A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After Spinal Cord Injury.

OBJECTIVE: To derive and validate a simple, accurate CPR to predict future independent walking ability after SCI at the bedside that does not rely on motor scores and is predictive for those initially classified in the middle of the SCI severity spectrum. DESIGN: Retrospective cohort study. Binary variables were derived, indicating degrees of sensation to evaluate predictive value of pinprick and light touch variables across dermatomes. The optimal single sensory modality and dermatome was used to derive our CPR, which was validated on an independent dataset. SETTING: Analysis of SCI Model Systems dataset. PARTICIPANTS: Individuals with traumatic SCI. The data of 3679 participants (N=3679) were included with 623 participants comprising the derivation dataset and 3056 comprising the validation dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported ability to walk both indoors and outdoors. RESULTS: Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately identified future independent walkers 1 year after SCI. Normal pinprick in both lateral heels provided good prognosis, any pinprick sensation in either lateral heel provided fair prognosis, and no sensation provided poor prognosis. This CPR performed satisfactorily in the middle SCI severity subgroup. CONCLUSIONS: In this large multi-site study, we derived and validated a simple, accurate CPR using only pinprick sensory testing at lateral heels that predicts future independent walking after SCI.

Evaluating tissue injury in cervical spondylotic myelopathy with spinal cord MRI: a systematic review.

PURPOSE: Cervical Spondylotic Myelopathy (CSM) is a degenerative condition that leads to loss of cervical spinal cord (CSC) integrity. Various spinal cord Magnetic Resonance Imaging (MRI) methods can identify and characterize the extent of this damage. This systematic review aimed to evaluate the diagnostic, biomarker, and predictive utilities of different spinal cord MRI methods in clinical research studies of CSM. The aim was to provide a comprehensive understanding of the progress in this direction for future studies and effective diagnosis and management of CSM. METHODS: A comprehensive literature search was conducted on PubMed and EMBASE from 2010 to 2022 according to PRISMA guidelines. Studies with non-human subjects, less than 3T magnetic field strength, non-clinical design, or not quantitatively focusing on the structural integrity of CSC were excluded. The extracted data from each study included demographics, disease severity, MRI machine characteristics, quantitative metrics, and key findings in terms of diagnostic, biomarker, and predictive utilities of each MRI method. The risk of bias was performed using the guide from AHRQ. The quality of evidence was assessed separately for each type of utility for different MRI methods using GRADE. RESULTS: Forty-seven studies met the inclusion criteria, utilizing diffusion-weighted imaging (DTI) (n = 39), magnetization transfer (MT) (n = 6), MR spectroscopy (n = 3), and myelin water imaging (n = 1), as well as a combination of MRI methods (n = 12). The metric fractional anisotropy (FA) showed the highest potential in all facets of utilities, followed by mean diffusivity. Other promising metrics included MT ratio and intracellular volume fraction, especially in multimodal studies. However, the level of evidence for these promising metrics was low due to a small number of studies. Some studies, mainly DTI, also reported the usefulness of spinal cord MRI in mild CSM. CONCLUSIONS: Spinal cord MRI methods can potentially facilitate the diagnosis and management of CSM by quantitatively interrogating the structural integrity of CSC. DTI is the most promising MRI method, and other techniques have also shown promise, especially in multimodal configurations. However, this field is in its early stages, and more studies are needed to establish the usefulness of spinal cord MRI in CSM.

Predicting Outdoor Walking 1 Year After Spinal Cord Injury: A Retrospective, Multisite External Validation Study.

BACKGROUND AND PURPOSE: Predicting future outdoor walking ability after spinal cord injury (SCI) is important, as this is associated with community engagement and social participation. A clinical prediction rule (CPR) was derived for predicting outdoor walking 1 year after SCI. While promising, this CPR has not been validated, which is necessary to establish its clinical value. The objective of this study was to externally validate the CPR using a multisite dataset. METHODS: This was a retrospective analysis of US SCI Model Systems data from 12 centers. L3 motor score, L5 motor score, and S1 sensory score were used as predictor variables. The dataset was split into testing and training datasets. The testing dataset was used as a holdout dataset to provide an unbiased estimate of prediction performance. The training dataset was used to determine the optimal CPR threshold through a "leave-one-site-out" cross-validation framework. The primary outcome was self-reported outdoor walking ability 1 year after SCI. RESULTS: A total of 3721 participants' data were included. Using the optimal CPR threshold (CPR ≥ 33 threshold value), we were able to predict outdoor walking 1 year with high cross-validated accuracy and prediction performance. For the entire dataset, area under receiver operator characteristic curve was 0.900 (95% confidence interval: 0.890-0.910; P < 0.0001). DISCUSSION AND CONCLUSIONS: The outdoor walking CPR has been externally validated. Future research should conduct a clinical outcomes and cost-benefit impact analysis for implementing this CPR. Our results support that clinicians may use this 3-variable CPR for prediction of future outdoor walking ability.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A411 ).

Spinal cord imaging markers and recovery of standing with epidural stimulation in individuals with clinically motor complete spinal cord injury.

Spinal cord epidural stimulation (scES) is an intervention to restore motor function in those with severe spinal cord injury (SCI). Spinal cord lesion characteristics assessed via magnetic resonance imaging (MRI) may contribute to understand motor recovery. This study assessed relationships between standing ability with scES and spared spinal cord tissue characteristics at the lesion site. We hypothesized that the amount of lateral spared cord tissue would be related to independent extension in the ipsilateral lower limb. Eleven individuals with chronic, clinically motor complete SCI underwent spinal cord MRI, and were subsequently implanted with scES. Standing ability and lower limb activation patterns were assessed during an overground standing experiment with scES. This assessment occurred prior to any activity-based intervention with scES. Lesion hyperintensity was segmented from T2 axial images, and template-based analysis was used to estimate spared tissue in anterior, posterior, right, and left spinal cord regions. Regression analysis was used to assess relationships between imaging and standing outcomes. Total volume of spared tissue was related to left (p = 0.007), right (p = 0.005), and bilateral (p = 0.011) lower limb extension. Spared tissue in the left cord region was related to left lower limb extension (p = 0.019). A positive trend (p = 0.138) was also observed between right spared cord tissue and right lower limb extension. In this study, MRI measures of spared spinal cord tissue were significantly related to standing outcomes with scES. These preliminary results warrant future investigation of roles of supraspinal input and MRI-detected spared spinal cord tissue on lower limb motor responsiveness to scES.

Lateral Corticospinal Tract and Dorsal Column Damage: Predictive Relationships With Motor and Sensory Scores at Discharge From Acute Rehabilitation After Spinal Cord Injury.

OBJECTIVE: To determine if lateral corticospinal tract (LCST) integrity demonstrates a significant predictive relationship with future ipsilateral lower extremity motor function (LEMS) and if dorsal column (DC) integrity demonstrates a significant predictive relationship with future light touch (LT) sensory function post spinal cord injury (SCI) at time of discharge from inpatient rehabilitation. DESIGN: Retrospective analyses of imaging and clinical outcomes. SETTING: University and academic hospital. PARTICIPANTS: A total of 151 participants (N=151) with SCI. INTERVENTIONS: Inpatient rehabilitation. MAIN OUTCOME MEASURES: LEMS and LT scores at discharge from inpatient rehabilitation. RESULTS: In 151 participants, right LCST spared tissue demonstrated a significant predictive relationship with right LEMS percentage recovered (ß=0.56; 95% confidence interval [CI], 0.37-0.73; R=0.43; P<.001). Left LCST spared tissue demonstrated a significant predictive relationship with left LEMS percentage recovered (ß=0.66; 95% CI, 0.50-0.82; R=0.51; P<.001). DC spared tissue demonstrated a significant predictive relationship with LT percentage recovered (ß=0.69; 95% CI, 0.52-0.87; R=0.55; P<.001). When subgrouping the participants into motor complete vs incomplete SCI, motor relationships were no longer significant, but the sensory relationship remained significant. Those who had no voluntary motor function but recovered some also had significantly greater LCST spared tissue than those who did not recover motor function. CONCLUSIONS: LCST demonstrated significant moderate predictive relationships with lower extremity motor function at the time of discharge from inpatient rehabilitation, in an ipsilesional manner. DC integrity demonstrated a significant moderate predictive relationship with recovered function of LT. With further development, these neuroimaging methods might be used to predict potential deficits after SCI and to provide corresponding targeted interventions.

Greater muscle volume and muscle fat infiltrate in the deep cervical spine extensor muscles (multifidus with semispinalis cervicis) in individuals with chronic idiopathic neck pain compared to age and sex-matched asymptomatic controls: a cross-sectional study.

Muscle size and composition (muscle volume and muscle fat infiltrate [MFI]) may provide insight into possible mechanisms underpinning chronic idiopathic neck pain, a common condition with no definitive underlying pathology. In individuals with chronic idiopathic neck pain > 3 months and age- and sex-matched asymptomatic controls, muscle volumes of levator scapulae, multifidus including semispinalis cervicis (MFSS), semispinalis capitis, splenius capitis including splenius cervicis (SCSC), sternocleidomastoid and longus colli from C3 through T1 were quantified from magnetic resonance imaging. Between-group differences were determined using linear mixed models, accounting for side (left or right), muscle, spinal level, sex, age, and body mass index (BMI). Individuals with pain had greater muscle volume (mean difference 76.8mm3; 95% CI 26.6-127.0; p = .003) and MFI (2.3%; 0.2-4.5; p = .034) of the MFSS compared to matched controls with no differences in relative volume, accounting for factors associated with the outcomes: muscle, spinal level, side (left had smaller volume, relative volume and MFI than right), sex (females had less volume and relative volume than males), age (older age associated with less relative volume and greater MFI), and BMI (higher BMI associated with greater muscle volume and MFI). Greater MFI in individuals with chronic idiopathic neck pain suggests a possible underlying mechanism contributing to neck pain. Perspective: These findings suggest MFI in the MFSS may be radiologic sign, potentially identifying patients with a less favourable prognosis. Future studies are needed to confirm this finding and determine if MFI is a contributor to the development or persistence of neck pain, or consequence of neck pain.

Towards defining muscular regions of interest from axial magnetic resonance imaging with anatomical cross-reference: a scoping review of lateral hip musculature.

BACKGROUND: Measures of hip muscle morphology and composition (e.g., muscle size and fatty infiltration) are possible with magnetic resonance imaging (MRI). Standardised protocols or guidelines do not exist for evaluation of hip muscle characteristics, hindering reliable and valid inter-study analysis. This scoping review aimed to collate and synthesise MRI methods for measuring lateral hip muscle size and fatty infiltration to inform the future development of standardised protocols. METHODS: Five electronic databases (Medline, CINAHL, Embase, SportsDISCUS and AMED) were searched. Healthy or musculoskeletal pain populations that used MRI to assess lateral hip muscle size and fatty infiltration were included. Lateral hip muscles of interest included tensor fascia late (TFL), gluteus maximus, gluteus medius, and gluteus minimus. Data on MRI parameters, axial slice location, muscle size and fatty infiltrate measures were collected and analysed. Cross referencing for anatomical locations were made between MRI axial slice and E-12 anatomical plastinate sections. RESULTS: From 2684 identified publications, 78 studies contributed data on volume (n = 31), cross sectional area (CSA) (n = 24), and fatty infiltration (n = 40). Heterogeneity was observed for MRI parameters and anatomical boundaries scrutinizing hip muscle size and fatty infiltration. Seven single level axial slices were identified that provided consistent CSA measurement, including three for both gluteus maximus and TFL, and four for both gluteus medius and minimus. For assessment of fatty infiltration, six axial slice locations were identified including two for TFL, and four for each of the gluteal muscles. CONCLUSIONS: Several consistent anatomical levels were identified for single axial MR slice to facilitate muscle size and fatty infiltration muscle measures at the hip, providing the basis for reliable and accurate data synthesis and improvements in the validity of future between studies analyses. This work establishes the platform for standardised methods for the MRI assessment of lateral hip musculature and will aid in the examination of musculoskeletal conditions around the hip joint. Further studies into whole muscle measures are required to further optimise methodological parameters for hip muscle assessment.

New insights into intrinsic foot muscle morphology and composition using ultra-high-field (7-Tesla) magnetic resonance imaging.

BACKGROUND: The intrinsic muscles of the foot are key contributors to foot function and are important to evaluate in lower limb disorders. Magnetic resonance imaging (MRI), provides a non-invasive option to measure muscle morphology and composition, which are primary determinants of muscle function. Ultra-high-field (7-T) magnetic resonance imaging provides sufficient signal to evaluate the morphology of the intrinsic foot muscles, and, when combined with chemical-shift sequences, measures of muscle composition can be obtained. Here we aim to provide a proof-of-concept method for measuring intrinsic foot muscle morphology and composition with high-field MRI. METHODS: One healthy female (age 39 years, mass 65 kg, height 1.73 m) underwent MRI. A T1-weighted VIBE - radio-frequency spoiled 3D steady state GRE - sequence of the whole foot was acquired on a Siemens 7T MAGNETOM scanner, as well as a 3T MAGNETOM Prisma scanner for comparison. A high-resolution fat/water separation image was also acquired using a 3D 2-point DIXON sequence at 7T. Coronal plane images from 3T and 7T scanners were compared. Using 3D Slicer software, regions of interest were manually contoured for each muscle on 7T images. Muscle volumes and percentage of muscle fat infiltration were calculated (muscle fat infiltration % = Fat/(Fat + Water) x100) for each muscle. RESULTS: Compared to the 3T images, the 7T images provided superior resolution, particularly at the forefoot, to facilitate segmentation of individual muscles. Muscle volumes ranged from 1.5 cm3 and 19.8 cm3, and percentage muscle fat infiltration ranged from 9.2-15.0%. CONCLUSIONS: This proof-of-concept study demonstrates a feasible method of quantifying muscle morphology and composition for individual intrinsic foot muscles using advanced high-field MRI techniques. This method can be used in future studies to better understand intrinsic foot muscle morphology and composition in healthy individuals, as well as those with lower disorders.

Assessing the spatial distribution of cervical spinal cord activity during tactile stimulation of the upper extremity in humans with functional magnetic resonance imaging.

Dermatomal maps are a mainstay of clinical practice and provide information on the spatial distribution of the cutaneous innervation of spinal nerves. Dermatomal deficits can help isolate the level of spinal nerve root involvement in spinal conditions and guide clinicians in diagnosis and treatment. Dermatomal maps, however, have limitations, and the spatial distribution of spinal cord sensory activity in humans remains to be quantitatively assessed. Here we used spinal cord functional MRI to map and quantitatively compare the spatial distribution of sensory spinal cord activity during tactile stimulation of the left and right lateral shoulders (i.e. C5 dermatome) and dorsal third digits of the hands (i.e., C7 dermatome) in healthy humans (n â€‹= â€‹24, age â€‹= â€‹36.8 â€‹± â€‹11.8 years). Based on the central sites for processing of innocuous tactile sensory information, we hypothesized that the activity would be localized more to the ipsilateral dorsal spinal cord with the lateral shoulder stimulation activity being localized more superiorly than the dorsal third digit. The findings demonstrate lateralization of the activity with the left- and right-sided stimuli having more activation in the ipsilateral hemicord. Contradictory to our hypotheses, the activity for both stimulation sites was spread across the dorsal and ventral hemicords and did not demonstrate a clear superior-inferior localization. Instead, the activity for both stimuli had a broader than expected distribution, extending across the C5, C6, and C7 spinal cord segments. We highlight the complexity of the human spinal cord neuroanatomy and several sources of variability that may explain the observed patterns of activity. While the findings were not completely consistent with our a priori hypotheses, this study provides a foundation for continued work and is an important step towards developing normative quantitative spinal cord measures of sensory function, which may become useful objective MRI-based biomarkers of neurological injury and improve the management of spinal disorders.

Dynamic per slice shimming for simultaneous brain and spinal cord fMRI.

PURPOSE: Simultaneous brain and spinal cord functional MRI is emerging as a new tool to study the central nervous system but is challenging. Poor B0 homogeneity and small size of the spinal cord are principal obstacles to this nascent technology. Here we extend a dynamic shimming approach, first posed by Finsterbusch, by shimming per slice for both the brain and spinal cord. METHODS: We shim dynamically by a simple and fast optimization of linear field gradients and frequency offset separately for each slice in order to minimize off-resonance for both the brain and spinal cord. Simultaneous acquisition of brain and spinal cord fMRI is achieved with high spatial resolution in the spinal cord by means of an echo-planar RF pulse for reduced FOV. Brain slice acquisition is full FOV. RESULTS: T2*-weighted images of brain and spinal cord are acquired with high clarity and minimal observable image artifacts. Fist-clenching fMRI experiments reveal task-consistent activation in motor cortices, cerebellum, and C6-T1 spinal segments. CONCLUSIONS: High quality functional results are obtained for a sensory-motor task. Consistent activation in both the brain and spinal cord is observed at individual levels, not only at group level. Because reduced FOV excitation is applicable to any spinal cord section, future continuation of these methods holds great potential.

Lateral Corticospinal Tract Damage Correlates With Motor Output in Incomplete Spinal Cord Injury.

OBJECTIVE: To investigate the relationship between spinal cord damage and specific motor function in participants with incomplete spinal cord injury (iSCI). DESIGN: Single-blinded, cross-sectional study design. SETTING: University setting research laboratory. PARTICIPANTS: Individuals with chronic cervical iSCI (N=14; 1 woman, 13 men; average age ± SD, 43±12y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Axial T2-weighted magnetic resonance imaging (MRI) of spinal cord damage was performed in 14 participants with iSCI. Each participant's damage was processed for total damage quantification, lateral corticospinal tract (LCST) and gracile fasciculus (GF) analysis. Plantarflexion and knee extension were quantified using an isokinetic dynamometer. Walking ability was assessed using a 6-minute walk test. RESULTS: Total damage was correlated with plantarflexion, knee extension, and distance walked in 6 minutes. Right LCST damage was correlated with right plantarflexion and right knee extension, while left LCST damage was correlated with left-sided measures. Right and left GF damage was not correlated with the motor output measures. CONCLUSIONS: MRI measures of spinal cord damage were correlated to motor function, and this measure appears to have spatial specificity to descending tracts, which may offer prognostic value after SCI.

Functional magnetic resonance imaging of the cervical spinal cord during thermal stimulation across consecutive runs.

The spinal cord is the first site of nociceptive processing in the central nervous system and has a role in the development and perpetuation of clinical pain states. Advancements in functional magnetic resonance imaging are providing a means to non-invasively measure spinal cord function, and functional magnetic resonance imaging may provide an objective method to study spinal cord nociceptive processing in humans. In this study, we tested the validity and reliability of functional magnetic resonance imaging using a selective field-of-view gradient-echo echo-planar-imaging sequence to detect activity induced blood oxygenation level-dependent signal changes in the cervical spinal cord of healthy volunteers during warm and painful thermal stimulation across consecutive runs. At the group and subject level, the activity was localized more to the dorsal hemicord, the spatial extent and magnitude of the activity was greater for the painful stimulus than the warm stimulus, and the spatial extent and magnitude of the activity exceeded that of a control analysis. Furthermore, the spatial extent of the activity for the painful stimuli increased across the runs likely reflecting sensitization. Overall, the spatial localization of the activity varied considerably across the runs, but despite this variability, a machine-learning algorithm was able to successfully decode the stimuli in the spinal cord based on the distributed pattern of the activity. In conclusion, we were able to successfully detect and characterize cervical spinal cord activity during thermal stimulation at the group and subject level.

Lateralization of cervical spinal cord activity during an isometric upper extremity motor task with functional magnetic resonance imaging.

The purpose of this study was to use an isometric upper extremity motor task to detect activity induced blood oxygen level dependent signal changes in the cervical spinal cord with functional magnetic resonance imaging. Eleven healthy volunteers performed six 5minute runs of an alternating left- and right-sided isometric wrist flexion task, during which images of the cervical spinal cord were acquired with a reduced field-of-view T2*-weighted gradient-echo echo-planar-imaging sequence. Spatial normalization to a standard spinal cord template was performed, and group average activation maps were generated in a mixed-effects analysis. The task activity significantly exceeded that of the control analyses. The activity was lateralized to the hemicord ipsilateral to the task and reliable across the runs at the group and subject level. Finally, a multi-voxel pattern analysis was able to successfully decode the left and right tasks at the C6 and C7 vertebral levels.

White matter microstructure changes induced by motor skill learning utilizing a body machine interface.

The purpose of this study is to identify white matter microstructure changes following bilateral upper extremity motor skill training to increase our understanding of learning-induced structural plasticity and enhance clinical strategies in physical rehabilitation. Eleven healthy subjects performed two visuo-spatial motor training tasks over 9 sessions (2-3 sessions per week). Subjects controlled a cursor with bilateral simultaneous movements of the shoulders and upper arms using a body machine interface. Before the start and within 2days of the completion of training, whole brain diffusion tensor MR imaging data were acquired. Motor training increased fractional anisotropy (FA) values in the posterior and anterior limbs of the internal capsule, the corona radiata, and the body of the corpus callosum by 4.19% on average indicating white matter microstructure changes induced by activity-dependent modulation of axon number, axon diameter, or myelin thickness. These changes may underlie the functional reorganization associated with motor skill learning.

Spinal cord lesion MRI and behavioral outcomes in a miniature pig model of spinal cord injury: exploring preclinical potential through an ad hoc comparison with human SCI.

STUDY DESIGN: prospective case series of Yucatan miniature pig spinal cord contusion injury model with comparison to human cases of spinal cord injury (SCI). OBJECTIVES: to describe magnetic resonance imaging (MRI) measures of spinal cord lesion severity along with estimates of lateral corticospinal tracts spared neural tissue in both a less severe and more severe contusion SCI model, as well as to describe their corresponding behavioral outcome changes. SETTING: University laboratory setting. METHODS: Following a more severe and less severe SCI, each pig underwent spinal cord MRI to measure lesion characteristics, along with locomotor and urodynamics outcomes testing. RESULTS: In the pig with more severe SCI, locomotor and urodynamic outcomes were poor, and both the spinal cord lesion volume and damage estimates to the lateral corticospinal tracts were large. Conversely, in the pig with less severe SCI, locomotor and urodynamic outcomes were favorable, with the spinal cord lesion volume and damage estimates to the lateral corticospinal tracts being less pronounced. For two human cases matched on estimates of damage to the lateral corticospinal tract regions, the clinical presentations were similar to the pig outcomes, with more limited mobility and more limited bladder functional independence in the more severe case. CONCLUSIONS: Our initial findings contribute valuable insights to the emergent field of MRI-based evaluation of spinal cord lesions in pig models, offering a promising avenue for understanding and potentially improving outcomes in spinal cord injuries.

Peak Slope Ratio of the Recruitment Curves Compared to Muscle Evoked Potentials to Optimize Standing Configurations with Percutaneous Epidural Stimulation after Spinal Cord Injury.

Background: Percutaneous spinal cord epidural stimulation (pSCES) has effectively restored varying levels of motor control in persons with motor complete spinal cord injury (SCI). Studying and standardizing the pSCES configurations may yield specific motor improvements. Previously, reliance on the amplitude of the SCES-evoked potentials (EPs) was used to determine the correct stimulation configurations. Methods: We, hereby, retrospectively examined the effects of wide and narrow-field configurations on establishing the motor recruitment curves of motor units of three different agonist-antagonist muscle groups. Magnetic resonance imaging was also used to individualize SCI participants (n = 4) according to their lesion characteristics. The slope of the recruitment curves using a six-degree polynomial function was calculated to derive the slope ratio for the agonist-antagonist muscle groups responsible for standing. Results: Axial damage ratios of the spinal cord ranged from 0.80 to 0.92, indicating at least some level of supraspinal connectivity for all participants. Despite the close range of these ratios, standing motor performance was enhanced using different stimulation configurations in the four persons with SCI. A slope ratio of ≥1 was considered for the recommended configurations necessary to achieve standing. The retrospectively identified configurations using the supine slope ratio of the recruitment curves of the motor units agreed with that visually inspected muscle EPs amplitude of the extensor relative to the flexor muscles in two of the four participants. Two participants managed to advance the selected configurations into independent standing performance after using tonic stimulation. The other two participants required different levels of assistance to attain standing performance. Conclusions: The findings suggest that the peak slope ratio of the muscle agonists-antagonists recruitment curves may potentially identify the pSCES configurations necessary to achieve standing in persons with SCI.

SCIseg: Automatic Segmentation of T2-weighted Intramedullary Lesions in Spinal Cord Injury.

Purpose: To develop a deep learning tool for the automatic segmentation of T2-weighted intramedullary lesions in spinal cord injury (SCI). Material and Methods: This retrospective study included a cohort of SCI patients from three sites enrolled between July 2002 and February 2023. A deep learning model, SCIseg, was trained in a three-phase process involving active learning for the automatic segmentation of intramedullary SCI lesions and the spinal cord. The data consisted of T2-weighted MRI acquired using different scanner manufacturers with heterogeneous image resolutions (isotropic/anisotropic), orientations (axial/sagittal), lesion etiologies (traumatic/ischemic/hemorrhagic) and lesions spread across the cervical, thoracic and lumbar spine. The segmentations from the proposed model were visually and quantitatively compared with other open-source baselines. Wilcoxon signed-rank test was used to compare quantitative MRI biomarkers (lesion volume, lesion length, and maximal axial damage ratio) computed from manual lesion masks and those obtained automatically with SCIseg predictions. Results: MRI data from 191 SCI patients (mean age, 48.1 years ± 17.9 [SD]; 142 males) were used for model training and evaluation. SCIseg achieved the best segmentation performance for both the cord and lesions. There was no statistically significant difference between lesion length and maximal axial damage ratio computed from manually annotated lesions and those obtained using SCIseg. Conclusion: Automatic segmentation of intramedullary lesions commonly seen in SCI replaces the tedious manual annotation process and enables the extraction of relevant lesion morphometrics in large cohorts. The proposed model segments lesions across different etiologies, scanner manufacturers, and heterogeneous image resolutions. SCIseg is open-source and accessible through the Spinal Cord Toolbox.

Lesion characteristics are associated with bowel, bladder, and overall independence following cervical spinal cord injury.

CONTEXT/OBJECTIVE: There is a growing global interest in quantifying spinal cord lesions and spared neural tissue using magnetic resonance imaging (MRI) in individuals with spinal cord injury (SCI). The primary objective of this study was to assess the relationships between spinal cord lesion characteristics assessed on MRI and bowel, bladder, and overall independence following SCI. DESIGN: Retrospective, exploratory study. PARTICIPANTS: 93 individuals with cervical SCI who were enrolled in a local United States Model Systems SCI database from 2010 to 2017. METHODS: Clinical and MRI data were obtained for potential participants, and MRIs of eligible participants were analyzed. Explanatory variables, captured on MRIs, included intramedullary lesion length (IMLL), midsagittal ventral tissue bridge width (VTBW), midsagittal dorsal tissue bridge width (DTBW), and axial damage ratio (ADR). OUTCOME MEASURES: Bowel and bladder management scale of the Functional Independence Measure (FIM) and FIM total motor score. RESULTS: When accounting for all four variables, only ADR was significantly associated with bowel independence (OR = 0.970, 95% CI: 0.942-0.997, P = 0.030), and both ADR and IMLL were strongly associated with bladder independence (OR = 0.967, 95% CI: 0.936-0.999, P = 0.046 and OR = 0.948, 95% CI: 0.919-0.978, P = 0.0007, respectively). 32% of the variation in overall independence scores were explained by all four predictive variables, but only ADR was significantly associated with overall independence after accounting for all other predictive variables (ß = -0.469, 95% CI: -0.719, -0.218, P = 0.0004). CONCLUSIONS: Our results suggest that the MRI-measured extent of spinal cord lesion may be predictive of bowel, bladder, and overall independence following cervical SCI.

Prognostic value of tissue bridges in cervical spinal cord injury: a longitudinal, multicentre, retrospective cohort study.

BACKGROUND: The accuracy of prognostication in patients with cervical spinal cord injury (SCI) needs to be improved. We aimed to explore the prognostic value of preserved spinal tissue bridges-injury-spared neural tissue adjacent to the lesion-for prediction of sensorimotor recovery in a large, multicentre cohort of people with SCI. METHODS: For this longitudinal study, we included patients with acute cervical SCI (vertebrae C1-C7) admitted to one of three trauma or rehabilitation centres: Murnau, Germany (March 18, 2010-March 1, 2021); Zurich, Switzerland (May 12, 2002-March 2, 2019); and Denver, CO, USA (Jan 12, 2010-Feb 16, 2017). Patients were clinically assessed at admission (baseline), at discharge (3 months), and at 12 months post SCI. Midsagittal tissue bridges were quantified from T2-weighted images assessed at 3-4 weeks post SCI. Fractional regression and unbiased recursive partitioning models, adjusted for age, sex, centre, and neurological level of injury, were used to assess associations between tissue bridge width and baseline-adjusted total motor score, pinprick score, and light touch scores at 3 months and 12 months. Patients were stratified into subgroups according to whether they showed better or worse predicted recovery. FINDINGS: The cohort included 227 patients: 93 patients from Murnau (22 [24%] female); 43 patients from Zurich (four [9%] female); and 91 patients from Denver (14 [15%] female). 136 of these participants (from Murnau and Zurich) were followed up for up to 12 months. At 3 months, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 9·3% (SD 0·9) of maximal total motor score (95% CI 7·5-11.2), 8·6% (0·8) of maximal pinprick score (7·0-10·1), and 10·9% (0·8) of maximal light touch score (9·4-12·5). At 12 months post SCI, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 10·9% (1·3) of maximal total motor score (8·4-13·4), 5·7% (1·3) of maximal pinprick score (3·3-8·2), and 6·9% (1·4) of maximal light touch score (4·1-9·7). Partitioning models identified a tissue bridge cutoff width of 2·0 mm to be indicative of higher or lower 3-month total motor, pinprick, and light touch scores, and a cutoff of 4·0 mm to be indicative of higher and lower 12-month scores. Compared with models that contained clinical predictors only, models additionally including tissue bridges had significantly improved prediction accuracy across all three centres. INTERPRETATION: Tissue bridges, measured in the first few weeks after SCI, are associated with short-term and long-term clinical improvement. Thus, tissue bridges could potentially be used to guide rehabilitation decision making and to stratify patients into more homogeneous subgroups of recovery in regenerative and neuroprotective clinical trials. FUNDING: Wings for Life, International Foundation for Research in Paraplegia, EU project Horizon 2020 (NISCI grant), and ERA-NET NEURON.