What to call spinal cord damage not due to trauma? Implications for literature searching

Objectives

To illustrate the importance of multiple search terms and databases when searching publications on spinal cord damage not due to trauma. To develop comprehensive search filter for this subject, compare the results for 2000–2009 with the Medical Subject Headings (MeSH) and Emtree term ‘spinal cord diseases’ and determine changes in the number of articles over this period.

Design

Literature searches and search filter development.

Setting

Australia.

Interventions

Titles and abstracts searched in MEDLINE and EMBASE (2000–2009) for articles involving humans using search terms ‘non-traumatic spinal cord injury’ and ‘nontraumatic spinal cord injury’ (concise search). Develop comprehensive search filter for ‘spinal cord damage not due to trauma’ and compare the results with the MeSH term ‘spinal cord diseases.’

Outcome measures

Annual publications (2000–2009) identified in MEDLINE and EMBASE literature searches.

Results

Concise search identified 35 articles published during 2000–2009. More publications were identified using the term ‘nontraumatic spinal cord injury’ (n = 20) than ‘non-traumatic spinal cord injury’ (n = 16). Publications increased for both terms ‘spinal cord diseases’ (2000 = 279; 2009 = 415) and ‘spinal cord damage not due to trauma’ identified by the comprehensive search filter (2000 = 1251; 2009 = 1921).

Conclusions

Concise searches using terms ‘non-traumatic spinal cord injury’ and ‘nontraumatic spinal cord injury’ fail to identify relevant articles unless combinations of terms and databases are used. These are inadequate search terms for a comprehensive search. Further research is needed to validate our comprehensive search filter. An international consensus process is required to establish an agreed term for ‘spinal cord damage not due to trauma.’     

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.     

A survey of Fellows in the College of Chiropractic Sports Sciences (Canada): their intervention practices and intended therapeutic outcomes when treating athletes

Objective

To compile baseline data regarding the treatment practices and therapeutic outcomes that fellows of the College of Chiropractic Sports Sciences Canada (CCSS(C)) strive for when treating athletes.

Design

Cross-sectional self-report mail out survey of CCSS(C) fellows.

Participants

Current registered fellows of the CCSS(C) as determined by the College at the time of survey distribution.

Results

The majority of questioned fellows believe that they can cause direct and specific improvements in an athlete’s sport performance. The most commonly utilized therapeutic intervention was spinal joint manipulation/mobilization. The most anticipated outcomes following the treatment of athletes with the goal of affecting athletic performance were “changing or improving aberrant body mechanics,” “restoring or improving aberrant muscle function,” and “improving joint function or reducing joint dysfunction.”

Conclusion

The majority of respondent fellows of the CCSS(C) believe their therapy to be effective in enhancing an athlete’s sport performance.     

Statewide Investigation of Medically Attended Adverse Health Conditions of Persons With Spinal Cord Injury

Background/Objective:

To report over a 10-year period the statewide prevalence and incidence of medically attended adverse health conditions in people with new traumatic spinal cord injury (TSCI).

Design:

Retrospective cohort study.

Methods:

(a) Identified all new TSCI cases discharged alive from statewide acute care hospitals, 1996 to 2000, using ICD-9-CM methodology. (b) Followed cases from 1996 to 2005 to quantify medically attended health conditions documented during emergency department visits, acute care hospitalizations, and outpatient hospital visits. (c) Used the life table method to calculate the prevalence and incidence of health conditions. (d) Examined Cox proportional hazard ratio of mortality by gender controlling for age and TSCI severity.

Results:

Nine hundred eighty-eight residents (257 women, 731 men) with TSCI were alive 90 days after discharge from acute care hospitalization from 1996 to 2000. Nine hundred twenty-three (251 female, 672 male) (93.4%) residents had an observed medically attended adverse health condition in the 10-year follow-up period. The most prevalent classes of diseases and disorders were (a) muscle and connective tissue, (b) renal and urinary, (c) digestive, (d) circulatory, (e) respiratory, (f) endocrine/nutritional/metabolic, and (g) infectious. Incidence of new injury was 29.0% for males and 26.9% for females. During the follow-up period, 49 women (19%) and 104 men (14%) died.

Conclusions:

People with TSCI experience diverse adverse health conditions in the 10 years after initial injury. An interdisciplinary health care provider team approach to allocating resources and implementing countermeasures to prevent or limit occurrence of these conditions is vital to these patients'' continuum of care.     

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Background/objective

Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.

Methods

Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.

Results

PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of “walk” or “both (walk and wheelchair)” on the discharge motor FIM for patients with AIS D injuries.

Conclusion

Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings.

Note

This is the second of nine articles in the SCIRehab series.     

The correlation between coronal balance and neuroaxial abnormalities detected on MRI in adolescent idiopathic scoliosis

Introduction

The indications for magnetic resonance imaging in presumed adolescent idiopathic scoliosis (AIS) have not been established, with some studies suggesting that rates of spinal cord abnormalities are low and question the use of the routine MRI in AIS.

Objective

Given the restraints on MRI resources the authors performed a retrospective audit to see if the presence of coronal or sagittal misbalance–balance could be used as a surrogate marker for the presence of spinal cord abnormalities in this patient group and hence reduce the need for unnecessary MRI scans.

Methods

We performed a retrospective review of imaging of patients with AIS at our centre over a 2-year-period. All MRI scans were reported by the senior author and the presence of spinal cord abnormalities noted. All plain films were assessed by a senior SpR and ST2 orthopaedic surgeons for Cobb angle, coronal balance, sagittal balance and Lenke classification.

Results

A total of 171 patients were identified with AIS. Of these, a total of 15 patients (9%) were found to have neural axis anomalies on MRI including syringomyelia, Chiari malformations and dural ectasia. The average Cobb angle was 44.9° with coronal balance varying from 67.2 mm left to 40.2 mm right. Sagittal balance varied from 125 mm negative to 83 mm positive. No correlation was found between coronal/sagittal misbalance and the presence of neural axis anomalies.

Conclusions

Our audit demonstrates that neither coronal nor sagittal misbalance should be used as an indicator of neural axis abnormalities.     

Definitions of Quality of Life: What Has Happened and How to Move On

Background:

Quality of life (QOL) is an important outcome in spinal cord injury (SCI) rehabilitation, but it is unclear how to define and measure it.

Objective:

The aims of this article are to (a) show how the concepts of QOL and health-related quality of life (HRQOL) have evolved over time, (b) describe the various ways QOL has been defined and measured, and (c) provide recommendations on how to be as clear and consistent as possible in QOL research.

Method:

A narrative review of the QOL literature was performed.

Results:

Roots of the term “quality of life” in health care can be traced back to the definition of health by the World Health Organization in 1948. The use of the word “well-being” in this definition is probably a main factor in the continuing confusion about the conceptualization of QOL. Within the field of SCI rehabilitation, the Dijkers’s QOL model, distinguishing between utilities, achievements, and subjective evaluations and reactions, has been very influential and the basis for several reviews and databases. Nevertheless, literature shows that it is still difficult to consistently use the term “quality of life” and categorize QOL measures. Several aspects of QOL that are specific for individuals with SCI have been identified.

Conclusions:

Researchers should be as specific and clear as possible about the concept and operationalization of QOL in their studies. Readers should not take the term “quality of life” for granted, but should inspect the topic of the study from the actual measures used.Key words: health status, outcome assessment, quality of life, spinal cord injuries     

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.     

Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.     

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study

Objectives

The objective of the study was to evaluate the safety and tolerance of use of the ReWalk^™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury.

Study design

Case series observational study.

Setting

A national spinal cord injury centre.

Methods

Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured.

Results

There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently.

Conclusion

Volunteer participants were able to ambulate with the ReWalk^™ for a distance of 100 m, with no adverse effects during the course of an average of 13–14 training sessions. The participants were generally positive regarding the use of the system.     

Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9451-y) contains supplementary material, which is available to authorized users.     

The emotive impact of medical language

Background

Words can shape or reinforce a patient’s coping strategies. We measured the emotional content of hand surgery words and some synonyms or alternatives in five categories (19 words total).

Methods

Healthy adult companions of 100 patients presenting to an orthopedic hand surgical practice were asked to score five hand surgery words and some synonyms and alternatives (19 total words) on three dimensions: affective/emotional (ranging from pleasant to unpleasant), arousal (ranging from calm to aroused), and dominance/control (ranging from dominated to feeling in control) using a validated methodology. Ratings were done using the self-assessment manikin—a validated graphic affective rating system.

Results

The emotional reaction to “discomfort” and “ache” was more positive than “pain.” The words “tear” and “defect” were more positive than “rupture.” The words “tight” and “stiff” were more positive than “locked” and “frozen.” The word “faded” was more positive than “degenerated,” “diminished,” and “wasted”. The words “overused” and “worn” were more positive than “cracked,” “inflamed,” and “broken.”

Conclusions

Some common hand surgery words have a relatively negative emotional content. Given that psychological distress is an important predictor of pain intensity and disability, additional research is merited to develop optimally positive language for describing musculoskeletal pathology.     

Invasive and non-invasive brain stimulation for treatment of neuropathic pain in patients with spinal cord injury: A review

Context

Past evidence has shown that invasive and non-invasive brain stimulation may be effective for relieving central pain.

Objective

To perform a topical review of the literature on brain neurostimulation techniques in patients with chronic neuropathic pain due to traumatic spinal cord injury (SCI) and to assess the current evidence for their therapeutic efficacy.

Methods

A MEDLINE search was performed using following terms: “Spinal cord injury”, “Neuropathic pain”, “Brain stimulation”, “Deep brain stimulation” (DBS), “Motor cortex stimulation” (MCS), “Transcranial magnetic stimulation” (TMS), “Transcranial direct current stimulation” (tDCS), “Cranial electrotherapy stimulation” (CES).

Results

Invasive neurostimulation therapies, in particular DBS and epidural MCS, have shown promise as treatments for neuropathic and phantom limb pain. However, the long-term efficacy of DBS is low, while MCS has a relatively higher potential with lesser complications that DBS. Among the non-invasive techniques, there is accumulating evidence that repetitive TMS can produce analgesic effects in healthy subjects undergoing laboratory-induced pain and in chronic pain conditions of various etiologies, at least partially and transiently. Another very safe technique of non-invasive brain stimulation – tDCS – applied over the sensory-motor cortex has been reported to decrease pain sensation and increase pain threshold in healthy subjects. CES has also proved to be effective in managing some types of pain, including neuropathic pain in subjects with SCI.

Conclusion

A number of studies have begun to use non-invasive neuromodulatory techniques therapeutically to relieve neuropathic pain and phantom phenomena in patients with SCI. However, further studies are warranted to corroborate the early findings and confirm different targets and stimulation paradigms. The utility of these protocols in combination with pharmacological approaches should also be explored.     

Effects of gender on inpatient rehabilitation outcomes in the elderly with incomplete paraplegia from nontraumatic spinal cord injury

Objective:

To examine gender differences in rehabilitation outcomes for patients with nontraumatic spinal cord injury.

Research Design:

Secondary analysis was conducted on Medicare beneficiary data from 65 to 74 year olds with incomplete paraplegia discharged from inpatient rehabilitation facilities in 2002 through 2005.

Main Outcome Measures:

Length of stay, Functional Independence Measure instrument motor item and subscale scores on discharge, and discharge destination.

Results:

Among patients with degenerative spinal disease, men had significantly longer rehabilitation stays than women (P < 0.001). Men with degenerative spinal disease had significantly lower discharge Functional Independence Measure scores than women, indicating more dependence in self-care (P < 0.001) and mobility (P < 0.001). Among patients with degenerative spinal disease, men were less likely to walk (odds ratio  =  0.58; 95% CI  =  0.38–0.87) and less likely to be independent with bladder management (odds ratio  =  0.44; 95% CI  =  0.31–0.62). Among patients with vascular ischemia, men were more independent (B  =  2.59; 99% CI  =  0.42–4.76) in mobility than women. There were no gender differences in the malignant spinal tumors group. There were no gender differences in being discharged to a community-based residence.

Conclusions:

Gender distributions varied by etiology. Gender differences were found in demographics, length of stay, and functional outcomes but not discharge destination. Men were more dependent than women at discharge in the etiology group with the least overall disability (degenerative spinal disease) and more independent in mobility than women at discharge in the etiology group with the most overall disability (vascular ischemia).     

Reliability of plain radiographic parameters for developmental dysplasia of the hip in children

Introduction

Few studies have evaluated the reliability and reproducibility of the femoral neck-shaft angle (NSA), center-edge angle (CEA), and acetabular index (AI) in young children with developmental dysplasia of the hip (DDH). We wanted to determine whether these parameters could be used reliably by practitioners.

Methods

Fifty radiographs from 21 children with DDH were reviewed. Analysis was performed by three observers, at two time periods. The intra- and inter-observer reliability for each measure was assessed.

Results

At time period one, we noted a “high” level of agreement between observers when measuring the NSA, a “low” level when measuring the CEA, and a “moderate” level when measuring the AI. At time period two, we noted a “very high” level of agreement between observers when measuring the NSA and a “high” level when measuring the CEA and AI. When comparing the measurements of observer 1 at the two different time periods, we noted nearly “very high” agreement when measuring the NSA, a “moderate” agreement when measuring the CEA, and a “high” agreement for the AI. In comparing the measurements of observer 2, we noted “very high” agreement for the NSA and “high” agreement for the CEA and AI. In comparing the measurements for observer 3, we noted nearly “very high” agreement for the NSA, nearly “high” agreement for the CEA, and “high” agreement for the AI.

Conclusion

It is difficult to reliably measure three-dimensional pelvic morphology on a frontal plane radiograph, especially when important pelvic landmarks have yet to ossify.     

Factors associated with early mortality after cervical spinal cord injury

Background

A relatively high early mortality rate (<30 days post-injury) for cervical spinal cord injury (SCI) has been observed.

Objective

To investigate this early mortality rate observed after cervical SCI and analyze the associated influential factors.

Methods

Medical records for 1163 patients with cervical SCI were reviewed, and the number of patients with early mortality was documented. Through logistic regression analysis, the effects of age, gender, occupation, cause of injury, severity of injury, highest involved spinal cord segment, nutritional condition during hospitalization, surgical treatment, tracheotomy, etc., on early mortality were assessed. Implementation of early treatment (i.e. surgery, tracheotomy, and nutritional support) and its effect on patient prognosis were also analyzed.

Results

Early mortality occurred in 109 of 1163 patients (9.4%). Four factors affected the early mortality rate, including level and severity of SCI, whether or not surgery was performed, the time interval between SCI and surgery, malnutrition, and tracheotomy. Patients with an American Spinal Injury Association grade of A, a high cervical SCI (C1–C3), and/or no surgical intervention were statistically more likely to have early mortality (P < 0.001).

Conclusion

Severe cervical SCI, upper-level cervical cord injury, malnutrition, and inappropriate tracheotomy are risk factors for early mortality in patients with cervical SCI. Surgery can reduce early mortality. Early tracheotomy should be performed in patients with complete upper-level cervical SCI, but patients with incomplete cervical SCI or complete low-level cervical SCI should initially be treated surgically to maintain smooth airway flow.     

Airway complications in traumatic lower cervical spinal cord injury: A retrospective study

Objective

To investigate risk factors for pneumonia in patients with traumatic lower cervical spinal cord injury.

Design

Observational study, retrospective study.

Setting

Spinal cord unit in a maximum care hospital.

Methods

Thirty-seven patients with acute isolated traumatic spinal cord injury at levels C4–C8 and complete motor function injury (AIS A, B) treated from 2004 to 2010 met the criteria for inclusion in our retrospective analysis. The following parameters were considered: ventilation-specific parameters, re-intubation, creation of a tracheostomy, pneumonia, antibiotic treatment, and length of intensive care unit (ICU) stay and total hospitalization.

Results

Among the patients, 81% had primary invasive ventilation. In 78% of cases a tracheostomy was created; 3% of these cases were discharged with invasive ventilation and 28% with a tracheostomy without ventilation. Pneumonia according to Centers for Disease Control criteria occurred in 51% of cases within 21 ± 32 days of injury, and in 3% at a later date. The number of pre-existing conditions was significantly associated with pneumonia. Length of ICU stay was 25 ± 34 days, and average total hospital duration was 230 ± 144 days. Significant factors affecting the duration of ventilation were the number of pre-existing conditions and tetraplegia-specific complications.

Conclusions

Our results confirm that patients with traumatic lower cervical spinal cord injuries defined by lesion level and AIS constitute a homogeneous group. This group is characterized by a high rate of pneumonia during the first 4 weeks after injury. The number of pre-existing general conditions and spinal injury-specific comorbidities are the only risk factors identified for the development of pneumonia and/or duration of ventilation.