Spinal cord injury : diagnostics, treatment, complications and outcome
Authors: Stenimahitis Vasilios 
Published: February 2025

<p dir="ltr">The global prevalence of spinal cord injury (SCI) is approximately 230-1300 cases per million populations per year and the estimated rate worldwide is 250,000 - 500,000 individuals per year. Preventable causes (traffic accidents and falls) are reported as the major cause of SCI. Fall is the most common cause of SCI in the elderly and compared to previous studies the mean age of individuals with SCI is now higher. No definite curative treatment is at the time available and depending on the extend and the level of the injury in the spinal cord the long-term neurological outcomes may differ considerably. Spinal cord infarction is an uncommon condition, with no available established diagnostic criteria at the time, no clearly clarified aetiology and despite the similarities to cerebral stroke, the implication of vascular risk factors in the pathophysiology of the condition is still not yet entirely understood. In traumatic SCI, the identification of predictors of long-term neurological outcome is crucial in the context of enabling the physician in decision-making regarding treatment strategies and rehabilitation approaches. Factors affecting quality of life in the aftermath of SCI are poorly understood. This thesis aims to study population-based cohorts with traumatic and nontraumatic SCI and to shine a new perspective by offering a fresh viewpoint to some of these questions.</p><p dir="ltr">Study I analyzed the baseline findings and evaluated the long-term outcome for individuals with spinal cord infarction (SCInf), both spontaneous and periprocedural. T2-weighted and diffusion-weighted (DWI) MRI were instrumental imaging techniques for the definite setting of diagnosis. The retrospective application of the recently presented diagnostic algorithm favors the general adoption of the proposed diagnostic criteria. The overrepresentation of vascular risk factors compared with the general population, points out their role in the pathophysiology of the condition. In cases of spontaneous SCInf, a more favorable outcome was observed compared to the periprocedural cases which furthermore were more extensive compared to the spontaneous cases that in turn, to a great degree, affected a single segment of the spinal cord. The neurological improvement shown at long-term follow-up draws special attention to the meaningfulness of active rehabilitation.</p><p dir="ltr">Study II, a systematic analytic review of the current literature on spontaneous SCInf, revealed that in 72% of the cases, although the exact pathophysiology is yet to be understood, at least one vascular risk factor was documented, thus underlying the importance of proper prophylactic management of factors such as hypertension, diabetes, hyperlipidemia and smoking in the context of stroke prevention. Potential to functional recovery was good and ability to walk with or without aids was reported in 71% of the cases, at approximately three years after spontaneous SCInf. Additionally, the introduction of DWI in the diagnostic work-up of SCInf is a valuable tool assisting in the definite diagnosis-setting.</p><p dir="ltr">Study III evaluated the impact of SCI on health-related quality of life (HRQoL) in patients that underwent surgery for traumatic subaxial spine injury. The patient- reported outcome measures (PROMs), specifically EQ-5D-3L and Neck Disability Index (NDI), were studied for the period 2006-2016. Source of data was the Swedish Spine Registry (Swespine). Analysis of PROMs at long-term follow-up times at 1-, 2- and 5-years post-surgery, revealed that the presence and the extend of SCI had negative impact on both outcome measures and that the Frankel grade scale (a classification of the extent of the neurological - functional impairment) was a significant predictor of PROMs. Additionally, analysis of PROMs results at follow-ups beyond 1-year post-surgery showed altogether no significant changes, regardless the extend of the SCI.</p><p dir="ltr">Study IV evaluated long-term follow-up for patients treated surgically for posttraumatic tethered cord syndrome and demonstrated that in the largest part of the patients, the surgical treatment either resulted in improvement of the neurological function or discontinued the neurological decline.</p><p dir="ltr">Study V evaluated retrospectively the long-term outcome and the predictors for neurological recovery in patients with cervical spinal cord injury by analyzing a decade's volume of data from a single, specialized care unit in Stockholm, Sweden. The extend of the initial SCI was a significant predictor for neurologic recovery and regaining of ambulation ability. The median age of the cohort was 64 years, displaying a shift toward an aging population being affected by cervical SCI. Old age was a negative prognostic factor associated with decreased recovery potential. The observed neurological improvement at follow-up underlined the potential for favorable outcome and illustrated the key role of tailored rehabilitative interventions in boosting patient outcomes. In that context, specialized rehabilitation strategies for the more vulnerable and frail older individuals, often presenting with pre-existing comorbidities, might prove to be beneficial and lead to improved functional outcome.</p><p dir="ltr">Study VI, a qualitative study based on semi-structured interviews, evaluated the subjective factors that have impact on quality of life (QoL) in individuals with SCI. Important parameters with impact on well-being were the management of SCI- related physical problems, desire to live an independent life and, the significance of community and a sense of belonging. Contrarily, long-term complications after SCI, especially pain, have a negative impact on QoL and underline the need for further research to enhance treatment options.</p><p dir="ltr">In conclusion, the findings of this thesis, draw attention to the role of MRI imaging techniques for the setting of the diagnosis of SCInf and turn the spotlight on the role of vascular risk factures in the pathophysiology of the condition. The periprocedural cases of SCInf were more extensive and were associated with less favorable outcome compared to the spontaneous cases. In subaxial traumatic cervical injuries, the presence of associated SCI and its severity had a negative impact on the HRQoL based on patient-reported outcomes measures. The potential for neurological improvement in the aftermath of traumatic cervical spinal injury, emphasized the key role of tailored rehabilitative interventions, especially for the more vulnerable older individuals. Components such as autonomy, management of long-term complications and the sense of belonging in the community, carry instrumental positive weight on QoL of individuals with SCI.</p><h3>List of scientific papers</h3><p dir="ltr">I. Long-term outcomes after periprocedural and spontaneous spinal cord Infarctions: a population-based cohort study. <b>Stenimahitis V,</b> Fletcher-Sandersjöö A, El-Haj VG, Hultling C, Andersson M, Sveinsson O, Elmi-Terander A, Edström E. Neurology. 2023 Jul 11;101(2):e114-e124. <a href="https://doi.org/10.1212/wnl.0000000000207377" rel="noreferrer" target="_blank">https://doi.org/10.1212/wnl.0000000000207377</a></p><p dir="ltr">II. Spontaneous spinal cord infarction: a systematic review. Gharios M, <b>Stenimahitis V,</b> El-Hajj VG, Mahdi OA, Fletcher-Sandersjöö A, Jabbour P, Andersson M, Hultling C, Elmi-Terander A, Edström E. BMJ Neurol Open. 2024 May 28;6(1):e000754. <a href="https://doi.org/10.1136/bmjno-2024-000754" rel="noreferrer" target="_blank">https://doi.org/10.1136/bmjno-2024-000754</a></p><p dir="ltr">III. The effect of concomitant spinal cord injury on postoperative health-related quality of life after traumatic subaxial cervical spine injuries: a nationwide registry study. El-Haj VG, <b>Stenimahitis V,</b> Singh A, Blixt S, Edström E, Elmi-Terander A, Gerdhem P. Arch Phys Med Rehabil. 2024 Jun;105(6):1069-1075. <a href="https://doi.org/10.1016/j.apmr.2024.01.021" rel="noreferrer" target="_blank">https://doi.org/10.1016/j.apmr.2024.01.021</a></p><p dir="ltr">IV. Long-term outcome following surgical treatment of posttraumatic tethered cord syndrome: a retrospective population-based cohort study. <b>Stenimahitis V,</b> Fletcher-Sandersjöö A, Tatter C, Elmi-Terander A, Edström E. Spinal Cord. 2022 Jun;60(6):516-521. <a href="https://doi.org/10.1038/s41393-022-00752-7" rel="noreferrer" target="_blank">https://doi.org/10.1038/s41393-022-00752-7</a></p><p dir="ltr">V. Long-term outcome and predictors of neurological recovery in cervical spinal cord injury: a population-based cohort study. <b>Stenimahitis V,</b> Gharios M, Fletcher-Sandersjöö A, El-Hajj VG, Singh A, Buwaider A, Andersson M, Gerdhem P, Hultling C, Elmi-Terander A, Edström E. Sci Rep. 2024 Sep 9;14(1):20945. <a href="https://doi.org/10.1038/s41598-024-71983-2" rel="noreferrer" target="_blank">https://doi.org/10.1038/s41598-024-71983-2</a></p><p dir="ltr">VI. Quality of life after spinal cord injury: a qualitative interview-based study. <b>Stenimahitis V,</b> Guenna Holmgren A, El-Hajj VG, Hultling C, Elmi-Terander A, Edström E. [Manuscript]</p>