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Articles
Summary
Lancet 2011; 377: 100410 Background Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to
Published Online counsel patients and to plan rehabilitation. We developed a reliable, validated prediction rule to assess a patients
March 4, 2011 chances of walking independently after such injury.
DOI:10.1016/S0140-
6736(10)62276-3
Methods We undertook a longitudinal cohort study of adult patients with traumatic spinal cord injury, with early
See Comment page 972
(within the rst 15 days after injury) and late (1-year follow-up) clinical examinations, who were admitted to one of
Spine Unit, Department
of Orthopaedics
19 European centres between July, 2001, and June, 2008. A clinical prediction rule based on age and neurological
(J J van Middendorp MD, variables was derived from the international standards for neurological classication of spinal cord injury with a
A J F Hosman MD, multivariate logistic regression model. Primary outcome measure 1 year after injury was independent indoor walking
M H Pouw MD); Department of based on the Spinal Cord Independence Measure. Model performances were quantied with respect to discrimination
Epidemiology, Biostatistics and
HTA (A R T Donders PhD); and
(area under receiver-operating-characteristics curve [AUC]). Temporal validation was done in a second group of
Department of Rehabilitation patients from July, 2008, to December, 2009.
Medicine (Prof A C H Geurts MD,
H Van de Meent MD), Radboud Findings Of 1442 patients with spinal cord injury, 492 had available outcome measures. A combination of age (<65 vs
University Nijmegen Medical
Centre, Nijmegen, Netherlands;
65 years), motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of
Department of Rehabilitation dermatomes L3 and S1 showed excellent discrimination in distinguishing independent walkers from dependent
Medicine, Jeerson Medical walkers and non-walkers (AUC 0956, 95% CI 09360976, p<00001). Temporal validation in 99 patients conrmed
College, Thomas Jeerson
excellent discriminating ability of the prediction rule (AUC 0967, 09390995, p<00001).
University, Philadelphia, PA,
USA (Prof J F Ditunno Jr MD);
and Spinal Cord Injury Center, Interpretation Our prediction rule, including age and four neurological tests, can give an early prognosis of an
Balgrist University Hospital, individuals ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might
Zurich, Switzerland
improve the ability to stratify patients in interventional trials.
(Prof A Curt MD)
Correspondence to:
Dr Joost J van Middendorp,
Funding Internationale Stiftung fr Forschung in Paraplegie.
Department of Orthopaedics,
PO Box 9101, 6500 HB Introduction reproducibility and validity of the rule to predict an
Nijmegen, Netherlands
Traumatic spinal cord injury has a profound eect on individuals ability to walk independently after injury
jvanmiddendorp@gmail.com
patients physical and psychosocial wellbeing. Although on a second group of patients.
the frequency of such injury is low at 10483 cases per
million people worldwide, this devastating disorder Methods
imposes a substantial burden on the health-care system.1 Study design and patient population
Despite advances in basic research into spinal cord repair Since July, 2001, 19 centres (ve centres originally) have
that show promise, no treatment that results in major gathered a standardised dataset of neurological and
neurological or functional recovery is available.2 functional outcomes of patients with spinal cord injury
After a spinal cord injury, a reliable prognosis of a as part of the European Multicenter Study on Human
patients potential functional outcome is essential for Spinal Cord Injury (EM-SCI).5 Data for neurological and
counselling and to design a personalised rehabilitation functional status were collected prospectively, per
programme.3 During rehabilitation, recovery of the ability protocol, within the rst 15 days and at months 1, 3, 6,
to walk is a high priority for such patients.4 However, no and 12 after injury. Because no proven eective treatment
prediction rule for the ability to walk independently after is available,2 treatment regimens are not standardised
traumatic spinal cord injury is available. within the EM-SCI network. Details of applied treatments
In this study we analysed data from a prospective, were not recorded systematically, but ranged from non-
longitudinal, multicentre cohort study5 of a operative interventions to very early (<6 h after injury)
representative European population with spinal cord surgical stabilisation and decompression of the spinal
injury to develop an accurate and simple clinical cord. Dependent on level and severity of injury,
prediction rule for a patients ability to walk independ- individually tailored rehabilitation programmes varied in
ently. Age at injury6 and variables from the international focus and intensity.
standards for neurological classication of spinal cord From the EM-SCI dataset we extracted data for all adult
injury7 are used in the clinical algorithm. We tested the (18 years) patients with acute traumatic spinal cord
A B
10
Probability of walking independently (%)
08
06
04
02
10 0 10 20 30 40 10 0 10 20 30 40
Prediction rule score Prediction rule score
Figure 3: Calibration plots of the prediction rule scores divided into four intervals
(A) Data from the 492 patients in the derivation group. (B) Data from the 99 patients in the validation group. The size of each point corresponds to the number of
patients in the interval and the vertical bars are the 95% CIs. The vertical stripes at the lower horizontal border represent the prediction rule scores of patients who were
not able to walk independently. The vertical stripes at the upper horizontal border represent the prediction rule scores of patients who were able to walk independently.
after traumatic spinal cord injury. Our prediction rule not (<24 h) versus subacute (<72 h) examinations.16 A post-hoc
only accords with these previous clinical data, but analysis in our study population showed that the timing of
provides a statistically reliable basis for prediction of examination (<24 h, <72 h, or <15 days after injury) did not
walking after such injury with an ecient and simple have a pronounced eect on the accuracy of the prediction
clinical examination. rule. Furthermore, whereas Kirshblum and colleagues3
Many neurological variables have been assessed for their postulated that patients with incomplete tetraplegia are
predictive value of ambulation outcomes.7,8,2023 Several less likely to be able to walk independently than are
studies have shown the prognostic value of the early patients with incomplete paraplegia, we noted no
assessment of only one neurological predictor, such as dierence in outcome between patients with tetraplegia
strength of the quadriceps femoris,24 strength of the hip and those with paraplegia.
exors,25 or anal sensation,20,21 but, except for a clinical A dichotomisation of SCIM item 12 was applied as the
trial20 and a European database,8 these studies have used primary functional outcome measure.8,11,12 The present
small samples. Use of multivariate prognostic models to study accords with previous studies,28 showing that the
determine outcomes after neurotrauma (eg, traumatic SCIM indoor mobility outcome is strongly correlated
brain injury) that include large samples and apply external with moderate and outdoor distance outcomes. Our
validation have gained increased recognition,26 but such prediction rule, however, can be applied to predict the
models have not been applied to traumatic spinal cord ability to walk independently for indoor distances only.
injury. Ours is an accurate and well validated prediction Strengths of our study include the prospectively
rule for walking after traumatic spinal cord injury. collected data in a large European population, the
Although our prediction rule is more accurate and less availability of validated and detailed information about
time consuming than the AIS grading system, to do patients initial neurological impairments assessed by
accurate and reliable assessments of the four neurological trained and certied physicians, the use of a well validated
tests, a physician must have experience in the physical clinical outcome measure for ambulation (SCIM), and a
examination of patients with traumatic spinal cord temporal validation of the derived clinical prediction rule.
injury.27 Furthermore, for assessment of injury severity Nonetheless, several potential limitations of our study
and eectiveness of treatments, the international exist. Although the applied dichotomous outcome is easy
standards for neurological classication of spinal cord to use, it does not provide detailed information about a
injury are the reference standard.27 patients quality of walking. Furthermore, because some
Neurophysiological variables such as somatosensory EM-SCI centres are specialised rehabilitation centres,
evoked potentials have been assessed for their prognostic acute-phase measurements were absent for many
value on ambulation outcomes,22 but they are time patients. Nonetheless, the clinical characteristics of
consuming to test and are therefore not suitable for patients who were excluded were much the same as for
inclusion in a simple prediction rule. Nonetheless, those who were included (webappendix p 1). Details of
neurophysiological assessments can be of value in patients patients lost to follow-up (eg, mortality) have not been
who cannot participate in a reliable physical examination. documented, which might have resulted in an
Variables that are highly correlated with others overoptimistic prediction model. Before application of
contribute little independent information and can be the prediction rule in clinical practice, an external
excluded before the development of a prognostic model.9 validation study is needed to assess its generalisability.29
By contrast with earlier reports,21 a high-volume study8 Moreover, the clinical ecacy of the prediction rule also
from the EM-SCI consortium showed that sacral PPS needs to be established by investigation of whether its
and LTS scores have a similar discriminative ability for use results in more ecient use of rehabilitation
prediction of an individuals ability to walk after traumatic resources and improved psychological wellbeing of
spinal cord injury. Because we wanted the prediction patients with spinal cord injury.3,30 Finally, although no
rule to be as simple as possible, we included only LTS eective treatment that results in major neurological or
scores in the initial model. Although the addition of the functional recovery is available, future eective treatment
PPS at L5 to the prediction rule resulted in a slightly strategies might necessitate a reassessment of the
higher AUC in the derivation group, its inclusion prediction rules accuracy.31
resulted in a marginally lower AUC in the validation Contributors
group. This occurrence was probably because, with the AJFH, AC, ACHG, and HVdM are all senior authors, managed the
addition of PPS at L5, the model was overtted to the project, and obtained funding. JJvM and ARTD did data analysis and the
preparation of the nal report. All authors contributed to the writing of
dataset from which it was derived. Overall, we think that the paper and read and approved the nal version.
the exclusion of PPS scores before development of a
Conicts of interest
model is a valid approach. We declare that we have no conicts of interest.
Because many of the EM-SCI centres are referral centres,
Acknowledgments
most (81%) of the neurological assessments had not been This work was supported by a grant from the Internationale Stiftung fr
done within 72 h after injury. There is no consensus about Forschung in Paraplegie (IFP), Zrich, Switzerland. All spinal cord injury
the dierence between the prognostic value of immediate centres participating in the EM-SCI network contributed to the study.
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