Ditunno J F, Graziani V, Tessler A
Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
Adv Neurol. 1997;72:325-33.
Precise and reliable neurologic assessment is a necessary tool for determining the extent and pattern of recovery after SCI. Recently agreed upon international standards establish a uniform neurologic classification to measure clinical outcomes. They are currently in use in three multicenter studies in more than 40 SCI centers in the United States. The Model System SCI centers report the use of these measures, such as impairment grades and neurologic levels, in almost 15,000 cases over the past 20 years and, more recently, motor scores in 3,500 patients. The NASCIS II multicenter trial on methylprednisolone used motor and sensory scores as endpoints in close to 500 patients, but have incorporated the international standards, which include a disability measure, in NASCIS III. The study of ganglioside effectiveness also is using these measures in many patients. In more focused studies, neurologic assessment soon after injury can predict walking in motor complete injuries based on pin prick sensation, and in motor incomplete injuries based on impairment grade and age. Eventual upper extremity function can be estimated based on the motor examination within 72 hours of injury. Both the motor score and motor level are more reliable in predicting upper extremity function than the single sensory level. This presumably reflects the greater importance of motor recovery on functional outcome. The proximal muscles of the lower extremities caudal to the lesion site recover before distal muscles, and this may be mediated by axons descending in the ventral tracts, which control primarily proximal rather than distal muscles. These axons may be preferentially spared and/or have greater capacity to compensate than those present in the lateral columns. In conclusion, standard neurologic assessment in SCI is extremely valuable in monitoring recovery in order to prognosticate functional outcome, evaluate effectiveness of drug interventions, and provide valuable clues to possible underlying mechanisms of recovery. The elucidation of these mechanisms will aid in the refinement of current treatments and development of new strategies to enhance neurologic recovery and functional outcome.
精确可靠的神经学评估是确定脊髓损伤（SCI）后恢复程度和模式的必要工具。最近达成共识的国际标准建立了统一的神经学分类方法来衡量临床结果。这些标准目前在美国40多个脊髓损伤中心的三项多中心研究中使用。模型系统脊髓损伤中心报告了在过去20年中近15000例病例中使用这些测量方法，如损伤分级和神经学水平，最近还报告了3500例患者的运动评分。纳罗多科甲基强的松龙治疗脊髓损伤II期多中心试验将近500例患者的运动和感觉评分作为终点指标，但在纳罗多科甲基强的松龙治疗脊髓损伤III期试验中纳入了国际标准，其中包括一项残疾测量指标。神经节苷脂有效性的研究也在许多患者中使用这些测量方法。在更有针对性的研究中，损伤后不久的神经学评估可以根据针刺感觉预测运动完全损伤患者的行走能力，根据损伤分级和年龄预测运动不完全损伤患者的行走能力。可以根据损伤后72小时内的运动检查来估计最终的上肢功能。运动评分和运动水平在预测上肢功能方面比单一感觉水平更可靠。这可能反映了运动恢复对功能结果的更重要性。损伤部位尾侧下肢的近端肌肉比远端肌肉先恢复，这可能是由腹侧束中下行的轴突介导的，这些轴突主要控制近端而非远端肌肉。这些轴突可能比外侧柱中的轴突优先得到保留和/或具有更大的补偿能力。总之，脊髓损伤中的标准神经学评估在监测恢复情况以预测功能结果、评估药物干预效果以及为恢复的潜在机制提供有价值线索方面具有极高价值。对这些机制的阐明将有助于改进当前治疗方法并开发新策略以促进神经恢复和改善功能结果。
