Challenge or opportunity: Rehabilitation outcomes in patients with metastatic spinal cord compression – a UK single center experience

Abstract

Context /Objective

Metastatic Spinal Cord Compression (MSCC) is a devastating complication of cancer, affecting approximately 3000 patients per annum in England. However, access to rehabilitation services for MSCC patients is limited. The London Spinal Cord Injury Centre has set up a bespoke MSCC rehabilitation pathway from May 2013. This article aims to describe the clinical features and functional outcomes of patients with MSCC admitted to a Specialist Spinal Cord Injury Rehabilitation Centre between May 2013 and December 2021.

Design

Retrospective analysis of medical records from a single specialist rehabilitation centre database.

Setting

London Spinal Cord Injury Centre (LSCIC), Stanmore, United Kingdom.

Participants

Adult patients diagnosed with MSCC who were admitted to and discharged from LSCIC from May 2013 to December 2021.

Interventions

Specialist Inpatient Spinal Cord Injury Rehabilitation Program.

Outcome Measures

Spinal Cord Independence Measure 19 (SCIM version III), Discharge Destination.

Results

A total of 40 patients with MSCC were admitted – 32 male and 8 female patients. The average length of stay was 6 weeks. 17(42.5%) patients had primary prostate cancer. Most patients (34(85%)) had thoracic MSCC. There was an improvement in the Spinal Cord Independence Measure in all patients with an average significant improvement from 43.8 to 64.5 (P < 0.001). There was no significant difference in SCIM scores between patients under 65 and over 65. 28 (70%) patients required psychological input. 33(82.5%) patients were discharged home.

Conclusion

Patients with MSCC show improvement in SCIM outcome measures after a six-week inpatient Specialist Spinal Rehabilitation program.

Introduction

Metastatic Spinal Cord Compression (MSCC) is a devastating complication of cancer, causing significant morbidity and mortality.¹ Spinal metastases affect 5% of all cancer patients, with the highest incidence seen in patients with prostate, breast, lung and haematological cancer.² For the purposes of this analysis, the National Institute of Health and Care Excellence’s – NICE (UK) 2008 definition of MSCC (“spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability”) was used.¹

Benign and malignant tumors have been reported as a common cause of non-traumatic spinal cord dysfunction (NT-SCD), accounting for 15–30% of NT-SCD cases in specialized rehabilitation units.^3,4 In the UK, patients with primary or secondary vertebral tumors form the majority of patients (out of a group which also includes spinal trauma and infections) who have spinal reconstruction surgery (5600 interventions over 2010/2011).⁵ In these patients, primary osseo-ligamentous spinal tumors and secondary vertebral tumors both may cause MSCC.^1,5 Currently, MSCC is estimated to affect approximately 3000 patients per annum in England.⁶ Due to an ageing population and improved oncological outcomes, it has been predicted that the incidence of tumor-related SCD will increase over the coming decades.^6,7 This will likely pose a challenge to the existing spinal rehabilitation capacity and pathways.

Research has shown that rehabilitation is of benefit to patients with MSCC.^8–12 However, it has also been highlighted that access to rehabilitation services for MSCC patients is limited.^13,14 This is not surprising considering the unique management challenges that a complex neuro-oncological condition such as MSCC would pose. When deciding on whether rehabilitation for MSCC would be constructive, consideration of patients’ desires, goals, mental and emotional state, medical stability, and prognosis all need to be taken into account. Would a patient really be able to benefit from an inpatient rehabilitation program without taking away precious time from loved ones? To assist the clinician and the patient in this decision, the Tokuhashi score (including the use of Karnofsky Performance status score) has aided by outlining overall MSCC prognosis: 95% of patients with a score of 12–15 are estimated to survive over one year, 73% of patients with a score of 9–11 are estimated to survive more than 6 months, and 85% of those who score less than 8 are estimated to live less than 6 months.¹⁵ Also, another limiting factor to MSSC rehabilitation is that much of the discussion around the funding and care of MSCC focuses mainly on acute oncological care.¹⁶

The 2008 National Institute for Clinical Excellence (NICE) UK guideline has made some suggestions for rehabilitation in MSCC. It suggests that for MSCC rehabilitation, a short (e.g. 4–6 weeks), goal-oriented inpatient stay is recommended for patients with a life expectancy of at least 3 months,¹ in order to optimise time in the community and out of hospital. This idea is in line with studies endorsing early access to rehabilitation to improve quality of life, independence, self-management of neurological impairment and allow patients to be discharged home and spend their last days with family.^17,18

Using this baseline guidance, the London Spinal Cord Injury Centre has set up a bespoke six-to-eight-week MSCC rehabilitation pathway from May 2013 admitting patients with MSCC from low grade tumors, with a Tokuhashi score of 9–15 who were hemodynamically stable with a stable spinal column.

The aims of this study were to describe the metastatic spinal cord injuries patient cohort admitted to a specialist SCI rehabilitation Centre, to evaluate rehabilitation outcomes of these patients and to explore any differences in outcomes based on age, American Spinal Injuries Association Impairment Scale and Surgical Intervention.

Methods

Design: A retrospective analysis of clinical data from a specialist Spinal Cord Injury Centre database from 2013 to 2021.

Inclusion Criteria: Adult patients diagnosed with MSCC, admitted to and discharged from the London Spinal Cord Injury Centre from May 2013 to December 2021.

Exclusion Criteria: Primary Spinal Cord tumors were excluded.

Setting and Data source: The London Spinal Cord Injury Centre (LSCIC) is one of eleven Specialist Spinal Cord Injury Centres in the UK who has developed a bespoke specialist rehabilitation pathway for treating patients with MSCC. The Centre currently has 33 beds for Spinal Cord Injured patients. From May 2013 there has been one rehabilitation bed allocated particularly for patients with MSCC.

Data for this analysis were collated by creating a Local LSCIC MSCC database. This database was created by collecting a list of all patients referred to the LSCIC with MSCC and cross referencing this with all patients admitted and discharged from LSCIC between May 2013 and December 2021. The following categories were set up in the excel database for ongoing data collection:

Age at admission, Sex, Primary Tumor, Date of Injury, Admission Date, Length of stay, Vertebral Levels of Metastases, Level of MSCC, International Standards for Neurological Classification of Spinal Cord Injury Classification (ISNSCI) assessment on admission and discharge, Pre-Admission Surgical Intervention (yes/no), SCIM on admission and discharge (with SCIM subsets self-care, sphincter and respiratory management, mobility), Pre-Admission Oncological Treatment, Inpatient Complications, Psychological input required during admission, Discharge destination.

Ethics permission: None required.

Principal measurements

SCIM III – Spinal Cord Independence Measure –

The SCIM is a validated outcome measure that assessed three domains of independence measures in patients with spinal cord injury.¹⁹ It consists of a total score of 100 with three subsections – “Self-care” (0–20), “Respiration and sphincter management” (0–40) and “Mobility” (0–40). Each category is scored using subsections in proportion to patients’ independence in these activities with full independence in an activity generating a maximum score. “Self-care” includes subcategories – Feeding (3 points), Bathing (6 points), Dressing (8 points), Grooming (3 points). “Sphincter and Respiratory Management” includes subcategories – Respiration (10 points), Sphincter Management Bowel (15 points) and Sphincter Management Bladder (10 points) and Use of Toilet (5 points). Mobility subcategories include “Mobility in bed” (10 points), “Transfers: bed-wheelchair” (2 points), “Transfers: wheelchair-toilet/tub” (2 points), ”Mobility Indoors” (8 points), “Mobility for moderate distance” (8 points), “Mobility Outdoors” (8 points), “Stair management” (3 points), “Transfers: wheelchair-car” (2 points), “Transfers: ground-wheelchair” (1 point).

Data extraction

Adult patients with MSCC were referred to the Specialist Rehabilitation Centre either via a National Database system called MDSAS (Medical Data Solutions and Services) or via direct letter referrals from Oncological or Spinal Surgical teams. A total of 295 patients were referred as MSCC from May 2013 to December 2021. Referrals were initially triaged (on paper, virtually or face-face) via the Outreach Admission planning team, then patients were further reviewed, if necessary, in the Spinal Cord Injury Outpatient Clinic. Patients were offered admission if they met the criteria of MSCC rehabilitation (Tokuhashi score of 9–15 with haemodynamic and spinal stability). Patients with poor survival prognosis and certain fast-growing primary tumors were excluded for e.g. Small Cell Lung Cancer and Colon Cancer.

Adult patients were included in the study if:

1. They were admitted to and discharged from LSCIC from May 2013 to December 2021

2. They had a diagnosis of MSCC

A total of forty (40) patients met the above criteria for inclusion into this study. Data were collected and collated in MS Excel and analyzed using GraphPad Prism.

Data handling and analysis

The data were analyzed using parametric statistics with 95% confidence intervals. Where appropriate, paired t-tests were used to compare SCIM data at admission and discharge. Further stratification was done by age (<65 years or > =  65 years), ASIA Impairment Score (AIS) (A, B, C or D) and whether there was surgical intervention or not.

In this analysis, the data were described and analyzed using parametric statistics. 95% confidence intervals were calculated.

Results

Demographics

From a total of 295 patients referred for MSCC, 40 were admitted with MSCC for specialist rehabilitation from May 2013 to December 2021. The low admission rate was likely related to the specific admission criteria; low grade tumors, haemodynamic and spinal stability, with a predicted survival of at least 6 months; inpatient specialist rehabilitation was offered to those who were deemed fit enough to engage with an intensive daily inpatient rehabilitation program.

Table 1 shows Demographic Data and Clinical Features of this Cohort of patients. The average age was 58, with 32 male and 8 female patients. The mean length of stay was 42 days (six weeks). The primary underlying cancer was prostate cancer in 42.5% of patients (17 patients). The vast majority of patients (34(85%)) had Thoracic MSCC with 5 patients showing multi-level MSCC.

Table 1.

Demographics and clinical features of patients admitted with MSCC.

	Whole sample
Parameter	All N = 40 (100%)
Age in years-Mean (SD)	58
M:F ratio	32:8 (80%:20%)
Length of stay (days) Mean (SD)	42
Primary Cancer
Prostate cancer	17(42.5%)
Multiple myeloma	7(17.5%)
Sarcoma	5(12.5%)
Breast cancer	3(7.5%)
Renal cell cancer	2(5.0%)
Adenocarcinoma lung	1(2.5%)
Myxoid mesenchymal tumor	1(2.5%)
Bladder cancer	1(2.5%)
Lymphoma	1(2.5%)
Adamantinoma	1(2.5%)
Medulloblastoma	1(2.5%)
Level of MSCC
Cervical	1(2.5%)
Thoracic	34(85%)
Cervical + thoracic	2(5%)
Thoracic + lumbar	3(7.5%)
Surgical intervention for MSCC Pre-admission
Yes	27(67.5%)
No	13(32.5%)
Non-surgical oncological treatment
Hormonal therapy	11(27.5%)
Chemotherapy only	4(10%)
Radiotherapy only	5(12.5%)
Radiotherapy + chemotherapy	9(22.5%)
Radiotherapy + hormonal therapy	4(10%)
Radiotherapy + chemotherapy + Hormonal therapy	1(2.5%)
Proton beam therapy	1(2.5%)
Not recorded	3(7.5%)
Nil non-surgical oncological treatment	2(5.0%)

SD: standard deviation.

Inpatient complications and discharge

Table 2 categorizes inpatient complications and shows the number of patients who required and received psychological input. It also highlights discharge destinations.

Table 2.

Inpatient complications and discharge destination.

Complications during admission
Nil	26 (65%)
Severe anemia requiring transfusion	1 (2.5%)
Pressure ulcer	3 (7.5%)
Rectal bleeding secondary to Low molecular weight heparin	1 (2.5%)
Deep vein thrombosis	1 (2.5%)
Pulmonary embolism	2 (5%)
Neutropenia with infection	2 (5%)
Other infection	3 (7.5%)
Limb weakness caused by tumor progression with nerve root compression	1 (2.5%)
Psychological Input
Number of patients who required and received psychological input	28 (70%)
Psychological input not required	8 (20%)
Psychological input not documented	4 (10%)
Discharge destination
Home	33(82.5%)
Acute transfer to Hospital/Referring Unit	3(7.5%)
Non-acute repatriation to Referring Unit	1(2.5%)
Sheltered housing	1(2.5%)
Aspire property	1(2.5%)
Hospice	1(2.5%)

The majority of patients (26 (65%)) did not have any complications during their rehabilitation. Some of the remaining complications reported and related to underlying malignancy included: Anemia (1 (2.5%)), Neutropenia with infection (2(5%)), Deep Vein Thrombosis (1(2.5%)), Pulmonary Embolism (2 (2.5%)), increased weakness secondary to tumor progression and nerve root compression (1(2.5%)); all of these were reported between 2013 and 2016. In the patients with Neutropenia, infections sustained included a Lower Respiratory Tract Infection and Cellulitis. Other complications reported included the development of Pressure ulcers (3(7.5%)), Per Rectal bleeding due to Low Molecular Weight Heparin use (1(2.5%)), and 3 other non-Neutropenic infections including pneumonia, infective gastroenteritis and one infection of unknow origin.

All patients admitted to the unit are offered psychological review and input. 28(70%) of patients required and received psychological input. 8(20%) were deemed not to require an input from the psychological team. For 4(10%) patients, there was no documentation around psychological review.

Most patients were discharged home (82.5%) with only 3 patients (7.5%) requiring acute transfer to a different hospital. The one patient who was discharged to a hospice has been living in this hospice for many years prior to admission.

Functional outcomes

Using the Spinal Cord Independence Measure version III (SCIM) scores, Table 3 summarizes functional outcome scores for the admitted MSCC cohort. There was highly significant increase in total SCIM score parameters between admission and discharge (P < 0.001). Of the documented subcategory scores, there was also a significant increase in the scores for all subsections (Self-care, Respiratory and Sphincter Management and Mobility) between admission and discharge (Figure 1).

Table 3.

Overall Spinal Cord Independence Measure (SCIM) outcome scores on admission and discharge (n = 40).

	N=	Admission Mean ± SD (95% CIs)	Discharge Mean (95% CIs)	Mean difference	95% CIs*	T	P value 2-tailed
Total SCIM score	37	43.8 ± 21.5 (36.6, 51.0)	64.5 ± 19.8 (57.9, 71.1)	20.7 ± 14.1	16.0, 25.4	8.893	<0.0001***
Subcategories:
Self-Care	10	9.8 ± 3.3 (7.4, 12.2)	15.5 ± 4.0 (12.7, 18.4)	85.7 ± 4.3	2.6, 8.8	4.17	0.0024***
Respiratory and Sphincter Management	10	15.5 ± 9.4 (8.8, 22.2)	25.0 ± 9.8 (18.0, 32.0)	9.5 ± 9.8	2.5, 16.5	3.055	0.0137*
Mobility	10	9.0 ± 7.1 (3.9, 14.1)	17.6 ± 10.4 (10.2, 25.0)	8.6 ± 5.3	4.8, 12.4	5.135	0.0006***

Figure 1.

Graph showing comparison of SCIM subscores from admission to discharge.

Difference in functional outcomes based on age

In both age groups (over 65 and under 65), there was a significant difference between admission and discharge SCIM scores as highlighted in Table 4. Although there was a greater change in SCIM scores in the under 65 age group, this was not significantly different from the change in SCIM scores in the over 65 age group. There was also a higher admission SCIM score in the over 65 age group. However, again there was no significant difference when compared to the under 65 age group.

Table 4.

Comparison of SCIM scores between age groups.

Parameter	Age <= 65 N = 24		Age > 65 N = 13		Difference between groups
SCIM
	Mean ± SD	95% CI	Mean ± SD	95% CI	P	T
Admission	42.5 ± 22.3	33.1, 51.9	46.3 ± 20.5	33.9, 58.7	0.50	0.68	NS
Discharge	66.3 ± 20.0	57.8, 74.7	61.3 ± 20.0	49.2, 73.4	0.49	0.68	NS
Change	23.8 ± 16.3	16.9, 30.6	15.0 6.0	11.4, 18.6	0.07	1.86	NS
P, t	P < 0.0001, 7.134		P < 0.001, 8.972

Difference in functional outcomes based on American Spinal Injury Association (ASIA) Impairment Scale (AIS)

Patients with an AIS of A, C and D on admission showed a significant improvement in SCIM. Patients with AIS D showed the most statistically significant improvement in SCIM scores from admission to discharge. Patients with a Complete Injury (ASIA Impairment Scale A) had the lowest admission average SCIM score and showed the largest mean change in SCIM. For patients with an AIS B on admission there was no significant improvement, contributed to by the small number of patients alongside the noted variability of the SCIM data within this group (Table 5).

Table 5.

Comparison of Spinal Cord Independence Measures of varying ASIA impairment scales at admission and discharge.

		SCIM Score
	n	Admission		Discharge			Change
AIS on Admission		Mean	SD	Mean	SD	P	Mean	SD
A	3	26.00	7.00	51.33	12.01	0.02**	25.33	6.35
B	4	29.25	16.58	45.75	17.10	0.16	16.50	17.77
C	8	32.75	12.33	50.13	16.05	0.001**	17.38	9.24
D	22	54.86	21.89	74.95	15.76	<0.0001***	22.00	15.91

It was also noted that comparing ASIA Impairment Scales on admission to discharge, that majority of the scales remained the same (35/40). This is demonstrated by orange boxes in Table 6. The variation existed in some patients with AIS B and C on admission; Two patients with AIS B on admission were AIS C on discharge, 1 AIS C changed to AIS D, 1AIS C changed to AIS B and 1 patient with AIS C changed to AIS A on discharge. With regard to the patient who went from AIS C to A, it was noted that she had a background of metastatic Breast Cancer with cervical, thoracic and sacral metastases with further disease progression during her admission.

Table 6.

Comparison of ASIA Impairment scales of patients on admission and discharge.

Difference in functional outcomes based on surgical intervention

There was no significant difference in the SCIM scores between the patients who had surgical intervention or non-surgical management of MSCC prior to the admission to the spinal unit. However, as seen in Table 1, many patients had other forms of treatment including non-surgical oncological treatment which may have also contributed to outcome measures (Table 7).

Table 7.

Comparison of SCIM scores between groups undergoing surgical intervention.

Parameter	No Surgical Intervention		Surgical Intervention		Difference Between Groups
SCIM	N =13		N = 27
	Mean ± SD	95% CI	Mean ± SD	95% CI	P	t
Admission	45.4 ± 20.3	33.1, 57.6	43.0 ± 22.5	33.5, 52.5	0.75	0.32	NS
Discharge	64.3 ± 18.7	53.0, 75.6	64.6 ± 20.8	55.8, 73.4	0.96	0.04	NS
Change	18.9 ± 8.6	13.7, 24.1	21.6 ± 16.5	14.7, 28.6	0.58	0.55	NS
P, t	P < 0.0001	7.88	P < 0.0001	6.43

Discussion

This study highlights that MSCC patients, despite the cancer burden, can achieve meaningful functional gains after rehabilitation in a specialist spinal injuries rehabilitation center. It has been previously shown that patients with Spinal Cord Dysfunction achieve improved health, functional and social outcomes when managed through a specialist spinal injury unit (SIU) system, compared to the non-specialist rehabilitation units.²⁰ However, specifically for patients with MSCC, this data strengthens existing findings of Fortin et al. ⁸ which showing functional improvement in pts with MSCC after inpatient spinal injury rehabilitation.⁷ In this study however, compared to Fortin et al., Spinal Cord Independence Measures (SCIM) scores were used instead of using Functional Independence measures (FIM) as the main outcome measure, as the SCIM has been shown to be a validated, highly comprehensive and highly reproducible outcome measure for patients with spinal cord injury.^19,22

Regarding the neurological and functional components of Rehabilitation Outcome Measures, it has been reported that 85% of patients classified as AIS A at admission have no change in their AIS status one year after the injury, as opposed to AIS B and C scores, which show progressive recovery in all but 19% and 25% of cases, respectively.²³ However, Wirth et al. have demonstrated that functional and motor recovery, with a significant improvement in SCIM II scores, could be achieved through rehabilitation despite little recovery in ASIA scores.²⁴ Our data is in line with this conclusion, with functional recovery being observed across our cohort, despite most of the patients having no change in their AIS classification at admission. It is not surprising to observe that in our cohort, AIS D patients had higher SCIM scores at admission and discharge, with the most statistically significant improvement in post rehabilitation as a result of the larger number of admissions compared to other AIS classes. It is important to note however that patients with AIS A, in particular, achieved statistically significant improvements in SCIM III score through our rehabilitation program, with the mean change being the largest compared to other AIS classes. Considering that the SCIM score has been shown to predict independence in activities of daily living,^25,26 our data represents further evidence for the value of rehabilitation to improve patients’ independence, self-management of disability, and quality of life in MSCC.

This data is also relevant as it provides a UK perspective. Most of the current studies around MSCC Rehabilitation have been conducted within rehabilitation centers outside of the UK.^7–14,27

With this data showing that patients with MSCC benefit from specialist inpatient rehabilitation, this may assist in helping the existing reluctance around admitting patients with MSCC into rehabilitation centers.^21,22

Regarding reluctance to admission of MSCC patients, it is known that issues around frailty and complications of medical treatment of cancer come into play when discussing access to rehabilitation.²² In the UK, age of 65 years is typically taken as the start of “older age” commonly associated with increasing frailty and age 65 is also the national average age at which MSCC is diagnosed.⁶ However, of note in this study, was the lack of a significance between the change in SCIM scores between the younger (under 65) and older cohort, showing that older patients, even on with a background with MSCC, continue to benefit from rehabilitation and should be given the opportunity to receive it, as suggested by the NICE 2014 Quality standard.⁶ On admission there was a slightly higher SCIM score in the over 65 patient cohort compared to the under 65 group. However, this was not a significant difference and would require further analysis, such as reviewing co-morbidities, type of primary cancer and relevant pre-admission interventions to determine what factors would have contributed to a higher SCIM score.

It is important to note that as part of holistic multidisciplinary specialist spinal rehabilitation, consideration should always be taken to providing psychological support for patients and their families with the likelihood of having adjustment difficulties with illness and treatment.²⁸ In our cohort of patients, all patients were offered psychological support from a dedicated ward psychology team including the availability of a Cancer Nurse Specialist and a psychiatrist if needed. As part of the psychological support system, we have commenced the use of Appraisals of Disability Primary and Secondary Scale (ADAPSS) which is a validated tool in helping to assess the psychological adjustment of patients of Spinal Cord Injury.²⁹ This helps to identify patients with poor psychological adjustment on admission so that appropriate inpatient input can be provided. The admission and discharge ADAPPS score will be added the ongoing prospective data collection regarding outcome measures from 2022.

Further regarding inpatient parameters, it is now our experience as shown by these results, that patients who were streamlined and admitted for specialist rehabilitation had fewer inpatient complications and an increased discharge rate to a home environment compared to all patients admitted with MSCC in some National hospital centers.³⁰ Even with the complications highlighted, it was noted by the treating team that the complications related to underlying malignancy occurred during the earlier years after setting up the MSCC pathway. Since then, the clinical team have adjusted and redesigned clinical practice and clinical monitoring to reduce the risk of developing some of these complications for example, extending the duration of Venous Thromboembolism Prophylaxis to six months after MSCC – injury instead of 8–12 weeks as is commonly used within care of cases with other causes of spinal cord injury.³¹

Strengths and limitations

• As there are very limited specialist admission MSCC pathways in UK centers, having specialist center real-life data of a recently developed MSCC pathway in an area which covers a large geographical region covering an 8-year period would be a useful basis for further studies and to provide guidance for future centers contemplating an MSCC spinal rehabilitation pathway. Also, having used the SCIM measures would allow for comparative studies to be conducted across Spinal Cord Injury Centres Internationally.

• As a retrospective single-center study, inherent limitations such as a small study size with selection bias and incomplete documented data would be expected. However, a very high percentage (93% of patients) did have documented recorded SCIM outcome measures required for the study which bodes well for the reliability. Regarding the documentation of the subcategories of SCIM, the full SCIM of each patient has recently (over the past three years) been uploaded to the electronic patient files and as such, there were only 10 records with the full subsection scores documented.

• Of note with MSCC, there are multiple variables which could possibly affecting outcomes- Age, primary Tumor type, medical co-morbidities, Surgical Intervention and Oncological and radiation treatments prior to admission. To include all of these in analysis would require a further multiple variant regression analysis regarding their effect on outcomes in patients with MSCC

Conclusion and future implications

We would ultimately hope for other Specialist Spinal Cord Injury Centres to consider admission of patients with MSCC for inpatient rehabilitation as an opportunity instead of a challenge; to provide specialist rehabilitation care with the aim of improving patient independence and patient and care givers’ experiences.

For future research, we aim to standardize the MSCC collection database at this spinal cord injury center to provide data for future studies with a larger sample size and to conduct multiple variant analyses as described above. Also, the information collected can be used to compare outcome measures to other patients with different causes of non-Traumatic spinal cord injuries, both at this center and other international centers.

In conclusion, this study shows that after a six to eight weeks of multidisciplinary specialist inpatient rehabilitation experience, patients with MSCC have demonstrated improved outcome measures.

Disclaimer statements

Contributors None

Funding None.

Conflicts of interest All authors have no conflicts of interests to declare.

Author contributions

• Dr Manish Desai conceptualized the idea for this analysis and assisted with editing the script.

• Dr Gisele Lafeuillee was responsible for planning, and execution of the study. She was also responsible for the data collection, presentation, and submission of the manuscript and for coordinating editing process.

• Francesco Magni shared writing of the initial draft of the Introduction, contributed to the data-collection and editing the script.

• Dr Sarah Knight assisted with statistical analysis of the results and with editing the script.