjects, seven exhibited responsiveness to neuromuscular electrical stimulation (78% responsiveness), with two participants excluded based on exclusion criteria. In the final five reported cases, all displayed α coefficient values indicating impaired neuromuscular accommodation, and one presented no α coefficient within the normal range. The inclusion of electrodiagnosis appears effective in averting non-responsiveness, suggesting the presence of ongoing polyneuropathies in paralyzed muscles., (© 2024 John Wiley & Sons Ltd.)

Background and Objectives: Neurological and functional recovery after traumatic spinal cord injury (SCI) is highly challenged by the level of the lesion and the high heterogeneity in severity (different degrees of in/complete SCI) and spinal cord syndromes (hemi-, ant-, central-, and posterior cord). So far outcome predictions in clinical trials are limited in targeting sum motor scores of the upper (UEMS) and lower limb (LEMS) while neglecting that the distribution of motor function is essential for functional outcomes. The development of data-driven prediction models of detailed segmental motor recovery for all spinal segments from the level of lesion towards the lowest motor segments will improve the design of rehabilitation programs and the sensitivity of clinical trials., Methods: This study used acute-phase International Standards for Neurological Classification of SCI exams to forecast 6-month recovery of segmental motor scores as the primary evaluation endpoint. Secondary endpoints included severity grade improvement, independent walking, and self-care ability. Different similarity metrics were explored for k-nearest neighbor (kNN) matching within 1267 patients from the European Multicenter Study about Spinal Cord Injury before validation in 411 patients from the Sygen trial. The kNN performance was compared to linear and logistic regression models., Results: We obtained a population-wide root-mean-squared error (RMSE) in motor score sequence of 0.76(0.14, 2.77) and competitive functional score predictions (AUC walker  = 0.92, AUC self-carer  = 0.83) for the kNN algorithm, improving beyond the linear regression task (RMSE linear  = 0.98(0.22, 2.57)). The validation cohort showed comparable results (RMSE = 0.75(0.13, 2.57), AUC walker  = 0.92). We deploy the final historic control model as a web tool for easy user interaction (https://hicsci.ethz.ch/)., Discussion: Our approach is the first to provide predictions across all motor segments independent of the level and severity of SCI. We provide a machine learning concept that is highly interpretable, i.e. the prediction formation process is transparent, that has been validated across European and American data sets, and provides reliable and validated algorithms to incorporate external control data to increase sensitivity and feasibility of multinational clinical trials., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Spinal cord injury (SCI) is a rare condition with a heterogeneous presentation, making the prediction of recovery challenging. However, serological markers have been shown to be associated with severity and long-term recovery following SCI. Therefore, our investigation aimed to assess the feasibility of translating this association into a prediction of the lower extremity motor scores (LEMS) at chronic stage (52 weeks after initial injury) in patients with SCI using routine serological markers. Serological markers, assessed within the initial seven days post-injury in the observational cohort study from the Trauma Hospital Murnau underwent diverse feature engineering approaches. These involved arithmetic measurements such as mean, median, minimum, maximum, and range, as well as considerations of the frequency of marker testing and whether values fell within the normal range. To predict LEMS scores at the chronic stage, eight different regression models (including linear, tree-based, and ensemble models) were used to quantify the predictive value of serological markers relative to a baseline model that relied on the very acute LEMS score and patient age alone. The inclusion of serological markers did not improve the performance of the prediction model. The best-performing approach including serological markers achieved a mean absolute error (MAE) of 6.59 (2.14), which was equivalent to the performance of the baseline model. As an alternative approach, we trained separate models based on the LEMS observed at the very acute stage after injury. Specifically, we considered individuals with an LEMS of 0 or an LEMS exceeding zero separately. This strategy led to a mean improvement in MAE across all cohorts and models, of 1.20 (2.13). We conclude that, in our study, routine serological markers hold limited power for prediction of LEMS. However, the implementation of model stratification by the very acute LEMS markedly enhanced prediction performance. This observation supports the inclusion of clinical knowledge in the modeling of prediction tasks for SCI recovery. Additionally, it lays the path for future research to consider stratified analyses when investigating the predictive power of potential biomarkers., Competing Interests: Declaration of competing interest The authors do not report any (financial or otherwise) conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Spinal Cord Injury (SCI) presents a significant challenge in rehabilitation medicine, with recovery outcomes varying widely among individuals. Machine learning (ML) is a promising approach to enhance the prediction of recovery trajectories, but its integration into clinical practice requires a thorough understanding of its efficacy and applicability. We systematically reviewed the current literature on data-driven models of SCI recovery prediction. The included studies were evaluated based on a range of criteria assessing the approach, implementation, input data preferences, and the clinical outcomes aimed to forecast. We observe a tendency to utilize routinely acquired data, such as International Standards for Neurological Classification of SCI (ISNCSCI), imaging, and demographics, for the prediction of functional outcomes derived from the Spinal Cord Independence Measure (SCIM) III and Functional Independence Measure (FIM) scores with a focus on motor ability. Although there has been an increasing interest in data-driven studies over time, traditional machine learning architectures, such as linear regression and tree-based approaches, remained the overwhelmingly popular choices for implementation. This implies ample opportunities for exploring architectures addressing the challenges of predicting SCI recovery, including techniques for learning from limited longitudinal data, improving generalizability, and enhancing reproducibility. We conclude with a perspective, highlighting possible future directions for data-driven SCI recovery prediction and drawing parallels to other application fields in terms of diverse data types (imaging, tabular, sequential, multimodal), data challenges (limited, missing, longitudinal data), and algorithmic needs (causal inference, robustness)., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: This research aims to construct and verify an accurate nomogram for forecasting the 3-, 5-, and 7-year outcomes in pediatric patients afflicted with spinal cord injury (SCI)., Methods: Pediatric patients with SCI from multiple hospitals in China, diagnosed between Jan 2005 and Jan 2020, were incorporated into this research. Half of these patients were arbitrarily chosen for training sets, and the other half were designated for external validation sets. The Cox hazard model was employed to pinpoint potential prognosis determinants related to the American Spinal Injury Association (ASIA) and Functional Independence Assessment (FIM) index. These determinants were then employed to formulate the prognostic nomogram. Subsequently, the bootstrap technique was applied to validate the derived model internally., Results: In total, 224 children with SCI were considered for the final evaluation, having a median monitoring duration of 68.0 months. The predictive nomogram showcased superior differentiation capabilities, yielding a refined C-index of 0.924 (95% CI: 0.883-0.965) for the training cohort and a C-index of 0.863 (95% CI: 0.735-0.933) for the external verification group. Additionally, when applying the aforementioned model to prognostic predictions as classified by the FIM, it demonstrated a high predictive value with a C-index of 0.908 (95% CI: 0.863-0.953). Moreover, the calibration diagrams indicated a consistent match between the projected and genuine ASIA outcomes across both sets., Conclusion: The crafted and verified prognostic nomogram emerges as a dependable instrument to foresee the 3-, 5-, and 7-year ASIA and FIM outcomes for children suffering from SCI., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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.)

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities than of the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Often, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: full CCS, unilateral CCS, and borderline CCS. Of the 1490 participants in our sample, 17.5% had full, 25.6% had unilateral, and 9% had borderline CCS, together encompassing >50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared with existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of American Spinal Injury Association (ASIA) Impairment Scale (AIS) D grade than those with motor incomplete tetraplegia without CCS. Upper Extremity Motor Score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, whereas their Lower Extremity Motor Score (LEMS) consistently remained higher than for those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar, with some differences observed within those with AIS D grade. The AIS grade, rather than the diagnosis of CCS, remains the foremost determinant influencing neurological and functional outcomes. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. Although there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

Study Design: A psychometric study., Objectives: To introduce a novel simple tool designed to evaluate the intensity of the phasic (dynamic) component of spastic motor behavior in spinal cord injury (SCI) people and to assess its reliability and validity., Setting: The study was developed in the Spinal Cord Unit at University Hospital Motol and Paraple Centre in Prague, Czech Republic., Methods: The Muscle Excitability Scale (MES) is designed to rate muscle motor response to exteroceptive and proprioceptive stimuli. The impairment rating ranges from zero muscle/muscle group spasm or clonus to generalized spastic response. The selected 0 to 4 scale allows for comparing the MES results with those of the Modified Ashworth Scale (MAS). After long-term use and repeated revisions, a psychometric analysis was conducted. According to the algorithm, two physiotherapists examined 50 individuals in the chronic stage after SCI., Results: The inter-rater reliability of MES for both legs showed κ = 0.52. The intra-rater reliability of MES for both legs showed κ = 0.50. The inter-rater reliability of simultaneously assessed MAS for both legs was higher, with κ = 0.69. The intra-rater reliability of MAS for both legs showed κ = 0.72. Spearman's rank correlation coefficient between MES and spasm frequency of Penn Spasm Frequency Scale (PSFS) was low, while the correlation coefficient between MES and the severity part of PSFS was moderate., Conclusions: The MES is a complementary tool for assessing the dynamic component of spastic motor behavior in SCI people. It allows a more comprehensive clinical characterization of spastic reflexes when used along with the MAS., (© 2024. The Author(s).)

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: Blood always shows coagulation changes after spinal cord injury (SCI), and identifying these blood changes may be helpful for diagnosis and treatment of SCI. Nevertheless, studies to date on blood coagulation changes after SCI in humans are not comprehensive. Therefore, this study aims to identify blood coagulation diagnostic biomarkers and immune changes related to SCI and its severity levels., Methods: Human blood sequencing datasets were obtained from public databases. Differentially expressed coagulation-related genes were analyzed (DECRGs). Enrichment analysis and assessment of immune changes were conducted. Weighted gene co-expression network analysis, least absolute shrinkage and selection operator logistic regression were used to identify biomarkers. Validation for these biomarkers was performed. The correlation between biomarkers and immune cells was evaluated. Transcription factors, miRNA, lncRNA, and drugs that can regulate biomarkers were analyzed., Results: DECRGs associated with SCI and its different grades were identified, showing enrichment in altered coagulation and immune-related signaling pathways. ADAM9, CD55, and STAT4 were identified as coagulation diagnostic biomarkers for SCI. IRF4 and PABPC4 were identified as coagulation diagnostic biomarkers for American Spinal Injury Association Impairment Scale (AIS) A grade of SCI. GP9 was designated as a diagnostic biomarker for AIS D grade of SCI. Immune changes in blood of SCI and its different grades were observed. Correlation between diagnostic biomarkers and immune cells were identified. Transcription factors, miRNA, lncRNA, and drugs that can regulate diagnostic biomarker expression were discovered., Conclusion: Therefore, detecting the expression of these putative diagnostic biomarkers and related immune changes may be helpful for predicting the severity of SCI. Uncovering potential regulatory mechanisms for biomarkers may be beneficial for further research., 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 Author(s). Published by Elsevier B.V. All rights reserved.)

Study Design: Retrospective multi-site cohort study., Objectives: To develop an accurate machine learning predictive model using predictor variables from the acute rehabilitation period to determine ambulatory status in spinal cord injury (SCI) one year post injury., Setting: Model SCI System (SCIMS) database between January 2000 and May 2019., Methods: Retrospective cohort study using data that were previously collected as part of the SCI Model System (SCIMS) database. A total of 4523 patients were analyzed comparing traditional models (van Middendorp and Hicks) compared to machine learning algorithms including Elastic Net Penalized Logistic Regression (ENPLR), Gradient Boosted Machine (GBM), and Artificial Neural Networks (ANN)., Results: Compared with GBM and ANN, ENPLR was determined to be the preferred model based on predictive accuracy metrics, calibration, and variable selection. The primary metric to judge discrimination was the area under the receiver operating characteristic curve (AUC). When compared to the van Middendorp all patients (0.916), ASIA A and D (0.951) and ASIA B and C (0.775) and Hicks all patients (0.89), ASIA A and D (0.934) and ASIA B and C (0.775), ENPLR demonstrated improved AUC for all patients (0.931), ASIA A and D (0.965) ASIA B and C (0.803)., Conclusions: Utilizing artificial intelligence and machine learning methods are feasible for accurately classifying outcomes in SCI and may provide improved sensitivity in identifying which individuals are less likely to ambulate and may benefit from augmentative strategies, such as neuromodulation. Future directions should include the use of additional variables to further refine these models., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Spinal cord injury (SCI) is a significant public health issue, leading to physical, psychological, and social complications. Machine learning (ML) algorithms have shown potential in diagnosing and predicting the functional and neurologic outcomes of subjects with SCI. ML algorithms can predict scores for SCI classification systems and accurately predict outcomes by analyzing large amounts of data. This systematic review aimed to examine the performance of ML algorithms for diagnosing and predicting the outcomes of subjects with SCI., Methods: The literature was comprehensively searched for the pertinent studies from inception to May 25, 2023. Therefore, electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically searched with individual search syntax., Results: A total of 9424 individuals diagnosed with SCI across multiple studies were analyzed. Among the 21 studies included, 5 specifically aimed to evaluate diagnostic accuracy, while the remaining 16 focused on exploring prognostic factors or management strategies., Conclusions: ML and deep learning (DL) have shown great potential in various aspects of SCI. ML and DL algorithms have been employed multiple times in predicting and diagnosing patients with SCI. While there are studies on diagnosing acute SCI using DL algorithms, further research is required in this area., (Copyright © 2024 Elsevier Inc. 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).)

Study Design: Pilot cohort study., Objective: To develop and implement a sacral electromyographic (sEMG) technique at bedside to ascertain sparing of sacral motor activity and reflexes in patients hospitalized for acute neurological conditions., Setting: Hôpital du Sacré-Coeur de Montréal a Canadian Level-1 university trauma center specialized in SCI care., Methods: Nine patients underwent digital rectal examination (DRE) and sEMG, assessing voluntary anal contraction and sacral spinal reflexes (bulbocavernosus reflex and the anal wink). Our sEMG technique utilized surface recording electrodes and tactile elicitation of reflexes. EMG signal was acquired at bedside through the Noraxon MR3 system., Results: It was quick, well accepted and did no harm. We found that contrary to the DRE, sEMG detected subclinical sacral motor activity and reflexes in 20% of cases for voluntary anal contraction and 40% of cases for the anal wink., Conclusion: We believe our sEMG technique is a powerful tool able to enhance management of patients suffering from acute neurological impairments and requiring sacral function assessment., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: The Seated Reach Test (SRT) is an assessment tool for evaluating the sitting balance of individuals with a spinal cord injury (SCI). We developed the Shoulder Shifting Test (SST), which is a tool for measuring the reaching distance of individuals with difficulty in raising their arms, such as individuals with tetraplegia., Objective: To investigate the agreement between the SST and the SRT and the usefulness of the SST., Subjects and Methods: Sixteen subjects with SCI (age 52.9 ± 13.0 yrs; four with tetraplegia) performed the SST and the SRT. We determined the correlation coefficient to determine the relationship between the two tests. A Bland-Altman analysis was performed to confirm the systematic error, and the relative error (RE) was used to determine the compatibility of the two tests in three directions (front, right, left). We assessed the SST's usefulness by determining how many of 47 subjects (age 59.6 ± 13.6 yrs; 23 with tetraplegia) could not perform the SRT and how many could perform the SST., Results: The tests were strongly correlated. No systematic errors between the tests were observed. In all three directions, >75% of the subjects had an RE <20%. Eleven of the 47 subjects with SCI were unable to perform either test. Four to ten of the 36 subjects performed the SST due to the difficulty in raising their arms., Conclusion: The SST was compatible with the SRT, and the sitting balance of more individuals with SCI could be assessed by the combination of these tests.

Throughout the central nervous system, the spinal cord plays a very important role, namely, transmitting sensory and motor information inwardly so that it can be processed by the brain. There are many different ways this structure can be damaged, such as through traumatic injury or surgery, such as scoliosis correction, for instance. Consequently, damage may be caused to the nervous system as a result of this. There is no doubt that optical devices such as microscopes and cameras can have a significant impact on research, diagnosis, and treatment planning for patients with spinal cord injuries (SCIs). Additionally, these technologies contribute a great deal to our understanding of these injuries, and they are also essential in enhancing the quality of life of individuals with spinal cord injuries. Through increasingly powerful, accurate, and minimally invasive technologies that have been developed over the last decade or so, several new optical devices have been introduced that are capable of improving the accuracy of SCI diagnosis and treatment and promoting a better quality of life after surgery. We aim in this paper to present a timely overview of the various research fields that have been conducted on optical devices that can be used to diagnose spinal cord injuries as well as to manage the associated health complications that affected individuals may experience.

Objective: This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury., Latest Developments: Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated., Essential Points: Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention., (Copyright © 2024 American Academy of Neurology.)

Study Design: A retrospective case-series., Objective: The study aims to use machine learning to predict the discharge destination of spinal cord injury (SCI) patients in the intensive care unit., Summary of Background Data: Prognostication following SCI is vital, especially for critical patients who need intensive care., Patients and Methods: Clinical data of patients diagnosed with SCI were extracted from a publicly available intensive care unit database. The first recorded data of the included patients were used to develop a total of 98 machine learning classifiers, seeking to predict discharge destination (eg, death, further medical care, home, etc.). The microaverage area under the curve (AUC) was the main indicator to assess discrimination. The best average-AUC classifier and the best death-sensitivity classifier were integrated into an ensemble classifier. The discrimination of the ensemble classifier was compared with top death-sensitivity classifiers and top average-AUC classifiers. In addition, prediction consistency and clinical utility were also assessed., Results: A total of 1485 SCI patients were included. The ensemble classifier had a microaverage AUC of 0.851, which was only slightly inferior to the best average-AUC classifier ( P =0.10). The best average-AUC classifier death sensitivity was much lower than that of the ensemble classifier. The ensemble classifier had a death sensitivity of 0.452, which was inferior to the top 8 death-sensitivity classifiers, whose microaverage AUC were inferior to the ensemble classifier ( P <0.05). In addition, the ensemble classifier demonstrated a comparable Brier score and superior net benefit in the DCA when compared with the performance of the origin classifiers., Conclusions: The ensemble classifier shows an overall superior performance in predicting discharge destination, considering discrimination ability, prediction consistency, and clinical utility. This classifier system may aid in the clinical management of critical SCI patients in the early phase following injury., Level of Evidence: Level 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, 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).)

Introduction: Spinal cord injury is one of the common injury which causes damage to the spinal cord due to trauma, diseases or degenerations leading to disability and decreasing life expectancy. The study aims to find the characteristics of spinal cord injury presenting at a tertiary care centre., Methods: A Descriptive hospital based cross-sectional study was conducted at Pokhara, Gandaki Province, from 28th March to 25th September, 2023. 139 participants were interviewed for the study. Structured interview schedule and validated questionnaires were used for data collection. Ethical approval was taken for the study (Reference number: 151/079)., Results: A total of 139 cases were observed; most common affected age group was between 25-55 years with a mean age of 48.68 years. Most (66.9%) of the spinal cord injury patients were not enrolled in health insurance program. Most 107 (77.0%) common cause for spinal cord injury was falls from height. Age, gender, occupation and duration of stay in the hospital were statistically significant with mode of treatment., Conclusions: Spinal cord injury mostly traumatic commonly due to fall from height affecting mainly male population residing in rural areas at their fourth decade of life who are mainly involve in manual work and agriculture. Spinal cord injury is a major health problem at global and local level causing major morbidity.

Objectives: To investigate if the sport concussion assessment tool version 5 (SCAT5) could be suitable for application to Para athletes with a visual impairment, a spinal cord injury, or a limb deficiency., Methods: A 16-member expert panel performed a Delphi technique protocol. The first round encompassed an open-ended questionnaire, with round 2 onwards being composed of a series of closed-ended statements requiring each expert's opinion using a five-point Likert scale. A predetermined threshold of 66% was used to decide whether agreement had been reached by the panel., Results: The Delphi study resulted in a four-round process. After round 1, 92 initial statements were constructed with 91 statements obtaining the targeted level of agreement by round 4. The expert panellist completion rate of the full four-round process was 94%. In the case of athletes with a suspected concussion with either limb deficiencies or spinal cord injuries, the panel agreed that a baseline assessment would be needed on record is ideal before a modified SCAT5 assessment. With respect to visual impairments, it was conceded that some tests were either difficult, infeasible or should be omitted entirely depending on the type of visual impairment., Conclusion: It is proposed that the SCAT5 could be conducted on athletes with limb deficiencies or spinal cord injuries with some minor modifications and by establishing a baseline assessment to form a comparison. However, it cannot be recommended for athletes with visual impairment in its current form. Further research is needed to determine how potential concussions could be more effectively evaluated in athletes with different impairments., Competing Interests: Competing interests: There are no commercial or financial associations to report. However, it should be noted that one of the authors is currently employed as the chairperson of a Para sport national governing body and multiple authors are members of the International Paralympic Committee (IPC) Medical Committee., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Recently, European Society of Cardiology (ESC) validated a prediction model to estimate 10-year fatal and non-fatal cardiovascular disease risk (CVDR) in individuals (aged 40-60 years) without previous cardiovascular disease or diabetes (ESC-SCORE2) and to provide indications for treatment. At present, data describing the CVDR in Paralympic athletes (PAs) are scarce and inconsistent. Therefore, we sought to assess the prevalence of risk factors in PAs to estimate their CVDR through SCORE2., Methods: We enrolled 99 PAs aged ≥ 40 y.o., who participated at 2012-2022 Paralympic Games, competing in 22 different sport disciplines classified according to sport type (power, skills, endurance and mixed) and disabilities: spinal cord injuries (SCI) and non-SCI. CVDR factors, anthropometric measurements and blood samples were collected., Results: Among the 99 PAs (78% males, mean age 45.7 ± 4.7 y.o.), 52.5% had SCI; 54% were dyslipidemic and 23% were smokers. According to ESC-SCORE2, 29% had high and 1% very-high CVDR. Women (compared to men) and endurance (compared to other sport) exhibited better CV profile. SCI showed no differences when compared with non-SCI for CVDR, excepted for a lower HDL and lower exercise performance. None of the dyslipidemic athlete was on pharmacologically treatment, despite the altered lipid profile had already been detected at younger age., Conclusion: PAs are a selected population, presenting a high CV risk profile, with 30% showing either high or very-high CVDR according to ESC-SCORE2. Dyslipidemia was the most common risk factor, underestimated and undertreated, emphasizing the need for specific preventive strategies in this special setting of athletes., (© 2024. The Author(s).)

Introduction: Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population., Case Presentation: This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively., Discussion: Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

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.)

Study Design: Retrospective cohort study., Objectives: To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C)., Settings: Multi-institutions in Japan., Methods: We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis., Results: Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness)., Conclusions: Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL., Sponsorship: No funding was received for this study., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

The present research focused on identifying necroptosis-related differentially expressed genes (NRDEGs) in spinal cord injury (SCI) to highlight potential therapeutic and prognostic target genes in clinical SCI. Three SCI-related datasets were downloaded, including GSE151371, GSE5296 and GSE47681. MSigDB and KEGG datasets were searched for necroptosis-related genes (NRGs). Differentially expressed genes (DEGs) and NRGs were intersected to obtain NRDEGs. The MCC algorithm was employed to select the first 10 genes as hub genes. A protein-protein interaction (PPI) network related to NRDEGs was developed utilizing STRING. Several databases were searched to predict interactions between hub genes and miRNAs, transcription factors, potential drugs, and small molecules. Immunoassays were performed to identify DEGs using CIBERSORTx. Additionally, qRT-PCR was carried out to verify NRDEGs in an animal model of SCI. Combined analysis of all datasets identified 15 co-expressed DEGs and NRGs. GO and KEGG pathway analyses highlighted DEGs mostly belonged to pathways associated with necroptosis and apoptosis. Hub gene expression analysis showed high accuracy in SCI diagnosis was associated with the expression of CHMP7 and FADD. A total of two hub genes, i.e. CHMP7, FADD, were considered potential targets for SCI therapy., (© 2024 The Authors. Journal of Cellular and Molecular Medicine published by Foundation for Cellular and Molecular Medicine and John Wiley & Sons Ltd.)

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.)

Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.

Introduction: Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation., Methods: This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI., Results: A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM., Conclusions: Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades., Design: Retrospective cohort study., Setting: Spinal Injuries Center, Fukuoka, Japan., Participants: Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher., Interventions: None., Outcome Measures: The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients., Results: Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination ( k  = 0.89, P  < 0.01, r  = 0.84, P  < 0.01)., Conclusions: The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.

Introduction: When it is difficult to determine whether a muscle is grade 0 or 1, manual muscle test (MMT) accuracy can be further improved by using needle electromyography (EMG) as a supplementary and confirmatory examination tool., Objective: To evaluate concordance between needle EMG and MMT findings for key muscles with motor grades 0 and 1 on the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) examination, and to potentially improve the prognosis for grade 0 muscles with proven muscle activity based on needle EMG findings., Design: A retrospective analysis., Setting: Inpatient tertiary rehabilitation facility., Interventions: Not applicable., Patients: One hundred seven patients with spinal cord injury (SCI) admitted for rehabilitation (n = 1218 key muscles, grades 0 or 1)., Main Outcome Measures: Inter-rater reliability between MMTs and needle EMG was analyzed using Cohen's kappa coefficient (κ). A Mantel Haenszel linear-by-linear association chi-square test was used to determine whether the presence of motor unit action potentials (MUAPs) in muscles graded 0 on the initial MMT at admission was associated with MMT grades at discharge and readmission., Results: Moderate-to-substantial agreement between needle EMG and MMT findings was observed (κ = 0.671, p < .01). Concerning key upper and lower extremity muscles, moderate and substantial agreement was identified, respectively. The lowest agreement was noted for C6 muscles. During follow up, 68.8% of muscles with proven MUAPs showed improved motor grades., Conclusions: At initial assessment, distinguishing between motor grades 0 and 1 is imperative because motor grade 1 muscles are more likely to have a better prognosis for improvement. Moderate-to-substantial agreement was observed between MMT and needle EMG findings. The MMT is a reliable method of muscle grading, yet needle EMG may be of value in certain clinical situations to evaluate for the presence of MUAPs when evaluating motor function., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Objectives: To demonstrate the different techniques used to perform successful penile vibratory stimulation (PVS) to induce ejaculation in men with spinal cord injuries (SCIs)., Design: A video demonstration of the PVS procedure performed in men with SCIs using the FertiCare 2.0 medical vibrator., Setting: Major University Medical Center., Patients: Men with SCIs., Intervention(s): Spinal cord injury is the leading cause of anejaculation in young men. After SCIs, most of these men will need a method of assisted ejaculation to achieve biological fatherhood. In this study, a newly designed and tested vibrator (FertiCare 2.0) was used to induce ejaculation. The initial assessment of each patient included a standard history, physical examination, level of injury determination using the International Standards for Neurological Classification of Spinal Cord Injury as well as assessment of the hip flexor reflex and the bulbocavernosus reflex. Patients with a level of injury at or rostral to T6 were pretreated with 10-40 mg of sublingual nifedipine to manage autonomic dysreflexia. A single vibrator was applied to the dorsum, or frenulum, of the glans penis. Stimulation is delivered in 2-minute increments to a maximum of 10 minutes per visit. Application of two vibrators or abdominal electrical stimulation concurrently with PVS was used in select patients. Ejaculated semen was collected in a sterile cup and examined after liquefaction. Bladder preparation using sperm wash medium was performed in patients suspected of experiencing retrograde ejaculation., Main Outcome Measure(s): Successful ejaculation after performing the PVS procedure in men with SCIs., Results: Penile vibratory stimulation was successful in 86% of men whose level of injury was T10 or rostral. The total motile sperm count in antegrade ejaculates produced using PVS was >5 million (lower limit considered for intrauterine insemination) in 71% of ejaculates. No complications because of PVS were observed in 3,700 trials performed by our group and none in the patients presented in this video., Conclusion(s): Penile vibratory stimulation is a safe and effective method for the management of ejaculatory dysfunction in men with SCIs. Penile vibratory stimulation can be performed by the male partner after an initial evaluation by a specialized provider, and the ejaculate can be used to perform home insemination., Competing Interests: Declaration of interests E.I. funding and travel support from Paralyzed Veterans of America – Grant #877., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The expression of microRNA (miRNA) changes in many diseases plays an important role in the diagnosis, treatment, and prognosis of diseases. Spinal cord injury (SCI) is a serious disease of the central nervous system, accompanied by inflammation, cell apoptosis, neuronal necrosis, axonal rupture, demyelination, and other pathological processes, resulting in impaired sensory and motor functions of patients. Studies have shown that miRNA expression has changed after SCI, and miRNAs participate in the pathophysiological process and treatment of SCI. Therefore, quantitative analysis and monitoring of the expression of miRNA were of great significance for the diagnosis and treatment of SCI. Through the SCI-related miRNA chord plot, we screened out miRNA-21-5p and miRNA-let-7a with a higher correlation. However, for traditional detection strategies, it is still a great challenge to achieve a fast, accurate, and sensitive detection of miRNA in complex biological environments. The most frequently used method for detecting miRNAs is polymerase chain reaction (PCR), but it has disadvantages such as being time-consuming and cumbersome. In this paper, a novel SERS sensor for the quantitative detection of miRNA-21-5p and miRNA-let-7a in serum and cerebrospinal fluid (CSF) was developed. The SERS probe eventually formed a sandwich-like structure of Fe 3 O 4 @hpDNA@miRNA@hpDNA@GNCs with target miRNAs, which had high specificity and stability. This SERS sensor achieved a wide range of detection from 1 fM to 1 nM and had a good linear relationship. The limits of detection (LOD) for miRNA-21-5p and miRNA-let-7a were 0.015 and 0.011 fM, respectively. This new strategy realized quantitative detection and long-term monitoring of miRNA-21-5p and miRNA-let-7a in vivo. It is expected to become a powerful biomolecule analysis tool and will provide ideas for the diagnosis and treatment of many diseases.

Study Design: Retrospective study OBJECTIVES: To describe the presenting symptoms/signs, clinical course and outcomes in hospitalised people with spinal cord injury (SCI) and symptomatic COVID-19 infections., Setting: One university hospital and two SCI centres in Switzerland., Methods: Descriptive analysis of symptoms/signs, clinical course and outcomes of people with SCI with symptomatic COVID-19 infections and need for hospitalisation., Results: Twenty-two people with SCI were included, 15 (68%) were male, median age 64.5 years (interquartile range, IQR, 52-73 years). Nine (41%) had tetraplegia, and eight (36%) were classified with motor-complete lesions. Frequent clinical symptoms were fever (59%), coughing (54%), fatigue (50%), and dyspnoea (27%). Most frequent complications were bacterial pulmonary superinfection (18%), and acute respiratory distress syndrome (18%). Fifteen persons (68%) needed oxygen therapy during the course of hospitalisation, and 7 (32%) people were ventilated. Median length of stay (LOS) was 23 days (IQR 15-35), varying by age for people under 60 years with a median LOS of 9 days (IQR 8-27), and for those older than 60 years with a median of 34 days (IQR 17-39), respectively. In total, 3 persons (14%) died during hospitalisation, all older with paraplegia., Conclusions: Typical symptoms like fever and coughing were not present in all people. People with tetraplegia did not demonstrate worse outcomes, on the contrary, they had shorter LOS, no difference in ventilation needs, and no higher mortality compared to people with paraplegia. Older people showed longer LOS. This study recommends close supervision of the SCI population to detect early signs and symptoms of COVID-19 infection., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Summary: Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 by the American Clinical Neurophysiology Society.)

Study Design: Consensus process., Objectives: To provide a reference for the Zone(s) of Partial Preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and analyze the initial impact of applicability of the revised ZPPs. Revisions include the use of ZPPs in selected incomplete injuries (in addition to prior use in sensorimotor complete injuries). Specifically, the revised motor ZPPs are applicable bilaterally in injuries with absent voluntary anal contraction (VAC) and the revised sensory ZPP for a given side is applicable if deep anal pressure (DAP), light touch and pin prick sensation in S4-5 are absent on that side., Setting: Committee with 16 ISNCSCI experts and datasets from the European Multicenter Study about Spinal Cord Injury (EMSCI)., Methods: Occurrence frequencies of applicable ZPPs were determined in an EMSCI cohort consisting of two ISNCSCI examinations from 665 individuals with traumatic SCI., Results: Motor ZPPs were derived in 35.2% of all datasets of incomplete injuries, while sensory ZPPs are much less frequent (1.0%). Motor ZPPs are applicable in all American Spinal Injury Association Impairment Scale (AIS) B datasets (mean ZPP length: 0.9 ± 1.0 segments), in 55.4% of all AIS C datasets (ZPP length: 11.8 ± 8.2 segments) and in 9.9% of the AIS D datasets (ZPP length: 15.4 ± 7.9 segments)., Conclusions: The revised ZPP allows for determining motor ZPPs in approximately 1/3 of all incomplete injuries. The broadened applicability enables the use of ZPPs beyond complete injuries for complementary description of residual functions in more individuals., Sponsorship: N/A., (© 2024. The Author(s).)

Study Design: Cross-sectional study., Objectives: To evaluate unsupported sitting posture impairments and identify postural regulatory strategies in cervical spinal cord injury (cSCI) participants via a head-mounted IMU sensor., Setting: A research lab in the United States of America., Methods: cSCI participants and controls maintained postural stability during unsupported sitting with eyes either open or closed. The head-mounted IMU sensor recorded accelerometer data to calculate cumulative sway motion. The postural regulatory strategy was analyzed by assessing the normalized power spectral density (PSD) in four frequency bands: 0-0.1 Hz (visual regulation), 0.1-0.5 Hz (vestibular regulation), 0.5-1 Hz (cerebellar regulation), and >1 Hz (proprioception and muscle control)., Results: Significant increases in postural sway were observed in cSCI participants compared to controls during unsupported sitting. For cSCI participants, normalized PSD significantly increased in the low-frequency bands (0-0.1 Hz and 0.1-0.5 Hz) but decreased in the high-frequency band (>1 Hz) compared to controls., Conclusions: cSCI participants were more reliant on visual and vestibular systems for sitting balance, while depending less on proprioception and muscle control compared to controls. These findings suggest that the altered postural regulatory strategy is ineffective in maintaining postural stability during unsupported sitting, emphasizing the importance of proprioception and muscle control for seated postural stability in cSCI participants., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objectives: The goal of this study is to implement machine learning (ML) algorithms to predict mortality, non-home discharge, prolonged length of stay (LOS), prolonged length of intensive care unit stay (ICU-LOS), and major complications in patients diagnosed with thoracolumbar spinal cord injury, while creating a publicly accessible online tool., Methods: The American College of Surgeons Trauma Quality Program database was used to identify patients with thoracolumbar spinal cord injury. Feature selection was performed with the Least Absolute Shrinkage and Selection Operator algorithm. Five ML algorithms, including TabPFN, TabNet, XGBoost, LightGBM, and Random Forest, were used along with the Optuna optimization library for hyperparameter tuning., Results: A total of 147,819 patients were included in the analysis. For each outcome, we determined the best model for deployment in our web application based on the area under the receiver operating characteristic (AUROC) values. The top performing algorithms were as follows: LightGBM for mortality with an AUROC of 0.885, TabPFN for non-home discharge with an AUROC of 0.801, LightGBM for prolonged LOS with an AUROC of 0.673, Random Forest for prolonged ICU-LOS with an AUROC of 0.664, and LightGBM for major complications with an AUROC of 0.73., Conclusions: ML models demonstrate good predictive ability for in-hospital mortality and non-home discharge, fair predictive ability for major complications and prolonged ICU-LOS, but poor predictive ability for prolonged LOS. We have developed a web application that allows these models to be accessed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Perinatal spinal cord injury is a relatively uncommon, but a frequently misdiagnosed disorder. Improvements in obstetric care have certainly led to a decrease in the incidence of birth related spinal cord trauma but unfortunately the incidence of hypoxic-ischemic encephalopathy is still very high. The exact incidence of spinal cord trauma is difficult to determine because the spinal cord is not routinely examined in far and few neonatal autopsies done in India. Here, authors present a neonate who received treatment for birth asphyxia and then had extubation failure which made the clock tick towards cervical cord injury. This baby had a hemorrhagic contusion of cervical spinal cord., (© 2023. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Aims: Neurogenic bladder (NB) is a prevalent and debilitating consequence of spinal cord injury (SCI). Indeed, the accurate prognostication of early bladder outcomes is crucial for patient counseling, rehabilitation goal setting, and personalized intervention planning., Methods: A retrospective exploratory analysis was conducted on a cohort of consecutive SCI patients admitted to a rehabilitation facility in China from May 2016 to December 2022. Demographic, clinical, and electrophysiological data were collected within 40 days post-SCI, with bladder outcomes assessed at 3 months following SCI onset., Results: The present study enrolled 202 SCI patients with a mean age of 40.3 ± 12.3 years. At 3 months post-SCI, 79 participants exhibited complete bladder emptying. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses identified the H-reflex of the soleus muscle, the American Spinal Injury Association Lower Extremity Motor Score (ASIA-LEMS), and the time from lesion to rehabilitation facility (TLRF) as significant independent predictors for bladder emptying. A scoring system named HALT was developed, yielding a strong discriminatory performance with an area under the receiver operating characteristics curve (aROC) of 0.878 (95% CI: 0.823-0.933). A simplified model utilizing only the H-reflex exhibited excellent discriminatory ability with an aROC of 0.824 (95% CI: 0.766-0.881). Both models demonstrated good calibration via the Hosmer-Lemeshow test and favorable clinical net benefits through decision curve analysis (DCA). In comparison to ASIA-LEMS, both the HALT score and H-reflex showed superior predictive accuracy for bladder outcome. Notably, in individuals with incomplete injuries, the HALT score (aROC = 0.973, 95% CI: 0.940-1.000) and the H-reflex (aROC = 0.888, 95% CI: 0.807-0.970) displayed enhanced performance., Conclusion: Two reliable models, the HALT score and the H-reflex, were developed to predict bladder outcomes as early as 3 months after SCI onset. Importantly, this study provides hitherto undocumented evidence regarding the predictive significance of the soleus H-reflex in relation to bladder outcomes in SCI patients., (© 2024 The Authors. CNS Neuroscience & Therapeutics published by John Wiley & Sons Ltd.)

Study Design: A retrospective study., Objective: This study examined the value of neutrophil-to-lymphocyte ratio at admission for early diagnosis, severity assessment, and prognosis of acute traumatic SCI., Setting: The First People's Hospital of Neijiang, China., Methods: This was a single-center, retrospective, cohort study of patients treated within 12 h of acute SCI between January 2018 and October 2022. Ninety-four SCI patients were selected as the Observation group, including 26 with complete injury (AIS grade A) and 68 with incomplete injury (AIS grade B-D), while 94 patients with simple spinal fracture were randomly selected as the Control group. Eighty-one observation group patients underwent surgical treatment, of which 33 had a higher AIS grade (Good prognosis subgroup) and 48 a lower or equal grade post-surgery (Poor prognosis subgroup). Univariate and multivariate analyses were performed to assess predictors of early diagnosis, severity, and 6-month outcome., Results: Initial white blood cell count, neutrophil count, monocyte count, and NLR were higher in the Observation group than the Control group, while lymphocyte count was lower in the Observation group. Multivariate logistic regression analysis identified NLR as an independent predictor of early diagnosis. Spinal canal encroachment ≥50%, neutrophil count, and NLR were higher in the complete injury subgroup, and spinal canal encroachment ≥50% was an independent predictor of complete injury, while NLR was not. The NLR was higher in the poor prognosis subgroup and was an independent risk factor., Conclusions: Peripheral blood NLR is useful for early diagnosis of acute SCI and is predictive of clinical outcome., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

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.

Objective: This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries., Latest Developments: There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries., Essential Points: Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery., (Copyright © 2024 American Academy of Neurology.)

Background: The Short-Form Qualiveen (SF-Qualiveen) questionnaire assesses the effect of bladder and urinary symptoms on patients' quality of life (QoL) with urological impairment caused by neurological diseases. There is no validated SF-Qualiveen questionnaire in Arabic, so this study aims to provide a translated and validated version of the SF-Qualiveen questionnaire among Arabic patients experiencing spinal cord injury (SCI)., Methods: Psychometric features such as content and construct validity, test-retest reliability, and internal consistency were analyzed. Construct validity was evaluated by contrasting the SF-Qualiveen with the Neurogenic Bladder Symptom Score Short-Form (NBSS-SF) questionnaire. Internal consistency was measured using Cronbach's alpha, whereas the intraclass correlation coefficient (ICC) was employed to assess the test-retest reliability. Factorial validity was established by principal component analysis (PCA)., Results: The internal consistency of the total SF-Qualiveen and the domains "Bother with limitations," "Fear," "Feeling," and "Frequency of limitations" showed good internal consistency (Cronbach's alpha of > 0.7). ICC was 0.90 for the total score, 0.83 for the bother with limitations, 0.80 for fears, 0.84 for feeling, and 0.81 for frequency of limitations. The correlation analysis revealed a positive association between the total scores on the NBSS-SF and the domains of the SF-Qualiveen, comprising bother with limitations (r = 0.53, p = 0.02), fears (r = 0.44, p = 0.03), feelings (r = 0.49, p = 0.04), and frequency of limitations (r = 0.46, p = 0.02). The best-fit four-factor model for confirming overall item communalities ranged from 0.552 to 0.814, which indicates moderate to high communalities, and confirms the homogeneity of the SF-Qualiveen using PCA., Conclusions: The findings of this validation study revealed that the SF-Qualiveen is a reliable and valid instrument appropriate for Arabic-speaking patients with SCI in both research and clinical practices., (© 2024. The Author(s).)