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PHYS THER
Vol. 88, No. 4, April 2008, pp. 471-484
DOI: 10.2522/ptj.20070049
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Inflammatory Myelopathies and Traumatic Spinal Cord Lesions: Comparison of Functional and Neurological Outcomes

Giorgio Scivoletto, Elena Cosentino, Alessia Mammone and Marco Molinari

G Scivoletto, MD, is Assistant Physician, Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy. Dr Scivoletto's institutional address: Spinal Cord Unit, IRCCS Fondazione S. Lucia, Via Ardeatina 306, 00179 Rome, Italy
E Cosentino, MD, is Assistant Physician, Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy
A Mammone, PhD, is Consultant for Statistical Analysis, Department of Statistics, Probability and Applied Statistics, Sapienza University of Rome, Rome, Italy
M Molinari, MD, PhD, is Chief Physician, Spinal Cord Unit, IRCCS S. Lucia Foundation, Rome, Italy

Address all correspondence to Dr Scivoletto at: g.scivoletto{at}hsantalucia.it


Submitted February 10, 2007; Accepted November 15, 2007


   Abstract
 
Background and Purpose: Outcomes knowledge is essential to answer patients' questions regarding function, to plan the use of resources, and to evaluate treatments to enhance recovery. The purpose of this study was to compare the outcomes of patients with traumatic spinal cord injury (SCI) with those of patients with inflammatory spinal cord lesions (ISCLs).

Subjects and Methods: The authors evaluated 181 subjects with traumatic SCI and 67 subjects with ISCLs. Using a matching cohorts procedure, 38 subjects were selected from each group. The measures used were the American Spinal Injury Association (ASIA) Impairment Scale (motor function), the Barthel Index (BI), the Rivermead Mobility Index (RMI), and the Walking Index for Spinal Cord Injury (WISCI).

Results: The subjects in the ISCL group were older than those in the SCI group, with a longer interval from onset of lesion to rehabilitation admission and more incomplete lesions. In the matching cohorts, at admission, the traumatic SCI group had RMI and WISCI scores comparable to those of the ISCL group, but the traumatic SCI group had lower scores on the BI (greater dependence on assistance for activities of daily living). At discharge, the 2 groups had comparable functional outcomes. The neurological status of the 2 groups was comparable at admission and discharge.

Discussion and Conclusion: The results indicate that, at admission, patients with SCI have a greater physical dependence for assistance with activities of daily living than patients with ISCLs who have comparable neurological status. Such a difference depends on factors not related to the spinal cord lesion, such as the presence of associated lesions, the need to wear an orthotic device, or the sequelae of surgery. The outcomes of patients with SCI are determined more by factors such as lesion level and severity and age than by etiology. This finding could have implications for health care planning and rehabilitation research.


   Introduction
Top
 Abstract
 Introduction
Subjects and Method
 Results
 Discussion
 Conclusions
 References
 
The outcome of nontraumatic and traumatic spinal cord lesions is still a matter of debate, probably because of the different features of the 2 populations. Patients with traumatic spinal cord lesions usually are younger and often have complete lesions and a shorter interval from onset of lesion to rehabilitation admission, whereas patients with nontraumatic spinal cord lesions usually are older and often have incomplete lesions and a longer interval from onset of lesion to rehabilitation admission.1 Due to these differences, it is difficult to compare the 2 groups of patients. In a recent retrospective study involving 1,085 patients with nontraumatic spinal cord injury (SCI) and 250 patients with traumatic SCI, Catz et al2 found a better prognosis for recovery in the first group. McKinley et al,1 however, found better functional outcome in patients with traumatic SCI who were younger and more severely injured. Scivoletto et al,3 in 2003, reported that neurological and functional outcomes were influenced more by age than by etiology. Ditunno4 noted the low attention paid to nontraumatic spinal cord lesions in the literature. Although the incidence of nontraumatic SCI is considered to be between 25% and 80% of all cases of SCI1,5–10 and although this percentage will probably increase in an aging society, most of the information available on recovery and outcomes after spinal cord lesions is based on research on traumatic spinal cord lesions.

Ditunno4 cautioned researchers not to generalize about nontraumatic spinal cord lesions because this area is very diverse and includes many diseases with different prognoses. Studies on the outcomes of the various nontraumatic etiologies are even fewer and only cover some specific pathologies (eg, degenerative spine disease with cord involvement, vascular and neoplastic myelopathies).11–13 No data are available on inflammatory diseases of the spinal cord.

The aim of the present work was to evaluate the functional and neurological outcomes of patients with inflammatory spinal cord lesions (ISCLs) and compare the outcomes with those of patients with traumatic SCI.


   Subjects and Method
Top
 Abstract
 Introduction
 Subjects and Method
Results
 Discussion
 Conclusions
 References
 
We examined the charts of 457 patients admitted to our spinal unit between 1996 and 2006 for a first rehabilitation treatment and selected patients with traumatic SCI or with ISCLs (bacterial, viral, post-infective, and post-vaccine myelitis). The latter group was as stable as the traumatic one because the few cases that showed disease progression were excluded from the study.

We recorded the following data: onset of lesion to admission time (LTA), injury variables (etiology and medical complications), length of stay as inpatients (LOS), and destination at discharge. The American Spinal Injury Association (ASIA) standards14 were adopted to assess subjects' neurological status. We used the ASIA Impairment Scale to evaluate sensory and motor function and neurological level. However, because it has been shown that motor evaluation is the best predictor of impairment in patients with SCI,15 we excluded data on sensory function and used only data on motor function in the data analysis. Lesions were considered incomplete whenever subjects showed signs of sacral sparing (conservation of motor or sensory function in the sacral segments).16 Regarding neurological level, subjects were classified as having cervical, thoracic, or lumbar lesions. Neurological recovery was considered present if subjects improved by at least one ASIA Impairment Scale grade. Functional status at admission and at discharge was assessed with the Barthel Index (BI) (a 0–100 scale, with lower scores denoting less independence in activities of daily living),17 the Rivermead Mobility Index (RMI) (a 0–15 scale designed to assess mobility),18 and the Walking Index for Spinal Cord Injury (WISCI) (a 0–20 scale designed to evaluate walking based on the need for physical assistance, braces, and assistive devices).19–21 Barthel Index items also were recorded to assess different areas of activities of daily living. Barthel Index and RMI scores were copied directly from the scales in the charts. As in the previous study by Scivoletto et al,3 WISCI scores were taken retrospectively from medical chart records.3 Only one researcher, who had experience with the scale (GS), assigned the WISCI scores based on the description of walking derived from the records.

ASIA motor score, BI, RMI, and WISCI score changes were calculated based on the difference between scores at admission and at discharge. ASIA motor function, BI, RMI, and WISCI efficiency scores also were calculated. Efficiency score refers to the difference in scoring at admission and at discharge related to the duration of the treatment (score changes for each scale divided by duration of rehabilitation stay). The efficiency score provides a basis for measuring the success of rehabilitation in terms of both individual patient performance and rehabilitation center performance22 and has been used as an outcome measure in patients with SCI.23,24

Bladder voiding modalities and autonomy in bowel management were assessed according to the Gruppo Italiano Studio Epidemiologico Mielolesioni (GISEM) study.10 Finally, we evaluated subjects' destination at discharge.

Matching Procedure

To correct for the concurrent effects of the different features of the 2 groups on neurological recovery and rehabilitation outcomes, we applied a matching procedure with 4 matching variables:

Each subject was identified by an injury type, age, or LTA group and categorized by etiology. Subjects were selected from each etiology group to create matched dyads based on their classification. In this way, 76 subjects (38 dyads) were selected (Tab. 1).


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  		Table 1. Composition of Dyads

 
Data Analysis

Descriptive values (mean ± SD) were calculated for all continuous clinical data. The data of the entire group of 248 subjects were analyzed using the Student t test for independent samples and the chi-square test.

Data from the dyads were analyzed by means of a paired t test, and the McNemar chi-square test was applied to assess contingency differences.3 Data from the dyads are presented separately for each ASIA Impairment Scale classification level. Differences were taken as significant at P<.05.


   Results
Top
 Abstract
 Introduction
 Subjects and Method
 Results
Discussion
 Conclusions
 References
 
The entire sample comprised 181 subjects with traumatic SCI and 67 subjects with inflammatory myelopathies. Subjects in the SCI group differed significantly from those in the ISCL group in several respects. Subjects in the ISCL group were more often female (P=.003), were significantly older (P<.001), and had longer LTAs (P<.001) and LOSs (P<.001) compared with subjects in the SCI group (Tabs. 2 and 3, Figs. 1 and 2). They also had a higher frequency of incomplete lesions (P=.001) and a lower frequency of cervical lesions (P=.001) (Tab. 3). As regards ASIA motor scores, RMI, BI, and WISCI scores, the ISCL group showed significantly better functional status at admission compared with the SCI group (Tab. 2, Fig. 2). At discharge, the subjects in the ISCL group had better outcomes than the subjects in the SCI group, but the differences were not significant (Tab. 2, Fig. 2).


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  		Table 2. Characteristics of Subjects With Traumatic Spinal Cord Injury (SCI Group) and Subjects With Inflammatory Spinal Cord Lesions (ISCL Group) According to Lesion Etiology: Continuous Variablesa

 

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  		Table 3. Characteristics of Subjects With Traumatic Spinal Cord Injury (SCI Group) and Subjects With Inflammatory Spinal Cord Lesions (ISCL Group) According to Lesion Etiology: Dichotomous Variablesa

 

Figure 1
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  		Figure 1. Means and standard deviations for age (in years), length of stay as inpatients (LOS) (in days), and interval from onset of lesion to admission for rehabilitation treatment (LTA) (in days) in subjects with traumatic spinal cord injury (SCI group) and subjects with inflammatory spinal cord lesions (ISCL group).

 

Figure 2
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  		Figure 2. Means and standard deviations for Barthel Index (BI), Rivermead Mobility Index (RMI), Walking Index for Spinal Cord Injury (WISCI) and American Spinal Injury Association (ASIA) motor (MS) scores at admission and at discharge in subjects with traumatic spinal cord injury (SCI group) and subjects with inflammatory spinal cord lesions (ISCL group) and their respective score change and efficiency. To obtain a better visualization of RMI and WISCI and of the efficiency scores, in the graph these values are reported as a percentage of the total.

 
In the matching cohorts, the SCI group had lower LTAs and higher LOSs compared with the ISCL group, but these differences were not significant. The ISCL group had a slightly higher frequency of neurological improvement compared with the SCI group (10/38 versus 9/38), but this difference did not reach statistical significance (P=.8) (Tabs. 4 and 5). With regard to the evaluation scales, at admission, the SCI group had significantly lower BI scores (P=.04) and nonsignificantly lower RMI and WISCI scores. Barthel Index subscale item scores were available only for 13 dyads. The SCI group had lower values for all BI subscale items, although none of these differences were statistically significant. The ASIA Impairment Scale motor scores at admission were perfectly comparable between groups (Tab. 4). At admission, the SCI group showed a higher (but not significant) frequency of complications (Tab. 5). At discharge, BI scores were comparable between groups, although the increase in BI scores was significantly higher in the SCI group. The RMI and WISCI scores at discharge were slightly, but not significantly, lower in the SCI group. The increase in RMI scores was comparable between the 2 groups, whereas the increase in WISCI scores was higher in the ISCL group. The ASIA Impairment Scale motor scores at discharge and the increases in motor scores were comparable between the 2 groups (Tab. 4). The efficiency scores for the 4 scales also were comparable between groups. Bladder-voiding modalities, bowel management independence, and discharge disposition also were comparable between groups (Tab. 5). When each ASIA Impairment Scale classification level was examined separately, subjects who were classified as ASIA A and B did not show any significant difference at both admission and discharge. Subjects in the SCI group who were classified as ASIA C showed significantly lower RMI scores at admission compared with subjects in the ISCL group (1.25±1.39 versus 0.00, P=.04). Subjects classified as ASIA D did not show significant differences (Supplemental Tabs. 1, 2, 3, 4, 5, and 6).


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  		Table 4. Characteristics of Dyads of Subjects With Traumatic Spinal Cord Injury (SCI Group) and Subjects With Inflammatory Spinal Cord Lesions (ISCL Group) According to Lesion Etiology: Continuous Variablesa

 

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  		Table 5. Characteristics of Dyads of Subjects With Traumatic Spinal Cord Injury (SCI Group) and Subjects With Inflammatory Spinal Cord Lesions (ISCL Group) According to Lesion Etiology: Dichotomous Variablesa

 

   Discussion
Top
 Abstract
 Introduction
 Subjects and Method
 Results
 Discussion
Conclusions
 References
 
To our knowledge, this is the first study that has compared the outcomes of inflammatory myelopathies and traumatic SCIs. The few articles that have dealt with nontraumatic SCIs usually have grouped the various etiologies together. As already stated, different etiologies may have different outcomes; thus, generalizations can lead to biases. The demographic characteristics of our subjects are in line with what has already been reported for people with traumatic and nontraumatic spinal cord pathology.31,32

In our study, both groups of subjects showed significant differences with regard to several prognostic factors: age, sex, LTA, and completeness and level of the lesion.3,26–29 Incomplete lesions were more frequent in the ISCL group, which also had fewer cervical lesions. Subjects in the SCI group were younger and had shorter LTAs. Therefore, the 2 groups were difficult to compare, and the outcomes of the total subject sample could have been biased by these differences. Because of the low frequencies of complete lesions and cervical lesions in the ISCL group, these subjects had a better functional and neurological status at admission. At discharge, the scores of the 3 evaluation scales (BI, RMI, and WISCI) were higher (although not significantly) for the ISCL group than for the SCI group. Thus, as in previous research,3 we decided to use a matching cohorts procedure to correct for the concurrent effects of the above-mentioned prognostic factors.

With regard to neurological outcome, both groups showed comparable neurological amelioration: 26% of the subjects in the ISCL group and 24% of the subjects in the SCI group improved their ASIA Impairment Scale level between admission and discharge. Motor scores at admission and discharge and motor score increase and efficiency also were comparable. Until now, only one study2 has examined the neurological outcome of patients with nontraumatic spinal cord lesions of different etiologies. In this investigation with a large sample, Catz et al found that the odds of any neurological recovery and of functional neurological recovery were significantly higher in patients with myelitis. In the past, the importance of adopting procedures to correct for the covariant effects of prognostic factors while examining different populations of patients3,4 was emphasized. The study by Catz et al was probably a case in which such procedures were needed. The differences between the findings of Catz and colleagues' study and those of the present study can be explained by the methodological differences and, in particular, by the matching cohorts procedure that we used, which allowed us to have 2 groups of highly comparable subjects with regard to level and severity of lesion, age, and LTA.

With regard to functional status, the SCI group had lower BI scores (ie, lower independence in activities of daily living) at admission compared with the ISCL group. This difference was not related to a specific area of activities of daily living, as subjects showed a trend to lower scores for all BI items. At discharge, BI scores were comparable between groups. Thus, it could be argued that the subjects in the SCI group had greater functional improvement, as rated with the BI, than the subjects in the ISCL group. This may represent a possible contradiction, considering the lack of effects of SCI etiology on the other indexes analyzed in the present study. Nevertheless, it should be considered that time-limited nonneurological trauma–associated factors (eg, the presence of associated lesions, the need to wear an orthotic device, the sequelae of major surgery) might limit functional status at admission but not at discharge without affecting a person's neurological status. Similarly, these factors could slow down the timing of rehabilitation, as confirmed by the trend toward longer LOS in the SCI group.

Another possible explanation of the difference in BI scores at admission between the SCI and ISCL groups may be related to LTA differences. Because the subjects in the SCI group had longer LTAs compared with subjects in the ISCL group, they may have undergone rehabilitation treatment that, although aspecific, produced an amelioration of their functional status. It could be suggested that differences in spinal shock severity may have contributed to the differences in "functional status" at admission. However, the effects of etiology on functional status due to differences in the spinal pathological processes (in particular, spinal shock) would be mirrored by differences in the neurological indexes. This was not the case in the present study. At admission, neurological status, as evaluated using impairment severity and motor scores, was highly comparable in the 2 groups. Furthermore, spinal shock is commonly said to resolve within 40 days, although recent research highlighted that some reflexes reappear a few hours or days after onset of the lesion.33 In the present study, both in the entire sample and in the matched cohorts, the average LTA was about 50 days. Therefore, it is highly probable that most of the subjects were already out of the shock phase. Based on these considerations, we do not believe that the differences in functional status at admission could be attributed to a more severe spinal shock in patients with traumatic lesions. Thus, BI differences at admission can reasonably be ascribed to nonneurological trauma–associated factors.

Mobility (RMI) and walking capacity (WISCI) at admission and at discharge were slightly lower in the SCI group than in the ISCL group, although the increases on the scales and their efficiency were comparable between groups. Both groups had the same outcome with regard to bladder and bowel management. As mentioned above, no data are available on the rehabilitation outcome of patients with inflammatory spinal cord lesions. The only comparison we could make was with the studies of McKinley and colleagues.1,34 They compared patients with traumatic SCI and patients with nontraumatic spinal cord lesions using a matching cohorts procedure and found better outcomes with regard to independence in activities of daily living for the patients with traumatic lesions. There are 2 possible explanations for the differences between the findings of our study and those of McKinley and colleagues. First, we selected inflammatory diseases that could show different outcomes than the other nontraumatic etiologies. Second, we used different statistical methods. In one study by McKinley et al,1 the subjects were divided into only tetraplegic incomplete and paraplegic incomplete and complete groups, whereas we divided our subjects into 3 lesion levels and classified them according to each ASIA Impairment Scale classification level. In the second study,34 the authors used a matching comparison similar to the matching procedure in our study, but they did not take into account the LTA.

Finally, with regard to discharge disposition, the 2 matched cohorts showed similar rates of returning home after discharge from rehabilitation (about 80%). As already underscored in other work,35–37 discharge disposition and, most of all, the risk of being institutionalized are influenced by factors other than etiology of the lesion. In patients with SCI and in patients with other neurological diseases, discharge dispositions depend mostly on the level of independence in activities of daily living (with a BI score of 60 considered the point at which patients move from dependence to assisted independence and also considered the cutoff score for home discharge)35,36 and on age.37

There are some limitations in the present study. One limitation is the possibility that the disease may worsen over time (eg, if myelitis represents the beginning of multiple sclerosis). Although patients who showed a worsening of their neurological status during the rehabilitation stay were excluded from the study, a subsequent deterioration cannot be excluded, and a follow-up study probably is needed. Another limitation is that, according to the GISEM study requirements,10 in our study sample we grouped together all types of myelitis (bacterial, viral, post-infective, and post-vaccine). As indicated by Ditunno,4 different etiologies could have an effect on outcomes.

To analyze the significance of the present study, it should be noted that the standard deviations in the 2 groups were very large in relation to the means. Thus, it is possible that in a larger sample some differences would emerge between the 2 groups. Accordingly, we performed a power analysis after the study (with BI score change as the primary outcome), which revealed that the power of the present matched cohort study was 57% and that, to reach a power of 80%, 58 pairs were required. Furthermore, the number of subjects for each ASIA Impairment Scale classification level was quite low, obliging us to group together ASIA A and B. As suggested by Ditunno,4 multicenter studies that involve a larger number of patients are needed.

A third limitation is that, because of the number of subjects, it was impossible to analyze the effect of neurological factors such as pain and spasticity that are known to play a role in patients' function but are not included in the ASIA examination. Again, multicenter studies involving larger numbers of patients would help to clarify this issue.


   Conclusions
Top
 Abstract
 Introduction
 Subjects and Method
 Results
 Discussion
 Conclusions
References
 
People with traumatic SCI and those with inflammatory myelopathies are very different with regard to several clinical features that can confound the evaluation of outcomes. When the confounding effects of age and of lesion severity and level are eliminated, at admission patients with traumatic SCI have a greater physical dependence on others for assistance with activities of daily living compared with people with inflammatory spinal cord lesions. As this difference is not mirrored by a difference in neurological status, it could be argued that it is related to nonneurological factors (eg, the presence of associated lesions, major surgery, the need to wear an orthotic device). At discharge, the 2 patient populations achieve comparable neurological recovery and functional status.

Three major conclusions can be drawn from the present study. First, rehabilitation treatment seems to have the same positive effect on recovery in both patients with traumatic SCI and those with nontraumatic spinal cord lesions. Second, if studies with larger numbers of subjects confirm that the outcome of patients with SCI is determined more by factors such as lesion level and severity and age than by etiology, then both patient populations could be used for clinical studies aimed at evaluating the efficacy of rehabilitation. Third, there is a need for international multicenter studies in order to investigate a larger number of patients with nontraumatic SCI and, thus, to make possible an in-depth evaluation of the outcomes of this patient population.


   Footnotes
 
Dr Scivoletto provided idea/research design. Dr Scivoletto, Dr Cosentino, and Dr Molinari provided writing. Dr Scivoletto and Dr Cosentino provided data collection. Dr Cosentino provided subjects. Dr Mammone provided data analysis. Dr Molinari provided project management and consultation.

The professional English-language editing of Claire Montagna is gratefully acknowledged.


   References
Top
 Abstract
 Introduction
 Subjects and Method
 Results
 Discussion
 Conclusions
 References
 

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