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The online version of this article, along with updated information and services, is located
on the World Wide Web at:
http://www.neurology.org/cgi/content/full/58/5/794
Neurology is the official journal of the American Academy of Neurology. Published continuously
since 1951, it is now a weekly with 48 issues per year. Copyright 2002 by AAN Enterprises, Inc.
All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
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AbstractBackground: The nature of the adaptive changes that occur in the cerebral cortex following injury to the
cervical spinal cord are largely unknown. Objective: To investigate these adaptive changes by examining the relationship
between the motor cortical representation of the paretic right upper extremity compared with that of the tongue. The
tongue was selected because the spinal cord injury (SCI) does not affect its movement and the cortical representation of
the tongue is adjacent to that of the paretic upper extremity. Methods: FMRI was used to map cortical representations
associated with simple motor tasks of the right upper extremity and tongue in 14 control subjects and 9 patients with
remote (5.5 months) cervical SCI. Results: The mean value for the site of maximum cortical activation during upper limb
movement was identical between the two groups. The site of maximum left hemispheric cortical activation during tongue
movement was 12.8 mm (p 0.01) medial and superior to that of control subjects, indicating the presence of a shift in
cortical activation. Conclusion: The findings indicate that the adult motor cortex does indeed adapt following cervical SCI.
The nature of the adaptation and the underlying biological mechanisms responsible for this change require further
investigation.
NEUROLOGY 2002;58:794 801
From the Departments of Medical Imaging (Drs. Mikulis and Crawley), Surgery (Dr. Fehlings and L. Rickards), and Physical Therapy (S. KalsiRyan),
Toronto Western Hospital of the University Health Network; and Departments of Rehabilitation Science (Drs. McIlroy and Staines, M. Verrier), Physiology
(Dr. McIlroy, M. Jurkiewicz, and M. Verrier), and Physical Therapy (Dr. McIlroy, M. Verrier), University of Toronto, Ontario, Canada.
Supported by the Ontario Neurotrauma Foundation (99119) and the National Sciences and Engineering Research Council of Canada (PGS-A).
Received July 13, 2001. Accepted in final form November 27, 2001.
Address correspondence and reprint requests to Dr. D.J. Mikulis, Department of Medical Imaging, Toronto Western Hospital, McLaughlin 3-404, 399
Bathurst Street, Toronto, Ontario, Canada M5T 2S8; e-mail: mikulis@uhnres.utoronto.ca
794
Age, y
Time since
injury, mo
Motor paradigm
ASIA
grade*
ASIA motor
level (right)
Upper/lower limb
Wrist
Tongue
22
5.5
C6
13/0
17
5.5
C7
14/0
65
5.5
C5
13/15
51
27.0
C7
16/0
42
9.0
C6
12/0
48
86.0
C7
17/10
67
29.0
C5
11/15
39
242.0
C6
9/0
29
156.0
C7
22/5
10
36
182.0
C6
14/0
11
35
180.0
C4
0/0
n
Mean SD
Range
X
X
11
11
11
11
11
10
10
41.0 16.0
84.3 89.1
1767
5.5242
* American Spinal Injury Association (ASIA) grade: A complete: no motor function or sensory function is preserved in the sacral segments S4 to S511; B incomplete: sensory but not motor function is preserved below the neurologic level and extends through the
sacral segments S4 to S5.11
Exclusion
Quadriparesis
Level C4 to C8
ASIA score A or B
M/L
A/P
I/S
Controls, n 14
33.7 8.2
27.2 3.7
57.7 7.4
Patients, n 10
32.8 5.8
27.8 7.1
57.0 5.6
0.766
0.794
0.800
Controls, n 14
35.2 6.0
29.1 5.3
57.0 4.0
Patients, n 10
33.9 5.2
28.3 7.5
57.8 4.2
0.582
0.783
0.648
FMA
p Value
COM
p Value
All values given in mm 1 SD displaced from the anterior commissure in Talairach space in the medial/lateral (M/L), anterior/
posterior (A/P), and inferior/superior (I/S) planes.
FMA focus of maximum activity; COM center of mass.
Right hemisphere
M/L
A/P
I/S
M/L
A/P
I/S
Controls, n 13
56.5 3.9
10.5 5.7
28.1 5.6
56.3 5.0
9.4 4.1
27.1 5.2
Patients, n 9
50.1 5.6
12.8 5.7
40.1 10.7
49.3 6.0
9.4 5.6
31.4 4.7
FMA
Difference
6.4
2.3
12.0
7.0
0.0
4.3
p Value
0.005*
0.373
0.002*
0.008*
0.977
0.058
COM
Controls, n 13
55.8 4.0
10.2 5.9
31.0 9.2
55.1 3.7
10.6 3.0
29.9 3.8
Patients, n 9
50.8 5.5
13.6 6.7
41.8 10.6
50.3 3.8
10.3 5.8
32.9 5.7
Difference
5.0
3.4
10.8
4.8
0.3
3.0
p Value
0.024
0.217
0.019
0.008
0.869
0.144
All values given in mm 1 SD displaced from the anterior commissure in Talairach space in the medial/lateral (M/L), anterior/posterior (A/P), and inferior/superior (I/S) planes.
* Significant at p 0.05.
FMA focus of maximum activation; COM center of mass.
796
NEUROLOGY 58
March (1 of 2) 2002
Table 5 Location (1 SEM) of M1 cortex controlling upper extremity function (knob) in patients and controls in medial/lateral (M/L),
anterior/posterior (A/P), and inferior/superior (I/S) planes
Left hemisphere
Location in
Right hemisphere
M/L
A/P
I/S
M/L
A/P
I/S
Controls, n 14
35.9 1.47
27.2 1.02
52.4 0.67
33.4 1.39
25.8 1.12
53.2 0.83
Patients, n 11
34.5 1.96
30.1 1.78
54.3 1.51
31.7 1.09
28.0 1.30
52.9 0.87
1.4 2.45
2.9 2.05
2.10 2.02
1.7 1.76
2.2 1.71
0.3 1.20
Difference
Shown is location of knob (hand representation within primary sensorimotor cortex) in mm.
tapping of the upper incisors at 1 cycle/second for 15 seconds alternating with a 15-second resting period carried
out over 5 minutes.
MRI was performed on a 1.5-T clinical scanner (Signa
Echospeed; GE Medical Systems, Milwaukee, WI) using a
spiral gradient echo sequence. Twenty-eight contiguous
slices of 4.5-mm thickness were obtained from the foramen
magnum to the vertex. One spiral trajectory was collected
per slice to give a 3.75-mm in-plane resolution. Other sequence parameters were repetition time (TR) 2,240 ms,
echo time 40 ms, 80 ms/spiral, flip angle 85 (set to
the Ernst angle for maximum signal-to-noise ratio within
gray matter for TR 2,240 ms and T1 of gray matter
850 ms). High-resolution T1-weighted fast inversion recovery spoiled gradient-recalled (SPGR) images were acquired
at 1.5-mm slice thickness for coregistration with the functional images.
Image and data analysis. Image analysis was performed off-line using Stimulate12 (available at: http://
www.cmrr.drad.umn.edu/stimulate) and AFNI13 software
(available at: http://afni.nimh.nih.gov/afni). Regions of activation were determined by cross-correlating the fMRI data
to the predicted hemodynamic response (boxcar waveform)
for each task using a voxel-by-voxel statistical analysis.
Voxels with a correlation coefficient (r value) falling above
the 99th percentile were deemed significant. Two methods
were used to localize task-related cortical activation measured contralaterally for wrist movement and bilaterally
for tongue movement. In the first method, the position of
the voxel with the highest r value within primary motor
cortex (M1) was recorded and was termed the focus of
maximum activation (FMA). In the second method, the
center of mass (COM) for the cluster of significant voxels
in M1 was determined. The x, y, and z coordinates for the
FMA and COM were then determined for each task. In all
cases, the FMA and COM fell within M1 determined visually by locating the central sulcus and the motor strip
directly anterior to it. The volume of contiguous voxels
exceeded 220 mm3 in all subjects. The results of the FMA
are used for the purpose of discussion as reference to the
COM data would have been redundant because the COM
measurements were within 2 mm of the FMA data. Nevertheless, COM data are reported in tables 3 and 4. Each
scan was subsequently normalized into standard stereotactic anatomic (Talairach) space.14 Although the Talairach
normalization procedure is not a necessary step in the
analysis of fMRI data, it allowed us to perform a group
analysis and compare our results with those in the literature. Distance between FMA for wrist extension and FMA
for tongue movement was calculated as the square root of
the sum of the squares of the difference between each FMA
Volume in
Actual
volume, mm3
Controls, n 14
1,403 836
1,327 852
Patients, n 10
1,577 928
1,508 1,115
0.635
0.656
p Value
Volume in Talairach
space, mm3
NEUROLOGY 58
March (1 of 2) 2002
Table 7 Volume 1 SD of activation within primary sensorimotor cortex during tongue tapping
Left hemisphere
Right hemisphere
Actual volume,
mm3
Volume in Talairach
space, mm3
Actual volume,
mm3
Volume in Talairach
space, mm3
Controls, n 13
1,592 1,041
1,145 743
1,352 800
1,225 835
Patients, n 9
1,128 786
1,094 846
1,181 573
1,051 577
0.883
0.589
0.594
Volume in
p Value
0.271
Figure 2. Motor level vs location of focus of maximum activation (FMA). The relationship between
level of injury and tongue FMA displacement is
shown for displacements in the medial/lateral (A),
anterior/posterior (B), and inferior/superior (C)
planes. AC-PC line joining the anterior and posterior commissures. Displacement of the FMA in
each of the three spatial dimensions is strongly (r
0.69, p 0.03) correlated to the level of the cervical
spine injury.
Figure 3. Focus of maximum activation (FMA) displacement vs American Spinal Injury Association (ASIA) motor
score. The spatial difference in FMA (in three dimensions)
between patients and control subjects during tongue movement vs degree of upper limb functional impairment
(ASIA right upper limb motor score) in the 10 patients is
shown. Displacement represents the square root of the sum
of the squares of the x, y, and z displacements away from
the mean location found in the control group. It can be
seen that the displacement increases with increasing
impairment.
patients with chronic complete cervical SCI is positioned superiorly and medially toward the adjacent
disconnected hand cortex compared with that in control subjects, whereas the location of the cortex controlling wrist movement is unchanged. Together, the
findings suggest that cortical adaptation or reorganization has occurred in the motor cortex of individuals with chronic cervical SCI in the form of shifts in
the location of maximum activation of normally efferented and afferented cortex. The disconnected cortex represents an available motor network that
becomes partially involved with, or is simply cofunctional with, motor control of a body part that is already directed by adjacent motor cortex (in this case,
the tongue) with preserved efferent and afferent connections. The possibility that these spatial shifts in
activation are the result of post-traumatic atrophy in
the disconnected cortex appears unlikely since the
position of the primary sensorimotor cortex controlling upper extremity function was not shifted. The
lack of a difference in the location of wrist control
between patients and normal volunteers is assumed
to be due to the fact that all patients, except for the
C4-injured patient, had some preservation of wrist
movement. However, it can be argued that even this
representation should have migrated superiorly and
medially since it also borders on the adjacent disconnected lower extremity cortex. The absence of such
changes in representation associated with wrist
movement remain unclear. As with all fMRI studies,
the assessment of the spatial extent of activation is
problematic owing to thresholding issues. It is therefore difficult to address expansion/enlargement of
800
NEUROLOGY 58
the cortical representation of tongue control. Nevertheless, the effect, if it exists, is not pronounced in
this group of patients since we were unable to detect
differences in the mean volume of activation compared with control subjects using conventional
thresholding (99th percentile) methods. If we had
studied a group of individuals with higher complete
cervical injuries (C4 and above), cortical expansion
might have been more obvious. It does appear, however, that the amount of shift is related to both the
level of the SCI and the degree of residual motor
function. These are not independent variables since
lower cervical injuries result in greater sparing of
upper extremity function.
Because a cross-section of patients with chronic
injuries (5.5 to 242 months) was assessed, the pattern of temporal evolution that leads to the observed
brain changes is unknown. It is unclear whether the
observed cortical adaptation evolves within hours of
the injury or if it occurs slowly over months or years.
There is evidence that cortical adaptation can occur
within minutes following pseudo-amputation of the
upper extremity in which all nerve conduction ceases
after temporary arterial occlusion.17 Once established, the nature of the adaptation, in terms of permanence and the degree of functional reassignment,
is of considerable interest. In a study of upper extremity amputees with long-term de-afferentation,
the cortical representation of primary orofacial sensation (the lips) migrated medially and superiorly
into the hand representation, exactly as we have
shown for the motor system in our spinal cordinjured subjects. This migration, however, could be
reversed within minutes of local anesthetic blockade
of the brachial plexus (but only in those patients
with phantom limb pain).18 Therefore, the observed
plastic changes are not likely mediated by new anatomic links, but more probably by rapid changes,
perhaps mediated by GABA, in the excitability of
particular pathways. The degree of functional reassignment of the disconnected cortex has also been
studied in chronic SCI, where TMS was used to
show that parts of the disconnected cortex retain
the ability to process sensations perceived by the
subject arising from the de-afferented region of the
body.19
These observations raise very important questions
concerning the nature of adaptation. Does it represent reorganization, with formation of new neural
connections, or is an unmasking phenomenon revealed in which absence of the sensory feedback to
the motor cortex leads to a loss of inhibition and an
overall increase in the excitability of a highly distributed motor network? The latter would be true if the
FMA remained stable or shifted only slightly, because it would be difficult to explain how increased
excitability would preferentially affect areas outside
of the main focus of activation. This evidence points
toward a true form of cortical reorganization consisting of new neural connections supported by data
from the C4-injured subject in whom the FMA actu-
March (1 of 2) 2002
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