Why sacral sparing

Clinical assessments were conducted by trained and certified neurological and rehabilitation physicians having at least 1 year of experience in examining SCI patients. Recovery of independent ambulation was defined as the primary functional outcome. The SCIM items address the ability to accomplish activities of daily living.

Besides self-care items, the SCIM also assesses the level of dependency in indoor and outdoor ambulation. The SCIM mobility items gradually range from total assistance to wheelchair use, to walking with aids, to walking without aids.

As the difference between indoor and outdoor mobility scores particularly reflect the difference in daily performance rather than in ambulatory capacity, only the indoor mobility follow-up scores were used for analysis. In addition, to distinguish dependent from independent indoor walkers, the SCIM indoor scores were converted to dichotomous outcomes.

As these versions are identical with respect to the graded scores of indoor and outdoor mobility items, the indoor mobility scores of SCIM versions II and III were grouped. In patients with absent 1-year follow-up measurements, 6-months follow-up measurements were used for analysis.

Patients were divided into two groups, namely those who were able to ambulate independently after 1 year and those who were not. Univariate logistic regression equations were then computed for each sacral sparing item separately. To identify the strongest predictive rule for ambulation in chronic phase after traumatic SCI, a stepwise backward multiple logistic regression was performed. All four sacral sparing items were entered into the model.

The area under the ROC receiver-operating characteristic curve AUC was used to assess the performance of the items separately and the model in terms of the accuracy of correct prediction. The curve illustrates the ability of the model to discriminate between patients who ambulate independently after 1 year and those who do not.

A test with no better discriminative ability than what would otherwise be obtained by pure chance will have an AUC of 0. All data analyses were performed using the SPSS software package version In total, patients were analyzed see Figure 1. Period of inclusion: January —October The mean time between injury and first ASIA assessment at the time of admission was 7. The NPV of the absence of anal sensation and voluntary anal contraction on the functional outcome was Univariate logistic regression equations were computed for each sacral sparing item separately.

With regard to the ability to walk independently, the predicted probability and effect sizes of each sacral sparing item are presented in Figure 2 and Table 3. All sacral sparing items did have an excellent ability AUC above 0. Multiple logistic regression showed that only the voluntary anal contraction as well as S4—5 LT and PP sensory scores contribute significantly to the prognosis of independent ambulation. This model showed the best discriminating ability to predict between patients who were able to walk independently and those who were not AUC: 0.

The use of the predictive model without anal sensory score AUC: 0. Determination of complete and incomplete SCI is commonly applied in prognosticating the functional recovery of patients.

This is the first study we are aware of that examines the validity of the acute phase ASIA sacral sparing items in reference to chronic phase functional recovery. We found that, except for anal sensation, both minimum and maximum scores of the sacral sparing criteria provided high NPVs and PPVs with respect to chronic phase ambulation.

The association between sacral PP preservation and improved ambulatory outcomes is consistent with that of earlier literature. One possible explanation for this low PPV might be the controversy around the definition and technique of the anal sensation examination. Referring to Waters et al. Regression modeling showed that only the combination of voluntary anal contraction and the S4—5 LT and PP sensation scores contribute significantly to the prognosis of ambulation.

With respect to chronic phase ambulation, the distinction between acute phase complete and incomplete SCI resulted in a significantly lower AUC than the AUC of the regression model. In other words, omitting the anal sensation score results in a better predictive model of independent ambulation than the currently applied combination of all four sacral sparing items. Therefore, we state that the currently applied distinction between complete and incomplete SCI is not the best indicator of ambulation recovery.

This study stresses the importance of further research on this topic. In the end, these efforts may result in an optimal functional predictive algorithm in the acute setting of traumatic SCI care. The eligibility criteria applied in this study resulted in a homogeneous traumatic SCI population of upper motor neuron lesions. Patients with a potential cauda equina and conus medullaris syndrome were excluded.

The rationale behind these exclusion criteria is that injured peripheral axons regenerate, whereas central axons normally do not. Another point of discussion remains, that is, the neurological cutoff level to exclude patients with potential cauda equina syndrome. The cutoff criterion was defined as injuries below neurological level L1 based on neuroanatomical considerations. To determine the validity of these pragmatic approaches, further investigation is warranted.

Within the EM-SCI database, validation of the sacral sparing was performed in a relatively large group of patients. Six-months follow-up measurements were used in the case of the absence of 1-year follow-up measurements. Therefore, replacement of the missing 1-year follow-up measurement by 6-month measurement is regarded as a valid approach. In our study, acute phase measurements ranged from 0 to 15 days post injury.

On the other hand, once the period between injury, examination and treatment increases, more putative confounders might influence the analysis of the functional prognosis of patients. One-year post injury independent ambulation was the outcome of interest in this study.

The SCIM indoor mobility item was assessed and analyzed for this purpose. Although this pragmatic approach resulted in a qualitative reduction of the data, we have been able to estimate the ability to walk independently indoors.

Therefore, using the SCIM indoor mobility item as an outcome measure can be regarded as a valuable and clinical relevant outcome. Some limitations of this study warrant consideration. Treatment regimens, including administration of methylprednisolone, blood pressure augmentation and urgent spinal cord decompression, are not standardized within the EM-SCI consortium.

Furthermore, despite examinations by trained and certified neurological and rehabilitation physicians having at least 1-year of experience in examining SCI patients, inter-rater differences of neurological examinations remain inevitable because of the multicenter nature of this study.

Nonetheless, recently, Savic et al. Another limitation of this study is the absence of details regarding spinal fractures and dislocations, co-morbidities, rehabilitation programs and walking aids within the EM-SCI database. In conclusion, all sacral sparing items did have an excellent ability for discriminating between the ability to walk independently or not.

Nonetheless, with respect to chronic-phase ambulation, a low PPV of the acute phase anal sensation examination was reported. Of the four sacral sparing criteria, the acute phase anal sensory score measurement does not contribute significantly to the prognosis of independent ambulation. This study stresses the importance of further investigation on functional predictive algorithms in the acute setting of traumatic SCI care. American Spinal Injury Association. The sacral spine is also the least likely area for spinal nerves to become compressed.

Some incomplete spinal injuries to this level are referred to. While there is no spinal cord in the sacral spine region, the sacral nerves actually originate in the lumbar spine. Damage done to the nerve roots in the lower lumbar spine and into the sacrum may have similar symptoms as spinal cord damage. Patients with sacral nerve injuries may have symptoms on one or both sides of the body. The patient will most likely be able to walk, and drive a car.

An injury to the sacral spinal cord may leave the patient with little or no bladder or bowel control, however, the patient will be completely autonomous and have the ability to perform their own self-care. The sacral region is home to the control center for pelvic organs such as the bladder, bowel, and sex organs.

Sexual function is a concern, especially in men who experience sacral spinal nerve injuries. Damaging either the S1, S2, S3, S4, or S5 vertebrae should leave the patient fairly functional with some issues controlling bowel and bladder function. Patients with injuries to the sacrum typically live very normal lives. Some assistance may be needed for these patients, but most do well on their own.

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Last updated on April 5, The sacral region of the spinal cord makes up most of the lower spinal column. Testing for Sacral Sparing After Spinal Cord Injury To determine if a spinal cord injury patient has sacral sparing, an anal exam is required. Your doctor will examine functions innervated by the bottom-most spinal cord segments S4-S5 like: light touch at the perianal area pinprick sensation at the perianal area deep anal pressure voluntary anal contraction To test for deep anal pressure, the doctor will insert their gloved finger into the rectum and ask the patient which direction they feel pressure being applied.

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