The changing demographics of traumatic spinal cord injury: An 11-year study of 831 patients

Abstract

Context/objective

Traumatic spinal cord injuries (T-SCI) have a devastating impact and place a significant financial burden on the healthcare system. The incidence of T-SCI ranges from 10.4 to 83 cases per million and varies with age, sex, or geographical region. This study describes the epidemiology and demographic characteristics of patients treated for T-SCI in our region over 11 years.

Design

Retrospective cohort study.

Setting

Single Level-I trauma center in Québec, Canada.

Participants

Patients who sustained T-SCI between 1 April 2000 and 31 March 2011.

Interventions

None.

Outcome measures

Data concerning T-SCI patients was retrieved from the Québec Trauma Registry. Information on age, sex, trauma, level of injury, type and severity of neurological deficit (ASIA scale), and treatment was extracted. Annual, age-standardized rates of T-SCI were calculated and trends over time were examined.

Results

Eight hundred and thirty-one patients with T-SCI were identified. The incidence of T-SCI did not change over time but there was a 13-year increase in age between 2002 and 2010. More than 60% of patients aged 55 years or more were injured following a fall and 80% became tetraplegic. These patients were more likely to have central cord syndrome (CCS) and incomplete neurological injury, compared to younger patients. The incidence of CCS increased from 25 to 37% over 11 years.

Conclusions

The T-SCI population is aging and is more frequently sustaining injuries associated with CCS, incomplete neurological deficits and tetraplegia.     

Body composition modifications in people with chronic spinal cord injury after supervised physical activity

Context

The Thoracolumbar Injury Classification System (TLICS) has been recently described to help surgeons in the decision-making process of thoracolumbar spinal trauma.

Objective

To analyze the potential relationships between the TLICS scores with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine System and patient''s neurological status.

Methods

Literature analysis of the potential scored injuries in the TLICS system, based on its individual scores, its total score, and its suggested proposed treatment, correlating these with the AO system and neurological status.

Results

Findings are presented according to the TLICS score. Patients with a TLICS 1–3 points, receiving conservative treatment, are AO type A injuries, generally neurologically intact. TLICS 4 group also included AO type A fractures, neurologically ranging from intact to complete spinal cord injury. TLICS 5–10 points includes AO type B and C injuries, regarding their neurological status, and burst fractures (AO type A) with concomitant neurological injury and most of the patients with incomplete deficits and cauda equina syndrome.

Conclusions

As a general overview, according to the TLICS, patients without neurological deficit and with AO type A injuries are conservatively treated. AO type B and C injuries are managed surgically, with regard to neurological status. Patients with cauda equina or incomplete injuries also received a higher severity score. Controversies still exist regarding the management of unstable burst fractures without neurological status. The role of the posterior ligamentous complex status and the magnetic resonance imaging in the decision-making process require more clinical evidence.     

Acetabular fractures before and after the introduction of seatbelt legislation

Objectives

To compare the incidence and severity of acetabular fractures and associated injuries before and after seatbelt legislation.

Design

A retrospective study.

Setting

Two major trauma centres, which are teaching hospitals.

Patients

Three hundred and ninety-three patients who sustained acetabular fractures during the 5 years before and 5 years after seatbelt legislation was enacted. Of these, the fractures in 198 patients (50.4%) resulted from a motor vehicle accident.

Main Outcome Measures

The number and severity of acetabular fractures and associated injuries.

Results

There has been a significant reduction in the number of acetabular fractures (p = 0.005) since seatbelt use became mandatory, and the complexity of the fractures has decreased. There has also been a marked reduction in associated injuries, such as fractures of other bones, and head, chest and abdominal injuries (p < 0.001).

Conclusion

The seatbelt law has been a useful preventive measure, resulting in a reduction in the incidence of acetabular fractures and associated injuries.     

Urodynamic patterns after traumatic spinal cord injury

Objectives

To study the correlation between neurological level of spinal injury and bladder functions as detected by urodynamic study.

Study design

Analytical study.

Setting and participants

Seventy individuals with traumatic spinal cord injury (SCI) admitted to the Department of Physical Medicine and Rehabilitation, S.M.S. Medical College and Hospital, Jaipur. Detailed clinical, neurological evaluation as per American Spinal Injury Association Classification and radiological assessment were done along with clinical examination of bladder and urodynamic study.

Results

Out of 65 patients with suprasacral injuries, 53 (81.5%) demonstrated hyperreflexia with or without detrusor sphincter dyssynergia, 6 (9.2%) detrusor areflexia, and 6 (9.2%) had normal bladders, 41 (59.4%) low compliance (<20 ml/cmH₂O), and 47 (72.30%) had high detrusor leak pint pressures (>40 cmH₂O). Of the five patients with sacral injuries, one (20%) showed detrusor hyperreflexia, four (80%) detrusor areflexia, and one (20%) had low bladder compliance; all five (100%) had high detrusor leak point pressures.

Conclusions

The correlation between somatic neurologic findings, spinal imaging studies, and urodynamic findings in patients with SCI is not exact. Therefore, bladder management should not completely rely only on clinical bladder evaluation or neurological examination alone, but should always include urodynamic studies.     

Psychosocial outcomes among youth with spinal cord injury by neurological impairment

Objective

Examine psychosocial outcomes of youth with spinal cord injury (SCI) as a function of neurological level (paraplegia/tetraplegia) and severity (American Spinal Injury Association (ASIA) Impairment Scale (AIS)).

Design

Survey research.

Setting

Three pediatric SCI specialty centers in the USA.

Participants

Youth with SCI ages 5–18 with neurological impairment classifications of: tetraplegia AIS ABC (tetraplegia ABC), paraplegia AIS ABC (paraplegia ABC), or AIS D.

Outcome Measures

Children''s Assessment of Participation and Enjoyment, Pediatric Quality of Life Inventory, Revised Children''s Manifest Anxiety Scale, and Children''s Depression Inventory.

Results

Three hundred and forty youth participated; 57% were male; 60% were Caucasian, 21% Hispanic, 7% African-American, 2% Native American, and 3% reported “other”. Their mean age was 8.15 years (standard deviation (SD) = 5.84) at injury and 13.18 years (SD = 3.87) at interview. Ninety-six youth (28%) had tetraplegia ABC injuries, 191 (56%) paraplegia ABC injuries, and 53 (16%) AIS D injuries. Neurological impairment was significantly related to participation and quality of life (QOL). Specifically, youth with paraplegia ABC and AIS D injuries participated in more activities than youth with tetraplegia ABC (P = 0.002; P = 0.018, respectively) and youth with paraplegia ABC participated more often than youth with tetraplegia ABC (P = 0.006). Youth with paraplegia ABC reported higher social QOL than youth with tetraplegia ABC (P = 0.001) and AIS D injuries (P = 0.002). Groups did not differ regarding mental health.

Conclusion

Interventions should target youth with tetraplegia ABC, as they may need support in terms of participation, and both youth with tetraplegia ABC and AIS D injuries in terms of social integration.     

Epidemiology of traumatic spinal cord injury in Asia: a systematic review

Study design

A systematic review.

Background

The number of traumatic spinal cord injury (TSCI) reports grows annually, especially in China and Korea. The epidemiological characteristics of TSCI in Asia differ from those in other countries. Thus, we compiled epidemiological factors from Asia to compare with those from other countries.

Method

We searched articles published in any language between January 1980 to December 2011 using the terms “spinal cord injury”, “traumatic spinal cord injury”, “epidemiology”, and “Asia”. The articles were reviewed for information regarding TSCI incidence, total cases, case criteria, case source, causes of injury, male/female ratio, mean age, prospective or retrospective, neurological level of injury, extent of injury, and America Spinal Injury Association Impairment Scale (AIS)/grade.

Results

Epidemiological data were extracted from 39 reports in the published literature that met the inclusion criteria. Only two studies reported prevalence rates. Incidence rates ranged from 12.06 to 61.6 per million. The average age ranged from 26.8 to 56.6 years old. Men were at higher risk than women. Motor vehicle collisions (MVCs) and falls were the main causes of TSCI. However, several countries reported war wounds as the major cause. The neurological level and extent of injury were mixed, and most patients were categorized as AIS/Frankel grade A.

Conclusion

TSCI is an important public health problem and a major cause of paralysis. We must understand the epidemiology to implement appropriate preventative measures. Asian epidemiology is different from that in other regions, so intervention measures must be established according to population-specific characteristics.     

Description of sensory preservation in children and adolescents with incomplete spinal cord injury

Background/objective

This cross-sectional, multicenter cohort study describes patterns of preserved sensation in persons with American Spinal Injury Association (ASIA) Impairment Scale (AIS) B (sensory incomplete, or SI) and AIS C/D (motor incomplete, or MI).

Methods

A total of 93 subjects with incomplete spinal injuries (58 with tetraplegia and 35 with paraplegia) were included for analysis. Sensation was based on the International Standards for Neurological Classification of SCI (ISNCSCI).

Results

In the 44 subjects with AIS B (SI), some light touch (LT) was present in 35% of dermatomes below the neurological level and pin prick (PP) in 8%. In contrast, in the 49 subjects with AIS C/D (MI), LT was present in 77% of dermatomes and PP in 27%. AIS C/D (MI) subjects with tetraplegia had more dermatomes with preserved sensation than those with paraplegia. When reviewing areas at highest risk for pressure sores, only 4 of 22 (19%) of subjects with AIS B (SI)/tetraplegia had any preserved LT or PP sensation in the periscapular region (dermatomes T1–T6). In the buttocks region (S3 and S4–S5), sensation was preserved in fewer than 50% of patients with either tetraplegia or paraplegia.

Conclusions

(1) Sensory sparing below the neurologic injury was found to be surprisingly sparse in patients classified as AIS B (SI) (35% LT and 8% PP). Sparing was considerably better in patients who were AIS C/D (MI) (77% LT and 27% PP). (2) Preserved sensation in the periscapular region was very low in subjects with tetraplegia (19%) and was also low in the buttocks, with fewer than half of those classified as AIS B (SI) with either tetraplegia or paraplegia reporting sensation.     

Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression

Purpose

Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the ‘timing of surgery’ is an important factor in survival and neurological outcome in patients with MSCC.

Methods

All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups—those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications.

Results

Patients’ age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24–48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (−0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups.

Conclusions

Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.     

Spontaneous conus medullaris infarction in a 79 year-old female with cardiovascular risk factors: a case report

Objective:

To detail the case of a 79 year-old female who presented with sudden bilateral neurological deficits of the lower extremities and was later diagnosed with non-traumatic conus medullaris infarction. The purpose of this case report is to inform primary contact practitioners of the presentation, diagnosis and the associated risk factors of this condition in order to facilitate prompt management.

Clinical Features:

Spinal cord infarction presenting as low back pain with a high degree of bilateral loss of motor strength, sensation and reflexes in the lower extremities and bowel/bladder dysfunction, in a patient with previous coronary artery bypass graft surgery and renal insufficiency.

Intervention and Outcome:

Referral to emergency within hours of symptom onset allowed for immediate assessment, management and relatively favourable partial recovery.

Summary:

Although rare, conus medullaris infarction is potentially devastating and requires an appropriate clinical index of suspicion for timely diagnosis, treatment and optimal neurological recovery.     

Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

Background

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

Methods

Case report and literature review.

Findings

A previously healthy man presented with Brown-Séquard syndrome below T5–T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

Conclusions

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.     

Simultaneously diagnosed pulmonary thromboembolism and hemopericardium in a man with thoracic spinal cord injury

Background

Simultaneous pulmonary thromboembolism (PTE) and hemopericardium is a rare but life-threatening condition. As hemopericardium is a contraindication to anticoagulation treatment, it is challenging to handle both conditions together.

Objective

The objective of the study was to report a rare case of a man with thoracic spinal cord injury presenting with simultaneous PTE and hemopericardium.

Design

Case report.

Subject

A 43-year-old man with incomplete T9 paraplegia (American Spinal Injury Association Impairment Scale D) complained of fever one and a half months after spinal cord injury sustained in a fall.

Findings

During evaluation of fever origin, chest computed tomography and transthoracic echocardiogram revealed simultaneous PTE and hemopericardium. After serial echocardiograms over 2 days demonstrated stability, intravenous heparin, and oral warfarin were administered and his medical status was observed closely. Ultimately, both conditions improved without significant complications.

Conclusion

We report successful treatment of man with acute spinal cord injury who presented with simultaneously diagnosed PTE and hemopericardium, a rare complication involving two distinct and opposing pathological mechanisms and conflicting treatments.     

Time and Effort Required by Persons with Spinal Cord Injury to Learn to Use a Powered Exoskeleton for Assisted Walking

Background:

Powered exoskeletons have been demonstrated as being safe for persons with spinal cord injury (SCI), but little is known about how users learn to manage these devices.

Objective:

To quantify the time and effort required by persons with SCI to learn to use an exoskeleton for assisted walking.

Methods:

A convenience sample was enrolled to learn to use the first-generation Ekso powered exoskeleton to walk. Participants were given up to 24 weekly sessions of instruction. Data were collected on assistance level, walking distance and speed, heart rate, perceived exertion, and adverse events. Time and effort was quantified by the number of sessions required for participants to stand up, walk for 30 minutes, and sit down, initially with minimal and subsequently with contact guard assistance.

Results:

Of 22 enrolled participants, 9 screen-failed, and 7 had complete data. All of these 7 were men; 2 had tetraplegia and 5 had motor-complete injuries. Of these, 5 participants could stand, walk, and sit with contact guard or close supervision assistance, and 2 required minimal to moderate assistance. Walk times ranged from 28 to 94 minutes with average speeds ranging from 0.11 to 0.21 m/s. For all participants, heart rate changes and reported perceived exertion were consistent with light to moderate exercise.

Conclusion:

This study provides preliminary evidence that persons with neurological weakness due to SCI can learn to walk with little or no assistance and light to somewhat hard perceived exertion using a powered exoskeleton. Persons with different severities of injury, including those with motor complete C7 tetraplegia and motor incomplete C4 tetraplegia, may be able to learn to use this device.     

Magnetic Resonance Imaging of Pressure Sores in Spinal Cord Injured Patients: Accuracy in Predicting Osteomyelitis

Objective:

Identify key magnetic resonance imaging (MRI) features that have a significant correlation with osteomyelitis of pressure ulcers in spinal injury patients.

Design:

Retrospective review study.

Participants:

Adult patients admitted to the National Spinal Injuries Centre with spinal cord injury (SCI) and signs of pressure ulceration investigated with MRI.

Methods:

Analysis of MRI examinations and clinical records collected over a 4-year period. Images were independently assessed by 2 experienced radiologists for osteomyelitis based on assigned predictive indicators including cortical bone erosion, soft tissue edema, deep collections, heterotopic new bone, hip effusion, and abnormal signal change of the marrow.

Results:

Thirty-seven patients underwent 41 MRI scans. The prevalence of osteomyelitis was highly correlated with cortical bone erosion (r = 0.84) and abnormal bone marrow changes on T1-weighted images (r = 0.82).     

Epidemiological profile of 239 traumatic spinal cord injury cases over a period of 12 years in Tianjin, China

Study design

Hospital-based retrospective review.

Objective

To describe the epidemiological characteristics and trends of traumatic spinal cord injury in Tianjin, China.

Setting

Tianjin Medical University General Hospital.

Methods

Medical records of 239 patients with traumatic spinal cord injury admitted to a general hospital from 1998 to 2009 were reviewed. Variables included gender, age, marital status, occupation, etiology, time of injury, level, and severity of injury. Epidemiological characteristics of different countries were compared.

Results

Over this period, the mean age of patients with traumatic spinal cord injury was 45.4 ± 14.1 years, and the male/female ratio was 4.6:1. In all, 86.2% were married. The leading cause was fall (52.3%), followed by motor vehicle collision (36.4%). The most common injury site was the cervical spinal cord, accounting for 82.0%. Incomplete tetraplegia made up for 59.4%, followed by complete tetraplegia (22.6%). Eight patients died after operation, six of whom died from respiratory complications.

Conclusion

The results of this study are in accordance with that of most other developing countries; falls and motor vehicle collisions were the two leading causes, but the mean age was older. Percentage of the aged with traumatic spinal cord injury was increasing. The low-falls group tended to expand over this period. All these data indicated that the preventive programs should focus on the traffic accidents and falls, and more attention should be paid to the aged for the vulnerability to low fall.     

Comparison of coronary artery calcification scores and National Cholesterol Education program guidelines for coronary heart disease risk assessment and treatment paradigms in individuals with chronic traumatic spinal cord injury

Objective

To investigate the risk of coronary heart disease (CHD) in individuals with spinal cord injury (SCI) according to the National Cholesterol Educational Program (NCEP) guidelines and CT coronary artery calcium scores (CCS).

Research

Cross-sectional study of consecutive sample of males with SCI presenting to a single site for CHD risk assessment.

Participants/methods

Males age 45–70 with traumatic SCI (American Spinal Injury Association (ASIA) A, B, and C) injured for at least 10 years with no prior history of clinical CHD. Medical history, blood-pressure, and fasting lipid panel were used to calculate risk for CHD with the use of the Framingham risk score (FRS). Risk and treatment eligibility status was assessed based on NCEP/FRS recommendations and by presence and amount of CCS. Percent agreement (PA) and kappa were calculated between the two algorithms. Spearman correlations were calculated between CCS and FRS and individual risk factors.

Results

A total of 38 men were assessed; 18 (47.4%) had CCS > 0. The PA between NCEP/FRS assessment and CCS was 18% with a kappa of −0.03. 11 (28.9%) had CCS > 100 or >75th percentile for their age, sex, and race, which might qualify them for lipid-lowering treatment. Only 26 were placed into the same treatment category by NCEP/FRS and CCS, for a PA of 68% with a kappa of 0.35. In all, 20 (52.6%) were eligible for lipid-lowering treatment by either NCEP/FRS (n = 9) or CCS (n = 11). Seven subjects were above the treatment threshold based on CCS, but not NCEP/FRS and five subjects were above the NCEP/FRS threshold, but not CCS. Just four subjects were eligible by both algorithms. CCS only correlated with FRS (r = 0.508, P = 0.001) and age (r = 0.679, P < 0.001).     

The incidence of spinal surgery in canada

Objective

To estimate the incidence of spinal surgery in 5 Canadian provinces over a 12-month period.

Design

Cumulative incidence study.

Setting

Five provinces (63% of Canada’s population).

Participants

All patients who underwent spinal surgery between July 1, 1992, and June 30, 1993, in British Columbia, Alberta, Ontario, New Brunswick and Newfoundland.

Main outcome measure

Overall spinal surgery rates per province and by age and sex.

Results

In the 5 provinces over the allotted 12-month period, 12 329 spinal surgical procedures were performed. The overall rate of spinal surgery for the 5 provinces was 80 per 100 000 population. Ontario had the lowest rate of 61 per 100 000; British Columbia had the highest at 89 per 100 000. Men aged 40 to 49 years in Newfoundland had the highest overall rate at 210 per 100 000. Calculation of relative risks determined that Newfoundland’s under-20 age groups for both sexes were almost 3 times as likely to undergo spinal surgery as the same age groups in Ontario (male relative risk = 2.73, female relative risk = 2.84). Males in British Columbia and Alberta had a statistically significant increased risk of surgery across all age groups except for those under 20 years old, and females in British Columbia showed a statistically significant increased risk of surgery across all age groups compared with those in Ontario. Males underwent 57.7% of all spine operations.

Conclusions

The incidence of spinal surgery is not uniform across Canada. Overall, the per capita rate is lower than in the United States. The explanation for this divergence remains unclear.     

Association between alendronate,serum alkaline phosphatase level,and heterotopic ossification in individuals with spinal cord injury

Context/objective

Only sparse evidence exists regarding the effectiveness of oral alendronate (ALN) in the prevention of heterotopic ossification (HO) in patients with spinal cord injury (SCI). The objective of this study is to investigate the protective effect of oral ALN intake on the appearance of HO in patients with SCI.

Study design

Retrospective database review.

Setting

A Spinal Cord Unit at a Rehabilitation Hospital.

Participants

Two hundred and ninety-nine patients with SCI during acute inpatient rehabilitation.

Interventions

Administration of oral ALN.

Outcome measures

The incidence of HO during rehabilitation was compared between patients with SCI receiving oral ALN (n = 125) and patients with SCI not receiving oral ALN (n = 174). The association between HO and/or ALN intake with HO risk factors and biochemical markers of bone metabolism were also explored.

Results

HO developed in 19 male patients (6.35%), however there was no significant difference in the incidence of HO in patients receiving oral ALN or not. The mean odds ratio of not developing versus developing HO given ALN exposure was 0.8. Significant correlation was found between abnormal serum alkaline phosphatase (ALP) levels and HO appearance (P < 0.001) as well as normal serum ALP and ALN intake (P < 0.05).

Conclusion

Even though there was no direct prevention of HO in patients with SCI by oral ALN intake, abnormal serum ALP was found more frequently in patients with HO development and without oral ALN intake. This evidence could suggest that ALN may play a role in preventing HO, especially in patients with acute SCI with increasing levels of serum ALP.