Surgical intervention combined with weight-bearing walking training promotes recovery in patients with chronic spinal cord injury: a randomized controlled study

Abstract

JOURNAL/nrgr/04.03/01300535-202412000-00032/figure1/v/2024-04-08T165401Z/r/image-tiff For patients with chronic spinal cord injury, the conventional treatment is rehabilitation and treatment of spinal cord injury complications such as urinary tract infection, pressure sores, osteoporosis, and deep vein thrombosis. Surgery is rarely performed on spinal cord injury in the chronic phase, and few treatments have been proven effective in chronic spinal cord injury patients. Development of effective therapies for chronic spinal cord injury patients is needed. We conducted a randomized controlled clinical trial in patients with chronic complete thoracic spinal cord injury to compare intensive rehabilitation (weight-bearing walking training) alone with surgical intervention plus intensive rehabilitation. This clinical trial was registered at ClinicalTrials.gov (NCT02663310). The goal of surgical intervention was spinal cord detethering, restoration of cerebrospinal fluid flow, and elimination of residual spinal cord compression. We found that surgical intervention plus weight-bearing walking training was associated with a higher incidence of American Spinal Injury Association Impairment Scale improvement, reduced spasticity, and more rapid bowel and bladder functional recovery than weight-bearing walking training alone. Overall, the surgical procedures and intensive rehabilitation were safe. American Spinal Injury Association Impairment Scale improvement was more common in T7-T11 injuries than in T2-T6 injuries. Surgery combined with rehabilitation appears to have a role in treatment of chronic spinal cord injury patients.

Figure 1

Study flow chart.

Figure 2

Kunming locomotor training program (KLTP) and Kunming Locomotor Scale (KLS) in patients with complete traumatic spinal cord injury. The KLTP comprises eight progressive steps. All subjects were trained starting at step 1. Once the subject consistently completed step 1, the training moved on to the next step, and the training continued in this way through each subsequent step. The 10-point KLS was used to assess locomotor recovery. The KLS is indicated by Roman numerals I to X and is based on the KLTP.

Figure 3

Change in the American Spinal Injury Association Impairment Scale (AIS) grade over time in both groups. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 4

American Spinal Injury Association (ASIA) score with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 5

The Kunming Locomotor Scale (KLS) and Walking Index for Spinal Cord Injury II (WISCI II) scores with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 6

Bladder and stool scores with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 7

The Modified Ashworth Scale (MAS) score with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 8

The Spinal Cord Independence Measure (SCIM) score with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 9

Happiness Index score with 95% confidence intervals according to group over time. Group A: Treatment group (surgery + rehabilitation); group B: control (rehabilitation only) group.

Figure 10

Magnetic resonance imaging before (A) and after surgery (B) in a patient in the treatment group. (A1, A2) The preoperative MRI image of the subject 01 showing the dilation of the central canal of the spinal cord below the level of injury (A1) and the measurements of the dilation (A2). (B1, B2) The postoperative MRI of the subject showing considerable improvement in the central canal dilation (B1) and the measurements of the dilation (B2).

Figure 11

Histopathological changes in the spinal cord of a patient who underwent surgical detethering 9 months after injury. Low (A, C) and high (B, D) magnification images. B and D represent the boxes in A and C, respectively. KP1-positive activated microglia and macrophages are visualized. Some cells exhibit amoeboid morphology. Cytoplasm filled with phagocytic vesicles is indicated by solid arrows. Activated microglia/macrophages clumped together are indicated by hollow arrows. Scale bars: 200 μm in A, C; 50 μm in B, D.

Figure 12

Representative MRI in a patient with chronic spinal cord injury. Pathological changes included myeloatrophy (A1, A2), interruption of spinal cord continuity (B1, B2), syringomyelia (C1, C2), and cystic degeneration (D1, D2).

Figure 13

Chronic perilesional spinal cord injury patterns and effects of surgical detethering. (A) Normal cerebrospinal fluid (CSF) flow (solid arrow). (B-I) Cavity formation in the spinal cord (oval), external tethering (grid pattern), and blockage of CSF flow (broken arrow). (B-II) Tethering (grid pattern) and blockage of CSF flow (broken arrow). (B-III) Syringomyelia formation (oval), tethering (grid pattern), blockage of CSF flow (broken arrow). (C) Improvement of CSF flow (solid arrow).

Figure 14

Intraoperative conditions encountered in chronic spinal cord injury (perilesional classification system). (A) I-Adhesion. Extensive tethering adhesions of the spinal cord, spinal dura mater, or arachnoid (black arrow). The subarachnoid space is completely or incompletely occluded. Cerebrospinal (CSF) flow is blocked and pulsation of the spinal cord is absent. (B) V-Myeloatrophy. The spinal cord appears pale and atrophied (black arrow); the surface lacks a visible blood supply. (C) III-Arachnoid cysts. Cystic adhesion leads to obstruction of CSF circulation, abnormal accumulation of CSF in the subarachnoid space, and formation of cysts (black arrow) that may compress the spinal cord. (D) II-Cystic degeneration. Cystic degeneration (black arrow) of the spinal cord adjacent to the lesion may contain necrotic material, including liquified blood cells. (E) IV-Syringomyelia. Adhesions lead to CSF flow obstruction and diversion of CSF into the spinal cord parenchyma, which expands the central canal (black arrow). (F) VI-Residual compression. Bone fragments or other adjacent structures compress or distort the spinal cord. (F) VII-Spinal cord transection type. Complete rupture of the spinal cord parenchyma (black arrow) is found. Pathologic changes observed during the surgery were summarized into seven classifications. I–VII represent the classifications.