Spinal cord lesions in Bangladesh: an epidemiological study 1994 - 1995

In-hospital mortality rate in subaxial cervical spinal cord injury patients: a systematic review and meta-analysis

PURPOSE

To determine existing trends concerning in-hospital mortality in patients with traumatic subaxial cervical spinal cord injury (SCI) over the last four decades.

METHODS

We searched MEDLINE and EMBASE to assess the role of the following factors on in-hospital mortality over the last four decades: neurological deficit, age, surgical decompression, use of computed tomography (CT) and magnetic resonance imaging (MRI), use of methylprednisolone in the acute post-injury period, and study location (developing versus developed countries).

RESULTS

Among 3333 papers after deduplication, 21 studies met the eligibility criteria. The mortality rate was 17.88% [95% confidence interval (CI): 12.9-22.87%]. No significant trend in mortality rate was observed over the 42-year period (meta-regression coefficient = 0.317; p = 0.372). Subgroup analysis revealed no significant association between acute subaxial cervical SCI-related mortality when stratified by use of surgery, administration of methylprednisolone, use of MRI and CT imaging, study design (prospective versus retrospective study), and study location. The mortality rate was significantly higher in complete SCI (20.66%, p = 0.002) and American Spinal Injury Association impairment scale (AIS) A (20.57%) and B (9.28%) (p = 0.028).

CONCLUSION

A very low level of evidence showed that in-hospital mortality in patients with traumatic subaxial cervical SCI did not decrease over the last four decades despite diagnostic and therapeutic advancements. The overall acute mortality rate following subaxial cervical SCI is 17.88%. We recommend reporting a stratified mortality rate according to key factors such as treatment paradigms, age, and severity of injury in future studies.

The consequence of head-loading on the neuro-musculoskeletal health of the ILembe District youth of KwaZulu-Natal

Background

Head-loading, as a mode of transporting food, water and firewood, is a longstanding tradition assigned to female South African youth and has been associated with adverse health consequences.

Objectives

This study determined the impact of head-loading on the neuromusculoskeletal health and proprioception of female South African youth.

Method

This study comprised a counterbalanced, within-subject, single-factor experimental design which compared the changes that occurred when the same independent variable (head-loading) within two homogenous groups was measured in terms of the dependent variables (outcomes: neuromusculoskeletal pain and proprioception) at two time periods, before and after the introduction of the independent variable. A cohort of South African female youth (n = 100), aged 9-17 years, voluntarily partook in the study. The participants were randomly distributed into an experimental (n = 50) and a control (n = 50) group. The experimental group stood in a head-loaded state with their respective habitual head-load mass. Their proprioception measurements were compared during their unloaded versus loaded states, with the proprioceptive measurements including the total proprioception index, the anterior-posterior (front-back) index and the medial-lateral (side-to-side) index. Participants furthermore completed a head-loading health-related questionnaire.

Results

Participants had a mean age of 12.3 ± 2.5 years, body mass of 44.4 ± 13.7 kg, stature of 145 ± 10 cm and a head-load mass of 8.0 ± 2.5 kg. Participants had poorer medial-lateral proprioception during head-loading as compared to their unloaded state (1.4 ± 0.8 as compared to 1.6 ± 0.9) (p < 0.05). Most youth (96%) experienced neuromusculoskeletal pain in their cervical vertebrae (40.9%), shoulders (27.3%), lumbar vertebrae (10.7%), arms (8.3%), legs (8.3%), knees (1.9%), fingers (1.5%), toes (0.5%) and thoracic vertebrae (0.5%) (χ²: p < 0.05).

Conclusion

Head-loading adversely affects the medial-lateral proprioception and neuromusculoskeletal health of participants.

Contribution

The findings of this study confirms that head-loading produces musculoskeletal pain.

Current status of traumatic spinal cord injury caused by traffic accident in Northern China

The study aims to investigate the characteristics of traumatic spinal cord injury (TSCI) caused by motor vehicle collisions (MVCs). The study included 649 cases who experienced MVC-induced TSCI. The mean age was 37.3 years old, ranging from 1 to 82 years old. The male-to-female ratio was 2.7:1. We extracted data of gender, age, occupation, neurological level of injury, fracture level, complications, vehicle type, accident type and other features. The results showed that the most common vehicles involved in accidents were passenger cars (65.1%). Collision was the leading cause of MVCs (35.8%). The lesion level was cervical in 51.6% and thoracic in 42.2%. The most common fracture levels in drivers and passengers were C3–C7, while those in pedestrians were T11–L2. The frequency of tetraplegia (51.6%) was slightly higher than paraplegia (48.4%), and cases with tetraplegia with incomplete injury accounted for 61.2%. MVC-induced TSCI has unique clinical features. Collision was the most common cause. People sitting in cars were more likely to suffer from cervical fractures, while thoracolumbar fractures were more common in pedestrians. Tetraplegic cases were mainly incomplete injuries, while paraplegic cases were mainly complete injuries.

Knowledge, Attitudes, Behavioural Practises, and Psychological Impact Relating to COVID-19 Among People Living With Spinal Cord Injury During In-Patient Rehabilitation in Bangladesh

Aim

The aim of this research is to focus on gaining an insight into the knowledge, attitudes, behavioural practises (KAP), and psychological impact relating to COVID-19 among the people living with spinal cord injury receiving in-patient rehabilitation.

Methods

A prospective, cross-sectional survey of people with SCI (N = 207), who were in active in-patient rehabilitation from two tertiary SCI Rehabilitation Centres in Bangladesh. Data were collected via face-to-face interviews, after voluntary consent, using a pretested, language validated questionnaire on Knowledge, Attitude and Behavioural practises (KAP) and the Depression, Anxiety, Stress Scale (DASS-21). Ethical approval and trial registration were obtained prospectively.

Results

A total of 207 people with SCI responded, among which 87% were men and 13% were women, with a mean age of 34.18 ± 12.9 years. Within the sample group, people living with tetraplegia comprised 33.8%, and people living with paraplegia comprised 66.2%. Overall, 63.8% of the participants were diagnosed with an SCI categorised as ASIA-A. Overall, the “knowledge score” was 8.59 ± 2.3 out of 12, “depression” was 11.18 ± 8, “anxiety” was 7.72 ± 5.1, and “stress” was 9.32 ± 6.7 from a total of 21 scores each category. The strong correlation was between knowledge, DASS scores, and age (p < 0.05). In addition, there was a strong correlation between knowledge, gender (p < 0.05) and education (p < 0.01). Binary logistic regression found a stronger association of knowledge and DASS scores with gender, young age, illiteracy (p < 0.01), and rural residence (p < 0.05). A positive relationship was found between depression and anxiety scores (p < 0.01) and a moderate positive relationship was found between depression and stress scores (p < 0.01). A positive attitude was reported by the majority of participants (p < 0.05). In terms of behavioural practises, participants reported both self and caregiver had followed health advice with regard to consulting health professionals (65.7%), implementing isolation (63.8%), taking droplet precaution care (87.4%), and hygiene care (90.3%).

Conclusion

Participants in this study reported high levels of knowledge, adoption of positive attitudes, and the practise of positive health advisory behaviours related to COVID-19 prevention procedures. However, high levels of depression, anxiety, and stress were also reported. Overall, women and younger participants were more likely to have high KAP, whereas those living in rural areas and with literacy challenges were less likely to report high knowledge scores.

Clinical and sociodemographic profiles of persons with spinal cord injury

AIM

To collect and correlate the sociodemographic and clinical details of persons with spinal cord injury who were admitted to the Department of Neurological Rehabilitation.

OBJECTIVES

To assess the sociodemographic characteristics and collect the clinical profiles of persons with spinal cord injury and to correlate their sociodemographic and clinical details.

MATERIALS AND METHODS

A retrospective file review was done over a period of 2 years from January 2017 to December 2018 to study patients with spinal cord injury who were admitted to the Neurological Rehabilitation ward of NIMHANS, Bengaluru, Karnataka, India.

RESULTS

A total of 60 patients were admitted with spinal cord injury. The mean age was 32.39 years and majority of the patients were young married males. Most of them belong to the low socioeconomic status and are housewives and daily wage laborers. Falls and road traffic accidents are the causes for the injury. Anxiety and depression are high among traumatic spinal cord injury patients.

CONCLUSION

This information may contribute to prevent SCI and to improve the quality of life of patients with SCI. It has implications for the primary care physicians who are at first contact to identify and refer them for specialized super speciality district hospitals for further treatment as they pose a great threat to public health and their proportions are increasing. It is imperative that trauma care is included in graduate medical training as well to facilitate early intervention after initial screening.

The demographics and traumatic causes of spinal cord injury in Nepal: An observational study

Introduction

There has been little systematic study of the epidemiology of traumatic spinal cord injury (TSCI) in Nepal, South-East Asia, and low- and middle-income countries (LMICs) in general. One third of the global morbidity and mortality due to injuries is concentrated in South-East Asia. We need to better understand the circumstances leading to TSCI if we are to make progress with prevention.

Method

The Spinal Injury Rehabilitation Centre (SIRC) in Nepal systemically collected prospective data describing people with TSCI admitted between September 2015 and August 2016. Descriptive analyses of variables yielded demographic, aetiological and clinical descriptors of this cohort. Cross-tabulations were used to explore the associations between variables.

Results

Of 184 admissions over one year, males were admitted to SIRC almost 2.3 times more often than females. Young adults (21–30 years) were the largest age group (34%). The majority of TSCI resulted in paraplegia (67%) and was complete in nearly half (49%). Falls caused the majority of TSCI (69%), and falls from trees were the most common. Road traffic injuries (RTIs) were the second leading cause (29%); the majority involved two- or three-wheeled motorised vehicles and patients were most commonly driving.

Conclusion

Falls were the leading cause of TSCI across both genders and all age groups, followed by RTIs, which occurred most often in young adults and men. Injury surveillance and further research would provide a greater understanding of the pattern of TSCI and enable progress in TSCI prevention and rehabilitation.

Surgery for Spinal Trauma: Early Days at a Young Institution in a Hilly State

Background Spinal trauma is associated with significant morbidity and affects the overall quality of life of the patient as well as their family. The aim of this study was to study the epidemiology, in-hospital outcome, and follow-up of patients undergoing surgery for spinal trauma.

Methods All patients who underwent surgery for spinal trauma at the Department of Neurosurgery between June 2016 and October 2019 were studied retrospectively. Data collected from patient record included demographic profile, mode of injury, level of injury, neurological status at admission, time from injury to operative intervention, hospital stay, neurological outcome at discharge, and follow-up. Postoperative computed tomography scans were done in all patients to check for adequacy of screw placement.

Results A total of 70 patients (45 males, 25 females) with a mean age of 36 years (range: 16–65 years) were operated for spinal injuries at our department during the study period. Fall was the most common mode of injury (77.1%), followed by road traffic accident (28.5%). Most common site of injury was lumbar spine (38.6%), followed by dorsal (32.9%) and cervical (28.5%). Out of the total, 27.1% of our patients were American Spinal Injury Association (ASIA) grade A at presentation whereas 18.6% were ASIA E. Remaining 54.3% patients had incomplete injuries (ASIA B, C, and D). Burst fracture was the most common morphology of injury (60%), followed by translational injuries (30%). Mean duration between injury and operative intervention was 20.8 days. The mean duration of hospital stay was 21.4 days (range: 8–90 days). Six patients expired during hospitalization. All these six cases had cervical spinal injury. One patient of dorsal spine injury with a complete neurological injury expired 6 months after discharge from the hospital (cause unknown). Nine of our cases showed neurological improvement on follow-up and in rest of the patients, neurological status remained same as preoperative status.

Conclusion Neurological status at admission (ASIA grade) and level of injury remain the most important predictor of the outcome. Spinal injury patients must be managed with a holistic and multidisciplinary approach. Rehabilitation is important for helping these patients in leading a productive life.

Loss of work-related income impoverishes people with SCI and their families in Bangladesh

Study design

Cross-sectional study.

Objectives

To determine the degree of impoverishment of people with spinal cord injury (SCI) and their families in Bangladesh caused by loss of work-related income following injury.

Setting

Spinal cord injury centre, Bangladesh.

Methods

A total of 410 wheelchair-dependent people with recent SCI about to be discharged from a hospital in Bangladesh were interviewed to determine the size of their families, their incomes from paid work prior to injury and the incomes of their family members. These data were used to calculate income per family unit and per family member prior to and immediately after injury.

Results

Ninety percent of the participants were men, 98% were from rural areas of Bangladesh and 58% were manual labours prior to injury. Median (interquartile range, IQR) family size was 5 (4–6) people. Prior to injury, 74% of participants were the main income earners for their families and 50% provided the only source of income for their families. Participants’ median (IQR) monthly income prior to injury was US$106 (US$60–US$180) per person and family members’ income was US$30 (US$19–US$48) per person. After injury, the median income (IQR) of each family member dropped to US$0 (US$0–US$18) placing 91% of families below the extreme poverty line of US$37.50 per person per month (equivalent to US$1.25 per day).

Conclusion

In Bangladesh, SCI have profound financial implications for individuals and their families and causes extreme poverty. This is because those most often injured are young and the main income earners for their families.

Descriptive epidemiology of traumatic spinal injury in Japan

BACKGROUND

Spine injury epidemiology in Japan has not been studied since the 1990s when its incidence was 39.4-40.2 per million and the major cause of injury was motor vehicle crashes. We elucidate the current epidemiological state of spinal injury and spinal injury patients in Japan for the clinicians and public health prevention programs.

METHODS

Spine injury patients were retrospectively selected from the Japan Trauma Data Bank (JTDB) from 2004 to 2013 for all ages and all spinal injuries. The Abbreviated Injury Scale codes (AIS98) were translated into injuries. The dataset was contributed by 241 hospitals nationwide. The data was analysed for the causes of spinal injury, injury severity, age, gender differences, injury types, survival, anatomic location, circumstances of injury and medical history.

RESULTS

A total of 25,792 (M, 70.1%, F, 29.9%, mean age: 53.4 years) spinal injury patients were recorded in the JTDB from 2004 to 2013, when multiple injuries were included the number of cases swelled to 33,892 (M, 70.4%, F, 29.6%). The number of patients with spinal injuries as a percentage of all traumatic patients in the JTDB was observed to increase from 2004 (15.4%) to 2013 (17.6%). The aetiology of the injuries was mostly falls (52.4%) and motor vehicle crashes (39.8%). Most injuries occurred at the cervical spine level (49.7%). Medical histories of cardiovascular diseases were found, due mostly to hypertension (19.6%). In total, most of the injuries were associated with fractures (64.8%) and others (30.7%) involved the spinal cord. Suicides (12.0%) and industrial accidents (9.0%) caused spine injury were uniquely prevalent in the population.

CONCLUSION

The number of spine injuries has increased in the JTDB between 2004 and 2013. Motor vehicle crashes have been replaced by falls due to various causes as the leading cause of spine injury. Suicides and industrial accidents are becoming a burden. More studies are needed to verify the actual incidence.

Incidence of acute spinal cord injury in the Czech Republic: a prospective epidemiological study 2006-2015

STUDY DESIGN

A prospective study.

OBJECTIVES

Analysis of epidemiological data about acute spinal cord injury (SCI) in the Czech Republic over a period of 10 years (2006-2015).

METHODS

A data collection system was implemented in the rehabilitation centres which provides care to patients with acute SCI in the Czech Republic. The recorded variables are as follows: age at time of SCI; gender; cause of injury; neurological level of injury (NLI); and its severity (ASIA Impairment Scale (AIS)). Data from 2006 to 2015 were analysed and trends were determined.

RESULTS

The overall number of acute SCI ranges between 250 and 300 cases annually. Two-third of the affected population are males. The average age at time of SCI is 49.1 years. The average incidence of traumatic SCI is 15.5 cases per year and is gradually decreasing. The leading cause of SCI are falls (44.5%), followed by traffic accidents (28.2%) and sports injuries including diving into water (19.7%). The incidence of non-traumatic SCI is 8.6 cases per year on average and has an upward trend. Inflammatory lesions account for 26.7% of cases, tumours account for 20.9%, and vascular related injuries make up 17.7%. The NLI occurs most often in the cervical segments (45.3%). The most frequently occurring lesions are motor incomplete: AIS D (33.3%).

CONCLUSION

This study shows a stable occurrence of SCI in the Czech Republic, with cervical and motor incomplete cases being the leading ones. Epidemiological data are needed to improve the care of SCI patients and to promote an active life following it.

Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge

STUDY DESIGN

Prospective follow-up study.

OBJECTIVES

To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers.

SETTING

The national referral hospital in Gaborone, Botswana.

METHODS

The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics.

RESULTS

Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care.

CONCLUSIONS

Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.

Epidemiological study of traumatic spinal cord injuries: experience from a specialized spine center in Iran

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

This study was performed for epidemiological assessment of Iranian Traumatic Spinal Cord Injuries (TSCI), referred to a specialized spine center.

SETTING

Patient recruitment and evaluations were conducted at the Brain and Spinal Injury Research Center, Tehran, Iran.

METHODS

This study was performed from September 2011 to March 2015 on 1137 consecutive TSCIs. History, clinicoradiological findings as well as chronic complications and social integration were recorded. The capture-recapture method was used to calculate a rough estimation of TSCI prevalence in Tehran Province.

RESULTS

Our report includes 1137 cases with a mean age of 29.1 years (s.d.=11.2 year)-79.2% of them being male (M/F=3.8/1). Rough estimation of TSCI prevalence in Tehran province was 2.36 per 10 000 population. Regarding etiology, 61.8% were due to motor vehicle accident (MVA), followed by falling 24.5%, heavy drop 5.2%, violence 3.8%, sport 2.8% and others causes 1.9%. Regarding injury level, 31.5% were cervical, 57.9% thoracic and 10.6% lumbar. Complete lesions were 53.5% of patients and 46.5% were incomplete. Most common neurological type was T1-S5 (American Spinal Injury Association Impairment Scale: A, B, C, 61.7%). Most common complications included urinary tract infection followed by pressure sore (grade III and IV, 37.5%), autonomic dysreflexia (37%) and neuropathic pain (31.2%). Substance abuse was observed in 8.8% of cases. Overall, ~25% in our cases were employed after TSCI. Secondary divorce was also much more frequent than normal matched controls.

CONCLUSION

MVA was the most common cause for TSCI. The elderly subjects were less frequent among our patients than more developed countries. The high rate of unemployment and divorce in our cases deserves special consideration.

Effectiveness and cost-effectiveness of telephone-based support versus usual care for treatment of pressure ulcers in people with spinal cord injury in low-income and middle-income countries: study protocol for a 12-week randomised controlled trial

INTRODUCTION

Pressure ulcers are a common and severe complication of spinal cord injury, particularly in low-income and middle-income countries where people often need to manage pressure ulcers alone and at home. Telephone-based support may help people in these situations to manage their pressure ulcers. The aim of this study is to determine the effectiveness and cost-effectiveness of telephone-based support to help people with spinal cord injury manage pressure ulcers at home in India and Bangladesh.

METHODS AND ANALYSIS

A multicentre (3 sites), prospective, assessor-blinded, parallel, randomised controlled trial will be undertaken. 120 participants with pressure ulcers on the sacrum, ischial tuberosity or greater trochanter of the femur secondary to spinal cord injury will be randomly assigned to a Control or Intervention group. Participants in the Control group will receive usual community care. That is, they will manage their pressure ulcers on their own at home but will be free to access whatever healthcare support they can. Participants in the Intervention group will also manage their pressure ulcers at home and will also be free to access whatever healthcare support they can, but in addition they will receive weekly telephone-based support and advice for 12 weeks (15-25 min/week). The primary outcome is the size of the pressure ulcer at 12 weeks. 13 secondary outcomes will be measured reflecting other aspects of pressure ulcer resolution, depression, quality of life, participation and satisfaction with healthcare provision. An economic evaluation will be run in parallel and will include a cost-effectiveness and a cost-utility analysis.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Ethics Committee at each site. The results of this study will be disseminated through publications and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12613001225707.

Evaluation of spinal cord injury animal models

Because there is no curative treatment for spinal cord injury, establishing an ideal animal model is important to identify injury mechanisms and develop therapies for individuals suffering from spinal cord injuries. In this article, we systematically review and analyze various kinds of animal models of spinal cord injury and assess their advantages and disadvantages for further studies.

Spinal cord injury: scenario in an Indian state

STUDY DESIGN

Prospective observational study.

OBJECTIVES

To find out the epidemiology and demographic factors associated with patients of traumatic spinal cord injury (SCI).

SETTING

Sawai Man Singh Medical College and Hospital, Jaipur, India.

METHODS

Consecutive SCI cases admitted from January 2000 to December 2008 were evaluated on a preformed proforma for demographic factors, epidemiological data and neurological status.

RESULTS

In 2716 cases of SCI, 1400 were cervical and 1316 thoracolumbar, with male to female ratio of 4.2:1 and 71% in the age group of 20-49 years. Around 79% patients were from rural background. About 23.3% were farmers while 22.9% were laborers. Among the causes of injury, 53% patients had a fall from height and 28% suffered from road traffic accidents. Fall of heavy object over head and back (10.7%), fall with heavy object over head (3.0%) and fall following electric shock (4.0%) were uncommon causes. Complete paralysis was found in 20.5% cervical and 23.3% in thoracic injuries. Extremity and rib fractures (10.6%) and head injuries (7.2%) were common associated injuries. About 55% cases were initially attended at non-specialized centers. Proper bladder and bowel management in early phase was lacking.

CONCLUSION

Epidemiological factors of SCI in Indian scenario are different from western countries with major cause being fall. The low socio-economic status and younger age group had a major financial, social and psychological impact as majority of the patients were the primary earning members of the family. Therefore, measures should be taken to reduce the incidence of SCI.

Surviving spinal cord injury in low income countries

BACKGROUND

Mortality rates from injuries are higher for people from poorer economic backgrounds than those with higher incomes (according to the World Health Organization [WHO]), and health care professionals and organisations dealing with people with disabilities experience that individuals with spinal cord injury (SCI) in low income countries face serious challenges in their daily lives.

OBJECTIVES

The aims of this study were to explore life expectancy (life expectancy is the average remaining years of life of an individual) and the situation of persons living with SCI in low income settings.

METHOD

Literature studies and qualitative methods were used. Qualitative data was collected through semi-structured interviews with 23 informants from four study sites in Zimbabwe representing persons with SCI, their relatives and rehabilitation professionals.

RESULTS

There are few publications available about life expectancy and the daily life of persons with SCI in low income countries. Those few publications identified and the study findings confirm that individuals with SCI are experiencing a high occurrence of pressure sores and urinary tract infections leading to unnecessary suffering, often causing premature death. Pain and depression are frequently reported and stigma and negative attitudes are experienced in society. Lack of appropriate wheelchairs and services, limited knowledge about SCI amongst health care staff, limited access to health care and rehabilitation services, loss of employment and lack of financial resources worsen the daily challenges.

CONCLUSION

The study indicates that life expectancy for individuals with SCI in low income settings is shorter than for the average population and also with respect to individuals with SCI in high income countries. Poverty worsened the situation for individuals with SCI, creating barriers that increase the risk of contracting harmful pressure sores and infections leading to premature death. Further explorations on mortality and how individuals with SCI and their families in low income settings are coping in their daily life are required to provide comprehensive evidences.

The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate

STUDY DESIGN

Literature review.

OBJECTIVES

Update the global maps for traumatic spinal cord injury (TSCI) and incorporate methods for extrapolating incidence data.

SETTING

An initiative of the International Spinal Cord Society (ISCoS) Prevention Committee.

METHODS

A search of Medline/Embase was performed (1959-Jun/30/2011). Enhancement of data-quality 'zones' including individual data-ranking as well as integrating regression techniques to provide a platform for continued regional and global estimates.

RESULTS

A global-incident rate (2007) is estimated at 23 TSCI cases per million (179,312 cases per annum). Regional data are available from North America (40 per million), Western Europe (16 per million) and Australia (15 per million). Extrapolated regional data are available for Asia-Central (25 per million), Asia-South (21 per million), Caribbean (19 per million), Latin America, Andean (19 per million), Latin America, Central (24 per million), Latin America-Southern (25 per million), Sub-Saharan Africa-Central (29 per million), Sub-Saharan Africa-East (21 per million).

DISCUSSION

It is estimated that globally in 2007, there would have been between 133 and 226 thousand incident cases of TSCI from accidents and violence. The proportion of TSCI from land transport is decreasing/stable in developed but increasing in developing countries due to trends in transport mode (transition to motorised transport), poor infrastructure and regulatory challenges. TSCIs from low falls in the elderly are increasing in developed countries with ageing populations. In some developing countries low falls, resulting in TSCI occur while carrying heavy loads on the head in young people. In developing countries high-falls feature, commonly from trees, balconies, flat roofs and construction sites. TSCI is also due to crush-injuries, diving and violence.

CONCLUSION

The online global maps now inform an extrapolative statistical model, which estimates incidence for areas with insufficient TSCI data. The accuracy of this methodology will be improved through the use of prospective, standardised-data registries.

The prevalence and impact of age and gender on rehabilitation outcomes in spinal cord injury in India: a retrospective pilot study

STUDY DESIGN

Retrospective, 1 year case series.

OBJECTIVES

To analyze the relationship between gender, age, injury-related variables and rehabilitation outcomes in patients with spinal cord injury (SCI).

SETTING

Tertiary Rehabilitation Center, Inpatient rehabilitation unit, India.

METHODS

The data from a series of SCI cases were analyzed. Each case was followed from admission into the hospital until their discharge. Patients were described according to age, gender, etiology of SCI, neurological classification, medical complications, American spinal injury association (ASIA) classification, length of rehabilitation stay and spinal cord independence measure (SCIM).

RESULTS

Forty-seven new SCI cases, 37 (78.7%) male and 10 (21.3%) female patients, were reported over a 1-year period during 2009-2010. Male patients were younger than the female ones, but the difference was not statistically significant. There was no statistically significant relationship between age or gender, and the following SCI variables: ASIA classification, neurological classification, SCI complications and length of stay (P>0.05). Traumatic etiology and Pott's disease was found be related with gender (P<0.05). There was no statistically significant relationship between age or gender and SCIM score at admission or discharge (P>0.05).

CONCLUSION

Age and gender are not significantly related to outcomes of rehabilitation or characteristics of SCI in this sample. Further research is needed to confirm the generalizability of these findings and to identify which factors contribute more strongly to SCI rehabilitation outcomes.

Against all odds: a qualitative study of rehabilitation of persons with spinal cord injury in Afghanistan

STUDY DESIGN

Cross-sectional, survey.

OBJECTIVES

To describe the challenges in rehabilitating patients with spinal cord injury in the orthopaedic centres of the International Committee of the Red Cross in Afghanistan.

SETTING

Afghanistan (Kabul, Herat, Mazar-i-Sharif, Jalalabad, Gulbahar), April 2012.

METHODS

Semi-structured interviews were conducted with managers and professional staff of ICRC and other concerned organizations/institutions (Ministries, hospitals, non-governmental organizations), and with people with SCI and their families. Quantitative data were extracted from routine statistics.

RESULTS

A reported annual incidence of roughly 21 SCI cases per million in Afghanistan could be established for the year 2011. Acts of violence were the most frequent cause, followed by spinal tuberculosis. Despite very elementary prehospital and hospital care, SCI individuals are rehabilitated within the limits set by available technology and socio-economic factors. Support to community reintegration is effective for the ones living within a radius determined by distance and security.

CONCLUSION

Rehabilitation of SCI patients would be ineffective without covering at least part of the services usually provided during the phases of acute hospital care and community reintegration. The question of whether services currently provided by foreign-based or funded organizations can be extended into a potential postconflict period, and by whom, remains open.

Bladder management of patients with spinal cord injuries sustained in the 2008 Wenchuan earthquake

This study's aim is provide an overview of the patients who suffered spinal cord injury (SCI) after the magnitude 8.0 Wenchuan earthquake, including each patient's demographic and epidemiological characteristics, bladder management status, and quality of life (QOL). We also assessed the relationships between bladder management methods, symptomatic urinary tract infection (SUTI), and QOL. Two years after the 2008 Wenchuan earthquake, a cross-sectional face-to-face survey was conducted on 180 patients with SCI. A self-administered questionnaire and the WHOQOL-BREF assessment were used to assess injury-related information, bladder management methods, and SUTI. Statistical analysis was performed using the Chi-square test and analysis of variance. A p value <0.05 was considered statistically significant. This study found that a male-to-female ratio of approximately 1.2:1, including 98 (54.4%) male patients and 82 (45.6%) female patients. Thoracic-level injuries were seen in 82 patients (45.56%), 60 (33.33%) patients had lumbar-level injuries, 18 (8.33%) patients had thoracolumbar-level injuries, and a small number of patients had cervical- or sacral-level injuries. Sixty-two patients (34.44%) demonstrated normal voiding, 65 (36.11%) required manually assisted voiding, 29 (16.11%) required catheterization, and 24 (13.33%) used aurine-collecting apparatus. The prevalence of SUTI was 43.89%. Patients who emptied their bladder via manually assisted voiding, catheterization, or with the use of a urine-collecting apparatus demonstrated higher rates of SUTI compared with patients who voided normally (p < 0.05); the patients who required catheterization had higher rates of SUTI compared with patients who required manually assisted voiding (p < 0.05). When manually assisted voiding and catheterization were compared with the use a urine-collecting apparatus, no statistically significant differences were observed in terms of the risk of developing SUTI. The patients in this study demonstrated low scores on the WHOQOL-BREF physical domain (11.61 ± 3.80), psychological domain (10.11 ± 3.63), social domain (11.46 ± 2.84), and environmental domain (11.86 ± 2.51). The patients who reported normal voiding also demonstrated the best QOL in terms of physical, psychological, and social component scores (p < 0.05). In conclusion, the percentage of women in this study is higher than that reported in other studies on traumatic causes of SCI. Patients who suffered SCI following the Wenchuan earthquake demonstrate poor bladder management status and are unable to take advantage of urodynamic testing that is used to monitor the functional state of the bladder. This study's findings indicate that bladder management methods influence the rate of SUTI and the QOL of patients with SCI. Caring for SCI patients following a disaster requires comprehensive long-term planning. Bladder management of patients with SCI is essential for improving the QOL of these patients.

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.

Traumatic spinal cord injuries--incidence, mechanisms and course

BACKGROUND

The primary purpose of this article is to provide an overview of demography, neurological level of injury, extent of lesion, incidence, prevalence, injury mechanisms as well as lethality and causes of death associated with traumatic spinal cord injuries.

MATERIAL AND METHOD

A literature search was carried out in PubMed, with the search words "traumatic spinal cord injury"/"traumatic spinal cord injuries" together with "epidemiology", and "spinal cord injury"/"spinal cord injuries" together with "epidemiology".

RESULTS

The reported annual incidence of traumatic spinal cord injuries varies from 2.3 per million in a study from Canada to 83 per million in Alaska. The prevalence is given as ranging from 236 per million in India to 1800 per million in the USA. The average age at the time of injury varies from 26.8 years in Turkey to 55.5 years in the USA. The ratio of men to women varies from 0.9 in Taiwan to 12.0 in Nigeria. The most frequent cause of injury is traffic accidents, followed by falls, violence and sports/leisure activity incidents. Patients with traumatic spinal cord injuries have a higher lethality than the normal population. The most frequent causes of death today are airway problems, heart disease and suicide.

INTERPRETATION

There are large geographical differences in reported incidence, prevalence and lethality. This is attributable to differences in definition, inclusion, classification and patient identification procedures in the various studies, together with geographical and cultural differences and differences in prehospital and hospital treatment.

Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan

Background:

Surgical stabilization of injured spine in patients with complete spinal cord injury is a common practice despite the lack of strong evidence supporting it. The aim of this study is to compare clinical outcomes and cost-effectiveness of surgical stabilization versus conservative management of spinal injury in patients with complete deficits, essentially from a developing country's point of view.

Methods:

A detailed analysis of patients with traumatic spine injury and complete deficits admitted at the Aga Khan University Hospital, Pakistan, from January 2004 till January 2010 was carried out. All patients presenting within 14 days of injury were divided in two groups, those who underwent stabilization procedures and those who were managed non-operatively. The two groups were compared with the endpoints being time to rehabilitation, length of hospital stay, 30 day morbidity/mortality, cost of treatment, and status at follow up.

Results:

Fifty-four patients fulfilled the inclusion criteria and half of these were operated. On comparing endpoints, patients in the operative group took longer time to rehabilitation (P-value = 0.002); had longer hospital stay (P-value = 0.006) which included longer length of stay in special care unit (P-value = 0.002) as well as intensive care unit (P-value = 0.004); and were associated with more complications, especially those related to infections (P-value = 0.002). The mean cost of treatment was also significantly higher in the operative group (USD 6,500) as compared to non-operative group (USD 1490) (P-value < 0.001).

Conclusion:

We recommend that patients with complete SCI should be managed non-operatively with a provision of surgery only if their rehabilitation is impeded due to pain or deformity.

Non-traumatic myelopathy at the Chris Hani Baragwanath Hospital, South Africa--the influence of HIV

BACKGROUND

Non-traumatic myelopathy from developing regions has been described widely. In these regions infections, mainly tuberculosis, followed by acute transverse myelitis and neoplasms, dominate. These are also regions of high HIV prevalence. In developed regions, the most prominent reported spinal cord disease in HIV/AIDS is vacuolar myelopathy (VM). Other myelopathy causes in HIV/AIDS include opportunistic infections, neoplasms, vascular lesions and metabolic disease. In developing regions, opportunistic infections are more commonly encountered with VM occurring less frequently.

AIM

To determine the influence of HIV on the myelopathy spectrum in an HIV endemic region.

DESIGN

Prospective case series.

METHODS

Hundred unselected consecutive in-patients admitted with myelopathy were studied. Myelopathy aetiologies were established by collating information obtained from magnetic resonance imaging (MRI) scans, CSF and blood studies, CXR findings, non-neurological illness and response to treatment. Data were analysed in terms of two cohorts, HIV positive and HIV negative.

RESULTS

Approximately 50% of the patients presenting and admitted to our hospital with non-traumatic myelopathy are HIV positive. The HIV positive myelopathy patients were younger (20-40 years) and had infectious aetiologies. Tuberculosis was the most frequently identified cause of myelopathy. The majority of HIV-positive patients had advanced HIV infection. Anti-retroviral treatment did not influence myelopathy aetiologies. The HIV-negative patients were older and had neoplasms, followed by degenerative spondylosis as the main myelopathy causes.

CONCLUSION

HIV influences the non-traumatic myelopathy spectrum in regions with high HIV prevalence. Empiric treatment of HIV-myelopathy patients with anti-tuberculous medications where resources are severely limited has merit.

Incidence of traumatic spinal cord injury in Aragón, Spain (1972-2008)

Long-term incidence studies are required to identify high-risk groups, establish trends, and forecast needs, and thus contribute to health care planning in spinal cord injury (SCI). This study aimed to determine the incidence of traumatic SCI over a 36-year period in Aragón, Spain, and compare rates with other published European estimates. Hospital records from the Servet Hospital, the only specialized SCI unit in the region, of a retrospective cohort with traumatic SCI between January 1972 and December 2008 were reviewed. Specification of SCI patient demographics, injury causes, and related factors was achieved by utilizing medical records available for inpatients, hospital archives, and central databases. A total of 540 cases were reported over the 36-year study period (79% were male). The age- and sex-adjusted incidence rate was 15.5 per million population (18.8 for males and 4.9 for females). Two incidence peaks were suggested, in the 20- to 29-year and 60- to 69-year age groups. Traffic accidents and falls were the main causes of injury. The highest peak occurs in young adults, mainly caused by traffic accidents. The majority of the lesions were at cervical or thoracic level, and ASIA grade A was most frequently observed. The proportion of SCI cases in persons older than 60 years, mostly due to falls, is increasing. The age-adjusted incidence rates found for the region of Aragón in Spain fall within the range of other published European estimates. Comparative epidemiological features for 2001-2008 suggest that there is room for prevention.

Characterization of spinal cord lesion in patients attending a specialized rehabilitation center in Bangladesh

STUDY DESIGN

This study was designed as a cross-sectional study.

OBJECTIVES

The objective of this study was to find out the clinical types and sociodemographic characteristics of patients with spinal cord lesion (SCL).

SETTING

Centre for the Rehabilitation of the Paralysed (CRP).

METHODS

Data were collected by face-to-face interview, with a structured interview schedule from admitted patients. Descriptive measures and χ(2)-test were applied for data analysis.

RESULTS

Of 107 patients, majority (20%) belonged to age group of 25-29 years (mean 31±12.2 years). About 83% were males; 65% married and 54% illiterate. Agricultural and other day laborers constituted the major occupation groups with mean monthly family income of US $60 (±$53). About 92% came from rural area and 84% belonged to nuclear family. About one-third of the patients were referred by the medical college hospitals. About 65% of the patients were admitted at 1-29 days of lesion with longest duration of 3 years. Patients were mostly (93%) traumatic. Fifty-four percent had paraplegia and most common skeletal level segment was cervical (44%). About 43% had pressure sores at admission. Eighty-nine percent needed management for bladder function through the use of catheter. Age, sex and occupation were associated with type of paralysis, skeletal level of injury and neurological condition; physical status, causes of lesion, type of injury and skeletal level of injury; and skeletal level of injury, respectively (P<0.05).

CONCLUSION

Major cause of SCL was traumatic. Available treatment facilities were inadequate and needed improvement through government and private initiatives.

A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention

STUDY DESIGN

Literature review.

OBJECTIVES

To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention.

SETTING

An initiative of the ISCoS Prevention Committee.

METHODS

The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality 'zones' allowed comparison between data.

RESULTS

Reported global prevalence of TSCI is insufficient (236-1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year.

CONCLUSION

Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.

Review paper: epidemiology of traumatic spinal cord injury: comparisons between developed and developing countries

A review of global epidemiological studies of traumatic spinal cord injury (TSCI) within 2 decades was undertaken to compare the incidence, mortality rate, patients' age, gender, causes, and severity of injury between developed countries and developing countries. The incidence rates varied greatly, and there was also a 2-fold difference between the highest mortality rate in developing countries and that in developed countries. Male sex and age from 30 to 50 years are strong risk factors in both these groups. Traffic accidents are the leading cause of injury in developed countries, whereas falls are the leading cause in developing countries. To clarify regional differences, future studies should contain long-term data about TSCI characteristics in a region-based population.

Epidemiology of spinal cord injuries in the 2005 Pakistan earthquake

STUDY DESIGN

Prospective observational study.

OBJECTIVES

To identify the epidemiological features specific to spinal injuries as a result of an earthquake.

SETTINGS

Rawalpindi, Pakistan in the months after the 8 October 2005 earthquake.

METHODS

In the month after the earthquake, the one established rehabilitation center was augmented with two makeshift spinal cord centers. Information on mechanism of injury, mode of evacuation, associated injuries was gathered, and a detailed clinical and radiological assessment was performed. Neurological status and functional outcome was determined after 10 weeks.

RESULTS

Of an estimated 650-750 spinal cord injuries, 187 were admitted to these centers, including 80 men and 107 women with a mean age of 28.3+/-12.4 years. Injuries occurred while standing in 57.8% of patients. Most (83.4%) who reached the spinal cord center were airlifted. A urinary catheter had been placed before admission in 91.5%. Most of the patients were paraplegic 89.3, with 50.8% incomplete injuries. Fracture or fracture dislocation was present in 70, and 75% underwent spinal fixation. Although pressure ulcers (28.9%) and urinary tract infections (39%) were common, deep venous thromboses (4.8%) and depression (5.8%) were seldom detected. At 10 weeks, 75% were continent or performing intermittent catheterization. There were no deaths and two births.

CONCLUSION

After a disaster, evacuation of persons with a spinal cord injury to a specialized center results in low mortality. Response planning for disasters should include early aggressive medical rehabilitation.

A global perspective on spinal cord injury epidemiology

Spinal cord injury (SCI) is a devastating condition often affecting young and healthy individuals around the world. This debilitating condition not only creates enormous physical and emotional cost to individuals but also is a significant financial burden to society at large. This review was undertaken to understand the global impact of SCI on society. We also attempted to summarize the worldwide demographics and preventative strategies for SCI in varying economic and climatic environments and to evaluate how cultural and economic differences affect the etiology of SCI. A PUBMED database search was performed in order to identify clinical epidemiological studies of SCI within the last decade. In addition, World Bank and World Health Organization websites were used to obtain demographics, economics, and health statistics of countries of interest. A total of 20 manuscripts were selected from 17 countries. We found that SCI varies in etiology, male-to-female ratios, age distributions, and complications in different countries. Nations with similar economies tend to have similar features and incidences in all the above categories. However, diverse methods of classifying SCI were found, making comparisons difficult. Based upon these findings, it is clear that the categorization and evaluation of SCI must be standardized. The authors suggest improved methods of reporting in the areas of etiology, neurological classification, and incidence of SCI so that, in the future, more useful global comprehensive studies and comparisons can be undertaken. Unified injury prevention programs should be implemented through methods involving the Internet and international organizations, targeting the different etiologies of SCI found in different countries.

Length of stay in hospital following spinal cord lesions in Israel

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To monitor length of stay (LOS) in a specialist spinal cord lesion (SCL) department in Israel, evaluate factors that affect it, and assess its association with other outcome measures.

SETTING

Loewenstein Rehabilitation Hospital, Raanana, Israel.

METHODS

In all, 1367 SCL patients treated between 1962 and 2000, and a group of 44 patients admitted between 1996 and 2002 were recruited. LOS, factors that affect it, and Spinal Cord Independence Measure second version (SCIM-II) gain and efficiency were measured. Data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. LOS associations were analyzed with ANOVA, ANCOVA, Pearson's chi(2) test, Pearson's correlation, and Cox proportional hazard model.

RESULTS

The mean LOS was 239 days for traumatic SCL (SD=168) and 106 days for non-traumatic SCL (SD=137). SCL etiology, SCL severity, and decade of admission to rehabilitation, were associated with the LOS (P<0.001). SCIM II gain correlated with LOS in the first 70 days after admission (r=0.81-0.82; P<0.001). In some patients, longer LOS was associated with a considerable increase in ability, through 5-8 months from admission.

CONCLUSIONS

LOS of patients with SCL in Israel is within the customary LOS range in Europe. Longer LOS in a specialist SCL department may be positively associated with improved rehabilitation outcome. Further study is required to determine the LOS that allows optimal achievements.

Traumatic spinal cord injury in Ontario, Canada

BACKGROUND

Few population-based analyses of spinal cord injuries exist from which to base Canadian prevention initiatives. This study aimed to calculate rates of traumatic spinal cord injury for the province of Ontario and describe these injuries by several epidemiologic parameters.

METHODS

Two thousand three hundred eighty-five hospital admissions were studied for April 1, 1994, through March 31, 1999.

RESULTS

Annual age-standardized rates declined from a maximum of 46.2 hospitalizations per 1 million population (95% confidence interval, 42.1-50.3) to 37.2 per 1 million (95% confidence interval, 33.8-41.0). Male rates declined over the study period, whereas female rates remained stable. Leading external causes included unintentional falls (1,030 of 2,385 [43.2%]), especially among the elderly, and transport injuries (1,021 of 2,385 [42.8%]), especially among those aged less than 40 years. Intentional injuries were most commonly seen among those aged 20 to 39 years (48 of 86 [55.8%]). Misclassification of some elder fall cases as spinal cord injuries is a methodologic concern.

CONCLUSION

The results indicate the relative importance of several external causes of injury and are useful in establishing rational priorities for prevention.

Compensatory locomotor adjustments of rats with cervical or thoracic spinal cord hemisections

The accurate measurement of behavioral compensation after CNS trauma, such as spinal cord injury, is important when assessing the functional effects of injury and treatment in animal models. We investigated the locomotor abilities of rats with unilateral thoracic or cervical spinal cord injuries using a locomotor rating (BBB) scale, reflex tests, and quantitative kinetic measurements. The BBB rating scale indicated that thoracic spinal hemisected (TH) rats had more severely affected hindlimbs compared to cervical spinal hemisected (CH) and sham-operated animals. Kinetic measurements revealed that CH and TH animals moved with different ground reaction force patterns, which nevertheless shared some similarities with each other and with the gait patterns of rats with different unilateral CNS lesions. Uninjured rats typically had an equal distribution of their body weight over the forelimbs and hind limbs, and used their forelimbs predominantly for braking while using their hind limbs mostly for propulsion. CH rats bore more weight on their hind limbs than their forelimbs, while TH animals bore more weight on their forelimbs than their hind limbs. Neither CH nor TH rats used the forelimb ipsilateral to the spinal hemisection for net braking or propulsion. The hindlimb contralateral to the hemisection was placed on the ground prematurely during the stride cycle for both CH and TH animals. The altered kinetics of the locomotor pattern in hemisected animals resulted in changes in the oscillations of total body potential and kinetic energies. These two forms of energy oscillate synchronously in intact locomoting rats, but were asynchronous during parts of the stride cycle in spinal hemisected animals. We conclude that rats develop a general compensatory response for unilateral CNS lesions, which may help stabilize the animal during locomotion.

Trauma sites and clinical features associated with acute hyperextension spinal cord injury without bone damage--relationship between trauma site and severity

To elucidate whether a relationship exists between the site of trauma and severity of acute hyperextension spinal cord injury without bone damage, we examined the clinical features of 25 male and 10 female patients aged 13 to 88 years. None of the patients had vertebral damage such as fracture and dislocation. The site of impact was classified as the buccal, forehead, or mandibular region. The neurological findings were assessed according to Frankel's classification at admission and at follow up after 3 months or more to assess outcome. Eleven patients suffered trauma in the buccal region, one patient in Frankel's grade B, three in grade C, and seven in grade D at admission. All 11 of these patients showed an improvement of one grade or more to an outcome of C in one patient, D in one, and E in nine. Trauma occurred at the forehead region in 18 patients, four in grade B, 10 in grade C, and four in grade D. Improvement was seen at follow up by one grade or more to C in one patient, D in 10, and E in seven. Trauma occurred at the mandibular region in six patients, four in grade B and two in grade C. Four of these patients showed improvement of one grade or more to grade B in one, grade C in four, and grade E in one. Overall, seven patients had poor outcomes, five of whom suffered trauma to the mandibular region, indicating that impact to the mandibular region tends to have an unfavorable clinical outcome. Our findings indicate that the site of trauma greatly influences the severity of hyperextension spinal cord injury.