Table 1. Incidence of DVT Post SCI

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Author/Year Treatment (n size) % of DVTs Test
Hon et al., (2019) (n=189) 16.4% Duplex scan
Morita et al., (2018) (n=75) 35.7% Doppler Ultrasonography
Passias et al., (2018) (n=488,262) 32-36%
Eichinger et al., (2018) Prophylactic anticoagulant therapy (n=185) 4% D-dimer
Clements et al., (2017) (n=222) 21%
Marion et al., (2017) (n=444) 1.6%
Mackiewicz et al., (2016) (n=63) 7.9% D-dimer and venous duplex scans
Piran et al., (2016) (n=151) 11%
Dietch et al., (2015) (n=8,238) 3.5-4.4% Ultrasonography
Masuda et al., (2015) (n=268) 10.4% Ultrasonography
Halim et al., (2014) LMWH + compression stockings or LMWH only (n=37) LMWH only=5.4% LMWH + compression stockings=21.6% Doppler Venous Ultrasonography
Giorgi Pierfranceschi et al., (2013) LMWH and compression stockings

(n=94)

23% Compression Ultrasound or lower limb colour Doppler ultrasonography, perfusion lung scintigraphy (Q scan)

matched with chest X-ray, or computed tomography pulmonary angiography

 Germing et al., (2010) (n=139) 45% Serial color duplex sonography
Sugimoto et al., (2009) (n=45) 21% Doppler Ultrasonography
Colachis & Clinchot (1993) Prophylaxis Treatment

(n=209)

14% Contrast venography

Ultrasound

Gunduz et al., (1993) Low-dose Heparin

(n=31)

53% Venography
Kulkarni et al., (1992) Low-dose unfractionated heparin

(n=97)

27%
Merli et al., (1988) Untreated

(n=17)

47% I125 fibrinogen scan

Impedance Plethysmography

Venography

Myllynen et al., (1985) Anticoagulant therapy (n=37) 100% I125 fibrinogen scan Venography
Green et al., (1982) External pneumatic calf compression (ENCP) or ENCP + aspirin + dipyrid

(n=28)

78% untreated

33% treated

Platelet aggregation studies
Rossi et al., (1980) N/A

(n=18)

72% I125 fibrinogen scan

Table 3. Mindfulness for Depression following SCI

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Author Year

Country
Research Design
PEDro Score
Total Sample Size

Methods Outcome

Hearn and Finlay  (2018)

United Kingdom

RCT

PEDro=7

NInitial=67 NFinal=43

Population: Mean age=44.4±10.4 yr; Gender: males=31, females=36; Time since injury (yr): 1-2=11, 2-4=18, 4-8=19, 8-12=6, 12-15=7, 15+=6; Level of injury: C=25, T=37, L=5; Severity of injury: AIS A=9, B=17, C=19, D=22.

Intervention: Participants were randomized to either an 8-wk online mindfulness intervention or an 8-wk internet delivered psychoeducation.

Outcome Measures: Depression symptom severity and anxiety (hospital anxiety and depression scale (HADS)), quality of life (QoL)(world health organization quality of life (WHOQOL-BREF) , pain perception (numeric rating scale), pain catastrophizing scale (PCS) and mindfulness (five facet mindfulness questionnaire (FFMQ).

1.     Significant differences post-intervention between groups for mindfulness facets of acting with awareness, describing and non-reactivity to inner experience (p<0.05) as well as total FFMQ score (p<0.05).

2.     No significant differences between groups for any QoL, pain intensity and mindfulness facets of observing and non-judging post-intervention (p>0.05).

3.     Significant between group difference in severity of depression and pain catastrophizing at 3-mo follow-up (p<0.050).

Table 2. Cognitive Behavioural Therapy Group Interventions

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Author Year

Country
Research Design
PEDro Score
Total Sample Size

Methods Outcome

Burke et al., (2019)

Ireland

RCT

PEDro=8

NInitial=69 NFinal=57

Population: Mean age=52±13 yr; Gender: males=52, females=17; Time since injury=16±12.1 yr; Level of injury: C=17, T=30; L=14, Not reported=8; Severity of injury: AIS A=4, B=2, C=3, D=4, Not reported=55.

Intervention: Participants were randomly assigned to either a control group where they went about their normal routine and the intervention group received an online six module cognitive behavioural therapy pain management program once per wk for 12 wk.

Outcome Measures: World Health Organization Quality of Life Bref (WHOQOL-Bref), International Spinal Cord injury Quality of Life Basic Data Set (ISCIQOLBDS), International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS), Douleur Neuropathique en 4 Questions (DN4), Chronic Pain Acceptance Questionnaire 8 (CPAQ8), Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and Pittsburgh Sleep Quality Index (PSQI).

1.     Moderate linear relationship found between the number of modules in which the users engaged in 80% or more of the content and reductions in overall pain intensity ((NRS) (p=0.05), the ISCIPBDS pain interference score (p=0.08), the LSF domain (p=0.039), the BPI interface scale (p=0.10) and the depression subscale of the HADS (p=0.10).

2.     At 3-mo follow-up a moderate linear relationship between module engagement and improvements in sleep quality (p=0.06), the AMS subcategory of the ISCIPBDS (p=0.09) and both the depression (p=0.03) and anxiety (p=0.05) subscales of the HADS.

Coker et al., (2019)

USA

RCT

PEDro=8

N=81

Population: Control Group (n=40): Mean age=52±15.3 yr; Gender: males=32, females=8; Time since injury=81.5 mo; Level of injury: complete=16, incomplete=24; Severity of injury: AIS A=16, B=3, C=8, D=13.

Intervention Group (n=41): Mean age=48±12.8; Gender: males=34, females=7; Time since injury=95 mo; Level of injury: complete=19, incomplete=22; Severity of injury: AIS A=19, B=2, C=7, D=13.

Intervention: Participants were randomized to either a control group in which they continued their normal rehabilitation or an intervention group in which they took part in an interactive cognitive behaviour therapy based learning program for one session per wk, 2 hrs per session for 6 wk with assessments at baseline, post intervention and at 8-wk intervals post intervention.

Outcome Measures: Moorong Self-Efficacy Scale (MSES), Generalized Self-Efficacy Scale (GSES), Diener Satisfaction with Life Scale (SWLS), Participation Assessment with Recombined Tools – Objective (PART-O), Patient Health Questionnaire – 9 (PHQ-9), and General Anxiety Disorder 7-Item (GAD-7).

1.     Non-significantly greater increase in MSES for the treatment group compared to the control group from baseline to 6-wk and neither group showed significant difference from baseline to the 30-wk follow-up (p=0.15).

2.     The treatment group showed significant improvements for the GSES, PHQ-9 and GAD-7 from baseline to 6-wk whereas the control group did not.

3.     Neither group showed significant changes in SWLS or PART-O from baseline to 6-wk.

4.     Despite the significant differences for the treatment group from baseline to 6-wk or from baseline to 30-wk follow-up, there are no significant differences in results between treatment and control.

Migliorini et al., (2016)

Australia

RCT

PEDro=8

NInitial=59 NFinal=48

Population: Intervention group (n=34): Mean age=47.5±12.2 yr; Gender: males=25, females=9; Time since injury=11.4±11.9 yr; Level of injury: complete paraplegia=5, incomplete paraplegia=8, complete tetraplegia=1, incomplete tetraplegia=18, unknown=2. Waitlist control group (n=25): Mean age=52.8±12.9 yr; Gender: males=17, females=8; Time since injury=19.8±14.0 yr; Level of injury: compete paraplegia=7, incomplete paraplegia=13, complete tetraplegia=2, incomplete tetraplegia=2, unknown=1.

Intervention: Participants were randomized to either an Electronic Personal Administration of Cognitive Therapy (ePACT) group in which the participants completed 10-module skills or a Waitlist Control group with assessments at baseline, 3 mo follow-up and 6 mo follow-up.

Outcome Measures: Depression, anxiety and stress scale-short (DASS21), personal well-being index, helplessness subscale and score above normative threshold of the depression, anxiety and stress scale-short form (DASS21).

1.     71 individuals accepted the option to try the ePACT, but 12 did not complete the intake process and those that completed the intake process and those that did not only differed significantly with regards to stress scores (p=0.05).

2.     No significant differences between groups at baseline besides for time since injury (p=0.02) and level of injury distribution.

3.     Dropouts from the intervention group did not differ significantly from those that did not drop out in any outcome measure.

4.     At post-intervention, the ePACT group showed a significant reduction in depression, anxiety and stress and satisfaction with life significantly improved (p<0.05 for all) while the waitlist control group improved significantly with a reduction in depression (p=0.01).

5.     Significant reductions in depression, anxiety and stress were maintained from post-intervention to 6 mo follow-up, and even reduced even more, albeit insignificantly.

Dorstyn et al., (2012)

Australia

RCT

PEDro=6

N=40

Population: Age=53.5yr; Gender: males=69%, females=31%; Level of injury: paraplegia=24, tetraplegia=16.

Intervention: Individuals with SCI were randomly assigned to receive telecounselling or standard inpatient care. Individuals in the treatment group received 12 weeks of biweekly phone motivational interviewing intervention for 20 mins.

Outcome Measures: Depression Anxiety Stress Scale-21 (DASS-21)

1.     Small improvement in depression (d=0.32) were seen among individuals that received telecounselling compared to standard treatment group post intervention.

2.     4 of the 8 individuals in the treatment group that reported mild, moderate or extremely severe levels of depression and/or anxiety reported no symptoms postintervention; with maintenance up to follow-up.

3.     Individuals in the standard care group reported increase in clinically significant symptoms of depression over time.

Heutink et al., (2012)

Netherlands

RCT

PEDro=6

NInitial=61 NFinal=59

Population: Mean age=58.8 yr; Gender: males=39, females=22; Duration of pain=5.4 yr; Type of pain=neuropathic.

Intervention: Individuals with SCI with chronic neuropathic pain were randomly assigned to receive interdisciplinary pain management which included Cognitive Behavioural Therapy (CBT) and education or wait list control group. The intervention consisted of 10 sessions over 10 week period with a comeback session 3 weeks after the 10th session.

Outcome Measures: Chronic Pain Grade Questionnaire; Hospital Anxiety and Depression Scale (HADS).

1.     No significant difference in HADS depression was seen between the two groups or over time.

Duchnick et al., (2009)

USA

RCT

PEDro=4

N=40

Population: Coping effectiveness training (CET): Mean age=50.8yr; Gender: males=95%; Level of injury: tetraplegia=40%; Severity of injury: AIS A=30%; B=30%; C=5%; D=35%; Supportive group therapy (SGT): Mean age=54.6yr; Gender: males=100%; Level of injury: tetraplegia=70%; Severity of injury: AIS A=20%, B=20%, C=20%, D=40%. Depression status=mild (no severe psychiatric condition score based on Mini-Mental State Examination).

Intervention: Participants were randomly allocated into either the CET group or the SGT group. Each inpatient group met 1x/wk for 60 min. The CET group focused on: stress and appraisal, problem solving, communication skills, behavioral strategies, cognitive strategies and social support/assertiveness. SGT group emphasized the sharing of experiences and information related to SCI, emotional and cognitive reactions, and support and education from peers and psychologist.

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D), State Trait Anxiety Inventory (STAI).

1.     No baseline differences were found.

2.     Mood change was not affected by treatment condition.

1.     Significant decrease in depression (CES-D) was seen at discharge (p<0.05). However, depression (p<0.05) increased significantly between discharge and follow-up (3 mo).

Schulz et al., (2009)

USA

RCT

PEDro=6

N=346

Population: Mean age=53 yr; Mean time since injury=8 yr.

Intervention: Participants with SCI and their caregivers were randomly placed into 3 groups: caregiver only intervention; dual target intervention; information only control condition. Interventions were provided through computer telephone over a 6 mo period. The intervention involved knowledge and cognitive behavioural skills for coping with SCI.

Outcome Measures: Center for Epidemiologic Studies Depression Scale (CES-D), health symptoms, self-care problems, social integration.

2.     Significant improvement in individuals with SCI’s CES-D and health symptoms were seen in the dual treatment group compared to the caregiver only group (p=0.014 versus p=0.031).

2.     Clinically significant improvement was also seen in caregivers in the dual target group compared to the caregiver only and control group on CES-D, burden, health symptoms.

Li et al., (2019)

China

Pre-Post

N=20

Population: Intervention group (n=9): Mean age=41.7±8.1 yr; Gender: males=9, females=0; Time since injury=8.1±4.1 mo; Level of injury: paraplegia=5, tetraplegia=4; Severity of injury: complete=5, incomplete=4.

Comparison group (n=11): Mean age=43.0±15.7 yr; Gender: males=11, females=0; Time since injury=8.2±4.1 mo; Level of injury: paraplegia=7, tetraplegia=4; Severity of injury: complete=5, incomplete=6.

Intervention: Participants were assigned to either an 8-wk coping oriented supportive program (COSP) or a comparison group going about their usual business.

Outcome Measures: Feasibility, acceptability, brief coping orientations to problems experienced inventory, experienced inventory, Moorong self-efficacy scale, hospital anxiety and depression scale (HADS), quality of life enjoyment and satisfaction questionnaire – short form and six-item social support questionnaire.

1.     Recruitment rate of this study was 88% and the retention rate was 100%, but 2 participants in the COSP group did not attend the minimum number of sessions necessary for analysis.

2.     Participants reported that the meeting times and the length of each meeting were very appropriate, while one participant mentioned meeting more frequently on a weekly basis.

3.     Encouragement and support from peers were reported as motivation enhancers and enjoyed the communication during the meetings.

4.     Significantly higher self-efficacy scores in the COSP group compared to the comparison group (p=0.048).

5.     Statistically significant effects of the COSP on participant’s life enjoyment and satisfaction (p=0.005) and satisfaction of social support (p=0.022).

6.     Statistically significant improvements in self-efficacy (p=0.008), depression (p=0.007) and satisfaction with medicine (p=0.046) for the COSP group, but not the comparison group.

Dear et al.,(2018)

Australia

Pre-Post

N=68

Population: Mean age=48.0±13.0 yr; Gender: males=34, females=34; Time since injury=8.0±10.0 yr; Severity of injury: complete=15, incomplete=44, unsure=9.

Intervention: Participants completed five online lessons and homework tasks for pain management with weekly support from a clinical psychologist.

Outcome Measures: Pain disability index (PDI), patient health questionnaire 9-item (PHQ-9), generalized anxiety disorder scale 7-item), Wisconsin brief pain questionnaire (WBPQ), pain self-efficacy questionnaire (PSEQ), pain catastrophizing scale (PCS), satisfaction with life scale (SWLS).

1.     Significant overall effect observed for pain-related disability (p<0.001), anxiety (p<0.001) and depression (p<0.001), as well as improvements in all three from baseline to post-treatment (p<0.001) and even further improvements at 3-mo follow-up (p<0.015).

2.     Significant overall time effect observed for pain self-efficacy (p<0.001), pain catastrophizing (p<0.001) and life satisfaction (p<0.001).

7.     Significant improvements from baseline to post-treatment for pain catastrophizing and life satisfaction (p<0.001) with life satisfaction improving from post-treatment to follow-up (p=0.006) but not pain catastrophizing (p=0.062).

Verwer et al., (2016)

Netherlands

Pre-Post

NInitial=14 NFinal=7

Population: Mean age=44.7 yr; Gender: males=11, females=3; Time since injury=15 mo; Level of injury: paraplegia=10, tetraplegia/unknown=4; Severity of injury: complete=6, incomplete=8.

Intervention: Participants engaged in an online self-help program called Psyfit in which they were asked to complete 2 of 6 modules with 4 wk given to complete each module and assesments taken pre-intervention, post-intervention and at 3-mo follow-up.

Outcome Measures: Adherence, satisfaction, mental health inventory-5 (MHI-5), center for epidemiological studies depression scale (CES-D), and the Warwick-Edinburgh mental well-being scale.

1.     75% of the participants completed the first module and 39% completed the second, 11 participants finished 50% or more of the first module and 7 completed the entire first module and started with the second module and these were considered the study completers.

2.     Five of the seven completers reported that the program was good and they would recommend it to others.

3.     The main criticism was that the program was not specified to SCI participants enough, and the other was that the program modules were too long and rigid, making them difficult to want to complete.

3.     Study completers showed significant improvements in the MHI-5 scores from pre- to post-intervention (p<0.05) and all scores decreased significantly between post-intervention and 3-mo follow-up (p<0.05), resulting in no significant difference from pre-intervention to 3-mo follow-up (p>0.05).

Heutink et al., (2014)

Netherlands

Follow-Up

N=29

Population: Mean age=56.5yr; Gender: males=21, females=8; Level of injury: paraplegia=18, quadriplegia=11; Severity of injury: incomplete=14, complete=15; Mean time post injury=5.4yr; Depression status=symptoms.

Intervention: Participants who received treatment in Heutink et al.,(2012) were assessed at 6, 9, and 12mo follow-up.

Outcome Measures: Hospital Anxiety & Depression Scale (HADS).

1.     HADS-depression scores did not change over time.

Dorstyn et al., (2011)

Australia

PCT

N=24

 

Population: Treatment: Mean age=53.2yr; Gender: males=9, females=2; Level of injury: paraplegia=6, quadriplegia=5; Severity of injury: complete=8, incomplete=3; Control: Mean age=44.5yr; Gender: males=11, females=2; Level of injury: paraplegia=8, quadriplegia=5; Severity of injury: complete=11, incomplete=2;

Intervention: Individuals were assessed using the Depression Anxiety Stress Scale-21 (DASS-21). Those with subclinical DASS-21 scores were placed in the control group. Those with moderate to severe scores were offered individual Cognitive Behavioural Therapy (CBT) treatment for a range of 7 to 22 sessions for 30-60mins each. These individuals were also prescribed low dose amitriptyline as well as 5 control participants for neuropathic pain.

Outcome Measures: Depression Anxiety Stress Scale-21 (DASS-21)

1.     Mood had no effect on functional independence measure outcomes at admission or discharge.

2.     Total DASS-21 scores did not change significantly over time in the treatment group however, depression subscores varied significantly.

3.     Mean depression subscores decreased significantly post interventions; however increased significantly at 3 mo follow-up.

3.     At 3 mo follow-up, 78% of individuals in the treatment group met clinical levels of caseness on the DASS-21; only 1 individual in the control group met these criteria.

Migliorini et al., (2011)

Australia

Pre-Post

N=3

Population: Age range=41-65yr; males=2, females=1; Severity of injury: incomplete=2, complete=1

Intervention: Participants were offered a computer based Cognitive Behavioural Therapy (CBT) intervention involving 10 modules.

Outcome Measures: Depression Anxiety Stress Scale-21 (DASS-21), PWI, SCL EWQ

1.     A reduction in DASS-21 depression and stress scale was seen in 2 Individuals; anxiety scale in all three individuals.

2.     Overall quality of life improved in 1 individual and remained the same in 2 individuals.

Perry et al., (2010)

Australia

PCT

N=36

 

Population: Mean age=43.8yr; M/F=28/8; Level of injury: tetraplegia=13, paraplegia=20, Severity of injury: complete=13, incomplete=23; Duration of pain=60.5 mo; Type of pain=mixed.

Intervention: Individuals with SCI and chronic pain were placed in either the multidisciplinary cognitive behavioural pain management program (PMPs) group which involved a pharmacological treatment plan and individual and group based CBT for pain; or the usual care group.

Outcome Measures: Hospital Anxiety and Depression Scale (HADS).

1.     A trend towards improvement on the HADS depression score was seen in the PMP group at 1 mo post treatment; however, the HADS depression scores returned to pre-treatment levels at 9 mo follow-up.

Norrbrink Budh et al., (2006)

Sweden

PCT

N=38

 

Population: Treatment: Mean age=53.2yr; Gender: males=9, females=18; Level of injury: C=15, Th=6, L/S=6; Severity of injury: AIS: A=4, C=3, D=19, E=1; Controls: Mean age=49.9yr; Gender: males=5, females=6; Level of injury: C=4, Th=7; Severity of injury: AIS: A=6, D=5; Depression status=mixed.

Intervention: The intervention group received education, Cognitive Behavioural Therapy (CBT), relaxation and body awareness training totaling 5 hr/wk for 10 wk while matched controls received no treatment for neuropathic pain. Depression was assessed as a secondary outcome.

Outcome Measures: Hospital Anxiety and Depression Scale (HADS).

1.     At 1 yr follow up, the sign test showed no significant change in depression levels HADS in the treatment group from baseline.

2.     However, the treatment group showed systematic decrease in depression as measured by relative change in position (95% confidence interval) at 1 yr follow up.

3.     Depression also decreased systematically in the treatment group compared to the control group at 1 yr follow up; however, the sign test showed no significant change

Kennedy et al., (2003)

United Kingdom

Cohort

NInitial=85; NFinal=85

Population: SCI: Age=16-65 yr; Cause of injury: trauma; Chronicity=acute. Depression status=mild (BDI=15)

Intervention: Consisted of 60-75 min sessions 2x/wk for 3.5 wk in small groups of 6-9 participants. Session topics were: normalizing stress, appraisal skills, problem solving, examination of thoughts feeling and behavior, awareness of negative assumptions, and choosing appropriate ways both to cope and to increase social supports.

Outcome Measures: Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI), Coping Strategies Scale (CSS), Self-Perception Scale (SPS), and Functional Impairment Measure (FIM). Measures were taken before and immediately after the intervention, and at a 6wk follow-up with the intervention group, and every 6 weeks with the historic control group.

1.     Mood: Depression scores decreased for the intervention group following the intervention (p=0.001).
Craig et al., (1999)
Australia

Case Control

NInitial=58; NFinal=58

Population: SCI: Age=16-73 yr; Gender: males=57, females=12; Severity of injury: complete=68%-71%; Chronicity=acute. Depression status=mixed group.

Intervention: 10 wk in small groups. Each session lasted 1.5-2 hrs replacing normal rehab therapy. Individuals underwent Cognitive Behavioural Therapy (CBT) attempts to change behaviour and feeling associated with the problem and considered maladaptive. Main aim of the program was to provide cognitive and behavioural skills to cope with the psychological and social difficulties encountered upon entering the community (as described above).

Outcome Measures: Re-admissions, drug usage, relationships, social discrimination, self-reports of adjustment

Percentages are reported for each area measured.

1.     Re-admission: More control were readmitted following discharge (p<0.05).

2.     Drug usage: Controls were found to have higher self-reported drug usage than the treatment group (cases) (p<0.05).

3.     Relationships and Social discrimination: No significant differences were noted between the two groups in relation to the types of relationship each person developed.

Self-reports of adjustment: Treatment groups said they had a higher number of persons who felt they had adjusted well compared to the controls (p<0.01).

King & Kennedy (1999)

United Kingdom

PCT

NInitial=38; NFinal=38

Population: Age=16-65 yr; Chronicity=acute; Depression status=mild

Intervention: Consisted of 60-75 min sessions 2x/wk with 6-9 people. Sessions included a mixture of didactic presentations, practical exercises and time allocated for open group discussions. Following components made up the program: appraisal training, cognitive behavioural coping skills training, and strategies for choosing an adaptive match between appraisals and coping skills, and obtaining and maintaining social support.

Outcome Measures: Functional Impairment Measure (FIM), Social Support Questionnaire (SSQ), Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI), COPE.

Pre-intervention comparisons of groups:

1.     The intervention group used religion significantly more and humour significantly less as coping strategies (p<0.05) than did controls.

2.     There were no pre-intervention differences between the groups on range of injury, social support, FIM scores, other coping strategies, depression or anxiety.

Post-intervention comparison of groups:

1.     Across time there were significant decrease in the depression scores (p<0.05).

 

Craig et al., (1998a)

Australia

Cohort

NInitial=69; NFinal=58

 

Population: Treatment: Mean age=31yr; Gender: males=23; females=5; Depression status=mixed group

Intervention: 10 wk inpatient program. Small groups (4-5/group) for 1.5 hr/wk. Major aim was to provide cognitive and behavioural skills to cope with the psychological and social difficulties encountered upon entering the community. Cognitive Behavioural Therapy (CBT) included muscle relaxation, visualization techniques, self-hypnosis and cognitive restructuring, social skills and assertiveness training, and sexuality sessions.

Outcome Measures: State Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI).

1.     Significant differences noted for depression overall, (p<0.05).

2.     Both the treatment and the control groups appeared to be less depressed 1 and 2 yr after injury.

3.     For individuals who scored high on the depression scale before therapy, (9 from each group) there were significant differences after treatment. (p<.01) with the control group reporting higher levels of depressive mood.

1.     Depressive mood scores showed significant differences across time (p<0.01) with scores 1 and 2 yr post injury significantly lower than pretreatment scores (p<0.01).

Craig et al., (1997)

Australia

PCT

N=69

Population: SCI: Age=16-73 yr; Gender: males=57, females=12; Severity of injury: complete=68%-71%; Chronicity=acute. Depression status=mixed group

Intervention: 10 wk program. Small groups (4-5/group), for 1.5 hr/wk. Provided cognitive and behavioural skills to cope with the psychological and social difficulties encountered upon entering the community. Cognitive Behavioural Therapy (CBT) included muscle relaxation, visualization techniques, self-hypnosis and cognitive restructuring, social skills and assertiveness training, and sexuality sessions.

Outcome Measures: State Trait Anxiety Inventory (STAI), Beck Depression Inventory( BDI), Rosenberg Self-Esteem scale.

2.     Significantly greater self-esteem for treatment group (p<0.01). Taking this into account, no significant differences between the groups were found immediately after injury or 1 yr later.

3.     No significant initial differences were found between the groups on anxiety and depression when comparing pre, post and 1 yr scores.

4.     BDI scores were significantly lower for both conditions 1 yr after injury (p=0.014).

5.     Those who scored>14 on the depressive mood scale were analyzed using repeated measures ANOVA. 22 persons (from both groups) were examined. Significant differences were noted between the groups (p<0.01).

6.     Significant differences were also noted across time for the BDI scores (p<0.01). Post hoc tests showed that the treatment group had significantly greater levels of improvement across time (p<0.05).

Table 1. Systematic Reviews and Meta-Analysis: All Treatments

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Authors Year

Country

Date of Studies Included

AMSTAR Score

Total Sample Size

Method Conclusions
 

Dorstyn et al. (2011)

Australia

Review of published articles between January 1980 and April 2010

AMSTAR=10

N=10

Method: Comprehensive literature search of English RCT, Cohort studies, case series, and review articles of traumatic SCI in adult age group (18+yr).

Databases: MEDLINE, Psych Info, Cochrane Library, Meditext, CINAHL, Scopus.

Level of evidence: Effect sizes were provided

Questions/measures/hypothesis:

Examine the effectiveness of cognitive behavioural therapy (CBT) in improving psychological outcomes post SCI.

1.     Effect sizes for assertiveness, coping, self-efficacy, depression, acceptance, anxiety, locus of control and self-esteem ranged from very small to large post CBT treatment.

2.     Moderate to large effect sizes were seen in quality of life post CBT treatment.

 

 

 

 

 

Mehta et al., (2011)

Canada

Review of published articles between January 1990 to October 2010

AMSTAR=10

N=9

Method: Comprehensive literature search of English RCT, Cohort studies, case series, and review articles of traumatic SCI in adult age group (18+yr). A meta-analysis was conducted.

Databases: MEDLINE, Psych Info, CINAHL, EMBASE.

Level of evidence: Moderate quality: Downgraded high-quality studies, non-randomized trials, prospective cohort studies; Low quality: Retrospective observational, retrospective cohort and case-control studies; Very low quality: Case series, case reports, reviews and others. Effect sizes were provided

Questions/measures/hypothesis:

Examine the effectiveness of Cognitive Behavioural Therapy (CBT) in improving psychological outcomes post SCI.

1.     One study demonstrated large effect sizes in the improvement of depression symptoms post CBT treatment; 4 studies demonstrated moderate effects; 4 studies demonstrated small effects. These effects were shown to last for up to 2yr in individuals diagnosed with major depressive disorder prior to the intervention.

2.     Moderate effects sizes were seen on anxiety symptoms were seen in 2 studies post CBT treatment; 2 studies reported small effect sizes and 1 study reported no effect of CBT on anxiety symptoms post SCI.

3.     CBT treatment resulted in small effects on self-esteem, coping and adjustment post SCI.

 

Elliot & Kennedy (2004)

USA

Time line not stated

AMSTAR=7

N=9

 

Method: Comprehensive literature search of English RCT, Cohort studies, case series, and review articles of traumatic SCI in adult age group (18 + years).

Databases: MEDLINE, PsycInfo.

Level of evidence: Moderate quality: Downgraded high-quality studies, non-randomized trials, prospective cohort studies; Low quality: Retrospective observational, retrospective cohort and case-control studies; Very low quality: Case series, case reports, reviews and others.

Questions/measures/hypothesis:

Examine the effectiveness of depression treatment post SCI.

1.     There was moderate level evidence from 3 studies for psychological interventions in improving depressive symptoms post SCI.

2.     There was high level evidence from 1 study and low level evidence from 4 studies for the use of antidepressants for depressive symptoms post SCI.

4.     Functional electrical stimulation (FES) was supported by 1 moderate level study.

Table 3. Use of Diffusion Tensor Imaging in Those With SCI

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Author Year

Country
Research Design
Score
Total Sample Size

Methods Outcome

Choe et al., (2017)

USA

Case Control

NInitial=29

NFinal=28

 

Population: SCI (n=18): Mean age=46.72±14.47yr; Gender: males=14, females=4; Level of injury: C=18; Time since injury=9.83±11.45yr; AIS: A=3, B=2, C=6, D=7.

Healthy Controls (n=10): Mean age=33yr (range=21-49); Gender: males=6, females=4.                                    Intervention: Diffusion fiber tractography was performed on all participants with a Philips 3-T scanner using a 16-channel neurovascular coil. Images were acquired using multi-slice pulsed gradient spin echo sequence, b=0 and 500s/mm2, 16 diffusion-weighted directions that sample a prolate tensor, TR/TE=6300/63ms, SENSE factor=2, 96X96X40 volume matrix, 1.5X1.5X3mm3 resolution (axial sections of 3mm thickness; zero-filled to 0.57X0.57X3mm3), and matrix size=256X256X40. The entire length of the spinal cord serves as the field of view. Regions of interest included the following regions relative to injury (RRI); epicenter RRI (ERRI); superior RRI (SRRI) defined as the region located above the superior edge of the ERRI up to approximately one vertebral level; inferior RRI (IRRI) defined as the region below the inferior edge of the ERRI to the length of approximately one vertebral level. Diffusion Tensor Imaging (DTI) indices were also averaged over all RRI to create an all-level region (AL) value for each index. DTI indices were measured for each spinal cord column region (left, right, dorsal, and ventral columns) within each RRI (ERRI, SRRI, IRRI). The International Standard of Neurological Classification for SCI (ISNCSCI) total score was determined for each SCI participant by summing the total motor score (upper and lower motor extremity scores) and total sensory score (left and right light touch). Outcome Measures: DTI indices: Fractional Anisotropy (FA); axial diffusivity (AD); radial diffusivity.

1.     All DTI indices of different RRIs differed significantly (p<0.05).

2.     DTI indices did not differ between spinal cord columns (i.e., left, right, dorsal, and ventral columns) (p>0.05).

3.     There were no significant relationships between DTI indices and total ISNCSCI scores from different spinal cord columns (p>0.05).

4.     For the AL region, individuals with SCI had significantly decreased and increased FA and RD compared to normal controls, respectively (p<0.05). There was no significant difference in AD in the AL region (p>0.05).

D’Souza et al., (2017)

India

Case Control

N=50

Population: SCI (n=20): Mean age=35.95±10.86yr; Gender: males=14, females=6; Level of injury: C=20; Time since injury=≤7d; AIS: NR.

Healthy Controls (n=30): Mean age=35.90±10.13yr; Gender: males=20, females=10.                                     Intervention: All participants underwent Diffusion Tensor Imaging (DTI) using a single shot echo planar imaging (EPI) sequence (b-value=0,700 s/mm2) using 20 diffusion encoding directions. Images were acquired using Sagittal T1: repetition time/echo time(TR/TE)=450/9.5ms; Sagittal T2:TR/TE–3630/104ms; Axial T1: TR/TE–450/9.6ms and Axial T2: TR/TE-500/15 ms. Images were acquired in the axial plane with an image matrix of 128X128, 5mm slice thickness with no inter-slice gap, and a 280X280mm field of view. SCI participants were reassessed clinically 1-2 mo after imaging.                                                     Outcome Measures: Mean diffusivity (MD); fractional anisotropy (FA); Frankel grading system score (FGS).

1.     At the level of injury, FA was significantly lower for SCI when compared to healthy controls (p<0.001). However, MD was significantly higher for SCI at the level of injury when compared to healthy controls (p<0.001).

2.     There were no significant differences in MD and FA above and below the injury when comparing SCI to healthy controls (p>0.05).

3.     There was a statistically significant positive correlation between FA values at the level of injury and FGS (r=0.86, p<0.001). In contrast, there was no significant correlation between MD at the level of injury and FGS (p>0.05).

4.     Qualitative analysis of the cord on tractography revealed that 12 cases suggested disruption in cord integrity.

Shanmuganathan et al., (2017)

USA

Case Control

NInitial=45

NFinal=31

 

Population: SCI (n=16): Median age=53(range=20-79)yr; Gender: males=13, females=3; Level of injury: C=16; Time since injury=≤5d; The International Standard of Neurological Classification for SCI (ISNCSCI) at discharge: A=5, B=2, C=3, D=6.

Healthy Controls (n=15): Median age=46(range=26-69)yr; Gender: males=12, females=3.                                             Intervention: All participants underwent Diffusion Tensor Imaging (DTI) with a 1.5-T Avanto scanner with a 12-channel head and four-channel neck array using single-shot echo planar imaging (EPI) sequence at a TE/TR of 87/2800 msec. Sagittal T2 (echo time/ repetition time (TE/TR)=109/4000 ms), fluid attenuation inversion recovery (FLAIR) (TE/TR=102/8000 msec, echo train length (ETL)=13), and axial T2 and T2*, three-dimensional [3D] susceptibility weighted imaging (SWI) (TE/TR: 16/30msec, flip angle: 20 degrees) images were included. For SCI, Regions of interest included areas of edema (confirmed by T2 and STIR sequences) and hemorrhage (confirmed by SWI and T2* sequences). For healthy controls, regions of interest included upper (lower brainstem-lower C2), mid (upper C3-lower C5), and lower (upper C6-lower T1) regions. The International Standard of Neurological Classification for SCI (ISNCSCI) was assessed at discharge and at 1-yr follow-up.                          Outcome Measures: ISNCSCI motor score; Spinal cord independence measure III (SCIM); Radial diffusivity (RD); axial diffusivity (AD); mean diffusivity (MD); fractional anisotropy (FA).

1.     FA was significantly lower in SCI when compared to lower (p<0.001), mid (p<0.001), and upper (p<0.001) regions in healthy controls.

2.     AD was significantly lower in SCI when compared to lower (p<0.001), mid (p<0.001), and upper (p<0.001) regions in healthy controls.

3.     RD was significantly higher in SCI when compared to mid (p<0.001) and upper (p<0.001) regions of healthy controls. There was no significant difference in RD when comparing SCI to the lower region of healthy control (p>0.05).

4.     There was no significant difference in MD when comparing SCI to all regions of healthy controls (p>0.05).

5.     Pearson correlations revealed significant correlations between MD and the presence of hemorrhagic contusions (r=0.42, p<0.05), ISNCSCI motor score (r=0.66, p<0.05), and SCIM (r=0.64, p<0.05).

6.     There was a significant correlation between FA and age (r=-0.55, p<0.05).

7.     AD was significantly correlated with presence of hemorrhagic contusion (r=0.42, p<0.05), ISNCSCI motor score (r=0.76, p<0.001), and SCIM (r=0.77, p<0.01).

8.     RD was significantly correlated with age (r=0.5, p<0.05) and ISNCSCI motor score (r=0.53, p<0.05).

9.     Step-wise regression revealed MD (r2=0.89, p=0.002), AD (r2=0.0.93, p<0.001), and RD (r2=0.86, p=0.014) were significant predictors of ISNCSCI motor score at the 1-year follow-up for participants with or without hemorrhage spinal cord injury. FA was not a significant predictor in the model (p>0.05).

10.   MD, AD, FA, and RD were not significant predictors of SCIM at 1-year follow-up for both hemorrhagic and non-hemorrhagic spinal cord injury (p>0.05).

Wang et al., (2016)

China

Observational

N=35

Population: SCI (n=35): Mean age=57.2yr (range=42-69); Gender: males=21, females=14; Level of injury: C=35; Time since injury=NR; AIS scale: NR.

Intervention: Imaging was performed on a 3.0T dual gradient superconductor MR with a gradient strength of 40mT/m and switching rate of 150mT/ms-1. Difusion Tensor Imaging (DTI) consisted of a single-shot spin-echo-planar sequence (b value=1000 s/mm2, repetition time/echo time=8000/87.6ms, section thickness=4mm, interlamellar spacing=0mm, bandwidth=250 kHz, field of view=180X180mm, image matrix=130X128, number of signals averaged=2. DTI grading was performed by two radiologists; Grade 1, 2, and 3 constituted mixed signal in lesion area but complete and continuous fiber bundle, abnormal signal and disordered fiber bundle in local lesion, interrupted fiber bundle, respectively. Outcome measures were evaluated before surgery and 1 yr after surgery.

Outcome Measures: Motor score; sensory score; American Spinal Injury Association (ASIA) index score (AIS).  

1.     There was a significant correlation between AIS and DTI grading before and after surgery (p<0.05, r=0.475; p<0.01, r=-0.529, respectively).

2.     There was also a significant correlation between DTI grading and motor score, as well as sensory score after surgery (p=<0.01, r=0.492; p<0.05, r=0.476, respectively).

3.     There were no significant correlations between DTI grading and motor score and sensory score before surgery (p>0.05).

Kim et al., (2015)

Korea

Case Control

N=38

Population: SCI (n=17): Mean age=47.0±13.4yr; Gender: males=11, females=6; Level of injury: C=17; Time since injury=13.1±19.9mo; Etiology: Vertebral fracture=5, compressive myelopathy=3, degenerative myelopathy=1, transverse myelopathy=2, cervical myelopathy=1, spinal cord contusion=4, ossification of posterior longitudinal ligament=1; AIS: A=4, B=1, C=2, D=10.

Healthy Controls (n=21): Mean age=38.5±15.7yr; Gender: males=13, females=8.                                            Intervention: All participants were assessed with Diffusion Tensor Imging (DTI) using a Tim 3-Tesla MR scanner with a 12-channel head coil and 4-channel neck coil. Axial images had the following parameters; repetition time/echo time (TR/TE)=5100/77ms; number of signals averaged (NEX)=10; b-value=0, 750s mm−2; diffusion direction=6; image matrix=140 X 36; field of view (FOV)=140X36 mm2; slice thickness=5 mm; total number of slices=17; voxel resolution=1.0X1.0X5mm3; bandwidth=916 Hz per pixel; and total acquisition time(TA)=6min and 2s. Sagittal T2-weighted images were acquired using a T2-weighted fast spin-echo (FSE) sequence. In the SCI participants, DTI indices were measured at the level of injury, above the injury (at least one vertebral segment above), and below the injury (at least one vertebral segment below). DTI indices of healthy controls were measured at C2-C3, C4-C5, and C6-C7 for comparison against above the injury, at the level of injury, and below the injury of SCI, respectively. DTI indices were assessed along the lateral, dorsal, and ventral regions of the spinal cord in all participants.                             Outcome Measures: AIS; American Spinal Injury Association (ASIA) motor and sensory scores; modified Barthel index score (MBI); Spinal cord independence measure III (SCIM); somatosensory evoked potentials (SEP) latency and amplitude; DTI indices: Intramedullary fractional anisotropy (FA), apparent diffusion coefficient (ADC); cerebrospinal fluid velocity (vCSF);

1.     SCI had significantly lower FA in all three regions (lateral, dorsal, ventral) and all levels (at injury, above injury, below injury) compared to healthy controls (p<0.05).

2.     SCI had significantly higher ADC in all three regions (lateral, dorsal, ventral) and at two levels (injury level and below injury) compared to healthy controls (p<0.05). However, there was no significant difference in ADC above the injury for all three regions (lateral, dorsal, ventral) (p>0.05).

3.     Peak systolic vCSF was significantly higher in SCI at the injury level when compared to healthy controls (p<0.05).

4.     Peak diastolic cCSF was significantly lower in SCI below the injury when compared to healthy controls (p<0.05).

5.     In SCI participants, FA was significantly correlated with systolic and diastolic vCSF above the injury and at the level of the injury (p<0.05). Systolic and diastolic vCSF at the injury and below the injury were significantly correlated with changes in FA at the injury level and above the injury (p<0.05)

6.     There were no significant correlations between ADC and vCSF (p>0.05).

7.     In SCI, there were significant negative correlations between both right and left ulnar nerve SEP latency and right lateral FA (r=-0.560, p=0.046; r=-0.676, p=0.041), left lateral FA (r=-0.676, p=0.011; r=-0.675, p=0.011), and dorsal FA (r=-0.641, p=0.018; r=-0.652, p=0.016).

8.     There was also a significant negative correlation between the right tibial nerve SEP latency and dorsal FA (p=0.010), as well as the left tibial nerve and both left lateral FA (r=-0.632, p=0.021) and dorsal FA (r=-0.695, p=0.008).

9.     There was a significant positive correlation between left tibial nerve SEP amplitude and ventral FA (r=0.585, p=0.036).

10.   FA of the ventral area at the level of injury was significantly correlated with ASIA sensory score (r=0.687, p=0.009).

11.   FA below the level of injury significantly correlated with AIS (r=-0.773, p=0.014) and SCIM (r=0.680, p=0.044).

12.   There was no significant correlation between both FA and ADC and ASIA motor score or MBI (p>0.05).

 

Koskinen et al., (2013)

Finland

Case Control

N=68

Population:

SCI group (n=28): Mean age: 59.9yr; Gender: males=22, females=6; Injury etiology: motor vehicle accident (n=10), fall (n=12), sports (n=3), assault (n=1), other (n=2); Level of injury: cervical=27, thoracic=1; Level of severity: AIS A=7, B=1, C=3, D=16, E=1; Mean time since injury: 13.1yr.

Healthy Control (CG) group (n=40): Mean age: 40.6yr; Gender: males=20, females=20.

Intervention: Researchers aimed to quantify the association between diffusion tensor imaging (DTI) parameters in individuals with cervical traumatic SCI.

Outcome Measures: Apparent Diffusion Coefficient (ADC), Fractional Anisotropy (FA), Radial Diffusivity (RD), International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), Functional Independence Measure (FIM).

1.     The FA values of the SCI were group were significantly lower than those of the CG group (p<0.001).

2.     ADC and RD values of the SCI group were significantly higher than those in the CG group (p<0.0001 and p<0.00001, respectively).

3.     In the SCI group, the FA values were positively correlated with the motor (p<0.01) and sensory (p<0.001) scores of ISNCSCI.

4.     In the SCI group, the FA values were positively correlated with the motor subscale of FIM (p<0.01).

5.     DTI revealed SCI pathology, which was undetectable using conventional MRI.

 Ellingson et al., (2008b)

USA

Case Control

N=8

 

 

Population: SCI (n=4): Mean age=42.25±14.04yr; Gender: NR; Level of injury: C=3, T=1; Time since injury=13±11.09yr; AIS: A=1, B=1, C=2.

Healthy Controls (n=4): Mean age=29±4.85yr; Gender: NR Intervention: Diffusion Tensor Imaging (DTI) images were obtained for all participants using a head coil and a 1.5T scanner. Twelve axial slices throughout the upper cervical spine using a single-shot EPI/SE (dual spin echo) pulse sequence were acquired with repetition time/echo time (TR/TE)=6000/88.1ms, field of view (FOV)=200 mm, and number of signals averaged (NEX)=4 (T2-weighted image only) for each participant. Images were taken rostral to the injury site and in equivalent regions for SCI and healthy participants, respectively. Morphology analysis was done by FIS tissue classification. Outcome Measures: Fractional anisotropy (FA); longitudinal apparent diffusion coefficient (LADC); transverse apparent diffusion coefficient (TADC); mean diffusivity (MD); cross-sectional area (CA).

1.     FIS images of SCI participants were less clear compared to healthy control vis-à-vis presence of distinct gray matter shape. Additionally, there seemed to be a changes in shape and decreases in size of the spinal cord in SCI comparted to controls.

2.     SCI had significantly lower TADC, LADC, and MD in gray matter (p=0.008; p=0.033; p=0.007, respectively), white matter (p=0.002; p=0.005; p<0.001, respectively), as well as individual white matter regions including the dorsal funiculus (p=0.039; p<0.001; p<0.001, respectively), and lateral funiculi (pp<0.001; p=0.01; p<0.001, respectively).

3.     There was no significant difference in TADC, LADC, and MD for cerebrospinal fluid (p>0.05).

4.     SCI had significantly smaller whole cord and white matter tract cross-sectional area compared to controls (p=0.001; p<0.001, respectively). There was no significant difference in cross-sectional area of gray matter (p=0.109).

5.     Frontal and sagittal diameters were significantly smaller in SCI (p<0.001; p=0.009, respectively), suggesting spinal cord atrophy.

 Ellingson et al., (2008a)

USA

Case Control

N=23

 

Population: SCI (n=10): Median age=37yr (range=25-67); Gender: NR; Level of injury: C=6, T=5; Time since injury=>4yr; Injury type: complete=4, incomplete=6.

Healthy Controls (n=13): Median age=25yr (range=25-67); Gender: NR Intervention: Diffusion Tensor Imaging (DTI) images of the entire spinal cord (c1-L1) were obtained for all participants using a CTL Spine Coil with anterior neck coil attachment. Images were acquired with TE/TR=96.3/6000ms, matrix size=128X128, number of signals averaged (NEX)=1, FOV=200mm, and a section thickness of 5mm with no intersection gap. Diffusion-weighted images (DWIs) were acquired with b=1500s/mm2 in 25 equidistant directions. A single T2-weighted (T2WI) (b =0s/mm2) was acquired for each section.      Outcome Measures: Fractional anisotropy (FA); Transverse apparent diffusion coefficient (TADC); longitudinal apparent diffusion coefficient (LADC); mean diffusivity (MD).

1.     Controls had higher whole cord FA compared to SCI, especially in white matter dense areas (p<0.001).

2.     Subjects with complete SCI had significantly higher TADC and MD throughout the whole spinal cord compared to subjects with incomplete SCI (p=0.011; p=0.037, respectively). However, there was no significant difference in LADC (p>0.05).

3.     Subjects with lower cervical lesions showed significantly lower TADC and MD throughout the spinal cord compared with thoracic lesions (p=0.012; p=0.019, respectively).

4.     TADC, LADC, and MD were significantly higher at the lesion in SCI compared to healthy controls (p<0.05 for all).

5.     Completeness of injury and level of injury were not significant factors for changes in LADC, TADC, and MD in the cervical spinal cord (p>0.05).

6.     There were no significant interactions between lesion level and vertebral level, as well as completeness of injury and vertebral level for TADC (p>0.05). However, FA was significantly lower in subjects with complete SCI compared to those with incomplete SCI (p<0.001).

7.     Comparisons between SCI with upper cervical lesions and healthy controls revealed significantly lower LADC, TADC, and MD for SCI at C1, C2, and C3 (p<0.05).

 

 

 

 

Shanmuganathan et al., (2008)

USA

Case Control

N=28

 

Population: SCI (n=20): Mean age=45.7±17.7yr; Gender: males=18, females=2; Level of injury: C=20; Time since injury=2hr-15d; The International Standard of Neurological Classification for SCI at discharge: A=5, B=2, C=3, D=6.

Healthy Controls (n=8): Mean age=34.2±10.7yr; Gender: males=6, females=2.                                             Intervention: All participants underwent Diffusion Tensor Imaging (DTI) with a 1.5T Avanto scanner with a 12-channel head and four-channel neck array using an echo-planar imaging (EPI) sequence at a repetition time/echo time (TR/TE) =8000/76ms and a resolution of 128X128 over a 20cm field of view (FOV). Images included sagittal T2 (TR/TE=4000/109ms), fluid-attenuated inversion recovery (TE/TR/echo train=8000/102ms/13), and axial T2 and T2* images. Regions of interest included upper (lower brainstem-lower C2), mid (upper C3-lower C5), and lower (upper C6-lower T1) regions. Medical records were reviewed to determine the extent of neurological deficit (e.g., quadriplegia, hemiplegia, radiculopathy, etc.).                         Outcome Measures: Apparent diffusion coefficient (ADC); fractional anisotropy (FA); relative anisotropy (RA); volume ratio (VR).

1.     ADC was significantly lower in the SCI group in the upper (p=0.013), mid (p<0.001), and lower (p<0.001) regions when compared to healthy controls.

2.     There were no significant differences in FA when comparing SCI to healthy controls at all three regions (p>0.05).

3.     SCI showed significantly lower RA in the mid region when compared to healthy controls (p=0.037). There was no significant difference in RA for the upper and lower regions (p>0.05).

4.     There were no significant differences in VR when comparing SCI to healthy controls at all three regions (p>0.05).

5.     Whole cord Diffusion Tenor Imaging parameters showed significantly lower ADC and RA in participants with SCI (p<0.001; p=0.022, respectively).

6.     Whole cord ADC, FA, and RA were significantly lower in SCI with hemorrhage compared to controls (p<0.001; p=0.0037; p<0.001, respectively). However, VR was significantly higher (p=0.008).

7.     Only whole cord ADC and RA were significantly higher in quadriplegic SCI compared to healthy controls (p<0.001; p=0.023, respectively).

8.     ADC, FA, and RA parameters at the injury site of all SCI were significantly lower compared to whole-cord healthy control Diffusion Tensor Imaging parameters (p=0.031; p<0.001; p<0.001, respectively). Whereas VR was significantly higher at the injury site (p<0.001).

Facon et al.,  (2005)

France

Case Control

N=26

Population: SCI group (n=15): Mean age: 53.9yr; Gender: males=10, females=5; Injury etiology: metastasis (n=4), degenerative (n=6), spondylodiscitis (n=5); Level of injury: C1-L1; Time since injury: >4yr.

Healthy Control (CG) group (n=11): Mean age: 36.7yr; Gender: males=8, females=3.

Intervention: Researchers aimed to evaluate the diagnostic accuracy of diffusion tensor imaging (DTI) in individuals with SCI and healthy controls. Comparisons were also made against T2-weighted fast spin echo (FSE).

Outcome Measures: Apparent Diffusion Coefficient (ADC), Fractional Anisotropy (FA).

1.     For the healthy subjects, averaged ADC values ranged from 0.00096mm2/s to 0.00105mm2/s and averaged FA values ranged from 0.745 to 0.751.

2.     Ten individuals had decreased FA (0.67), and one had increased FA values (0.831); only two individuals had increased ADC values (1.03).

3.     There was a statistically significant difference in the FA values CG and SCI groups (p=0.012).

4.     FA had a much higher sensitivity (SE=73.3%) and specificity (SP=100%) in spinal cord abnormalities detection compared with T2-weighted FSE imaging (SE=46.7%, SP=100%) and ADC (SE=13.4%, SP=80%).

Table 1. Diagnosis and Prognostication with MRI

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Author Year

Country
Research Design
Score
Total Sample Size

Methods Outcome
Diagnostic Value

Yasin et al., (2017)

Pakistan

Observational

N=38

 

Population: SCI (n=10): Mean age=28.35±7.67yr; Gender: males=31, females=7; Level of injury: C=12, L=16; Mean time since injury=4.98±3.84d; AIS scale: NR.

Intervention: Individuals suspected of SCI underwent magnetic resonance imaging (MRI) for diagnosis.

Outcome Measures: Sensitivity; specificity; predictive value; diagnostic accuracy.

1.     MRI is a highly sensitive and accurate technique

2.     Sensitivity=96.55%

3.     Specificity=88.89%

4.     Predictive value=96.55%

5.     Diagnostic accuracy=94.74%

Ghasemi et al., (2015)

Iran

Observational

N=40

 

Population: SCI (n=40): Mean age(men)=43.56±18.82yr; Mean age(women)=48.47±20.45yr; Gender: males=25, females=15; Level of injury: C=3, T=9, L=14; thoracolumbarsacral=3; unaffected=11; Mean time since injury=≤24hr; AIS scale: NR.

Intervention: Two stages of magnetic resonance imaging (MRI) was performed on all individuals (one with contrast and one without). MRI was obtained using a 1.5T system with a spine coil. Images were acquired using sagittal T1 and T2 sequences. Psychometrics were obtained for various spinal cord injury patterns.

Outcome Measures: Specificity; positive predictive value (PPV); negative predictive value (NPV); positive likelihood (PL); negative likelihood (NL).

1.     For SCI with edema, MRI without contrast had specificity, PPV, NPV, PL, and NL of 75%, 100%, 100%, 94.11%, and 68.4%, respectively.

2.     For SCI with edema MRI with contrast had specificity, PPV, NPV, PL, and NL of 100%, 100%, 100%, 100%, and 0%, respectively.

3.     For SCI with hemorrhage, MRI without contrast had specificity, PPV, NPV, PL, and NL of 100%,100%,100%, 100%, and 0%, respectively.

4.     For SCI with hemorrhage, MRI with contrast had specificity, PPV, NPV, PL, and NL of 50%, 100%, 100%, 0.44%, and 13%, respectively.

5.     For SCI with combination of hemorrhage and edema, MRI without contrast had specificity, PPV, NPV, PL, and NL of 0%, 100%, 0%, 0.60%, and 6%, respectively.

6.     For SCI with combination of hemorrhage and edema, MRI with contrast had specificity, PPV, NPV, PL, and NL of 100%, 100%, 100%, 100%, and 0%, respectively.

Karpova et al., (2013)

Canada

Case series

N=17

Population: Cervical Myelopathy (n=17): Mean age=54.5yr; Gender: males=13, females=4.

Intervention: To assess the intra-and inter-observer reliability of commonly used quantitative magnetic resonance imaging (MRI) measures such as transverse area (TA), compression ratio (CR), maximum canal compromise (MCC), maximum spinal cord compression (MSCC).

Outcome Measures: Intra-class correlation coefficients (ICC).

1.     The mean±SD for intra-observer ICC was 0.88±0.1 for MCC, 0.76±0.08 for MSCC, 0.92±0.07 for TA, and 0.82±0.13 for CR.

2.     Additionally, inter-observer ICC was 0.75±0.04 for MCC, 0.79±0.09 for MSCC, 0.80±0.05 for CR, and 0.86±0.03 for TA.

Prognostication

Seif et al., (2018)

Switzerland

Case Control

N=47

 

Population: SCI (n=24): Mean age=49.7±19.8yr; Gender: males=19, females=5; Level of injury: C=12, T=9, L=2, S=1; Mean time since injury=45.6±20.7d; AIS scale: A=6, B=5, C=4, D=9.

Healthy controls (n=23): Mean age=35.9±10.9yr; Gender: males=13, females=10; Level of injury: N/A; Time since injury=N/A; AIS scale: N/A. Intervention: All participants underwent magnetic resonance imaging (MRI) using a 3T system. Sequences included T1-weighted 3D magnetization Prepared Rapid Acquisition Gradient-Echo (IMPRAGE) of the whole brain extending to the cervical C5 level (field of view=224 X 256, matrix=224 X 256, repetition time/echo (TR/TE)=2420/4.18 ms, bandwidth=150 hz/pixel). Microstructural changes were assessed with three different 3D multi-echo fast low-angle shot (FLASH) gradient-echo sequences. Participants were assessed at baseline, 2, 6, 12, and 24 mo post-SCI.

Outcome Measures: Cross-sectional spinal cord area (SCA); anterior-posterior width (APW); left-right width (LRW); lower extremity motor score (LEM); Microstructural parameters: magnetization transfer (MT); longitudinal relaxation rate (R1); effective transverse relaxation rate (R2).

1.     There was a significant association between baseline APW and LEM at 2 mo (r2=0.97, p=0.03).

2.     There was also a significant association between RI of the cord and pinprick score at 12 mo (r2=0.71, p=0.04).

3.     SCA (p=0.004) and APW (p=0.005) were significantly lower compared to controls at baseline. There was no significant difference in LRW between the two groups at baseline (p=0.67).

4.     There were no significant differences in microstructural measures of MT, R1, and R2 in the cervical cord when comparing SCI to controls (p>0.05).

Dalkilic et al., (2018)

Canada

Observational

NInitial=36

NFinal=34

Population: SCI (n=36): Mean age=42.1±13yr; Gender: males=23, females=13; Level of injury: C=36; Mean time since injury=12.87hr; AIS: A=20, B=7, C=9.

Intervention: Individuals were assessed using magnetic resonance imaging (MRI) pre-operatively with a 1.5T MRI system. Conventional MRI sequences included were fast-spin-echo (FSE) T1-weighted sagittal image with repetition time/echo time(TR/TE) =533/10ms, T2-weighted sagittal image with TR/TE=3000/84ms, FSE T2-weighted axial image with TR/TE=3390/98ms, and T2 gradient echo weighted axial image with TR/TE=1030/24ms. AIS grade was assessed pre-operatively (baseline) and 6mo post-injury. Outcome measures below were assessed by MRI.  

Outcome Measures: Intramedullary lesion length (IMLL); hematoma length; CSF effacement length; cord expansion length; maximal cord compression (MCC).

1.     Hematoma length (p=0.006), CSF effacement length (p=0.007), and cord expansion length (p=0.031) differed significantly between individuals with baseline AIS grades A, B, and C. There were no significant differences in IMLL and MCC (p>0.05).

2.     A logistic regression model of MRI found that only CSF effacement and hematoma length were statistically significant predictors of baseline AIS grade (p<0.05). The model had 72.2% accuracy for AIS grade classification.

3.     IMLL (p=0.031) and hematoma length (p=0.002) were significantly higher in individuals who converted their AIS grade within 6mo compared to those who did not. CSF effacement, cord expansion length, and MCC did not differ significantly between the two groups (p>0.05).

Aarabi et al., (2017)

USA

Observational

N=100

 

Population: SCI (n=100): Mean age=39.5±16.8yr; Gender: males=89, females=11; Level of injury: C=100; Time since injury: ≤12hr=51, >12hr=49; AIS: A=52, B=29, C=19.

Intervention: Individuals who underwent surgical spinal cord decompression were included in this longitudinal, retrospective study. AIS grade was re-evaluated at 6wk, 3mo, 6mo, and 12mo following discharge.  Post-operative magnetic resonance imaging (MRI) was used to assess outcome measures. Outcome measures below were assessed by MRI.

Outcome Measures: AIS grade conversion at 6mo post-surgery; Intramedullary lesion length (IMLL); evidence of decompression; presence of intramedullary hematomas.

1.     IMLL was a significant predictor of AIS impairment scale grade conversion at 6mo in univariate (p<0.001) and sole predictor in multivariate (OR=0.950, CI: 0.931-0.969) analysis. The multivariate model predicted 5% and 40% decreases in the odds of AIS scale grade conversion for 1-and 10mm increases in IMLL, respectively.

2.     Univariate analysis showed that the presence of intramedullary and evidence of decompression were significantly related to AIS grade conversion at 6mo (p<0.001), however, were not significant in multivariate analysis (stepwise multiple logistic regression) (p>0.05).

Martinez-Perez et al., (2017)

Canada

Observational

N=86

 

Population: Incomplete SCI (n=86): Mean age=47.6yr (range=18-87); Gender: males=68, females=18; Level of injury: C=86; Time since injury=<72hr for all; AIS at admission: B=12, C=29, D=35, E=38.

Intervention: This retrospective review examined individuals who presented with acute incomplete cervical SCI secondary to blunt trauma. Magnetic resonance imaging (MRI) was performed at initial diagnosis using a 1.5T system. Axial and sagittal planes had a slice thickness of 3mm. Image sequences included axial T1-weighted, T2-weighted, and gradient echo images, as well as sagittal T1-weighted, T2-weighted, and short tau inversion recovery (STIR). AIS assessments were done initial examination and 1yr follow-up. Outcome measure below were assessed by MRI.

Outcome Measures: Length of edema (LOE); intramedullary hemorrhage; AIS

1.     LOE >36mm was significantly associated with poor neurological outcome (i.e., no improvement in AIS).

2.     There was no significant difference in intramedullary hemorrhage when comparing individuals who had AIS improvement and those who did not (p>0.05).

Matsushita et al., (2017)

Japan

Observational

N=102

 

Population: SCI (n=102): Mean age=62.36yr (range=16-86); Gender: males=88, females=14; Level of injury: C=102; Time since injury=<72h for all AIS scale: A=32, B=15, C=42, D=13.

Intervention: Individuals presenting with acute cervical SCI were included in the study. Magnetic resonance imaging (MRI) was performed using a 1.5T system with sagittal T2-weighted images (fast-recovery fast spin echo, echo train length=15, receiver bandwidth=150Hz/Px, matrix=384 X 229, section thickness=3mm, field of view=24cm).  American Spinal Injury Association motor score (AMS) and modified Frankel D grade were assessed at admission and discharge.

Outcome Measures: Increased intramedullary signal intensity (ISI); American Spinal Injury Association score (AMS); Frankel D score.

1.     There was a significant negative correlation between ISI and AMS at both admission (r=-0.3766, p<0.001) and discharge (r=-0.4240, p<0.001) for individuals admitted within 1 day of SCI.

2.     There was also a significant negative correlation between ISI and AMS at both admission (r=-0.6840, p<0.001) and discharge (r=-0.5293, p<0.01) for individuals admitted 2-3 days of SCI.

3.     Receiver operating characteristic curve analysis determined an optimal ISI cut-off of 45mm for high versus low Frankel D score (i.e., not walking versus walking, respectively) in individuals who were admitted 2-3 days after SCI. With this cut-off, there was a significant positive correlation between ISI and being able to walk (p<0.001).

Song et al., (2016)

Korea

Observational

N=102

 

Population: Complete SCI (n=10): Mean age=55.4yr (range=23-79); Gender: males=8, females=2; Level of injury: C=10; Time since injury=<12hr for all; AIS scale: A=10.

Incomplete SCI (n=75): Mean age=57.2yr (range=28-87); Gender: males=65, females=10; Level of injury: C=75; Time since injury=<12hr for all; AIS scale: B=NR, C=NR, D=NR. Neurologically intact (n=17): Mean age=54.3yr (range=24-71); Gender: males=14, females=4; Level of injury: C=17; Time since injury=<12hr for all; AIS scale: E=17.

Intervention: Medical records of individuals who underwent magnetic resonance imaging (MRI) scans for suspected spinal cord injury were assessed.                                   Outcome Measures: Maximum spinal canal compression (MSCC); maximum cord compression (MCC); intramedullary lesion length (IMLL); intramedullary hemorrhage; spinal cord edema.

1.     There was no significant difference in MSCC across the three groups (p=0.085).

2.     Complete SCI showed significantly higher MCC compared to the other two groups (p<0.001).

3.     Intramedullary hemorrhage and edema had significantly greater incidence in complete SCI compared to incomplete SCI and neurologically intact individuals (p<0.001).

Zohrabian et al., (2016)

USA

Observational

N=108

 

Population: SCI (n=108): Mean age=48.9±20.9yr; Gender: NR; Level of injury: C=108, L=16; Time since injury=<72hr for all; AIS scale: NR.

Intervention: Individuals suspected of SCI underwent neurological examination and diagnostic-quality magnetic resonance imaging (MRI) of the cervical spine.

Outcome Measures: upper and lower boundaries of edema; lesion epicenter; upper and lower boundaries of cord hemorrhage; neurological level of injury (NLI).     

1.     All outcome measures showed statistically significant positive correlations with NLI.

2.     Upper (r=0.72, p<0.01) and lower (r=0.61, p<0.01) boundaries of hemorrhage had the strongest correlation with NLI.

3.     Bland-Altman analysis demonstrated that upper boundary of cord hemorrhage demonstrated the best agreement with NLI (p<0.01).

Schroeder et al., (2016)

USA

Observational

N=75

Population: Increased T2 signal (n=32): Mean age: 57.1yr; Gender: males=19, females=13; Injury etiology: fall=24, motor vehicle accident=6, diving=; 2 Level of severity: mean Glasgow coma scale=15.0, mean injury severity score=22.2.

No increase in T2 signal (n=43): Mean age: 57.3yr; Gender: males=31, females=12; Injury etiology: fall=31, motor vehicle accident=8, diving=2, sports=1, other=1; Level of severity: mean Glasgow coma scale=15.0, mean injury severity score=16.8.

Intervention: Individuals with central cord syndrome were stratified based on presence of signal intensity on magnetic resonance imaging (MRI). Physician progress notes were reviewed for outcomes 1 wk post-injury.

Outcome Measures: American Spinal Injury Association (ASIA) Motor Score (AMS), Surgery, Severity of injury.

1.     Individuals in the increased signal group had more severe neurological injury on AMS at admission (p=0.01).

2.     Throughout the wk, individuals with increased signal intensity maintained stable AMS whereas individuals without increased signal intensity on MRI declined within the first wk (p=0.07).

3.     Individuals with increased signal intensity tended to experience less severe mechanism of injury through less major (p=0.09) and minor (p=0.15) injuries.

4.     Incidence of surgical treatment and decompression was similar between both groups (p=0.99, p=0.10).

5.     Individuals with increased signal intensity on MRI spent longer time in the ICU (p=0.001), but there was no difference in length of stay (p=0.22).

6.     There was no significant relationship of age, sex, injury severity score, stenosis, or surgery with AMS (p>0.05).

Mabray et al., (2016)

USA

Observational

N=25

Population: SCI (n=25): Mean age=38.32±15.74yr; Gender: males=17, females=8; Level of injury: T=24, without detectable injury=1; Mean time since injury=14.68±18.56hr; AIS at admission: A=11, B=2, C=, D=6, E=5.

Intervention: This retrospective cohort study examined individuals who presented with acute thoracic or thoracolumbar SCI. MRI was performed at initial diagnosis using a 1.5T system. Images included sagittal T1 (slice thickness=3 mm, time to repetition/time to echo (TR/TE)=520-630/9-15ms, echo train length (ETL)=3, field of view (FOV)=30 cm2, acquisition matrix=512 X 512), sagittal T2 (slice thickness=3mm, TR/TE=3100-4000/105-120ms, ETL=19-21, FOV=30cm2, acquisition matrix=512 X 512), and axial T2 sequences (slice thickness=4 mm, TR/TE=4000-4800/102-120 ms, ETL=25, FOV=18 cm, acquisition matrix=512 X 512). AIS was assessed upon admission and at discharge. Outcome measures below were assessed by MRI.

Outcome Measures: Brain and Spinal Cord Injury Center (BASIC) grade; Maximum canal compromise (MCC); Maximum spinal cord compression (MSCC); greatest longitudinal extent of injury (LEI); sagittal grade.

1.     Sagittal grade (rho=-0.83, p<0.001), LEI (rho=-0.83, p<0.001), and BASIC (rho =-0.93, p<0.001) showed significant negative correlations with AIS at discharge.  There were no significant correlations between AIS score at discharge and both MCC and MSCC (p>0.05).

2.     In a multi-variable optimal scaled regression model, BASIC was the only statistically significant predictor of AIS at discharge (p=0.001).

Wang et al., (2016)

China

Observational

N=35

 

Population: SCI (n=35): Mean age=57.2yr (range=42-69); Gender: males=21, females=14; Level of injury: C=35; Time since injury=NR; AIS scale: NR.

Intervention: Imaging was performed on a 3.0T dual gradient superconductor MR with a gradient strength of 40mT/m and switching rate of 150mT/ms-1. Sagittal flair-T1W1 (repetition time/echo time(TR/TE)=3200/116.8ms, section thickness=3mm, interlamellar spacing=1mm, field of view (FOW)=24X24 mm, image matrix=320X224, number of signals averaged (NEX)=2), sagittal FRFSE-T2W1 (TR/TE=2698/25.8ms, section thickness=3 mm, interlamellar spacing=1mm, FOV=240X240, image matrix=320X224, NEX=2), and axial FRFSE-T2W1 (TR/TE=3200/121ms, section thickness=4mm, interlamellar spacing=0.5mm, bandwidth=41.7kHz, FOV=180X180mm, image matrix=288X224, NEX=4) sequences were acquired for all individuals. MRI grading was performed by two radiologists; Grade 1, 2, and 3 constituted no static compression on spinal cord (no abnormal signals on sagittal T1W1 and T2W1), compression on spinal cord (normal sagittal T1W1 + increased signal intensity (ISI) on sagittal T2W1), and obvious compression on spinal cord (Low signal intensity on T1W1 + ISI on T2W1, respectively. Outcome measures were evaluated before surgery and 1 yr after surgery.

Outcome Measures: Motor score; sensory score; American Spinal Injury Association index score (AIS).  

1.     There were no significant correlations between MRI and motor score, sensory score, or AIS before and after surgery (p>0.05).

Wilson et al., (2012)

Canada

Case Series

N=376

Population: SCI (n=736): Mean age=43.2yr; Gender: males=294, females=82; Level of severity: AIS A=136, AIS B=63, AIS C=58, AIS D=119; Mean time since injury=76.1hr.

Intervention: Individuals received MRI following traumatic SCI. Outcomes were assessed at baseline and 1yr follow-up.

Outcome Measures: MRI signal, American Spinal Injury Association Impairment Scale (AIS), American Spinal Injury Association Motor Scale (AMS), Functional Independence Measure (FIM).

1.     MRI signal characteristics consistent with spinal cord edema or hemorrhage predicted worse functional outcome.

2.     Parameters for predicting FIM motor score at 1yr (b=50.28) were MRI signal (m=­4.83, p=0.19), AIS grade (m=12.47, p<0.01), AMS score (m=9.17, p<0.01), and age (m=-0.33, p<0.01).

3.     Parameters for predicting FIM score at 1yr (b=-2.93) were MRI signal (m=­0.29, OR=0.75, p=0.54), AIS grade (m=1.36, OR=3.90, p<0.01), AMS score (m=1.35, OR=3.86, p<0.01), and age (m=-0.03, OR=0.97, p<0.01).

Miyanji et al., (2007)

Canada

Observational

N=100

 

Population: SCI (n=100): Mean age=45yr (range=17-96); Gender: males=79, females=21; Level of injury: C=100; Median time since injury=24hr; AIS scale: A=26, B-D=51, E=22, Unknown=1.

Intervention: Individuals with SCI were recruited as participants for this prospective study. Comparisons were made among injury severity American Spinal Injury Association (ASIA) A, B-D, and E. All individuals underwent MRI. Neurological assessment was done at baseline (time of MRI) and last clinical visit.

Outcome Measures: Maximal canal compromise (MCC); maximum spinal cord compression (MSCC); lesion length; American Spinal Injury Association (ASIA) motor score; presence of: intramedullary hemorrhage, edema, cord swelling (focal widening of cord).

1.     Frequency of intramedullary hemorrhage, edema, and cord swelling were more common in ASIA A versus ASIA B-D (p<0.001). Moreover, they were directly correlated with SCI severity (p<0.001).

2.     MCC and MSCC were more substantial in ASIA A compared to ASIA B-D (r2=0.222, p=0.005; r2=0.171, p=0.002, respectively).

3.     Lesion length was significantly greater in ASIA A compared to ASIA B-D (r2=0.343, p=0.005).

4.     Step-wise multivariate regression found that the best model for predicting baseline ASIA included MCC, MSCC, and cord swelling.

5.     Step-wise multivariate regression adjusted for baseline ASIA motor score found that only intramedullary hemorrhage and cord swelling were predictive of follow-up ASIA motor score.

Boldin et al., (2006)

Austria

Observational

N=29

 

Population: SCI with Hemorrhage (n=17): Mean age=35.4±12.3yr; Gender: NR; Level of injury: C=17; Median time since injury=10(range=5-12)d; AIS scale: A=8, B=8, C=1.

SCI without Hemorrhage (n=12): Mean age=55±19.3yr; Gender: NR; Level of injury: C=12; Median time since injury=6(range=5-11)d; AIS scale: B=3, C=7, D=2.

Intervention: Participants with closed cervical SCI were recruited for this prospective study. MRI was performed on all participants. Neurological impairment was assessed at time of MRI and at median follow up of 35 mo (range=24-65).  

Outcome Measures: hemorrhage length; edema length; American Spinal Injury Association (ASIA) classification; recovery rate (RR) of the following: motor score; sensory score; pin prick score. 

1.     Participants with spinal cord hemorrhage had significantly longer edema (p=0.002) and more severe ASIA scores (p<0.001).

2.     Participants with complete motor SCI were significantly more likely to have indications of hemorrhage compared to those with incomplete lesions (p<0.001).

3.     Baseline motor, pin prick, and sensory scores were significantly lower in the presence of hemorrhage (p=0.006; p=0.001; p=0.001, respectively).

4.     RR of pin prick and sensory scores were significantly lower in participants with hemorrhage (p=0.008; p=0.011, respectively). There was no significant difference in RR of motor score between hemorrhage versus no hemorrhage (p>0.05).

5.     ANOVA revealed statistically different edema lengths among the levels of ASIA score (p=0.001). ASIA A was statistically longer than ASIA C, D, and E. There was no difference in edema length when comparing ASIA A to B (p>0.05).

6.     Hemorrhage length was longer in complete SCI (ASIA A) compared to incomplete SCI (ASIA B-E) (p=0.002).

7.     Logistics regression revealed that length of edema was the only predictive measure for all participants (hemorrhage and no hemorrhage). Each mm increase in edema resulted in a 1.15 (1.03-1.29) increased rate of retaining a complete SCI (p=0.022).

Shepard & Bracken (1999)

USA

Observational

N=191

Population: SCI (n=191): Mean age=NR; Gender: males=162, females=29; Level of injury: NR; Time since injury: ≤9hr=99, >9hr=92; Injury severity: Complete=75, Incomplete=87, Normal=29.

Intervention: This was a retrospective review of participants from another study. Participants who received MRI within 72hr of injury were included in this study. Participants were assessed neurologically based on responses to pin prick, light touch, and motor function at baseline and at 6wk follow-up.

Outcome Measures: Positive MRI response of: hemorrhage, contusion, edema; neurological assessment (see intervention).

1.     Participants characterized with a complete SCI based on radiologic and neurologic examination were significantly more likely to have spinal cord hemorrhage compared to those classified as neurologically normal on motor function but with impaired sensation (p=0.01).

2.     There was no significant difference in the presence of contusion and edema when comparing complete SCI to incomplete SCI (p>0.05).

3.     Participants whose MRI imaging indicates hemorrhage or contusion are significantly more likely to have lower motor, pin, and touch scores at baseline (p<0.05). However, there are no significant differences for participants with edema (p>0.05).

4.     There was no statistical difference in recovery of pin, motor, and touch scores at 6wk when comparing participants who have hemorrhage, contusion, or edema (p>0.05).

5.     A logistic regression adjusting for neurological examination scores at baseline found that there were no significant increased odds for a complete spinal cord injury in the presence of hemorrhage, contusion or edema (p>0.05).

8.     There was no significant difference in motor function and sensory recovery at 6wk when comparing participants with hemorrhage, contusion, and edema (p>0.05).

Selden et al., (1999)

USA

Observational

N=55

Population: Cervical Myelopathy (n=55): Mean age: 29.2yr; Gender: males=36, females=19; Injury etiology: motor vehicle accident=32, diving accident=11, fall=9, other=3; Level of injury range: C2-T1; Level of severity: Frankel grade A=32, B=9, C=8, D=6; Time since injury range: <17hr.

Intervention: Individuals with traumatic cervical myelopathy underwent magnetic resonance imaging (MRI) of the spine. Outcomes were assessed at admission and at the most recent follow-up visit an average of 18.5mo.

Outcome Measures: Frankel Grade, Medical Research Council (MRC) motor grades, Spinal cord length and diameter, Presence of hematoma, edema, and hemorrhage.

1.     Abnormal T2-hyperintensity MRI images representing edema were present in 54 of 55 individuals.

2.     Rostrocaudal length of signal changes, but not spinal cord swelling or maximal diameter, was significantly correlated with poor neurological function on Frankel Grades at admission (p=0.001).

3.     Abnormal T2-hypointensity representing intra-axial hemorrhage was present in 22 individuals (40%), all which had poor Frankel Grade A or B injuries on admission and this was significantly different than those without hypointense signals (p=0.001).

4.     Rostrocaudal length of hemorrhage signal changes were significantly correlated with worse Frankel Grades after MRI (p=0.049), but not at follow-up.

5.     Rostrocaudal length of edema, but not maximal diameter or length, was significantly correlated with worse Frankel Grade at the follow-up (p=0.036).

6.     The strongest predictor of neurological outcome was Frankel Grade at presentation (p<0.001).

7.     Hemorrhage on MRI scans were correlated with motor-complete injury at admission and associated with poor long term Frankel Grade scores.

8.     There was a decrease in Frankel Grade at admission to follow-up for rostrocaudal length of hematoma (p=0.028), compression via extra-axial hematoma (p=0.077) and rostrocaudal length of edema (p=0.071).

9.     There was a significant negative correlation between length of spinal edema on MRI and total motor score improvements on MRC (p=0.041).

Flanders et al., (1996)

USA

Case Series

NInitial=118

NFinal=104

Population: SCI (n=104): Mean age: 34 yr; Gender: males=91, females=13; Injury etiology: motor vehicle accident (n=49), fall (n=27), sport (n=8), other (n=20); Level of injury: cervical; Level of severity: AIS A=43, B=23, C=28, D=10; Time since injury: <1wk.

Intervention: Individuals with cervical SCI who underwent MRI were retrospectively analyzed for prediction of motor recovery.

Outcome Measures: American Spinal Injury Association Motor Score.

1.     Individuals with spinal cord hemorrhage had significantly worse upper and lower motor scores at the time of injury and at 12mo (p<0.001).

2.     Individuals without spinal cord hemorrhage had little recovery of lower extremity function.

3.     Upper extremity function improved in all individuals (p<0.001); however, individuals without hemorrhage showed the largest improvements.

Takahashi et al., (1993)

Japan

Observational

N=49

Population: SCI (n=29): Mean age=47.7 yr; Gender: males=42, females=7.

Intervention: Individuals received MRI within 1wk of SCI. Some individuals (n=25) received follow-up MRI. All individuals were classified based on MRI pattern: Type 0 for T1/T2WI isointensity, Type I for T1WI isointensity and T2WI hyperintensity, Type II for T1WI hypointensity and T2WI hyperintensity, and Type III for T1WI hyperintensity.

Outcome Measures: MRI pattern, Signal intensity, Cord compression, Recovery.

1.     Individuals presented with compression of varying degrees: none (n=5), minimal (n=7), moderate (n=22), or severe (n=15). Most common causes were subluxation (n=17) and fracture (n=11).

2.     Individuals initially presented with the following MRI patterns: Type 0 (n=13), Type I (n=30), Type II (n=1), and Type III (n=5). They later presented with the following patterns: Type 0 (n=4), Type I (n=8), and Type II (n=13).

3.     Individuals showed recovery of varying degrees: none (n=22), some recovery (n=16), or complete recovery (n=11).

4.     Initial MRI pattern was associated with recovery as follows: Type 0 had 92%, Type I had 53%, and both Types II and III had 0%.

5.     Subsequent MRI pattern was associated with recovery as follows: Type 0 had 75%, Type I had 63%, and Type II had 69%.

6.     Initial T2WI high intensity area was associated with recovery as follows: <1 vertebral body was 100%, 1-2 vertebral bodies was 88%, and >2 vertebral bodies was 20%.

7.     Subsequent T2WI high intensity area was associated with recovery as follows: <1 vertebral body was 100%, 1-2 vertebral bodies was 67%, and >2 vertebral bodies was 0%.

8.     Compression was associated with recovery as follows: severe had 33%, moderate had 55%, minimal had 71%, and none had 100%.

Schaefer et al., (1992)

USA

Observational

N=57

 

Population: Group 1 (n=21): Mean age=27.2yr; Gender: NR; Level of injury: C=21; Time since injury=NR; Mean American Spinal Injury Association (ASIA) motor score: 12.1.

Group 2 (n=17): Mean age=43.5yr; Gender: NR; Level of injury: C=17; Time since injury=NR; Mean ASIA motor score=28.6.                                        Group 3 (n=19): Mean age=38.4yr; Gender: NR; Level of injury: C=19; Time since injury=NR; Mean ASIA motor score=38.3.                               Intervention: Individuals with closed cervical spinal cord injuries were recruited as participants for this study. All participants underwent MRI. Neurological assessment (ASIA motor score) was assessment at baseline (time of MRI) and at follow-up. Participants were divided into three groups based on MRI findings. Group 1 consisting of patterns characteristic of intramedullary hematoma; group 2 had intramedullary edema over more than one spinal region without hemorrhage; group 3 had intramedullary edema restricted to one spinal segment or less.

Outcome Measures: ASIA motor score; Median percent recovery.

1.     Group 1 had no statistically significant improvement in ASIA motor scores at follow-up (p>0.05).

2.     Group 2 had significantly greater median recovery score compared to group 1 (p<0.02).

3.     Group 3 had significantly greater median recovery score compared to both group 1 and 2 (p<-.001; p<0.01, respectively).

4.     Baseline median ASIA motor score was significantly greater than group 1 (p<0.001). However, there was no difference in baseline ASIA motor score when comparing group 3 to 2 (p>0.05).

Table 2. The use of MRI in Individuals Without Radiographic Abnormalities

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Author Year

Country
Research Design
Score
Total Sample Size

Methods Outcome

Martinez-Perez et al., (2017)

Canada

Observational

N=48

 

Population: Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) (n=48): Mean age=54±18.3yr; Gender: males=40, females=8; Level of injury: C=48; Time since injury: ≤72hr; American Spinal Injury Association (ASIA): A=2, B=5, C=15, D=26.

Intervention: Individuals who were admitted to hospital with cervical SCI, received MRI imaging within 72 hr, diagnosed with SCIWORA, and had at least 1 yr of follow-up were included in this retrospective study. MRI was performed using a 1.5T magnet with axial T1-weighted images, T2-weighted images, and gradient echo (GRE); and sagittal T1-weighted images, T2-weighted images, and short TI inversion recovery sequences. Neurological status was assessed using the ASIA impairment scale at baseline and 1-yr follow-up. Neurological improvement was defined as the improvement of at least 1 point on the ASIA Impairment Scale.

Outcome Measures: Disk integrity; swelling; intramedullary hematoma; extramedullary hematoma; edema; cervical canal stenosis; lesion length; maximal canal; maximal spinal cord compromise.

1.     There were no significant associations with any of the outcome measures and neurological improvement, with the exception of MRI lesion length. In particular, shorter lesions on MRI were associated with neurological improvement (p=0.01).

Ouchida et al., (2016)

Japan

Observational

N=68

 

Population: Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) (n=68): Mean age=62(16-93)yr; Gender: males=52, females=16; Level of injury: C=68; Time since injury: ≤4hr; AIS: A=6, B=7, C=24, D=31.

Intervention: Individuals diagnosed with SCIWORA were included in this study. T2-weighted sagittal images were acquired using a 1.5T MRI for all individuals. Additionally, individuals underwent a delayed MRI 2 weeks after injury. Outcome measures were assessed at diagnosis and 1-yr follow-up.

Outcome Measures: Increased signal intensity (ISI) grade and range; prevertebral hyper-intensity range (PVH); Neurological status: Japanese Orthopaedic Association scoring system (JOA score).

1.     There was no significant correlation between JOA and ISI grade and range at admission (p=0.11, r=-0.19; p=0.10, r=-0.20, respectively). However, there was a significant correlation between JOA and PVH at admission (p<0.001, r=-0.55).

2.     There were significant correlations between JOA and ISI grade and range, as well as PVH on delayed MRI imaging (p<0.001, r=-0.49; p<0.05, r=-0.24; p<0.001, r=-0.46, respectively).

Table 20. Systematic Review of Syringomyelia and Tethered Spinal Cord

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Author Year

Country
Research Design
AMSTAR Score
Sample Size

Methods Outcomes

Bonfield et al., (2010a)

USA

Systematic Review

AMSTAR=6

N=22 studies

Objective: To determine the indications for surgical intervention and optimal surgical intervention technique for post-traumatic syringomyelia (PTS).

Methods: Comprehensive literature search of English articles of all individuals with traumatic syrinx, excluding case reports.

Databases: MEDLINE, EMBASE, Cochrane, Web of Science.

Evidence: Levels of evidence were assigned using GRADE criteria (very low, low, moderate, or high). Clinical recommendations were made using a modified Delphi approach (weak or strong).

 

1.     Strength of evidence was very low (n=16) to low (n=6).

2.     Overall recommendations were weak.

3.     The incidence of PTS was 0.5-4.5% and was twice as common in complete versus incomplete injury.

4.     Surgical intervention for PTS was effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.

5.     Spinal cord untethering with expansile duraplasty was the preferred surgical technique.

6.     Direct surgical decompression beyond realignment/stabilization of a thoracic complete SCI to reduce the risk of future PTS was not supported.

7.     Surgical intervention for incidental, asymptomatic syrinx was not supported.

Table 19. Syringomyelia and Tethered Spinal Cord

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Author Year

Country
Research Design
PEDro Score
Sample Size

Methods Outcomes

Falci et al. (2009b)

USA

Case Series

N=362

Population: Mean age: 40.5 yr; Level of injury: C1-C6=163, C6-T1=83, T1-S5=116; Severity of injury: AIS A=232, AIS B=36, AIS C=41, AIS D=51, AIS E=2; Mean time since injury: 10.7 yr.

Intervention: Participants who received cord untethering, expansion duraplasty, and cyst shunting for progressive myelopathy were retrospectively analyzed. Outcomes were assessed at pre-op, post-op, and follow-up.

Outcome Measures: American Spinal Injury Association (ASIA) scores; Clinical status; Complications.

1.     At post-op, participants showed significant increases in ASIA light touch score (n=308; +1.39, p=0.029) and pinprick score (n=307; +1.41, p=0.029), and a non-significant decrease in ASIA motor score (n=263; -0.32, p=0.059).

2.     At 1 yr follow-up, participants showed non-significant changes in ASIA motor score (n=100; -.128, p=0.102), light touch score (n=110; +0.74, n=0.437), and pinprick score (n=109; +0.58, p=0.633).

3.     At last follow-up, participants showed a significant decrease in ASIA motor score (n=134; -1.16, p=0.015) and non-significant changes in light touch score (n=157; -0.76, p=0.391) and pinprick score (n=157; +0.1, p=0.996).

4.     Participants reported decreases in neuropathic pain (n=99; 47%), spasticity (n=53; 60%), and hyperhidrosis (n=38; 77%).

5.     Participants reported arrest of progressive loss of both motor and sensory function (n=204; 89%), of motor function (n=152; 93%), and of sensory function (n=128; n=97%).

6.     Complications were CSF leak/collection (3.8%), DVT/PE (2.35%), wound infection (0.48%), bacterial meningitis (0.48%), myocardial infarction (0.24%), and death (0.48%).

Falci et al.

(1999) USA

Case Series

N=59

Population: Mean age: 38 yr; Gender: males=49, females=10; Level of injury: C1-C6=24, C6-T1=20, T1-S5=15; Severity of injury: AIS A=53, AIS B=1, AIS C=3, AIS D=2; Mean time since injury: 12 yr.

Intervention: Participants who received cord untethering and/or cyst shunting for progressive myelopathy were retrospectively analyzed at 1 yr post-op.

Outcome Measures: American Spinal Injury Association (ASIA) scores; Clinical status; Complications.

1.     Participants showed non-significant increases in ASIA scores when compared to pre-op (p>0.05): light touch (+0.67), pinprick (+1.3), and motor (+0.41).

2.     Participants without previous surgery (n=34) showed increases in ASIA scores when compared to pre-op: pinprick (+3.88, p<0.05), light touch (+2.38, p>.05), and motor (+1.47, p>0.05).

3.     Participants with previous surgery (n=25) showed non-significant decreases in ASIA scores when compared to pre-op (p>0.05): light touch (-0.7), pinprick (-0.8), and motor (-0.5).

4.     Participants showed recovery of lost functional activity (64.3%), substantial improvement in spasticity (62.5%), substantial improvement in neurogenic pain (55.6%), prevention of further neurologic deterioration (95.8%), and improvement in hyperhidrosis (100%).

5.     Complications were CSF leak/collection (8.4%), wound infection (1.7%), cyst recurrence (1.7%), and meningitis (1.7%).

Table 18. Systematic Review Examining Predictors of Spinal Stenosis

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Author Year

Country
Research Design
AMSTAR Score
Sample Size

Methods Outcomes

Wilson et al. (2013b)

Canada

Systematic Review

AMSTAR=7

N=5 studies

Objective: To assess the frequency, timing, and predictors of symptom development in individuals with radiographical evidence of spinal cord compression (SCC), spinal canal stenosis (SCS), and/or ossification of posterior longitudinal ligament (OPLL) but no symptoms of myelopathy.

Methods: Comprehensive literature search of English longitudinal cohort studies of participants aged >18 yr with imaging evidence of SCC, SCN, or OPLL, without symptoms of myelopathy and history of tumor, infection, arthritis, or previous SCI. Data analysis was performed by calculating relative risks (RR) and 95% confidence intervals (95%CI).

Databases: MEDLINE, Cochrane, Google Scholar.

Evidence: Studies were assessed for quality using AHRQ guidelines (I, II, or III). Levels of evidence were assigned GRADE criteria (insufficient, low, moderate, or high). Clinical recommendations were made using a modified Delphi approach (weak or strong). Statistical significance was defined as p<0.05.

1.     Quality of studies was II (n=1) and III (n=4).

2.     Overall strength of evidence was moderate.

3.     Overall strength of recommendations was strong.

4.     Only three studies (n=355) of the total five (n=832) were included in meta-analysis.

5.     In SCC or SCS (n=199), myelopathy development within 44 mo (24-144 mo) was 22.6%.

6.     In SCC or SCS, significant predictors of myelopathy development were presence of symptomatic radiculopathy (RR=3.0, 95%CI=2.0-4.4, p=0.007), prolonged somatosensory-evoked potentials (RR=2.9, 95%CI=1.7-5.1, p=0.007), prolonged motor-evoked potentials (RR=3.2, 95%CI=1.9-5.6, p=0.033), and lack of cervical cord MRI hyperintensity (RR=1.7, 95%CI=1.0-2.7, p=0.0036).

7.     In OPLL (n=606), myelopathy development within 60-360 mo ranged from 17.0% to 61.5%.

8.     In a subset of OPLL (n=156), predictors of myelopathy development were lateral deviation (RR=2.1, 95%CI=1.4-3.1), increased cervical range of motion (p=0.03), and canal stenosis >60%.

9.     The authors made a strong recommendation based on moderate evidence: individuals with SCC/SCS secondary to spondylosis, without evidence of myelopathy, and with clinical or electrophysiological evidence of cervical radicular dysfunction or central conduction deficits may be at higher risk for development myelopathy and should be considered for surgical intervention.

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