Acta Neurochirurgica

https://doi.org/10.1007/s00701-020-04701-2

ORIGINAL ARTICLE - SPINE TRAUMA

Early clinical predictors of functional recovery following traumatic

spinal cord injury: a population-based study of 143 patients
Thea Overgaard Wichmann 1 & Mette Haldrup Jensen 1 & Helge Kasch 2,3 & Mikkel Mylius Rasmussen 1

Received: 7 November 2020 / Accepted: 30 December 2020

# The Author(s), under exclusive licence to Springer-Verlag GmbH, AT part of Springer Nature 2021

Abstract
Background Traumatic spinal cord injuries (TSCI) are associated with uncertainty regarding the prognosis of func-
tional recovery. The aim of the present study was to evaluate the potential of early clinical variables to predict the
degree of functional independence assessed by Spinal Cord Independence Measure III (SCIM-III) up to 1 year after
injury.
Methods Prospectively collected data from 143 SCI patients treated in Western Denmark during 2012–2019 were retrospectively
analysed. Data analysis involved univariate methods and multivariable linear regression modelling total SCIM-III scores against
age, gender, body mass index (BMI), comorbidity, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades
A–B and C–D, ASIA Motor Score (AMS), timing of surgical treatment and occurrence of medical complications. Statistical
significance was set at p < .05.
Results Univariate analyses indicated that variables significantly associated with decreased functional independence included
increased age (p = .023), increased BMI (p = .012), pre-existing comorbidity (p = .001), AIS grades A–B (p < .001), decreased
AMS (p < .001) and occurrence of medical complications (p < .001). However, in the multivariable regression model were pre-
existing comorbidity (p = .010), AIS grades A–B (p < .001), low AMS (p < .001) and late surgical treatment (p = .018) significant
predictors of decreased functional independence 1 year after injury.
Conclusion TSCI patients with greatest potential for functional recovery up to 1 year after injury seem to be patients that
immediately after trauma present with few or no comorbidities, who sustain motor-incomplete injuries and undergo early
decompressive surgery.

Keywords Spinal cord injury . Trauma . Predictors . Functional recovery

Abbreviations AMS American Spinal Injury Association Motor Score

ADL Activities of daily living ALT American Spinal Injury Association Sensory
ASIA American Spinal Injury Association Score for Light Touch
AIS American Spinal Injury Association Impairment BMI Body mass index
Scale CI Confidence intervals

This article is part of the Topical Collection on Spine trauma

Presentation at a conference None of the content has been presented at
a conference.

* Thea Overgaard Wichmann 2

Spinal Cord Injury Centre of Western Denmark, Department of
Thewic@rm.dk Neurology, Viborg Regional Hospital, Viborg, Denmark
3
Department of Clinical Medicine, Aarhus University,
1
Department of Neurosurgery, Aarhus University Hospital, Palle Aarhus, Denmark
Juul-Jensens Boulevard 165, 8200 Aarhus N, Denmark

Coef Coefficient
ISNCSCI International Standards for Neurological
Classification of Spinal Cord Injury
IQR Interquartile range
R2 Adjusted R-square
SCIM-III Spinal Cord Independence Measure III
TSCI Traumatic spinal cord injury
Introduction
Traumatic spinal cord injury (TSCI) remains a potentially de-
bilitating condition with limited options for prediction of func-
tional recovery [25, 36]. Therefore, patients and their relatives
have to manage a long period of uncertainty about the prog-
nosis for recovery. Recovery of motor function is of para-
mount importance for patients as they often have concerns
towards their ability to perform activities of daily living
(ADL) independently [2]. Functional outcome is therefore
considered the most important outcome parameter when eval-
uating recovery. Assessment of functional outcome can be
performed using validated measurements. These comprise
the International Standards for Neurological Classification of
Spinal Cord Injury (ISNCSCI) of the American Spinal Injury
Association (ASIA) and the Spinal Cord Independent
Measure III (SCIM-III) [4, 9]. The SCIM-III score evaluates
patients’ ability to perform ADLs independently, whereas the
ASIA score evaluates patients’ sensory and motor function.
Although the SCIM-III score is recommended as the primary
outcome measure, studies mainly use the ASIA score or the
Functional Independence Measure (FIM). The FIM score is
not specific to TSCI [5, 17, 26, 28].
Identification of the most important predictive factors for
functional recovery is of great importance for patients, their
relatives and clinicians [21]. Accurate prediction of functional
outcome enables proper guidance of patient’s expectations
towards recovery and adequate counselling of patients and
their relatives during the recovery process. It may further sup-
port guidance and timely optimization of treatment, thereby
improving functional outcome [31]. Still, the ability to predict
the prognosis of recovery is limited [21]. Several variables
have been investigated pertaining to predict outcome and de-
velop reliable predictive tools [1, 7, 13, 14, 22]. Only few
studies use the SCIM-III score and address the predictive val-
ue of clinical variables from the acute care hospitalization,
although these variables may support the decision-making
regarding treatment from the earliest stage [4]. Certain vari-
ables have been proposed as moderate or strong predictors of
functional outcome, e.g. age, surgical treatment, ASIA
Impairment Scale (AIS), ASIA Motor Score (AMS) and
ASIA Sensory Score for Light Touch (ALT) [1, 12–14].
Yet, further research is required to support these findings
and to evaluate other variables that may delay or impact the
Acta Neurochir
rehabilitation process, e.g. body mass index (BMI), burden of
pre-existing comorbidities, timing of surgical treatment and
occurrence of medical complications during the acute hospi-
talization [18, 19, 30]. In order to address this knowledge gap,
the objective of the present study was to evaluate the potential
of early clinical variables to predict total SCIM-III score up to
1 year following TSCI.
Materials and methods
Study cohort
For this population-based study, participants were identified
from the hospital registry using principal diagnosis codes ac-
cording to the International Classification of Diseases 10th
edition (ICD-10) (Table 1). Subjects with acute TSCI consec-
utively admitted to the Department of Neurosurgery at Aarhus
University Hospital for acute care and the Spinal Cord Injury
Centre of Western Denmark for inpatient rehabilitation be-
tween 2012 and 2019 were considered eligible. All levels of
TSCI were deemed eligible. Subjects with age under 13 years,
concomitant traumatic brain injury, missing baseline ASIA
scores and follow-up SCIM-III scores were considered ineli-
gible. Institutional board review approval was obtained prior
to study initiation.
Data extraction
Medical records provided information related to the patient,
injury, acute care hospitalization and inpatient rehabilitation.
Patient-related information included age, gender, BMI,
smoking status and pre-existing comorbidity (diabetes
mellitus, cardiovascular diseases, respiratory diseases and
neoplastic diseases). Injury-related information included bony
level of injury, energy of injury (high-energy: transport acci-
dents, falls from heights or crushing injuries by heavy objects;
low-energy: falls from flat ground), mechanism of injury (fall,
transport, sports, assault, other), neurological level of injury
(NLI) (paraplegia or tetraplegia), treatment strategy (conser-
vative treatment or surgical treatment), timing of surgical
treatment (≤ 24 h or > 24 h), causes of surgical treatment >
Table 1 ICD-10
diagnosis codes DT093 DS14.X
DM471C DS22.X
DG82.X DS23.X
DG952.X DS24.X
DT144.X DS32.X
DS12.X DS33.X
DS13.X DS34.X
Acta Neurochir

24 h, and neurological evaluation performed in accordance Table 2 Description of outcomes and predictor variables
with ISNCSCI. The neurological evaluation covered AIS, Description
AMS and ALT. AIS was defined as grade A (no sensory or
motor function preserved in the sacral segments), grade B Outcome variables
(sensory function preserved, but no motor function preserved SCIM-III Continuous 0–100
below the neurological level), grade C (motor function pre- Predictor variables
served in less than half of key muscles below the neurological Age Continuous Years
level having a muscle grade ≥ 3) and grade D (motor function Gender Binary Male
preserved in at least half (or more) of key muscles below the Female
neurological level having a muscle grade ≥ 3). AIS was BMI Continuous kg/m2
grouped into motor-complete (AIS grades A–B) and motor- Pre-existing comorbidity Binary Yes
incomplete (AIS grades C–D); AMS was defined as a total No
score between 0 and 100 assessing ten key muscles bilaterally, AIS grade Binary Motor complete
ranging from paralysis (0) to active movement against full Motor incomplete
resistance (5); ALT was defined as a total score of 112 ASIA Motor Score Continuous 0–100
assessing 28 dermatomes bilaterally as absent, altered or nor- Timing of surgical treatment Binary ≤24 h
mal. Acute care hospitalization–related information included >24 h
days of hospitalization and occurrence of medical complica- Medical complications Binary Yes
tions (pneumonia, urinary tract infection and pressure ulcer). No
Inpatient rehabilitation information included SCIM-III regis-
tered approximately 12 months after injury. Supported by the ASIA, American Spinal Injury Association; AIS, American Spinal Injury
literature, 6-month follow-up SCIM-III scores were used, if Association Impairment Scale; BMI, body mass index; SCIM-III, Spinal
Cord Independent Measure III
the 12-month follow-up SCIM-III scores were unavailable [6,
27]. The SCIM-III score comprised three scales: self-care (6
items with a total sub-score of 0–20), respiration and sphincter timing of surgical treatment and occurrence of medical com-
management (4 items with a total sub-score of 0–40), mobility plications (Table 2). The associations were expressed as coef-
and transfers (9 items with a total sub-score of 0–40). The sum ficients, 95% confidence intervals (CI) and p values. The ad-
of all sub-scores generates a total SCIM-III score ranging from justed R-squared (R2) value was used to evaluate the regres-
0 to 100, reflecting complete dependence and complete inde- sion model’s goodness-of-fit. Lack of fit was indicated by
pendence, respectively. p > .05. Stata/IC 16.0 (StataCorp LP, College Station, TX)
was used for all statistical tests and results were considered
Statistical analyses statistically significant at p < .05.

To describe the study population, we summarized categorical

variables as absolute counts and percentages, and continuous
variables as medians with interquartile ranges (IQR) due to
non-normally data distribution. Data normality was tested by
QQ-plots and histograms. Comparison analyses comprised a
chi-squared test (or Fisher’s exact test, if the number of obser-
vations was < 5) for categorical variables and a Wilcoxon
rank-sum test for continuous variables. The statistical model-
ling of total SCIM-III score was based on univariate analyses
and multivariable linear regression. Univariate analyses were
performed to determine the association between the total
SCIM-III score and the predictor variables, while multivari-
able linear regression was used to assess the ability of the
predictor variables to predict the total SCIM-III score.
Variable selection for univariate analyses and multivariable
regression was based on clinical experience and previous re-
search [26, 34]. Univariable prescreening and variable selec-
tion algorithms were not used due to the risk of introducing
bias into the results [11, 15, 34]. The predictor variables were
age, gender, BMI, pre-existing comorbidity, AIS, AMS,
Results
Characteristics of study population
Study population characteristics are outlined in Table 3. A
total of 143 patients with a median age of 56 years old (range
13–80 years) was included. The gender distribution was
skewed with a male preponderance (78%). Patients tended
to be non-obese, non-smokers and without pre-existing co-
morbidities. Transport accidents (43%) and falls (41%) were
the leading mechanisms of injury, thus mostly high-velocity
injuries (81%). A higher incidence of cervical injuries (68%)
was observed as compared to thoracic (27%) and lumbar in-
juries (5%). Upon acute care admission, most patients present-
ed with AIS grade A (38%) and tetraplegia (69%). The pre-
ferred treatment strategy was surgical treatment (93%) within
24 h from injury (64%). Causes of surgical treatment after 24 h
from injury (n = 47) were delayed diagnosis (n = 14), transfer
 Acta Neurochir

Table 3 Descriptive statistics of the study population (n = 9), treatment of concomitant traumatic injuries (n = 4) or
Gender, n (%) medical conditions (n = 4), or organizational problems (n = 2).
Male 112 (78%) The causes were unknown in three cases. During acute care
Female 31 (22%)
hospitalization, medical complications occurred in 67 (47%)
Age in years, median (IQR) 56 (32–67)
patients with highest incidence of urinary tract infections
BMI in kg/m2, median (IQR) 24 (22–27)
(34%). The median length of acute care hospitalization was
21 days (range 3–163 days) until admission to inpatient reha-
Smoking status, n (%)
bilitation. A SCIM-III score was available at 12 months post-
Non-smoker 97 (68%)
injury for 80 (56%) patients and at 6 months post-injury for 63
Smoker 46 (32%)
(44%) patients. When comparing these two groups of patients,
Pre-existing comorbidity, n (%)
there was no significant difference in any of the studied char-
Cardiovascular disease 36 (25%)
acteristics, despite a significantly higher occurrence of pres-
Respiratory disease 12 (8%)
sure ulcer in patients with 12-month follow-up (p = .047). The
Diabetes mellitus 9 (6%)
median total SCIM-III score was 65 (35–93).
Neoplastic disease 2 (1%)
Mechanism of injury, n (%)
Predictors of the degree of functional independence
Transport 62 (43%)
Fall 59 (41%)
Univariate analyses indicated that increased age (p = .023),
Other 11 (8%)
increased BMI (p = .012), pre-existing comorbidity
Sport 10 (7%)
(p = .001), AIS grades A–B (p < .001), decreased AMS
Assault 1 (1%) (p < .001) and occurrence of medical complications
Energy of injury, n (%) (p < .001) were significantly associated with decreased func-
High velocity 116 (81%) tional independence.
Low velocity 27 (19%) Multivariable linear regression was based on patients who
Bony level of injury, n (%) underwent surgical treatment. As data on BMI were missing
Cervical 98 (68%) from four patients, the regression model was based on 129
Thoracic 38 (27%) patients. Four variables were significantly associated with to-
Lumbar 7 (5%) tal SCIM-III score: presence of pre-existing comorbidity
Neurological level of injury, n (%) (p = .010), AIS grades A–B (p < .001), low AMS score
Tetraplegia 99 (69%) (p < .001) and surgical treatment > 24 h post-injury
Paraplegia 44 (31%) (p = .034). Neither age (p = .059), gender (p = .181), BMI
ASIA Impairment Scale grade, n (%) (p = .890) nor occurrence of medical complications
AIS A 55 (38%) (p = .292) was a significant predictor (Table 4). The adjusted
AIS B 16 (11%) R2 of .696 indicated an overall fit of the linear regression
AIS C 37 (26%) model (p < .001), thereby confirming the model fit.
AIS D 35 (25%)
ASIA Motor Score, median (IQR) 49 (20–65)
ASIA Light Touch Sensory Score, median (IQR) 64 (41–94) Discussion
Treatment strategy, n (%)
Surgical treatment 133 (93%) Results from our study indicate that pre-existing comorbidity,
Conservative treatment 10 (7%) AIS grades A–B, low AMS and surgical treatment > 24 h after
Medical complications, n (%)a injury during acute care hospitalization significantly predict
Urinary tract infection 49 (34%) decreased functional independence. These findings broadly
Pneumonia 25 (17%) confirm earlier results [4, 26].
Pressure ulcer 15 (10%) Identification of predictors of functional outcome has in-
Length of acute care hospitalization in days, median (IQR) 21 (13–43) creasingly gained interest given the uncertainty regarding
functional recovery. When predicting outcome by clinical var-
ASIA, American Spinal Injury Association; AIS, American Spinal Injury iables, the variables of interest should reflect the acute care
Association Impairment Scale; BMI, body mass index
a
hospitalization, as important decision-making regarding treat-
Complications in total
ment is made during this period. Furthermore, patients and
their relatives request information on what to expect of recov-
between hospitals (n = 11), indication for conservative treat- ery. The SCIM-III score is recommended as the primary out-
ment initially or indication for subacute surgical treatment come measure as it covers the most important aspects of
Acta Neurochir

Table 4 Univariate analyses and

multivariable linear regression Univariate analyses Multivariable linear regression
model of predictors of degree of
functional independence Coef 95% CI p Coef 95% CI p

Age −.29 −.55:−.04 .023* −.17 −.33:.06 .059

Gender
Female −1.98 −14.1:10.1 .748 −4.63 −11.4:2.19 .181
Male Ref. Ref.
BMI −1.36 −2.41: −.30 .012* .04 −.59:.67 .890
Pre-existing comorbidity
Yes −18.0 −28.3:−7.71 .001* −9.19 −16.2:−2.19 .010*
No Ref. Ref.
AIS grade
Motor complete (A/B) −35.8 −43:9:−27.7 <.001* −24.3 −30.5:−17.9 <.001*
Motor incomplete (C/D) Ref. Ref.
ASIA Motor Score .84 .71:.97 <.001* .66 .53:.79 <.001*
Timing of treatment
>24 h 1.46 −9.15:12.0 .785 −6.9 −13.3:−.52 .034*
<24 h Ref. Ref.
Medical complications
Yes −17.8 −27.4.−8.27 <.001* 3.25 −2.8:9.3 .292
No Ref. Ref.

ASIA, American Spinal Injury Association; AIS, American Spinal Injury Association Impairment Scale; BMI,
body mass index; CI, confidence intervals; Coef, coefficients
*Statistical significance at p < .05

functional recovery, which is the ability to reengage into
ADLs independently. Yet, only few studies evaluate function-
al outcome using the total SCIM-III score [4, 12, 20, 24].
However, these studies are based on small sample sizes, rang-
ing from 70 to 88 patients [26]. The preponderance of studies
evaluates functional outcome by FIM, thereby hampering the
cross-comparisons between studies [26, 34].
We therefore fitted a multivariable regression model based
on 129 patients in order to evaluate predictors of the degree of
functional recovery. Our model demonstrated pre-existing co-
morbidity, AIS grade, AMS and timing of surgical treatment
as significant predictors of functional recovery. Neither age,
gender, BMI nor occurrence of medical complications was a
significant predictor. A prior study, however, supports the
finding that AIS grade and AMS are significant predictors of
total SCIM-III score 1 year after injury [20]. Contrary to our
study, they included ALT and suggest ALT as the strongest
outcome predictor. Furthermore, they argue that ALT pro-
vides a better understanding of injury severity compared to
AMS [20]. We argue that AMS provides a better understand-
ing of recovery as motor function recovery is pivotal for
regaining functional independence. As AMS does not consid-
er sacral neurological function and sensory function, AIS
could provide an even better understanding of functional re-
covery compared to AMS.
Our results indicate that presence of pre-existing comorbid-
ity significantly predicts functional recovery. We included
cardiovascular, respiratory and neoplastic diseases and diabe-
tes mellitus, thus some of the most common comorbidities. It
seems reasonable to believe that a higher burden of comorbid-
ities increases the risk of medical complications and prolongs
the length of hospitalization, thereby causing a delay in the
rehabilitation process. This may explain why comorbidity
serves as a predictor of decreased functional outcomes [26].
Additionally, it seems intuitive that older age is correlated
with lower functional outcome as older age is associated with
a higher burden of comorbidities. Earlier studies indicate that
adolescents have significantly higher total SCIM-III scores
compared to adults, thereby reflecting a higher degree of func-
tional independence among adolescents [10]. However, the
influence of age on functional outcome is debated [10, 20]
and we did not find age to be a significant predictor in any
of our models. This may be attributed to the low frequency of
adolescents in our study population, or the low frequency of
AIS grades B and C as the effect of age increases with injury
severity [33].
Consensus exists regarding the beneficial effect of decom-
pressive surgery on functional outcome. Currently, the timing
of surgical treatment remains controversial, although evidence
supports early surgical treatment. Studies generally use AIS

grade conversion as a primary outcome measure applying
different cut-off values of surgical timing, e.g. 6, 8, 12, 24,
48 or 72 h [8, 12, 14]. A cut-off value of 24 h does, however,
seem most feasible from a clinical perspective. Prior studies
have shown a beneficial effect of surgical treatment when
performed within the first 24 h [8, 12, 14, 35]. Supporting
these studies, our results indicate that patients who undergo
surgery within the first 24 h obtain a significantly higher de-
gree of functional independence compared to patients under-
going surgery later than 24 h from injury. Surprisingly, the
timing of surgery was not significant in the univariate analy-
sis. This finding is in accordance with a previous report and is
probably a result of variable interaction; e.g. the timing of
surgery may be influenced by age and pre-existing comorbid-
ities [20]. As elderly patients often have multiple pre-existing
comorbidities, and thereby a higher risk of morbidity and
mortality, surgeons may be more likely to offer early surgical
treatment to younger patients with few or no pre-existing co-
morbidities. Still, early surgical treatment should be
proceeded if feasible and if the anticipated benefits of surgery
exceed the risks of surgery.
In our study population, the causes of surgery later than
24 h from injury were primarily delayed diagnosis, transfer
between hospitals and indication for conservative treatment or
subacute surgical treatment. This emphasizes the need for
strategies to determine the likelihood of TSCI in the pre-
hospital setting, so TSCI-directed treatment can be initiated
immediately, and patients can be transferred to the TSCI-
treating hospital without delays. These strategies would be
valuable in TSCI patients presenting with vague symptoms
or unknown trauma mechanism.
Individuals having sustained a TSCI are highly susceptible
to infections, particularly pneumonia and urinary tract infec-
tions, and likely to develop pressure ulcers. These complica-
tions may delay or deteriorate the rehabilitation process and
thereby decrease functional recovery [19]. The incidence of
medical complications during the acute care hospitalization
was 47%. Earlier studies report higher incidences [3, 4].
Although we did not find a statistically significant association
between SCIM-III and occurrence of medical complications
in our model, recent studies provide evidence that early oc-
currence of complications impacts functional outcome nega-
tively [18, 19]. The relatively narrow spectrum of medical
complications may explain why our results were non-signifi-
cant. Considering the different results and the preventable
nature of these complications, early identification and treat-
ment should be proceeded. Obesity and overweight can re-
duce mobility and leave patients more susceptible to medical
complications. Prior studies have evaluated the influence of
obesity and overweight on functional outcome reaching a con-
sensus [4, 16, 23, 29, 32]. Studies have employed BMI as a
continuous and dichotomous variable with different cut-off
values. Increased BMI has been demonstrated to be a
Acta Neurochir
statistically significant predictor of decreased functional out-
come [4, 16]. Nonetheless, our results did not find a signifi-
cant association between continuous BMI and functional out-
come in any of the regression models. These results may re-
flect a low frequency of obesity and overweight in our study
population.
Due to the retrospective study design, some limita-
tions must be addressed. It is, however, important to
emphasize that all variables were collected prospectively.
First, the difference in follow-up time may be a limita-
tion, although our comparison analysis showed no signif-
icant difference between groups, despite a higher fre-
quency of pressure ulcers in patients with 12-month fol-
low-up. Therefore, it seems unlikely that this difference
had influenced the results of our study. Second, patients
with missing baseline ASIA scores and follow-up SCIM-
III scores were excluded. These were patients with per-
manent address in other regions or countries, patients
who had died during the first year after injury and pa-
tients without neurological deficits necessitating rehabil-
itation. None of these patients was admitted to inpatient
rehabilitation and evaluated by SCIM-III. Both institu-
tions involved in this study went from paper medical
records to electronic medical records during the early
study period, and ASIA scores and SCIM-III scores were
lost during the period of transition. Third, our study is
based on patients eligible for inpatient rehabilitation from
a single institution. This may limit our findings’ gener-
alizability to the total TSCI population. Fourth, other
potential predictors of functional recovery exist, e.g. du-
ration of surgery, amount of blood loss, length of hospi-
talization (acute care hospitalization, intensive care unit
and inpatient rehabilitation), necessity of intubation and
mechanical ventilation. Despite the importance of these
potential predictors, investigation of their predictive val-
ue is beyond the scope of this manuscript.
Conclusion
Our results indicate that by evaluating the clinical status and
the timing of surgical treatment during acute care hospitaliza-
tion, the clinicians are able to more precisely identify patients
with greatest recovery potential up to 1 year after injury. These
are patients with few or no comorbidities, motor-incomplete
patients and patients undergoing early decompressive surgery.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval For this type of study, formal consent is not required.
Acta Neurochir
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