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Assessment of the Sympathetic Level of Lesion in Patients with Spinal Cord Injury

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Assessment of the Sympathetic Level of Lesion in Patients with Spinal Cord Injury Spinal Cord (2009) 47, 122–127 & 2009 International Spinal Cord Society All rights reserved 1362-4393/09 $32.00 www.nature.com/sc ORIGINAL ARTICLE Assessment of the sympathetic level of lesion in patients with spinal cord injury JG Previnaire1, JM Soler2, W El Masri3 and P Denys4 1Spinal Department, Centre Calve´, Fondation Hopale, Berck sur Mer, France; 2Laboratoire d’urodynamique et de sexologie, Centre Bouffard Vercelli, Cerbe`re, France; 3Midlands Centre for Spinal Injuries, RJ and AH Orthopaedic Hospital, Shropshire, UK and 4Service de Re´e´ducation Neurologique, Hoˆpital Raymond Poincare´, Garches, France Study design: To study the vasomotor responses (skin axon-reflex vasodilatation (SkARV) to stimulation of the skin in spinal cord injury (SCI) patients. Objective: To assess the completeness of the sympathetic injury and to define the sympathetic level of lesion in paraplegic and tetraplegic patients. Setting: Centre Calve, Fondation Hopale and Centre Bouffard-Vercelli, France. Subjects: A total of 81 SCI patients ranging from C2 to L2. Method: A mechanical stimulation was applied to the skin on both sides of the trunk, using a blunt instrument. The presence of an abnormal response below the lesion helped define the sympathetic level. Results: Above the lesion, SkARV was observed in all patients. In patients with a complete sympathetic injury, the response below the lesion was either a vasoconstrictor response in upper motor neuron lesions, or total absence of SkARV in lower motor neuron lesions. There was excellent correspondence between complete somatic (American Spinal Injury Association (ASIA) A) and complete sympathetic lesions (100% of paraplegic and 94% of tetraplegic patients), whereas an incomplete somatic (ASIA B– D) lesion was often associated with a complete sympathetic lesion. In 34% of complete ASIA A patients, a sympathetic zone of partial preservation was found, extending below the lesion on sensory denervated dermatomes. Conclusion: SkARV is a simple bedside test that allows the assessment of sympathetic completeness of injury across the lesion as well as the excitability of the isolated spinal cord. We suggest that the definition of sympathetic level should be part of the classification of complete thoracic SCI. Spinal Cord (2009) 47, 122–127; doi:10.1038/sc.2008.87; published online 29 July 2008 Keywords: axon-reflex vasodilatation; spinal cord injury; autonomic nervous system Introduction Localized vasodilatation of the skin is a physiological phenom- neuronal mechanisms, the spreading axon-reflex flare is enon that can be elicited by a variety of stimuli (thermal, suggested to be neurally mediated by C-fibre antidromic mechanical, electrical and chemical). It is part of a triple vasodilatation via the release of the neuropeptides substance response following a direct contact, first described by Lewis:1 P and calcitonin gene-related peptide.1,2 Thomas,3 Guttmann and Chapelle4,5 studied the cuta- neous reflex response to determine the level of the lesion, the first component was a local red reaction, which was a evoking a mechanical stroke with the end of a reflex hammer primary and local dilatation of the minute vessels of the skin; across the thorax of complete spinal cord injury (SCI) the second component, or flare, was a widespread patients. In chronic patients, there was a clear limitation of dilatation of the neighbouring arterioles; the flare below the lesion (dermatographia alba) in distinct the third component, or wheal (local oedema), was a local contrast to the spreading flush above the lesion (dermato- increased permeability of the vessel wall. graphia rubra). They related this diminished vasodilatation below the lesion to an increase of the sympathetic vasocon- Whereas the first immediate reddening is a vascular strictor tone in the isolated cord. Skin manifestations are one reaction to the stimulus without the involvement of of the conditions recognized in the assessment of the autonomic function in SCI patients.6 Correspondence: Dr JG Pre´vinaire, Spinal Department, Centre Calve´, Fonda- Our aim was to study the skin axon-reflex vasodilatation tion Hopale, 62600 Berck sur mer, France. (SkARV) using a mechanical non-invasive stroke, to evaluate E-mail: [email protected] Received 14 March 2008; revised 19 June 2008; accepted 22 June 2008; the segmental sympathetic vasomotor component of the published online 29 July 2008 skin above and below the lesion, to assess the completeness Sympathetic level of lesion in SCI patients JG Previnaire et al 123 of the sympathetic injury and to define a sympathetic level level or within the sensory zone of partial preservation of lesion. This sympathetic level was then compared to the (sensory ZPP), American Spinal Injury Association (ASIA) neurological level or SkARV extend across the lesion on sensory denervated of lesion and to the ASIA Impairment Scale, to determine if dermatomes. The term ‘sympathetic zone of partial they coincide or not. preservation’ (sympathetic ZPP) refers to those sensory denervated dermatomes that remain sympathetically innervated. Material and method When SkARV extend across the lesion down to T12, no Study design sympathetic level of lesion could be defined. The SkARV test was performed in 81 consecutive SCI patients Left and right sides were recorded separately, as the levels (34 tetraplegics and 47 paraplegics; Table 1). A mechanical of lesion can differ by side of body. The result of the SkARV stimulation was evoked by tracing a line on the skin using a test was read and agreed upon by two individuals (the blunt instrument, usually the edge of a wooden tongue investigator and a nurse). depressor cut in half down the longitudinal axis. A steady pressure was applied on the skin. In all patients, the line was Patients traced on both sides of their naked trunk, starting from the They were mostly traumatic SCI patients (79 out of 81 clavicle down to T12 dermatome. We then observed and patients), aged 18 years or more, all out of spinal shock. The compared the evolution of the SkARV on each side. clinical data are reported in Table 1. The tetraplegic group All subjects were studied lying on their back, at a included six patients with an ASIA sensory level above C4. comfortable ambient temperature. SkARV tests were per- The severity of lesion is defined according to the ISCoS/ASIA formed either in bed or in association with urologic Impairment Scale as ASIA A (complete, no sensory or motor assessments. Bladder filling or penile vibratory stimulation function is preserved in the sacral segments), ASIA B (PVS) was initiated immediately after the stroke. We have (incomplete, sensory but not motor function is preserved repeated the examination twice in some patients. As SkARV below the neurological level and includes the sacral tests are routinely performed as part of our neurological segments), ASIA C and D (incomplete, partial motor examinations, the institutional review board approval was function preserved).7 The type of lesion referred to the level not sought for this study. of spinal injury above or at the spinal sacral segment that did or did not induce sacral reflexes. Lesions were classified as Classification upper motor neuron (UMN) or lower motor neuron (LMN) By analogy with the International Spinal Cord Society respectively. In this study, all UMN patients presented with 7 (ISCoS)/ASIA classification, we defined the sympathetic some spasticity above the sacral area, whereas all LMN level of lesion as the most caudal segment of the spinal cord patients were flaccid. For the assessment of the sensory ZPP, with normal sympathetic function, that is, the last trunk only the thoracic segments extending from T3 to T12 dermatome where a normal SkARV could be seen. (corresponding to the dermatomes were a SkARV could be The term ‘complete sympathetic injury’ is used when the seen) were taken into account. SkARV does not extend to T12. In patients with complete ASIA A lesions, two different situations can be identified: Results either SkARV is found on sensory dermatomes that are The normal SkARV consists in the combination of a flare and normally or partially innervated, that is at ASIA sensory a local oedema (Figures 1 and 2). They both begin to appear Table 1 Characteristics of the population All (n ¼ 81) Tetraplegics (n ¼ 34) Paraplegics above T12 (n ¼ 44) Low paraplegics below T12 (n ¼ 3) Age (years) 38.2±10.7 35.7±11.0 40.0±11.0 40.9±4.5 Evolution (years) 7.7±6.9 5.0±4.5 9.9±8.4 5.1±3.3 Sex 10 women 5 women 4 women 1 woman 71 men 29 men 40 men 2 men Type of lesion 66 UMN 33 UMN 32 UMN 1 UMN 15 LMN 1 LMN 12 LMN 2 LMN Severity of lesion 60 ASIA A 18 ASIA A 39 ASIA A 3 ASIA A 9 ASIA B 8 ASIA B 1 ASIA B F 4 ASIA C 4 ASIA C FF 8 ASIA D 4 ASIA D 4 ASIA D F Sensory ZPP 48 sides 6 sides 42 sides F 0–5 segments 1–5 segments 0–4 segments F (1.6±1.0) (2.5±1.4) (1.5±0.9) F Abbreviations: ASIA, American Spinal Injury Association; LMN, lower motor neuron; UMN, upper motor neuron; ZPP, zone of partial preservation, expressed by side of body. Data for age and evolution are given as mean values±standard deviations. Spinal Cord Sympathetic level of lesion in SCI patients JG Previnaire et al 124 SkARV above the lesion In paraplegic patients above T12, the SkARV was always observed above the lesion. In the three patients with a complete lesion below T12, a normal SkARV was found on all thoracic dermatomes. As a rule, SkARV was usually maximal at the C4 dermatome, and decreased progressively down the thorax. SkARV below the lesion Complete (ASIA A) patients above T12 (Tables 2 and 3).In UMN paraplegic and tetraplegic patients, the SkARV below the lesion appeared with diminished flare and oedema (Figures 1 and 2).
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