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RESEARCH PAPER
Outcomes in patients admitted for rehabilitation with spinal cord orcauda equina lesions following degenerative spinal stenosis
JACOB RONEN1,2, DIANA GOLDIN3, MALKA ITZKOVICH1,2, VADIM BLUVSHTEIN1,
ILANA GELERNTER4, ARKADY LIVSHITZ5, YORAM FOLMAN2,6, & AMIRAM CATZ1,2
1Loewenstein Rehabilitation Hospital, Raanana, 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 3Tel Aviv
Medical Center, Tel Aviv, 4The Statistical Laboratory, School of Mathematics, Tel Aviv University, Tel Aviv, 5Sapir Medical
Center, Kfar Sava, and 6Hylel-Yaffe Hospital, Hadera, Israel
AbstractPurpose. To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 atLoewenstein Rehabilitation Hospital, Israel.Method. This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equinalesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change inFrankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitationwere analyzed with ANOVA.Results. Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset wasfound to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C onadmission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had asignificant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect onlength of stay.Conclusions. Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurologicalrecovery and survive for many years. They require adequate care in a specialist rehabilitation system.
Keywords: Spinal cord lesion, cauda equina lesions, spinal stenosis, survival, recovery, length of stay
Introduction
Spinal stenosis (SS) is the etiology of a substantial
portion of non-traumatic spinal neurological lesions
(SNL) among patients admitted to inpatient rehabi-
litation [1 – 5]. The term SS refers to narrowing of
the entire cross-sectional area of the vertebral canal,
nerve root canals, or intervertebral foramina due to
spondylosis and degenerative disc disease. The
process usually occurs in the cervical and lumbar
spine, and less frequently in the thoracic spine.
Patients usually become symptomatic at age 50 or
older. Cervical stenosis usually presents with cervical
radiculopathy; patients complain of radiating arm
pain with numbness and paresthesia and/or weakness
in the muscles supplied by that nerve root. In severe
stenosis of the central canal, patients may present
with signs and symptoms of myelopathy: Numbness
in the fingers and toes and difficulty in walking. In
more severe cases, bowel and bladder control
dysfunction may appear. Lumbar stenosis usually
presents with symptoms of low back pain (LBP) and
radiating leg pain, sometimes with bladder and bowel
difficulties. The classic presentation, radiating leg
pain associated with walking and relieved by rest, is
neurogenic claudication; it is rarely accompanied by
neurological deficit. When it is, the deficit may
represent cauda equina impairment (if the central
Correspondence: Amiram Catz, MD, Medical Director, Department IV, Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, 278 Ahuza St., PO Box 3,
Raanana 43100, Israel. E-mail: [email protected]
Accepted November 2004.
Disability and Rehabilitation, July 2005; 27(15): 884 – 889
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2005 Taylor & Francis Group Ltd
DOI: 10.1080/09638280500030886
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canal is compressed) or a pure lumbar radiculopathy
(if the compression is lateral). Stenosis of the
thoracic spine may result in myelopathy [6]. Treat-
ment can be conservative or surgical. Many studies
have assessed the management of SS [6 – 16], but
most of them include many patients without SNL
and outcomes are usually described in terms of
reduction of pain and improvement in function.
Only scant information is available about SS out-
comes that are important for patients with SNL, such
as survival, neurological recovery, and length of stay
(LOS) in hospital. The present study concentrated
on patients with a neurological deficit and assessed
these outcome measures in patients admitted to
rehabilitation with spinal cord or cauda equina lesion
following SS (SSSNL).
Methods
The study included 262 patients with SSSNL,
admitted between 1962 and 2000 to Loewenstein
Rehabilitation Hospital, the premier referral center
for rehabilitation medicine for hospitals throughout
Israel. Most of the patients were admitted to
rehabilitation following decompressive surgery, but
data collection on the operative procedures was
beyond the scope of this study.
Demographic and clinical data were collected by
reviewing the hospital charts. Mortality data were
collected from the Population Registry of the Israel
Ministry of Internal Affairs. Survival rates were
estimated using the product limit (Kaplan-Meier)
method, and differences between subgroups were
analyzed by logrank test (univariate analysis). The
Cox proportional hazard model was employed to
determine the probability of mortality (‘hazard’) in
the presence of specific risk factors (multivariate
analysis) [17]. The time of SNL onset was defined as
the earliest time of SSSNL symptoms and signs
mentioned in the hospital records.
The severity of neurological deficit below the
spinal level of injury was graded according to Frankel
et al. [18] as described in a previous publication on
recovery of spinal cord injury [19]. In most cases,
Frankel grades had not been assigned during
hospitalization, so for purposes of the study they
were assigned retroactively on the basis of the
examination protocols.
The degree of neurological recovery or regression
in each patient was determined by comparing the
Frankel grade of neurological deficit at first admis-
sion for rehabilitation (initial Frankel grade) with the
grade at discharge from the same hospitalization.
Recovery rate was assessed either as any recovery,
namely a recovery of at least one Frankel grade from
a grade of A, B, C or D, or as useful recovery, namely a
recovery from Frankel grades A, B, or C at admission
to grades D or E at discharge. In the authors’
opinion, the change from a non-functional status
represented by Frankel grades A, B and C, to a
functional status, represented by grades D and E, is
an important aspect of recovery from the point of
view of rehabilitation medicine. Other studies have
also used such an assessment of recovery [19,20].
The assessment of useful recovery did not include
patients with an initial Frankel grade of D or E.
Logistic regressions were used to examine the
association between various affecting factors and
recovery [17].
Analyses of the LOS in hospital for rehabilitation
due to SSSNL were performed after a square root
transformation to approach a normal distribution.
The associations of LOS with potentially affecting
factors were analyzed by ANOVA: One-way ANO-
VA for multiple comparisons between decade of
admission and SNL severity, and three-way ANOVA
for age, gender, and Frankel grade. Statistical
significance was defined by p5 0.05. Data were
analyzed by SPSS for Windows, version 11 (SPSS
Inc., USA).
Results
Demographic and clinical data
The patients included in the study were 180 men
(69%) and 82 women (31%), with a median age of
61 years and a mean age of 58.6 years (SD=11.9
years) at lesion onset. The SNL was cervical in 163
patients (62%), thoracic in 41 (16%), and lumbar in
58 (22%). The mean time from SNL onset to
rehabilitation was 34.5 months (SD=47.9 months).
Initial Frankel grade was A in two patients (0.8%), B
in 22 patients (8.4%), C in 124 patients (47.3%),
and D in 114 patients (43.5%). The initial Frankel
grade for thoracic SNL was C in 59% of the lesions
and D in 32%; for cervical or lumbar SNL it was C
or D in about 45% of the lesions; it was B in about
8% at all SNL levels. Eighteen patients were
admitted before 1970, 28 between 1971 and 1980,
83 between 1981 and 1990, and 133 between 1991
and 2000.
Outcome
Survival. Mortality data were available in 261 of the
262 patients. One-hundred-and-seventy of them
(65%) survived at the end of the follow-up period
(May 2001). The longest survival at that time was 35
years. The accumulated survival was 92.7%
(SE=1.7%) 5 years after the SNL onset, 80.4%
(SE=2.8%) ten years after the SNL onset, 61%
(SE=4.1%) 15 years after the SNL onset, 42.1%
(SE=5.0%) 20 years after the SNL onset, and 32%
Outcomes of spinal neurological lesions caused by spinal stenosis 885
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(SE=5.5%) 25 years after the SNL onset (see Figure
1). Median survival time was 17.6 years.
After controlling for gender, initial Frankel grade,
SNL level, and decade of SNL onset, the mortality
risk was 1.08 times higher for every additional year of
age at SNL onset (p5 0.001; 95% confidence
interval: 1.06 – 1.11). The effects of gender, initial
Frankel grade, SNL level, and decade of SNL onset
on the risk of mortality were not statistically
significant when controlling for the other affecting
factors.
Neurological recovery. Eighty-six patients, represent-
ing 58% of the 148 patients who had initial Frankel
grades of A, B, or C and 32.8% of all SSSNL
patients, achieved useful recovery and showed an
improvement during the course of rehabilitation to
Frankel grades D and E (see Table I). Eighty-eight of
them (59%), and 116 of all patients with SSSNL
(44.3%), showed any recovery (partial or complete).
The frequency of any recovery in patients who had
initial Frankel grades of A, B, or C was inversely
related to the severity of the original deficit (see
Table II).
When controlling each initial Frankel grade, age at
admission to rehabilitation, gender, SNL level, and
decade of admission to rehabilitation for all the other
listed variables, the initial Frankel grade, age, and
SNL level had a significant effect on useful recovery
and on any recovery (p5 0.05), while gender and
decade did not have a significant effect on recovery.
The odds of useful recovery during rehabilitation
were 4.6 times higher for initial Frankel grade C
versus A or B, and 5% lower for each additional year
of age. The odds of useful recovery were also lower
for thoracic and cervical versus lumbar SNL (see
Table III). The effects of thoracic and cervical SNL
on recovery were not statistically different.
The odds of any recovery were 2.7 times higher
(95% confidence interval =CI=1.05 – 7.2) for initial
grade C versus A or B (p=0.038), and 4% lower
(CI= 2 – 7%) for each additional year of age at
admission to rehabilitation (p=0.001). The odds of
any recovery for thoracic SNL were 76% lower
versus lumbar SNL (p5 0.005), and 65% lower
(CI= 18 – 85%) versus cervical SNL (p=0.016),
while those for cervical were not significantly
different from those for lumbar SNL (p=0.359).
The odds of any recovery from initial grade D were
not significantly different from those of any recovery
from initial grade A or B (p=0.066).
LOS. The mean LOS was 99.7 days (SD=65.7 days;
range= 7 – 336 days). When controlling for two age
groups at rehabilitation (4 60 years or 5 61 years),
gender, and initial Frankel grade (A, B, and C or D),
only Frankel grade had a significant effect on LOS
(p5 0.001), while the effects of age and gender were
not significant (p=0.557 and 0.693). Mean LOS
decreased through the decades, but the decrease was
not statistically significant (p=0.6). The differences
in LOS between SNL levels were also non-significant
(p=0.3) (see Table IV).
Discussion
Although SS may be followed by pre- or post-
operative SNL, which may cause morbidity and
death, the orthopedic and rehabilitation medicine
literature pays little attention to outcomes of
neurological complications of SS or its treatment.
Studies of SS rarely delve into the consequences of
the related myelopathy, and most SNL studies focus
on traumatic spinal cord lesions (TSCL). But
although the number of patients with TSCL ad-
mitted to rehabilitation has remained approximately
constant over the last four decades in our practice
[19,21], the number of patients with SSSNL is
continually increasing. More SSSNL patients were
admitted in the last ten years before the conclusion of
the study than during the preceding three decades.
The increase in admissions probably reflects the
increase in public and professional awareness of the
role of rehabilitation in the treatment of SNL. It is of
interest, therefore, to examine the characteristics and
outcomes in this group of patients.
SSSNL characteristics
As in other studies, patients with SSSNL in the
present study are older than patients with either
TSCL or non-traumatic SNL of other etiologies
[4,5,19 – 26], and the SSSNL is usually incomplete
[4,23,26], C being the prevailing Frankel grade on
admission. But unlike other studies, the present
Figure 1. Survival following spinal neurological lesions due to
spinal stenosis. Acc. survival =Accumulated survival rate. Time= -
Time from lesion onset to death or end of follow-up.
886 J. Ronen et al.
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Table I. Changes in the severity of neurological damage by Frankel grade between admission for rehabilitation and discharge from
hospitalization, in percent of patients (n=262). Total of A, B, and C grades at admission (56.5%) minus total at discharge (23.7%)=32.8%,
representing 58% of 56.5%.
Frankel Grade Relative proportion of the grade
on admission (%)
Relative proportion of the grade
at discharge (%)
Change in the relative proportion
of the grade (%)
A 0.8 0.8 0
B 8.4 3.8 74.6
C 47.3 19.1 728.2
D 43.5 64.9 21.4
E 0 11.4 11.4
Table II. Relationship between severity of neurological damage and recovery. Changes in Frankel grade between admission for rehabilitation
and discharge from hospitalization, in percent of initial number of patients for each grade (n).
Frankel grade at dischargee
Frankel grade on
admission (n)
A (%) B (%) C (%) D (%) E (%)
A (2) 100 0 0 0 0
B (22) 0 45.5 9.1 45.5 0
C (124) 0 0 38.7 59.7 1.6
D (114)) 0 0 0 75.4 24.6
Table III. Odds of useful recovery during rehabilitation, controlling for affecting factors. SNL severity by Frankel grading. Age and decade at
rehabilitation. For age, the odds are for each additional year. Each decade is compared to 1991 – 2000.
95% confidence interval
Affecting factor Odds p lower upper
SNL severity 4.6 0.004 1.61 13.09
Age 0.95 0.005 0.91 0.98
SNL level 0.01
C vs L 0.27 0.018 0.09 0.80
T vs L 0.13 0.003 0.03 0.49
Gender 1.5 0.299 0.68 3.42
Decade 0.296
1961 – 1970 2.26 0.380 0.36 14.03
1971 – 1980 2.90 0.097 0.82 10.20
1981 – 1990 0.94 0.882 0.41 2.17
SNL= spinal neurological lesion, C= cervical SNL, L=Lumbar SNL, T= thoracic SNL, vs = versus.
Table IV: LOS by Frankel grade, decade of admission to rehabilitation, and SNL level.
Mean LOS (days) SD (days)
Frankel grade A 297 55
Frankel grade B 139 62
Frankel grade C 115 67
Frankel grade D 72 48
Admission before 1970 110 83
Admission between 1971 – 1980 105 65
Admission between 1981 – 1990 104 58
Admission between 1991 – 2000 94 68
Cervical SNL 102 66
Thoracic SNL 107 72
Lumbar SNL 89 58
SNL: Spinal neurological lesion.
Outcomes of spinal neurological lesions caused by spinal stenosis 887
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research includes mainly cervical SSSNL (62% vs
31% or less) [4,5,23].
SSSNL outcome
Survival. Survival appears shorter than that of
patients with TSCL and non-traumatic spinal cord
lesions (NTSCL) described in other publications
[1,21,27 – 29]. However, the median survival of 17.6
years found in SSSNL patients with a median age of
61 years at lesion onset is not far from expected
survival at age 61 in the general population of Israel.
It indicates that despite relatively old age and
neurological compromise, these patients can live for
many years; it is therefore necessary to ensure their
maximal survival and the best possible quality of life
during these years. Only age at lesion onset had a
significant effect on survival in patients with SSSNL.
The effects of SNL level and severity and that of the
decade of lesion onset, which were significant
following TSCL [21,27 – 29], were not significant
in SSSNL. This is probably because of the distribu-
tion of the examined factors in SSSNL patients: most
of the patients had Frankel Grade C or D, cervical
SCL, and relatively recent lesion onset, so other
grades, levels, or periods of lesion onset could hardly
influence survival.
Neurological recovery. Neurological recovery was
remarkable. Almost 60% of the patients with Frankel
grades A, B, or C showed useful recovery, and 44% of
all SSSNL patients showed any recovery. For com-
parison, in previous studies useful recovery was found
in 27% of TSCL [19] and 51% of mixed NTSCL [2],
and any recovery in 34% of mixed SNL [23].
In SSSNL, recovery was inversely related to initial
Frankel grade when the initial Frankel grade was A,
B, or C. The effect of initial Frankel grade D on
recovery, however, was not significantly different
from that of initial Frankel grades A or B, which
indicates that despite the high recovery rate, SSSNL
patients tend to retain some neurological deficit.
In addition to the initial Frankel grade, age at
rehabilitation and SNL level had a significant effect
on recovery. Recovery was more likely in cervical and
lumbar than in thoracic SNL, but the advantage of
cervical lesions was not sufficient for useful recovery,
which was better only in lumbar SNL. The less
reversible nature of thoracic SCL is probably related
to the fact that a more prolonged pressure is involved
in its pathogenesis, while the pathogenesis of cervical
and lumbar SNL includes more fluctuations in
pressure owing to the excess mobility of the cervical
and lumbar spine.
LOS. The LOS of the patients with SSSNL was
within the range presented in European publica-
tions describing patients with TSCL, and much
longer than spinal cord lesions (SCL) LOS in
American studies [4,5,22,23,26,30]. Only Frankel
grade affected SSSNL LOS significantly. How-
ever, controlling for various potentially affecting
factors, LOS was found shorter in patients with
SSSNL than in patients with most other SNL
etiologies, including trauma. This may suggest
that although rehabilitation of SSSNL and TSCL
patients was based on similar considerations of
SNL severity and the achievement of expected
function, patients with SSSNL achieved their
expected functional results earlier than patients
with TSCL, therefore requiring shorter LOS,
because the expected functional outcome in
patients with SSSNL is lower than that of the
patients with TSCL. Similarly, in a previous
study, the LOS of patients with non-traumatic
spinal cord lesions was shorter than that of
patients with TSCL who were admitted with
similar FIM scores and had similar FIM effi-
ciency [3].
Limitations. The study focused on patients with
SNL that followed degenerative SS, and the results
cannot be generalized to all SS patients. The
clinical condition is described in terms of SNL
severity and level, which are relevant for patients
with spinal neurological deficits, and not in
functional terms, such as walking ability, which
are more relevant for other SS patients. In
addition, the outcomes demonstrated in this retro-
spective study, which does not contain detailed
data about the management procedures, does not
allow any interpretation of the effect of surgery or
rehabilitation. It does allow, however, inference
from what is accepted for patients with TSCL with
comparable outcomes, and may thereby contribute
to the assessment of the role of rehabilitation
medicine in the care of SSSNL.
Conclusion
In conclusion, the findings of the present study
indicate that despite their relatively old age and of
comorbidities likely to be present at their age,
patients with SSSNL who undergo decompressive
surgery and rehabilitation may survive many years
and achieve significant neurological recovery. How-
ever, many of them tend to remain with neurological
deficits, which may be relatively mild but still cause a
significant disability and lethal complications. There-
fore, to ensure longevity and quality of life, patients
with SSSNL require adequate care and functional
restoration in a specialist rehabilitation system,
similarly to TSCL patients with comparable neuro-
logical deficit.
888 J. Ronen et al.
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Acknowledgment
This study was supported by the Unit of Medical
Services, Rehabilitation Department, Israel Ministry
of Defense.
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