Comorbid illness is associated with survival and length of hospital stay in patients with chronic disability. A prospective comparison of three comorbidity indices

OBJECTIVES

This study was designed to determine if comorbidity added more information than knowing only the patient's age in predicting survival and length of hospital stay.

METHODS

The authors compared the relative predictive validity of three comorbidity indices: the Cumulative Illness Rating Scale, the Charlson Index, and a count of International Classification of Diseases, 9th Revision, Clinical Modification medical diagnoses in relation to survival and length of hospital stays in patients with spinal cord injury. The sample consisted of 330 longitudinally followed spinal-cord injured patients admitted between January 1989 and December 1990 who were followed for an additional 18 months.

RESULTS

During the follow-up, 25 (7.5%) patients died and 249 (75.5%) were readmitted to hospital with a median of one admission (range, 1-8). The corresponding lengths of hospital stay ranged from 0 to 548 days, with a median of 7 days.

CONCLUSIONS

Patients who died were not significantly older but had higher comorbidity scores. Using patients alive at the end of the follow-up period, linear regression models were fit to the data to determine if comorbidity added more information regarding length of hospital stay than knowing only the patient's age. In the model that included only age as an independent variable, there was a significant relation between age and length of stay (F(1,303) = 5.2; P = 0.012). The R2 value for this model was 0.017. In further models that included age and each of the three comorbidity scores (separately) as the independent variables, the model that included age and the Cumulative Illness Rating Scale yielded the highest R2 value (R2 = 0.062). This study is among the first to compare three different measures of comorbidity and documents that comorbidity provides more information than knowing only the patient's age in relation to survival and length of hospital stay.

Traumatic spinal cord injuries in Thailand: an epidemiologic study in Siriraj Hospital, 1989-1994

The records of 219 patients with spinal cord injuries admitted to the Siriraj Hospital. Bangkok from January to December 1994 were reviewed retrospectively. The average patient age was 32.8 years (range = 12-75 years); the male/female ratio was 5.6:1. The most common cause of injury was road traffic accident (50.7%), followed by falls (31%), assault (8.7%) and being hit by moving objects (7.8%). As a result of the injury, 52 (23.7%) patients were tetraplegic, 58 (26.5%) were tetrapapetic, 63 (28.8%) were paraplegic and 46 (21.0%) were paraparetic. The mortality rate was 16%. The leading cause of death was a respiratory complication, accounting for 89% of the total deaths.

Respiratory management, survival, and quality of life for high-level traumatic tetraplegics

Although spinal cord injury is devastating and can compromise the respiratory system, particularly when the cervical cord is injured, aggressive use of noninvasive respiratory muscle aids can reduce the otherwise commonly seen complications of pneumonia, bronchial mucous plugging, atelectasis, and respiratory failure. Accessory muscle function can also usually be improved and the muscles then recruited to help maintain adequate alveolar ventilation during the acute spinal cord injury recovery period. Noninvasive assisted ventilation can be successful for patients with compromised lung function during the acute rehabilitation period as well as on a long-term basis. Removal of an indwelling tracheostomy tube results in improved quality of life from many points of view, a decreased number of local tracheostomy complications, a decreased number of serious respiratory infections, an improved ability to communicate, and an increased ability to use the mouth for functions such as operating computers and wheelchairs.

Mortality and neurologic morbidity after repair of traumatic aortic disruption

BACKGROUND

Traumatic disruption of the thoracic aorta frequently results in death before operative repair. The determinants of mortality after repair, however, are uncertain. In addition, intraoperative strategies for reducing the incidence of spinal cord injury remain controversial.

METHODS

The records of 45 consecutive patients undergoing repair of traumatic disruption of the thoracic aorta at a single institution during a 9-year period were reviewed in a retrospective fashion. Patient age ranged from 15 to 81 years (mean age, 33.9 years). Twenty-two patients (49%) had multiple associated injuries, and 8 (18%) had isolated aortic injuries. Nine patients (20%) experienced preoperative hypotension (systolic blood pressure of less than 90 mm Hg). Repair was performed with partial bypass in 22 patients, a heparinized shunt in 2, and no distal perfusion (clamp and sew technique) in 21.

RESULTS

Nine patient (20%) died after operation. Multivariate logistic regression analysis of preoperative and intraoperative variables identified advancing age and preoperative hypotension as independent predictors of operative death. The presence of associated injuries was not an independent predictor of operative death. All 4 patients with injuries proximal to the aortic isthmus died. Ten patients were excluded from analysis of spinal cord injury either because of preoperative neurologic deficit or because of death before postoperative evaluation. Six (17%) of the remaining 35 patients had development of paraplegia: 5 of the 15 patients having the clamp and sew technique, 1 of the 2 with a shunt, and 0 of the 18 patients with bypass (p < 0.05, clamp and sew versus bypass). In the clamp and sew group, patients in whom paraplegia developed had significantly longer aortic clamp times than those without neurologic injury (40.6 +/- 4.4 minutes versus 28.7 +/- 2.9 minutes, respectively; p < 0.05).

CONCLUSIONS

Advancing age, preoperative hypotension, and perhaps injury location are important determinants of death after repair of traumatic disruption of the thoracic aorta. Adjunctive perfusion with partial bypass should be used during repair to reduce the incidence of spinal cord injury.

The long term outcome in 149 patients with spinal cord injury

A longitudinal follow-up study of 149 spinal cord injured patients is presented. Ninety two patients have been visited and interviewed at home 7-10 years after injury (28% died during the follow-up). Disability was assessed using the Functional Independence Measure (FIM), and was correlated with the neurological level, impairment and spasticity. The handicap was assessed using the Reintegration to Normal Living Index (RNLI). Multivariate analysis showed a correlation with age, neurological impairment, sexual impairment, living conditions and social life. There was a high correlation with depression and the Functional Independence Measure. The early neurological examination correlated with their long term disability but not with their handicap.

Superoxide radicals play important roles in the pathogenesis of spinal cord injury

To investigated a possible role of superoxide dismutase (SOD) in the pathogenesis of spinal cord injury (SCI), the change in the circulatory status in an experimental SCI model of rats was examined. The blood pressure (BP) of the SCI group decreased markedly by compression or head-up-tilt (60 degrees). The extent of the BP decrease was diminished by the administration of along acting SOD (SM-SOD) prior to injury. Compression, tilting and the administration of SM-SOD increased the sensitivity of resistant arteries to acetylcholine. SM-SOD treated rats had a significantly lower mortality than was found in untreated rats. These findings indicate that superoxide radicals may contribute to the pathogenesis of spinal cord injury and orthostatic hypotension caused by SCI.

Failure of methylprednisolone to improve the outcome of spinal cord injuries

The infusion of methylprednisolone (MP) within 8 hours of injury for spinal cord injuries (SCI) has been advocated to improve the motor function of patients after this catastrophic injury. However, clinical improvement in the outcome of SCI has not been consistently identified, despite the use of MP. We reviewed the outcome of SCI patients with MP to those without MP (No-MP) at two Level I Trauma Centers from 1989-1992. Acute SCI patients were identified from the trauma registries with trauma demographics and hospital data obtained from registry and medical records. Rehabilitation data for Functional Independence Measure (FIM) was obtained from the rehabilitation institute database. Primary outcome parameters were mortality, and for survivors, patient mobility (6 point scale) and FIM scores. There were 145 acute SCI patients: 80 treated with MP and 65 with No-MP. FIM data was available on 45 MP and 25 No-MP patients. There was no difference in the admission trauma score, ICU length of stay (LOS), or hospital LOS between the two groups. The MP patients were significantly younger (30 years vs 38 years, P = < 0.05) and had lower ISS scores (24 vs 31, P = < 0.05). There was no statistically significant difference in mortality (MP, 3.8% vs No-MP, 10.7%) between the two groups. Although admission mobility was not statistically different (MP, 5.99 vs No-MP, 5.90), there was a significantly poorer discharge mobility in the MP group when compared to the No-MP group (MP, 5.16 vs No-MP, 4.67, P = < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Life expectancy of ventilator-dependent persons with spinal cord injuries

OBJECTIVE

The purpose of this study is to estimate age-specific life expectancies for ventilator-dependent persons with spinal cord injury (SCI).

DESIGN

Nonconcurrent prospective study.

SETTING

Federally designated model SCI care systems.

PATIENTS

The study included all 435 persons admitted to a model SCI care system between 1973 and 1992 who survived at least 24 h postinjury and who were either ventilator dependent at rehabilitation discharge or who died prior to discharge while still ventilator dependent.

INTERVENTION

None.

OUTCOME MEASURES

Standardized mortality ratio (SMR), life expectancy, and causes of death.

RESULTS

The overall 1-year survival rate was 25.4%, while the 15-year survival rate was 16.8%. Among those who survived the first year, cumulative survival over the next 14 years was 61.4%. The mortality rate for persons injured since 1980 was reduced by 60% compared with persons injured between 1973 and 1979. Among year 1 survivors, the subsequent mortality rate was reduced by 39% for persons injured between 1980 and 1985, and 91% for persons injured since 1986, relative to persons injured between 1973 and 1979. The leading cause of death was respiratory complications, particularly pneumonia.

CONCLUSIONS

With the development of improved methods of prevention and management of respiratory complications in this population, life expectancies should continue to improve. As a result, additional attention should be focused on enhancing the quality of life for these individuals.

Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury

STUDY DESIGN

This study retrospectively analyzed vertebral column fractures in trauma patients during a 2-year period. Data from a multicenter trauma registry were used.

OBJECTIVES

The purpose of this study was to ascertain and describe the initial in-hospital morbidity and mortality rates for patients with vertebral column fractures with and without spinal cord injury.

SUMMARY OF BACKGROUND DATA

Patients with vertebral fractures and associated spinal cord injuries experience more medical complications than those without spinal cord injuries. However, the precise incidence and relative risk of complications during acute care hospitalization for these two groups are not well documented.

METHODS

Vertebral column fractures in 419 adolescent and adult trauma patients hospitalized during a 2-year period were retrospectively analyzed using data from a multicenter trauma registry.

RESULTS

Of the 419 patients, 104 (24.8%) had an associated spinal cord injury. More than half of the spinal cord injury patients (52.9%) and 20.6% of those without spinal cord injury had one or more complications during their hospitalization. Complications resulted in an average of 33.1 extra hospital days, which extrapolates nationally into 1.5 million additional days annually. The four complications differing most significantly in incidence between the spinal cord injury group and the non-spinal cord injury group were: urinary tract infections (24.0% vs. 8.6%), respiratory (23.1% vs. 8.6%), cardiac (11.5% vs. 3.2%), and decubitus ulcer (7.7% vs. 1.0%). Pneumonia, although not statistically different, was high in both groups (13.5% vs. 7.3%).

CONCLUSIONS

The incidence of the 25 types of medical complications reported here provides specific and relevant information to assist health professionals in treating patients during their acute care. We estimate that complications during initial hospitalization add $1.5 billion annually to the cost of caring for patients with vertebral fractures in the United States.

Spinal cord missile injuries during the Lebanese civil war

BACKGROUND

Spinal cord injuries due to penetrating wounds are not uncommon. The management of these injuries remains controversial especially with regard to the effect of laminectomy on the neurological outcome.

METHODS

Between 1980 and 1989, 64 patients injured by bullets and shell fragments to the spinal cord were reviewed. There were 58 males and 6 females: 24 injuries (37.5%) involved the cervical spine, 37 (57.8%) the dorsal spine, and 3 (4.7%) the lumbar spine. One group (group I) consisted of 47 patients (73.4%) who had immediate and complete sensorimotor loss of function. Another group (group II) contained 13 patients (20.3%) who presented with incomplete and non-progressive spinal cord deficit. One patient (1.6%) (group III) had progressive spinal cord deficit. Three patients (4.7%) (group IV) had injuries to the cauda equina.

RESULTS

The results were analyzed using a chi-squared test when possible. In group I, 20 patients (42.5%) underwent laminectomy with no recovery, and 27 (57.5%) were treated conservatively, with 1 patient (3.7%) achieving marked improvement (p > 0.05). In group II, 3 patients (23.1%) underwent laminectomy with the 3 (100%) improved, and 10 patients (76.9%) were treated conservatively, with 8 (80%) recovering (p > 0.05).

CONCLUSIONS

Our data in groups I and II agree with previously published literature that shows no significant advantage of performing laminectomies following penetrating spinal cord injuries. Moreover, group I patients had a poor prognosis whether laminectomy was done or not, and group II patients had a good prognosis whether laminectomy was done or not.

Neurological recovery, mortality and length of stay after acute spinal cord injury associated with changes in management

Based on epidemiological data from two populations of patients with acute spinal cord injury (ASCI), three outcome measures were compared to evaluate the effectiveness of management of ASCI patients in a regional, specialized acute spinal cord injury unit (ASCIU). The two populations consisted of a pre-ASCIU group of 351 patients managed from 1947-73 before the establishment of the ASCIU, and an ASCIU group of 201 patients managed in an ASCIU from 1974-81. The three outcome measures were mortality rate, length of stay (LOS) during first hospitalization, and neurological recovery. Linear regression and multiple regression analyses were used to determine whether differences in the outcome measures were attributable to differences in admission variables in addition to the influence of the ASCIU. The results showed that the patients treated in the ASCIU had a significant reduction in the mortality rate of almost 50% (P = 0.022), a significant reduction in the LOS of almost 50% (P < 0.001), and a significant increase in neurological recovery consisting of a doubling of the neurological recovery scale utilized (P < 0.001). Multiple regression analysis showed that the reduction in mortality rate was significantly influenced by differences in the admission variables between the two groups. However, the establishment of the ASCIU was associated with a significant reduction in LOS and a significant improvement in neurological recovery. Thus, these results support the view that management of ASCI patients in a regional, multidisciplinary unit is medically advantageous and can reduce the LOS.

A model for estimating spinal cord injury prevalence in the United States

A model was developed to provide a tool to forecast demographic trends in populations of people with traumatic spinal cord injury at the national and state level. This information is critical to planning for the allocation and distribution of resources to care for people with spinal cord injury. The literature on incidence, mortality, and prevalence of spinal cord injury in the United States was reviewed and reported values were evaluated for incorporation into the model. A linear relationship between age specific survival rates of the spinal cord injury population, and expected survival rates in the absence of spinal cord injury was established and this provided the basis for projections using age cohort survival methodology. The model's projections indicate a need for future expansion of capacity to treat traumatic spinal cord injury in the private sector, and a need to prepare for an aging disabled population. The annual number of traumatic spinal cord injury cases admitted to hospitals is projected to increase from approximately 11,500 in 1994 to almost 13,400 in 2010. Age adjusted post-hospitalization incidence rate in 1994 is estimated at approximately 38 per million (23 per million for females and 55 per million for males). A 20% increase in the US spinal cord injury prevalence can be expected over the next 10 years, going from approximately 207,000 estimated in 1994, to 247,000. During this time, the veteran segment, which currently comprises 22% of the spinal cord injury population, is projected to decline.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery in the acute treatment of spinal cord injury: a review of the past forty years

This review is concerned with changes that have occurred during the past forty years in surgery as acute therapy for spinal cord injury. Included is a summary of experimental and clinical information upon which many of the decisions for change were based. Despite the evidence, following World War II, of improvement of mortality and morbidity with non-invasive treatment of spinal cord injuries, increased utilization of surgery has continued to the present. Reasons include a decrease in mortality and morbidity with modern surgical techniques, easier handling of the patient with an unstable spine who has early fusion, and the decrease in hospital and rehabilitation costs with earlier stabilization and earlier mobilization.

A study of the factors affecting the outcome of vertebromedullary injuries

Between 1982 and 1991, 194 patients were treated for cervical vertebromedullary injuries in the Department of Neurosurgery, Cerrahpasa Medical Faculty of the University of Istanbul. The data were evaluated with the multiple regression method using the SPSS/PC statistical package to predict the factors influencing the outcome. In the initial neurological examination, motor deficit was detected in 63.4% of the patients, sensorial deficit was seen in 53.6% of the patients and respiratory failure in 12.9%. Of these patients 46.4% were treated surgically and 53.6% medically. Evaluating the findings and outcomes with the Frankel scale, no change in neurological status was detected in 44.8% of the patients. Improvement was detected in 36.1% and deterioration in 19.1%, the mortality rate being 18.6%. It is concluded that the main factor predicting the outcome of patients with vertebromedullary injury is the initial neurological status (P < 0.0001).

Early outcome in cervical spinal cord injured patients older than 50 years of age

STUDY DESIGN

This study retrospectively reviewed consecutive spinal cord injured patients older than 50 years of age.

OBJECTIVE

This study established reasonable expectations for the early clinical outcome of cervical spinal cord injured patients greater than 50 years of age.

SUMMARY OF BACKGROUND DATA

Previous studies of cervical spinal cord injuries have concentrated on long-term morbidity and mortality. Little data has been reported on the early clinical outcome during rehabilitation.

METHODS

Forty-two consecutive patients older than 50 years of age at the time of cervical cord injury were reviewed. Data was collected from the time of injury to discharge from rehabilitation (< 4 months) and included morbidity, mortality, and disposition of the patient.

RESULTS

There were 15 complete and 27 incomplete cervical cord lesions. Forty-five percent were caused by falls, 42% by motor vehicle accidents. Serious associated morbidity was 81% in complete cord injuries and 34% in incomplete lesions. Overall mortality was 23%. Complete cord injury mortality rate was 60% in this age group. All patients over 65 years of age with complete cord injuries died.

CONCLUSIONS

Incomplete cervical cord lesions have the best prognosis for return to home and a functional lifestyle. Complete cervical cord injuries in patients older than 50 years of age have a 60% mortality rate. Complete cervical cord injuries in patients over 65 years have a poor prognosis for survival.

Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury

We have made a retrospective comparative study of patients with spinal cord injury, nine with a diaphragmatic pacemaker and 13 with mechanical ventilation. Clinical outcome, cost and subjective satisfaction with both modalities have been evaluated. The functional status was the same with both types of treatment. Proper management of an electric wheelchair and optimal phonation were attained, respectively, in 100% and 89% of pacers and in 77% and 77% of mechanically ventilated. The rate of hospital discharge and satisfaction with the treatment were significantly better for pacers. The time devoted to ventilatory assistance and cost were also more favourable in this group.

[Follow-up of spinal injuries with transverse spinal cord lesion]

There are several scores available for assessment of disability and handicap in rehabilitation. In primary treatment most interest has so far been given to the assessment of neurological recovery after operative decompression of the spinal cord. Comparison of the results obtained with this method and the outcome in patient groups treated conservatively revealed no quantitative differences. However, the quality of results was found to be better after surgery, particularly in the functional outcome. Scores should take account of this. The neurological classification of ASIA, IMSOP and DMGP seems to be suitable for assessment of the course through-out the rehabilitation period.

[Central nervous system trauma in children. Clinical analysis of 782 cases]

A series of consecutive 782 children with severe head trauma and spinal cord injury who were managed surgically or conservatively in the Department of Neurosurgery, Medical Academy in Poznań during 31 years was analysed. The clinical history, severity of injury (scales AIS, ISS), outcome of head and spinal cord injuries are reviewed. Factors important in predicting a poor outcome included the presence of brainstem contusion, intracranial haematomas and complete and severe partial spinal cord lesions.

The use of porous corundum ceramics in spinal surgery

Between 1987 and 1991 the spine was stabilised in 205 patients using corundum ceramic implants. The radiological results were assessed with a follow up of from 6 to 24 months and were graded as good in 81%. Poor results were not due to the implanted material, but were usually caused by failure to obtain full correction of the deformity at operation. Porous ceramic implants produce better radiological results, with a decrease in operating time and a reduced risk of infection.

Sledding deaths in Ontario

Traumatic injury from sledding and tobogganing can be reduced. The objective of this study was to determine the incidence of sledding and tobogganing deaths in Ontario. Operator, vehicle (sled), and environmental factors associated with these events were also examined. A retrospective series of cases from the Provincial Chief Coroner's Office identified all patients fatally injured while sledding or tobogganing in Ontario between 1986 and 1991. Communities should pay careful attention to injury prevention when planning organized sledding areas.

Factors contributing to the increased threat to life following spinal cord injury

An analysis of the mortality rate of 3486 spinal injured patients treated in the early posttraumatic period in the years 1965-1989 in Konstancin, Poland is presented. The data show that the life of the spinal cord injured is threatened by several factors, the most important of which appear to be: the level and degree of the spinal cord lesion; certain causes of injury predisposing to severe nervous system injury; advanced age; and to some extent, concomitant injuries and methods of treatment. The significance of age is demonstrated by a nearly tenfold increase in mortality in the oldest age group of patients with complete spinal cord lesions as compared to the youngest age group of up to 20 years with the same degree of spinal cord damage.

Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome

The cardiovascular response of the patient with acute spinal cord injury (SCI) is known to be altered secondary to the cord injury. Our current protocol of managing the acute phase of patients with SCI includes invasive hemodynamic monitoring (with arterial line and Swan-Ganz catheter) and support with fluids and dopamine and/or dobutamine, titrated to maintain a hemodynamic profile with adequate cardiac output (to be determined by oxygen consumption and delivery) and a mean blood pressure of > 90 mm Hg. We feel that this protocol provides two benefits: 1) maintaining the mean blood pressure improves the morbidity of these patients by deterring ischemia and accompanying secondary insults; 2) aggressive monitoring and hemodynamic intervention help stabilize the hemodynamic status of these patients and make it possible to consider early surgery in selected cases. Our hypothesis is that the pulmonary vascular bed is more sensitive to the sympathectomized effect of acute complete cervical SCI. We analyzed the demographic, neurologic, and hemodynamic data of 50 consecutive patients during their first week postinjury. All had signs of myelopathy; 31 (62%) were considered clinically complete. Of the 50 patients, 9 (18%) died, 20 did not improve functionally, and 21 improved. The mean heart rate (82.1 +/- 13.3), blood pressure (94.4 +/- 9.4), pulmonary artery pressure (22 +/- 5) and wedge (12.7 +/- 3.4), cardiac index (4.5 +/- 0.9), systemic vascular resistance index (SVRI) (1637 +/- 399), pulmonary vascular resistance index (PVRI) (181 +/- 80), and oxygen transport (694 +/- 156) showed good response to the treatment. Because the measurements were obtained during treatment, they differ from the expected "classic sympathectomized" response, but they provide a database for further analysis of hemodynamic manipulation in SCI. An analysis of the hemodynamic parameters did not differentiate between complete and incomplete lesions or between patients with functional improvement. We determined, on the basis of the initial hemodynamic measurements, that no patient with a clinically complete motor deficit (Frankel Grade A+B) improved of the 10 who had measurements compatible with either: 1) PVRI < 100 with SVRI < 1200; or 2) PVRI < 115 with SVRI < 1300 or PVR/SVR ratio of < 0.08 when SVRI was < 1600. These patients could not have other measurements that showed low SVRI < 1350 with PVRI > 139. At odds with this unique group, 13 of 29 patients with the same clinical picture and without the above physiological criteria of severe hemodynamic deficit eventually improved (P < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Ventilator-assisted youth: appraisal and nursing care

An interdisciplinary review of 16 ventilator-assisted, cervical-cord injured youth, aged 3-19 years, was completed to explore long-term outcomes and develop recommendations for care. Ten youths were younger than 12 years; 6 were adolescents. The mean initial hospital length of stay was 192 days. Discharged youths were followed for 1-73 months after hospitalization. Nursing implications were developed using a systems approach with North American Nursing Diagnosis Association (NANDA) approved diagnoses. Nursing case management was used to coordinate discharge planning and continuity of care. At the time of data collection 13 youths had been successfully reintegrated to home, school and community, the least restrictive environments for all.

Features of spinal cord injury in Taiwan (1977-1989)

In order to establish an etiological and statistical base for spinal cord injuries, 1,617 spinal cord injured patients admitted to the Chang Gung Memorial Hospital in Taiwan during the period of 1977 to 1989 were reviewed. The most common causes of injury were pedestrian (29.31%) and motorcycle (28.88%) accidents. The greatest incidence of injury was in the 26-35 year age group. The complete tetraplegic patients had the highest mortality rate (26.5%). Additional features studied were the time of occurrence and pattern of injury. Information gathered from this study suggest the need to establish a Spinal Cord Injury Prevention Program, to develop a Prehospital Care System and set up comprehensive Spinal Cord Injury Units in Taiwan. We expect this study to be adaptable to other similar developing countries.

Long-term survival of veterans with traumatic spinal cord injury

OBJECTIVE

To investigate the long-term survival of veterans with traumatic spinal cord injury (SCI).

DESIGN

Survival in a retrospective inception cohort of veterans suffering service-connected traumatic SCI is compared with survival among veterans disabled by other conditions, survival among nondisabled veterans, and a population-based life table.

SETTING

Subjects were identified from a national census of veterans with service-connected disabilities, using a selection algorithm based on disability codes.

PATIENTS

A retrospective cohort of 5545 male veterans with traumatic SCI, surviving at least 3 months after injury, is compared with a stratified random sample of 7077 disabled veterans without SCI, a stratified random sample of 6967 nondisabled veterans, and a life table formed from similarly aged American males.

MAIN OUTCOME MEASURE

Survival curves, extending from 3 months to 40 years after injury.

RESULTS

The mean life expectancy of veterans suffering traumatic SCI and surviving at least 3 months is an additional 39 years after injury, 85% that of similarly aged American males. Although survival with traumatic SCI was comparable to that of the disabled control subjects for approximately 20 years after onset, a clear deficit occurred beyond this point. Older age at injury is a stronger predictor of poorer long-term survival than is complete quadriplegia.

CONCLUSIONS

Among patients who survive the acute phase of their traumatic SCI, long-term survival is relatively good. Health care planners, providers, and communities should anticipate an increasing number of persons aging with SCI.

Fatal injury surveillance report, Delaware, 1990. Head and spinal cord injuries

The Delaware Disabilities Prevention Program is funded through a five-year Centers for Disease Control and Prevention (CDC) grant to prevent primary and secondary disabilities associated with mental retardation and low socioeconomic status; head and spinal cord injuries; and sickle cell disease. This report focuses on fatal head and spinal cord injuries. Death certificates and autopsy reports from 1990 were the data sources used for this study. In 1990, 122 fatal head injuries and 20 fatal spinal cord injuries occurred among Delaware residents. Eight of these individuals experienced both head and spinal cord injuries. Motor vehicle crashes caused the majority of both head and spinal cord deaths. Suicides, homicides, and falls were the other major causes of fatal head injuries. Deaths are only the tip of the injury iceberg. Head and spinal cord injuries can cause lifelong disabilities affecting family, friends, and the entire community.

Traumatic spinal cord injuries in the rural region of Taiwan: an epidemiological study in Hualien county, 1986-1990

In order to survey the epidemiological characteristics of traumatic spinal cord injuries (SCI) in Hualien county, a retrospective study was conducted from January 1986 to December 1990 in four local general hospitals. During this period, 135 traumatic SCI patients were identified and 99 of them were residents of Hualien county. The estimated annual incidence of traumatic SCI in Hualien county was 56.1 per million population. As a result of injury 36 patients were tetraparetic, 33 tetraplegic, 12 paraparetic and 18 paraplegic. The male/female ratio was 4:1. The mean age of onset for male patients was 44 years, and that for female patients was 46 years. The major causes of SCI were traffic accident (61.6%) followed by accidental falls (23.3%). The average duration of hospitalisation ranged from 62 days in paraparetics to 132 days in tetraplegics. Ten patients died of respiratory failure or sepsis, and the mortality rate was 10.1%. Our data revealed that traumatic SCI was prevalent in Hualien county in comparison with epidemiological studies elsewhere. The special population composition of Hualien county and the preponderance of the motorcycle as a transportation vehicle in this area might result in its unique epidemiological characteristics.

Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America

Acute spinal cord injury occurred in 2.6% of the 114,510 patients entered into the Major Trauma Outcome Study from 1982 to 1989. The most common causes of spinal cord injury were motor vehicle accidents (40%), falls (20%), and gunshot wounds (13.6%). Almost 80% of patients with spinal cord injury had multiple injuries. Cervical cord injury was seen in 65% of patients with isolated spinal cord injury, but in only 52% of patients with multiple injuries. The hospital mortality rate was 17%, with patients with multiple injuries having a significantly higher mortality rate than patients with isolated spinal cord injury (19.8% vs 6.9%). The TRISS method overpredicted the mortality rate among patients with multiple injuries (450 vs 379), but not among those with isolated injury. A program for better national surveillance and prevention of spinal cord injury is warranted.

The epidemiology of traumatic death. A population-based analysis

Despite the proliferation of trauma systems, there are no population-based data describing the epidemiology of traumatic death. To provide these data, we reviewed all trauma deaths occurring in San Diego (California) County during 1 year. There were 625 traumatic deaths during the study (27.3 deaths per 100,000 population per year). Motor vehicle trauma was the most common cause of injury leading to death (N = 344 [55.2%]; 15.0 annual deaths per 100,000 population). Central nervous system injuries were the most common cause of death (48.5%, or 13.2 deaths per 100,000 population per year). Sepsis was responsible for only 2.5% of the overall mortality. Based on life-table data, traumatic death resulted in an annual loss of 1091 years of life per 100,000 and an annual loss of 492 years of productivity per 100,000. Injury continues to account for an enormous loss of life despite improvements in survival wrought by trauma systems.

Causes of death during the first 12 years after spinal cord injury

A study of 9,135 persons injured between 1973 and 1984 and treated at any of 13 regional spinal cord injury care systems was conducted to compare their age-, sex-, race-, and cause-specific mortality rates with those of the general population. All subjects survived at least 24 hours. Follow-up was terminated in December, 1985 when 854 persons (9.3%) had died. Although many persons had multiple causes of death, the leading primary causes were pneumonia, nonischemic heart disease, septicemia, symptoms and ill-defined conditions, pulmonary emboli, and ischemic heart disease. During the study period, spinal cord injured persons were 82.2 times more likely to die of septicemia, 46.9 times more likely to die of pulmonary emboli, and 37.1 times more likely to die of pneumonia than comparable individuals from the general population. Though some cause-specific mortality rates for spinal cord injured persons have declined dramatically, many remain substantially above normal. Before life expectancies increase further, improved methods for preventing and managing these fatal complications must be developed.

[The problem of the sacrum fracture. Clinical analysis of 377 cases]

Sacral fractures are rare injuries that are often neglected because of the general severity of the patient's injuries. They are typical injuries in patients with polytraumata. A "hidden" injury, they are often diagnosed late or are even missed. In a well-documented consecutive series of 1,350 patients with pelvic fractures treated in the trauma department of the Hannover Medical School between 1972 and 1991, a total of 377 sacrum fractures were evaluated in a retrospective study. The cause of the accident, mechanism of injury, concomitant injuries, diagnostic procedures, classification of the pelvic injury (TILE), as well as the classification of the sacrum injury (DENIS), treatment and outcome were analyzed in all cases. Observed complications with special attention to injuries to the lumbosacral plexus were correlated with the classification of the sacrum and pelvis, as well as with a detailed analysis of the fracture pattern and fracture characteristics. In 89.4% at least one additional body region was injured in these patients. PTS (Hannover Polytrauma Score) groups III and IV included 42.5% of the patients. With an improved diagnostic protocol (radiological a.p. views, oblique views and CT scan), the observed rate of sacrum fractures was 33%. Neurological deficits occurred in 15.1% of the patients. In contrast to the literature, the rate of neurological deficits was related more to the degree of pelvic instability (TILE) than to the specific fracture pattern in the sacrum. In stable injuries (TILE A) neurological deficits were only seen in exceptions. In type B injuries the maximum rate was 10%, whereas in unstable fractures (TILE C) the rate of neurological deficits was 32.6% in transalar fractures (DENIS zone I), 42.9% in transforaminal fractures (DENIS zone II), and 63.6% in central fracture types (DENIS zone III). Additional risk indicators for neurological impairment are avulsion fractures of the sacrum, comminuted and bilateral fracture lines. The fracture classification should thus be modified. Our own experience with operative therapy for sacral fractures (open revision of the sacral plexus together with internal stabilization of the fracture) is still limited, but based on the experience presented, further development of the treatment protocol for sacrum fractures should be considered.

Pediatric spinal injury: review of 61 deaths

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.

Tracheostomy in spinal cord injured: frequency and follow up

Among 600 traumatic spinal cord injured (SCI) patients admitted during a 20 year period, 67 had a tracheostomy performed (11.2%). Of these 67 patients 46 had a cervical SCI. A concomitant thoracic trauma had occurred significantly more often in the group with thoracic or lumbar SCI than in those with a cervical SCI. The period from injury to tracheostomy was 0-48 days (median 4.4 days), and from tracheostomy to decannulation 3-167 days (median 31 days). At follow up 20 (30%) had died, primarily because of respiratory problems. Of the remaining 47 patients, 43 (91%) responded to a follow up questionnaire 3.5-21.7 years (median 10.4 years) after the injury. In the follow up 53% reported never to have had any inconvenience or trouble related to the tracheostomy. The major inconvenience among the others had been of cosmetic origin (28%), and 3 had had a surgical revision for this reason. At the time of follow up 9 patients (21%) still had certain complaints, primarily described as difficulty in swallowing. Minitracheostomy might in the future reduce the number of these complications.

Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago

Mortality, morbidity, health, functional, and psychosocial outcomes were examined in 834 individuals with long term spinal cord injuries. All were treated at one of two British spinal injury centres: the National Spinal Injuries Centre at Stoke Mandeville Hospital or the Regional Spinal Injuries Centre in Southport; all were 20 or more years post injury. Using life table techniques, median survival time was determined for the overall sample (32 years), and for various subgroups based on level and completeness of injury and age at injury. With the number of renal deaths decreasing over time, the cause of death patterns in the study group as it aged began to approximate those of the general population. Morbidity patterns were found to be associated with age, years post injury, or a combination of these factors, depending upon the particular medical complication examined. A current medical examination of 282 of the survivors revealed significant declines in functional abilities associated with the aging process. Declines with age also were found in measures of handicap and life satisfaction, but three quarters of those interviewed reported generally good health and rated their current quality of life as either good or excellent.

[Clinical rehabilitation of the spinal cord injury patient--is the Guttmann concept still valid?]

The focus of Guttmann's treatment concept had been to set up a comprehensive rehabilitation system, aimed not only at saving the life of a person with paraplegia or tetraplegia but at giving it meaning as well. Progress made in the fields of rescue services, anaesthesia, intensive medicine, in spinal surgery, neurourology and diagnostics (CT, MRI) as well as in pharmacology, have decisively enhanced the possibilities of clinical rehabilitation, and have in some respects entailed deviations from Guttmann's classical treatment principles. Moreover, the patient population has changed in profile in the course of time, due to better chances of survival also in high-level tetraplegia, greater numbers of higher-age SCI patients and of patients with non-traumatic SCI (tumours, metastases, infections). A higher life expectancy achieved by better possibilities as regards prevention and treatment of SCI-related complications, new challenges for the future emanate from age-related diseases occurring in addition to the spinal lesion.

Mortality after spinal cord injury: a four-year prospective study

Research has suggested that mortality after spinal cord injury (SCI) is correlated with lower levels of social and vocational activities and lower life satisfaction. The purpose of this study was to use prospective data from a 1985 SCI follow-up study to identify predictors of survival status four years later. In 1985, responses to the revised Life Situation Questionnaire were obtained from 347 participants with SCI. Survival status was ascertained in 1989; 89% (n = 309) were known to be alive and 6% (n = 22) were deceased. Multivariate ANOVA was used to compare the surviving and deceased participant groups using the 1985 data. Results suggested that survivors had superior adjustment on many of the variables tested in 1985. In particular, the survivors were more active, rated their adjustment as better, were more satisfied with many areas of life, and reported fewer problems (especially with emotional distress). Recent medical history (ie, nonroutine doctor visits and hospitalizations) was not related to survival. This study reaffirms the importance of psychologic, social, and vocational variables as predictors of survival. A call is made for rehabilitation psychologists to address tough issues (eg, substance abuse) and to thoroughly study more specific health behaviors as they relate to survival after SCI.

Prognostic factors for 12-year survival after spinal cord injury

A study of 9,135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury care systems was conducted to determine both overall survival and the effects of prognostic factors. All subjects survived at least 24 hours, and followup ended December 31, 1985. Cumulative 12-year survival was 85.1% (88.2% of normal). Survival ranged from almost 95% (more than 96% of normal) for persons who were younger than 25 years at time of injury and who had neurologically incomplete lesions, to 18.1% (26.9% of normal) for persons who were at least 50 years old at time of injury and who had neurologically complete quadriplegia. Spinal cord injury mortality rates ranged from 1.68 to 15.98 times higher than corresponding rates for non-spinal-injured persons. Although mortality rates for many persons with spinal cord injuries have declined dramatically during the past few decades, these data confirm the continued poor prognosis for older persons with neurologically complete quadriplegia.

The effect of single doses of radiation on mouse spinal cord

We have used a mouse model to study spinal cord injury following single doses (12 to 75 Gy) of radiation. The spinal cord (T9,10-L4,5) of C3Hf/Sed//Kam mice was irradiated and response graded using four levels of neurological change. Findings were: (a) the doses required to paralyze 50% of animals (ED50) were 19.79, 20.77, and 21.85 Gy for mild, partial, and complete paralysis, respectively, as measured 200-360 days after radiation. (b) Most damage was progressive but it was not necessarily so; after doses up to 28 Gy recovery was occasionally seen. (c) Latency depended on the dose and the level of damage. Following doses around the ED50, paralysis occurred between 180 to 300 days. (d) There were significant fluctuations in the dose-latency relationship at doses less than 35 Gy. Latency may be not a reliable endpoint to compare biological effects of radiation in this dose range. (e) The radiosensitivity of mouse spinal cord was similar to that reported for rats. (f) Histologically, demyelination was the dominant lesion in the paralyzed animals. We conclude that the mouse is a good animal model to study radiation damage to the spinal cord, at least when a 2.2 cm length is irradiated.

Prevention of thromboembolism after spinal cord injury

Thromboembolism is a major cause of morbidity and mortality in patients with spinal cord injury. The prevalence of DVT approaches 100%, and 1 to 2% will die of PE. Following injury, there is hypercoagulability as reflected by an increase in von Willebrand factor activity and antigen, and increased platelet reactivity to collagen. Thrombosis usually occurs 1 to 3 weeks after injury, with a peak between days 7 and 9. Intermittent calf compression boots reduce the frequency of thrombosis to 40%, and the addition of aspirin, 300 mg twice daily, and dipyridamole, 75 mg thrice daily, decrease this further to 25%. In an attempt to provide more effective prophylaxis, a further trial was conducted using heparin. Twenty-nine patients were randomized to receive 5000 U subcutaneously every 12 hours and compared with an equal number of patients treated with doses of heparin adjusted to prolong the APTT to 1.5 times control values; the mean dose was 13,200 U every 12 hours. Thromboembolism occurred in 9 (31%) of those on the fixed dose (6 DVT and 3 PE) and only 2 (7%) on the adjusted dose (p less than 0.05); however, 7 (24%) of the patients receiving the higher doses of heparin had bleeding compared with none of those on the fixed dose (p less than 0.02). Most recently, we have compared the safety and effectiveness of a low molecular weight heparin (Logiparin, Novo) with standard heparin. The former was given once daily in a dose of 3500 anti-Xa units, and the latter was 5000 U every 8 hours, both given subcutaneously.(ABSTRACT TRUNCATED AT 250 WORDS)

[Factors increasing life threat in patients with lesions of the spinal cord]

Mortality of spinal cord trauma has been analysed. An analysis included 3,486 patients treated early after spinal trauma in 1965-1989. Life threat in patients, who underwent trauma to the spinal cord embraces several factors. The most important is are: the level and degree of the lesion to the spinal cord, certain causes precipitating severe lesions to the nervous system, advanced age, and--to some degree--accompanying lesions, way of therapy, advances in medical technology, and intensive treatment technics. Available data indicate that the life of patients admitted to the hospital with symptoms of complete interruption of the cervical segment of the spinal cord is threatened to the highest degree. Falls from heights (scaffolding, roofs etc.), and certain road accidents are particularly dangerous. A special group of accidents is fall from the horse carriage in which advanced age of the victims plays the most important role. Mortality rate in the elderly is about tenfold higher, than in the group of subjects under 20 years with the same degree of lesions to the spine.

Effect of dosage and timing of administration of naloxone on outcome in the rat ventral compression model of spinal cord injury

The effect of the dosage and timing of administration of naloxone after spinal cord injury in rats via the ventral compression technique is presented. The rat ventral compression technique allows for a ventral compression of the spinal cord without the requirement of a previous laminectomy. It therefore facilitates the creation of an experimental lesion that is similar to that observed in the human clinicopathological situation. The first part of the two-part study presented herein involved the determination of the optimal dose of naloxone, administered intraperitoneally 45 minutes after the creation of the lesion. Of the groups studied (control group through 10.0 mg/kg group), 2.0 mg/kg of naloxone proved to be superior to both lesser and greater dosages. The second part of the study involved the administration of a 2.0 mg/kg dose of naloxone at varying intervals ranging from 10 minutes before lesioning to 24 hours after lesioning. A multiphasic response was again demonstrated, with an optimal time of administration occurring 45 minutes after the creation of the lesion. A significant effect was offered by a midrange dose of naloxone (2.0 mg/kg), administered at 45 minutes after injury (P less than 0.02 by analysis of variance and Duncan's multiple range test). These findings are discussed with respect to recent evidence regarding the effects of narcotic antagonists on both mu and kappa narcotic receptors. Past and future experiments must account for these responses to multiphasic dosage and timing of administration. Failure to do so may lead to erroneous conclusions.

Initial factors predicting functional performance in patients with traumatic tetraplegia

The authors present a prospective analysis of the functional outcome in 99 patients with traumatic tetraplegia consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 29% death rate. Eighteen months after injury, 33% of the patients were dependent (not able to perform activities of daily living without the presence of a helping individual), 38% were independent. Two predictors of independence (age and initial Yale Scale Score) were found by a statistical analysis of the course of the disorder.

Falls resulting in spinal cord injury: patterns and outcomes in an older population

Falls are the major cause of spinal cord injuries in older people. The pattern of injury seen most frequently is that of a central cord syndrome due to cervical hyperextension. The medical records of 58 patients over 50 years of age who sustained a spinal cord injury in a fall were reviewed for circumstances of onset, length of stay and outcomes of rehabilitation. The study identified elderly single or widowed men, and those who use alcohol, as high risk groups.

Cause of death for patients with spinal cord injuries

An epidemiologic study of 5131 patients sustaining spinal cord injuries between 1973 and 1980 was conducted to determine and characterize the leading causes of death in this population. Patients who were studied had been admitted to one of seven federally designated regional spinal cord injury care systems and they survived for at least 24 hours after injury. When follow-up was terminated, 459 patients (9%) had died. Overall, the leading cause of death was pneumonia, followed by other subsequent unintentional injuries and suicides. The highest ratios of actual to expected deaths were for septicemia, pulmonary emboli, and pneumonia. Pneumonia was the leading cause of death among quadriplegics and persons at least 55 years of age, while among paraplegics and persons who were less than 55 years of age, subsequent unintentional injuries and suicides were the leading causes of death. While there is conclusive evidence that mortality rates for spinal-cord injured persons have declined dramatically since the end of World War II, many cause-specific mortality rates remain substantially above normal.

Microangiographic study of spinal cord injury and myelopathy

Post-mortem microangiography has been performed in 12 patients with traumatic cervical cord injury, 2 patients with myelopathy, and one patient with post-traumatic syringomyelia. Microangiography defined 4 zones in the injured spinal cord. In traumatic injury, the size and extent of the non-filling area (Zone 1) was directly related to the injury force. Subsequently these areas became cavitated. Surrounding the non-filling area, widely extending areas demonstrated filling of capillaries but showed damaged neurons and axons (Zone 2). In the chronic stage, Zone 2 replaced by gliomesenchymal tissue. The capillaries in the gliomesenchymal scars revealed a distorted abnormal arrangement (Zone 3). In a case with myelopathy, the hypervascular areas (Zone 4) were observed just around the chronically compressed area. The vascular increases were considered to be a reaction against chronic compression. In a patient with post-traumatic syringomyelia, the vascular network of the posterior grey matter disappeared and the central arteries were distorted by the distending forces of the syrinx. The microangiographs suggested that vascular factors might play a significant role in original cavity formation; but in cavity extension, these factors were not primary.

A prospective study on acute spinal injuries

This work examines demographic and clinical characteristics of 163 consecutive cases of acute spinal injuries in a small area of Western Turkey, since 1982. These include all spinal injuries with or without neurological symptoms. Combined conservative and surgical methods were used for treatment. Age, sex, etiology, site of injury, radiologic findings, neurological status, and outcome are compared with the other studies. The results have been found to be parallel to those of the other studies except for some regional differences like an excess of tractor accidents.