Longitudinal motor system changes from acute to chronic spinal cord injury

Abstract Background and purpose In acute spinal cord injury (SCI), magnetic resonance imaging (MRI) reveals tissue bridges and neurodegeneration for 2 years. This 5‐year study aims to track initial lesion changes, subsequent neurodegeneration, and their impact on recovery. Methods This prospective longitudinal study enrolled acute SCI patients and healthy controls who were assessed clinically—and by MRI—regularly from 3 days postinjury up to 60 months. We employed histologically cross‐validated quantitative MRI sequences sensitive to volume, myelin, and iron changes, thereby reflecting indirectly processes of neurodegeneration and neuroinflammation. General linear models tracked lesion and remote changes in volume, myelin‐ and iron‐sensitive magnetic resonance indices over 5 years. Associations between lesion, degeneration, and recovery (using the Spinal Cord Independence Measure [SCIM] questionnaire and the International Standards for Neurological Classification of Spinal Cord Injury total motor score) were assessed. Results Patients' motor scores improved by an average of 12.86 (95% confidence interval [CI] = 6.70–19.00) points, and SCIM by 26.08 (95% CI = 17.00–35.20) points. Within 3–28 days post‐SCI, lesion size decreased by more than two‐thirds (3 days: 302.52 ± 185.80 mm 2 , 28 days: 76.77 ± 88.62 mm 2 ), revealing tissue bridges. Cervical cord and corticospinal tract volumes transiently increased in SCI patients by 5% and 3%, respectively, accompanied by cervical myelin decreases and iron increases. Over time, progressive atrophy was observed in both regions, which was linked to early lesion dynamics. Tissue bridges, reduced swelling, and myelin content decreases were predictive of long‐term motor score recovery and improved SCIM score. Conclusions Studying acute changes and their impact on longer follow‐up provides insights into SCI trajectory, highlighting the importance of acute intervention while indicating the potential to influence outcomes in the later stages.