Initial factors predicting survival in patients with a spinal cord injury

Advance in hyperbaric oxygen therapy in spinal cord injury

Spinal cord injury (SCI) is a severe lesion comporting various motor, sensory and sphincter dysfunctions, abnormal muscle tone and pathological reflex, resulting in a severe and permanent lifetime disability. The primary injury is the immediate effect of trauma and includes compression, contusion, and shear injury to the spinal cord. A secondary and progressive injury usually follows, beginning within minutes and evolving over several hours after the first ones. Because ischemia is one of the most important mechanisms involved in secondary injury, a treatment to increase the oxygen tension of the injured site, such as hyperbaric oxygen therapy, should theoretically help recovery. Although a meta-analysis concluded that hyperbaric oxygen therapy might be helpful for clinical treatment as a safe, promising and effective choice to limit secondary injury when appropriately started, useful and well-defined protocols/guidelines still need to be created, and its application is influenced by local/national practice. The topic is not a secondary issue because a well-designed randomized controlled trial requires a proper sample size to demonstrate the clinical efficacy of a treatment, and the absence of a common practice guideline represents a limit for results generalization. This narrative review aims to reassemble the evidence on hyperbaric oxygen therapy to treat SCI, focusing on adopted protocols in the studies and underlining the critical issues. Furthermore, we tried to elaborate on a protocol with a flowchart for an evidence-based hyperbaric oxygen therapy treatment. In conclusion, a rationale and shared protocol to standardize as much as possible is needed for the population to be studied, the treatment to be adopted, and the outcomes to be evaluated. Further studies, above all, well-designed randomized controlled trials, are needed to clarify the role of hyperbaric oxygen therapy as a strategic tool to prevent/reduce secondary injury in SCI and evaluate its effectiveness based on an evidence-based treatment protocol. We hope that adopting the proposed protocol can reduce the risk of bias and drive future studies.

Impact of Mechanism of Injury on Long-term Neurological Outcomes of Cervical Sensorimotor Complete Acute Traumatic Spinal Cord Injury

OBJECTIVE

Mechanism of injury is a largely understudied descriptor of acute traumatic spinal cord injury (tSCI). This study sought to compare the impact of high-energy and low-energy mechanisms of injury in neurological outcomes of cervical sensorimotor complete tSCI.

METHODS

Patients with tSCI were identified in 4 prospective, multicenter clinical trials and registries. American Spinal Injury Association Impairment Scale (AIS) grade was assessed ≤ 72 hours postinjury and followed up between 12 to 52 weeks. Patients were included if they had a cervical and sensorimotor complete (AIS-A) injury at baseline. Study outcomes were change in AIS grade and lower extremity motor, upper extremity motor, and total motor scores. Propensity score matching between high-energy mechanisms of injury (HEMI; e.g. , motor vehicle collisions) and low-energy mechanisms of injury (LEMI; e.g. , falls) groups was performed. Adjusted groups were compared with paired t-tests and McNemar test.

RESULTS

Of 667 patients eligible for inclusion, 523 experienced HEMI (78.4%). HEMI patients were younger, had lower body mass index, more associated fractures or dislocations, and lower baseline lower extremity motor scores. After propensity score matching of these baseline variables, 118 pairs were matched. HEMI patients had a significantly worse motor recovery from baseline to follow-up based on their diminished change in upper extremity motor scores and total motor scores.

CONCLUSION

Cervical sensorimotor complete tSCIs from HEMI were associated with significantly lower motor recovery compared to LEMI patients. Our findings suggest that mechanism of injury should be considered in modelling prognosis and in understanding the heterogeneity of outcomes after acute tSCI.

In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI).

SETTING

The study was performed at the Indian Spinal Injuries Centre, New Delhi.

METHODS

Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression.

RESULTS

Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality.

CONCLUSION

Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.

Epidemiological State, Predictors of Early Mortality, and Predictive Models for Traumatic Spinal Cord Injury: A Multicenter Nationwide Cohort Study

STUDY DESIGN

Multi-center, retrospective cohort study.

OBJECTIVE

To determine the epidemiology, identify predictors of early mortality, and develop predictive models for traumatic spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

Despite improved initial care and management strategies, traumatic SCI remains a devastating event. Knowledge of the epidemiological state and predictive factors for mortality is important for developing strategies and counseling; however, they have not been adequately investigated, and predictive modeling regarding outcomes remains an underused modality for patients with traumatic SCI.

METHODS

Using a nationwide trauma registry-the Japan Trauma Data Bank-we identified adult (≥18 yrs) patients with SCI between 2004 and 2015. The endpoint was in-hospital mortality. Characteristics of each patient were described. Multivariate logistic regression analyses were performed to identify factors significantly associated with in-hospital mortality and develop a predictive model.

RESULTS

In total, 236,698 patients were registered in the database. Of the 215,835 adult patients, 8069 (3.7%) had SCI. The majority had SCI at the cervical level with falls at ground level being the primary etiology. Over the study period, median age, the proportion of cervical SCI, and the etiology of falls at ground level increased. The mortality rate was 5.6%. The following eight factors, age, sex, Glasgow Coma Scale on arrival (GCS), hypotension on arrival, bradycardia on arrival, severe head injury, Injury Severity Score (ISS), and neurological severity of SCI, were independently associated with mortality. A predictive model consisting of these variables predicted mortality with area under the receiver operating characteristic curve of 0.88 (95% confidence interval [CI], 0.86-0.90).

CONCLUSION

Over the 12-year period, patient characteristics, etiology, and post-SCI outcomes significantly changed. We identified eight prognostic factors of early mortality. A predictive model including these factors showed excellent performance and may improve treatment strategies, healthcare resource allocation, and counseling.

LEVEL OF EVIDENCE

3.

Therapeutic systemic hypothermia for a pediatric patient with an isolated cervical spinal cord injury

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults.Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report.Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.

Spinal cord injury increases the risk of type 2 diabetes: a population-based cohort study

BACKGROUND CONTEXT

Previous studies on the risk and prevalence of diabetes among spinal cord injury (SCI) patients are limited and controversial.

PURPOSE

To compare the risk and incidence rate (IR) of Type 2 diabetes in SCI and non-SCI patients.

STUDY DESIGN

This is a population-based retrospective cohort study.

PATIENT SAMPLE

Data from Taiwan's National Health Insurance Research Database for the period 1997 to 2010 were analyzed. Patients aged 20 years and older newly identified with SCIs during this period were included in the SCI cohort. A non-SCI comparison cohort was randomly selected from National Health Insurance beneficiaries and matched with the SCI cohort based on age, sex, and index date.

OUTCOME MEASURES

Both cohorts were followed until the first of the following occurred: the diagnosis of Type 2 diabetes (International Classification of Disease, Ninth Revision, Clinical Modification codes 250), withdrawal from the insurance system, the end of 2010, or death.

METHODS

A Cox proportional hazards regression analysis was used to estimate the risk of developing diabetes.

RESULTS

Taiwan possesses an older SCI population, with a mean age of 51.6 years. The IR for diabetes in patients with and without SCIs was 22.1 per 10,000 person-years and 17.2 per 10,000 person-years, respectively. The adjusted hazard ratio (HR) for diabetes was 1.33 times higher in patients with SCIs than in those without SCIs. In patients with SCIs, men (adjusted HR=1.23, 95% confidence interval (CI)=1.04-1.44), older people (adjusted HR=4.26 in patients older than 65 years, 95% CI=3.16-5.74), patients with comorbidity (adjusted HR=1.36, 95% CI=1.14-1.62), and patients with a complete thoracic SCI (T-spine injury) (adjusted HR=2.13, 95% CI=0.95-4.79) were more likely to be diagnosed with diabetes than other patient subgroups.

CONCLUSIONS

Our findings may facilitate the prioritizing of preventive health strategies and planning of long-term care for SCI patients.

Persistent hypoalbuminemia is a predictor of outcome in cervical spinal cord injury

BACKGROUND CONTEXT

Hypoalbuminemia is associated with increased morbidity and mortality in various clinical settings and several major diseases. Albumin has multiple physiologic properties that could be beneficial in central nervous system injury.

PURPOSE

We sought to determine if albumin is associated with patient outcome after cervical spinal cord injury by conducting a retrospective analysis.

STUDY DESIGN/SETTING

A retrospective study of cervical spinal cord injury (CSCI) patients was conducted to investigate if serum albumin levels and other characteristics influence outcome (mechanical ventilation and death).

PATIENT SAMPLE

A total of 178 consecutive patients were included in the present study.

OUTCOME MEASURES

Demographic data were recorded, including age, gender, smoking history, time from injury to admission, severity of neurologic injury, neurologic level of lesion, mechanism of neurologic injury, Glasgow Coma Score, vitals in the Orthopedic Department, the occurrence of early surgical intervention (48 hours after injury), and daily serum albumin levels.

METHODS

No funds were received in support of this work. No specific conflicts of interest were involved in this article. Serum albumin levels and other characteristics known to influence outcome were included in univariate statistical analyses and the multiple logistic regression model to analyze the relationship with mechanical ventilation and death after cervical injury.

RESULTS

Approximately 41.0% (73/178) of patients had complete spinal cord injury (ASIA A), 36.5% (65/178) of patients required mechanical ventilation, and 8.4% (15/178) of patients died within the first month after injury. Albumin remained lower than 30 g/L for a period of time (≥5 days) in patients with an unfavorable outcome (patients requiring mechanical ventilation or who had died). Multiple logistic regression analysis identified age (>50 years), persistent hypoalbuminemia (<30 g/L and ≥5 days), C5 and above neurologic injury, and ASIA A as predictors for mechanical ventilation. In addition, persistent hypoalbuminemia, ASIA A, and C4 and above neurologic injury were significantly associated with death.

CONCLUSION

Similar to the ASIA scale and neurologic level, persistent hypoalbuminemia seems to be an independent predictor of outcome in patients with CSCI. Thus, a randomized trial assessing albumin in the treatment of cervical spinal cord injury is warranted.

Is undernutrition risk associated with an adverse clinical outcome in spinal cord-injured patients admitted to a spinal centre?

BACKGROUND/OBJECTIVES

To evaluate whether undernutrition risk measured using the Spinal Nutrition Screening Tool (SNST) and the Malnutrition Universal Screening Tool (MUST) is associated with worse clinical outcomes in respect of length of in-patient hospital stay (LOS) and mortality in the 12 months after admission to a spinal cord injuries (SCIs) centre.

METHODS

A multicentre, prospective, cross-sectional observational study was conducted in four UK SCI centres (SCICs). A total of 150 SCI patients (aged 18-88 years (median: 44 years), 30.7% females) were studied between July 2009 and March 2010. LOS and mortality 12 months after admission to the SCIC was monitored. Multivariate regression analysis was used to identify unique predictors of the variance of LOS.

RESULTS

The patients initially undernourished or at risk of undernutrition (44.6%) had a significantly longer LOS (median (days): 129 vs 85, P=0.012) and greater 12-month mortality (% deceased: 9.2% vs 1.4%, P=0.036). In addition, serum albumin and new admission to an SCIC were identified as independent predictors for long LOS.

CONCLUSION

The present study suggests that undernutrition risk, as identified by the SNST, is associated with adverse clinical outcomes. Nutritional screening should be helpful in improving clinical outcomes if it promotes more appropriate and effective nutritional intervention.

Spinal cord injuries related to cervical spine fractures in elderly patients: factors affecting mortality

BACKGROUND CONTEXT

Spinal cord injuries (SCIs) related to cervical spine (C-spine) fractures can cause significant morbidity and mortality. Aggressive treatment often required to manage instability associated with C-spine fractures is complicated and hazardous in the elderly population.

PURPOSE

To determine the mortality rate of elderly patients with SCIs related to C-spine fractures and identify factors that contribute toward a higher risk for negative outcomes.

STUDY DESIGN/SETTING

Retrospective cohort study at two Level 1 trauma centers.

PATIENT SAMPLE

Thirty-seven consecutive patients aged 60 years and older who had SCIs related to C-spine fractures.

OUTCOME MEASURES

Level of injury, injury severity, preinjury medical comorbidities, treatment (operative vs. nonoperative), and cause of death.

METHODS

Hospital medical records were reviewed independently. Baseline radiographs and computed tomography or magnetic resonance imaging scans were examined to permit categorization according to the mechanistic classification by Allen and Ferguson of subaxial C-spine injuries. Univariate logistic regression analyses were performed to identify factors related to in-hospital mortality and ambulation at discharge. There were no funding sources or potential conflicts of interest to disclose.

RESULTS

The in-hospital mortality rate was 38%. Respiratory failure was the leading cause of death. Preinjury medical comorbidities, age, and operative versus nonoperative treatment did not affect mortality. Injury level at or above C4 was associated with a 7.1 times higher risk of mortality compared with injuries below C4 (p=.01). Complete SCI was associated with a 5.1 times higher risk of mortality compared with incomplete SCI (p=.03). Neurological recovery was uncommon. Apart from severity of initial SCI, no other factor was related to ambulatory disposition at discharge.

CONCLUSIONS

In this elderly population, neurological recovery was poor and the in-hospital mortality rate was high. The strongest risk factors for mortality were injury level and severity of SCI. Although each case of SCI related to C-spine fractures is different, physicians may be able to use these findings to help better determine the prognosis and guide subsequent treatment.

Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review

OBJECT

The object of this study was to identify, by means of a systematic review of the literature, the acute clinical predictors of neurological outcome, functional outcome, and survival after traumatic spinal cord injury (SCI).

METHODS

A comprehensive computerized literature review search was performed, using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews. Selected articles were classified according to their level of evidence. Articles were then stratified into one of 3 domains depending on whether the primary focus was clinical prediction of 1) neurological outcome, 2) functional status, or 3) survival. For each study selected, clinical predictors related to patient demographic characteristics, injury mechanism, or neurological examination findings were extracted, and the individual relationship to outcome was defined.

RESULTS

The initial search resulted in 376 citations. After application of the inclusion and exclusion criteria and study review, 51 relevant articles were identified and graded. Of these, 25 provided predictors for neurological outcome, 22 for functional outcome, and 15 for survival, with several of the articles providing information on more than one type of outcome. All of the included studies were designated as providing Class I, II, or III levels of evidence. The severity of neurological injury (as measured by admission Americal Spinal Injury Association Impairment Scale grade, Frankel grade, or injury completeness), level of injury, and the presence of a zone of partial preservation were consistent predictors of neurological outcome. Severity of neurological injury, level of injury, reflex pattern, and age were consistent predictors of functional outcome. Finally, severity of neurological injury, level of injury, age, and the presence of multisystem trauma seen with higher-energy injury mechanisms were consistent predictors of survival.

CONCLUSIONS

On the basis on this review, the authors have identified a constellation of acute clinical features that may help to define an individual's profile for recovery and survival after SCI. This study will help to facilitate communication in the clinical realm and assist in classifying subsets of patients within future clinical studies.

Survival after spinal cord injury: a systematic review

Spinal cord injury (SCI) leading to neurological deficits produces long-term effects that persist over a lifetime. Survival analysis of patients with SCI, at individual and population level, is important for public health management and the assessment of treatment achievements. The current study evaluated survival following traumatic and non-traumatic SCI worldwide. A systematic review was conducted, and all included papers were assessed for quality using a purposely designed assessment form. Survival data were presented in Kaplan-Meier curves and compared using the log-rank test. Sixteen studies were included of which 11 concerned traumatic SCI, four non-traumatic SCI, and one both. Crude standard mortality rates (SMRs) revealed that overall mortality in SCI is up to three times higher than in the general population. Survival rates were statistically significantly lower in non-traumatic SCI than in traumatic SCI (log-rank p = 0.000). Age at injury, neurological level, extent of lesion, and year of injury have been described as predictors of survival. Causes of death stem from secondary complications, with failure of the respiratory system being the leading cause. This is the first systematic literature review on survival analysis following SCI worldwide. An increase in survival over time was found. However, the SMRs of individuals with SCI still exceed those of an age-matched non-disabled population, mainly due to secondary complications. Lower survival rates were observed in non-traumatic SCI compared with traumatic SCI.

Risk factors for mortality in traumatic cervical spinal cord injury: Brazilian data

BACKGROUND

Predictive factors for mortality are different among countries; knowledge of risk factors is important for planning strategies to reduce mortality in trauma. The objective of this study was to identify predictors of death in traumatic cervical spinal cord injury (TSCI) in Brazil.

METHODS

From 2001 to 2005, 84 patients with clinically detectable TSCI were identified in this retrospective study. For each patient, neurologic and associated injuries, physiologic variables, complications, treatment, and hospital mortality were recorded. Bivariate and multivariate logistic regression analyses were done to identify predictors of mortality.

RESULTS

Twenty-two (26.2%) patients died in hospital. Car crash (39%) and falls (37.85) were the most frequent causes of trauma. The causes of death were as follows: neurologic, 8 (36.4%); respiratory, 4 (18.2%); septic complications, 2 (9.1%); venous thrombosis and embolism, 2 (9.1%); and undetermined, 4 (18.2%). Bivariate analysis identified absent neurologic function (risk ratios [RR] = 4.5; 95% confidence intervals [CI], 1.6-12.7), high injury severity score (p = 0.001) and low revised trauma score (p = 0.001); Glasgow Coma Scale (GCS) score <9 (RR = 47.4; 95% CI, 5.4-413.2); shock at admission (RR = 2.5; 95% CI, 0.8-7.9); vasopressor use (RR = 25.8; 95% CI, 6.1-109.6); mechanical ventilation (RR = 31.9; 95% CI, 6.6-154.0); acute renal insufficiency (RR = 10.0; 95% CI, 0.98-102.1) as associated with mortality. The mainly independents predictors for mortality were GCS score <9 and vasopressor use. Lowest mortality rate (5.2%) was observed for patients with TSCI alone.

CONCLUSIONS

GCS score <9, mechanical ventilation, and vasopressor use were predictors of mortality with TCSI, and if these risk factors were absent, we observed low mortality rate.

Cervical spine injuries in the elderly: acute postoperative mortality

STUDY DESIGN

This study retrospectively reviewed 12 years of consecutive patients with cervical spine injuries.

OBJECTIVE

To establish reasonable expectations for short-term postoperative survival of the elderly patient with a cervical spine injury.

SUMMARY OF BACKGROUND DATA

Previous studies have outlined dismal expectations for patients older than 65 years, with cervical spine injuries. This result has led many surgeons to consider more conservative treatment when compared to younger patients with similar injuries.

METHODS

A total of 458 patients treated surgically over a 12-year period at a single tertiary spine care center were reviewed. The patients were divided into 2 groups by age, older and younger than 65 years. Prospective data were collected from the time of admission to discharge from the acute care facility, and included age, injury etiology, anatomic and neurologic injury patterns, and morbidity and mortality

RESULTS

There were 74 patients older than 65 years and 384 younger than 65 years who underwent surgical stabilization of their injury. The overall mortality rate during the initial hospitalization was 3.9%. The mortality rate of the elderly group was 12.2%, while 2.3% for the younger patients. Common postoperative morbidities in the older group included myocardial infarction, deep vein thrombosis, pulmonary emboli, and gastrointestinal bleeds. In the younger group, pneumonia, respiratory failure, and urinary tract infections were more frequent.

CONCLUSIONS

The realistic expectation for short-term postoperative survival in the elderly patient with a cervical spine injury is 87.8%. With a complete neurologic injury, 80.0% short-term survival was observed. Incomplete neurologic injury yielded 83.3% short-term survival. Close to 100.0% survival can be expected with no neurologic injury.

Critical care and perioperative management in traumatic spinal cord injury

Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.

The Tetrafigap Survey on the long-term outcome of tetraplegic spinal cord injured persons: Part III. Medical complications and associated factors

STUDY DESIGN

To study the short- and long-term medical complications encountered in tetraplegic spinal cord injured persons (TSCI) and to give prominence to both the medical and socio-economic factors with which they are respectively associated.

METHODS

The Tetrafigap Study is a multicentre epidemiological survey carried out using self-administered questionnaires studying the global long-term outcome of TSCI patients after the initial phase of rehabilitation.

RESULTS

The data for 1668 patients were analyzed. The rate of rehospitalizations was 74.4% with on average three stays per patient and as reported causes, in descending order: urinary complications, systematic follow-up, pressure sores, respiratory complications, contractures, bowel complications, pains and secondary fractures of the lower limbs. At the time of the survey, 84.7% of patients mentioned awkward contractures, 73.8% pains, 55.9% embarrassing urinary leakage and 14.1% pressure sores. With regard to persons suffering from complete motor lesion, urinary complications and pressure sores were more frequently reported, whereas for persons suffering from incomplete motor lesions, awkward contractures and pains were more frequent. In the elderly, pains were more often mentioned, and pressure sores and pain were also the most common in patients coming from lower socio-professional status. Contractures and pain decreased with time. All these complications but pressure sores and pain are statistically interrelated.

CONCLUSION

The medical complications of spinal cord injured persons are frequent, they are linked to biological, psychological and environmental factors, and are interrelated. Therefore, seeking mid- and long-term risk factors must be given priority in order to better adapt attempts at increasing secondary prevention.

Recent trends in mortality and causes of death among persons with spinal cord injury

OBJECTIVE

To identify and quantify trends in mortality and causes of death among persons with spinal cord injury.

DESIGN

Cohort study.

SETTING

Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States.

PATIENTS

A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury.

MAIN OUTCOME MEASURE

Length of survival and cause of death.

RESULTS

Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes).

CONCLUSION

While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.

Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury

PURPOSE

The objective of this study was to identify predictors of death and mechanical ventilation in patients with traumatic cervical spinal cord injury.

METHODS

From 1981 to 1994, 72 patients with traumatic cervical spinal cord injury resulting in neurological deficits were identified in this retrospective study. For each patient, neurological and associated injuries, physiological variables, complications, hospital mortality and the need for mechanical ventilation were recorded. Univariate and multivariate logistic regression analyses were done to identify predictors of mortality and the need for mechanical ventilation.

RESULTS

Fifteen patients (21%) died in the first three months after injury. Univariate analyses identified age, heart disease, neurological level at C4 and above, GCS < or = 13, forced vital capacity and cough, to be associated with mortality. Multivariate logistic regression identified age (P = 0.01), neurological level (P = 0.03) and GCS (P = 0.05) as independent predictors of mortality. In 41 patients (57%), the lungs were mechanically ventilated. Univariate analyses identified. The following predictors of the need for mechanical ventilation: neurological level at C5 and above, complete cord lesions, copious sputum, pneumonia and lung collapse. Multivariate logistic regression identified copious sputum (P = 0.01) and pneumonia (P = 0.01) as independent predictors of the need for mechanical ventilation.

CONCLUSION

Age, neurological level and GCS are independent predictors of mortality in patients with traumatic cervical spinal cord injury. Copious sputum and pneumonia are independent predictors of the need for mechanical ventilation.

Mortality after spinal cord injury: an 11-year prospective study

OBJECTIVE

To identify the relative risk of mortality after spinal cord injury (SCI) as a function of level of psychosocial, vocational, and medical adjustment.

DESIGN

A prospective design was used: data on life adjustment was obtained at one time (1985), with subsequent survival status ascertained 11 years later (1996). Logistic regression was used to identify the relative risk of mortality given the level of adjustment on a number of predictor variables.

SETTING

All participants were selected from outpatient files of a Midwestern university hospital.

PARTICIPANTS

A total of 345 participants with SCI completed study materials in 1985 (a 78% response rate), 330 of whom could be definitively classified in 1996 as either survivor or deceased. Of these 330 participants, 84% were alive in 1996 (n = 278) and the other 16% were deceased (n = 52).

MAIN OUTCOME MEASUREMENTS

The Life Situation Questionnaire (LSQ) was used to measure nine primary predictors related to life adjustment after SCI, including employment status and eight predictor scales: Medical Instability, Adjustment, General Satisfaction, Emotional Distress, Dependency, and Poor Health. The LSQ was also used to generate data on 34 individual items that were used in exploratory predictive analyses.

RESULTS

All but one of the 8 primary adjustment predictors from 1985 significantly predicted 1996 mortality status. Dependency and low overall satisfaction were among the most significant predictors of mortality.

CONCLUSIONS

Overall quality of life is important to the longevity of people with SCI, and comprehensive rehabilitation programs are needed to promote a level of life adjustment that maximizes longevity after SCI.

Ventilatory function in cervical and high thoracic spinal cord injury. Relationship to level of injury and tone

Weakness and spasticity of chest wall muscles are known to adversely affect pulmonary function in spinal cord-injured patients. To test the assertion that impaired strength and increased tone contribute to ventilation deficits, 52 patients with recent acute traumatic cervical and high thoracic spinal cord injury underwent complete pulmonary function testing. Regression analyses were performed to determine relationships between spinal cord injury level and pulmonary function test results and between Ashworth scale tone ratings and pulmonary function test results. Level of injury was found to be significantly correlated with expiratory reserve volume (and percent predicted expiratory reserve volume), residual volume/total lung capacity ratio, and negative inspiratory pressure but not with vital capacity, forced expiratory volume in one second, forced expiratory volume in one second/vital capacity ratio, inspiratory capacity, total lung capacity, functional residual capacity, residual volume, or positive expiratory pressure. There were significant correlations between Ashworth Scale tone ratings and negative inspiratory pressure but not between tone ratings and any of the other pulmonary function test results. It appears that muscle strength may be a more important factor than muscle tone in determining pulmonary function in spinal cord-injured patients and that both strength and tone are closely related to negative inspiratory pressure.

Pulmonary function testing in spinal cord injury: correlation with vital capacity

Spinal cord injury (SCI) causes restrictive ventilatory changes, with reductions in vital capacity, functional residual capacity, and expiratory reserve volume. Vital capacity (VC) often is used as an indicator of overall pulmonary function in these patients. In an effort to determine the extent to which VC correlates with other pulmonary function tests, 52 patients with recent acute traumatic SCI underwent complete pulmonary function testing. Statistical relationships were determined between VC and nine other tests. VC was found to be significantly correlated with forced expiratory volume in 1 s, inspiratory capacity, expiratory reserve volume, functional residual capacity, residual volume (RV), total lung capacity (TLC), and RV/TLC ratio, but not with maximum positive expiratory pressure nor with maximum negative inspiratory pressure. The excellent correlations between vital capacity and nearly all of the other pulmonary function tests support the use of VC as a single global measure of overall ventilatory status in SCI patients.

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.

Spirometry--acceptability and reproducibility in spinal cord injured subjects

The American Thoracic Society (ATS) has formulated guidelines for spirometry. We hypothesized that individuals with SCI (SCI), as a result of weak respiratory muscles, would exhibit poor test acceptability and reproducibility. Seventy-eight SCI subjects (39 with complete SCI) answered a respiratory questionnaire and performed spirometry. Of those with complete SCI, the proportion of subjects which met ATS criteria decreased with higher levels of injury. Poor test performance was not associated with age, respiratory symptoms or muscle fatigue. The most common reason for failing to meet ATS criteria for acceptability was excessive back extrapolated volumes (EBEV). Individuals with efforts that were acceptable except for EBEV and/or for exhalation of less than six seconds had values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) that were reproducible. If ATS criteria for acceptable spirometry were used in studying subjects with SCI, individuals producing otherwise reproducible values for FVC and FEV1 would be excluded. We found reproducibility similar to what has been reported in other cohorts and conclude that longitudinal study of respiratory function in SCI is feasible.

Assessment of rehabilitation in patients with spinal cord injuries: methodological considerations

It is becoming a necessity to predict the outcome of spinal cord injured patients, because their prognosis has greatly improved in recent years. The assessment of rehabilitation should be done with methodology to avoid selection bias and confounding factors, and to choose criteria for measuring outcome. Some simple rules are proposed in order to correctly use major statistical models.

The older adult with a spinal cord injury

Sixty-two consecutive acute spinal cord injury (SCI) patients who were aged 55 years or older were studied and compared to 296 SCI patients of age less than 55 years. Compared to younger patients, the older group had significantly more females (29%), preexisting medical conditions (87%), associated injuries (55%), incomplete quadriplegic patients (63%), and persons whose injuries resulted from falls (53%). There were no differences between groups in frequency of ventilator use, occurrence of medical complications, or acute length of stay, but older patients tended to have fewer surgical spinal fusions (40%), shorter rehabilitation stays (66.5 days), more indwelling urethral cathteters (31%), and more nursing home discharges (19%). With other factors being controlled, advancing age was predictive only of nursing home discharge, and not of acute or rehabilitation lengths of stay. Among older SCI patients, those with complete injuries were nearly 3 times as likely to have been discharged to nursing homes in our series compared to older patients with incomplete lesions. Although many aspects of the presentation, course, and care of older SCI individuals are similar to those of younger patients, there are several unique features of older adults with a SCI.

Electromyographic study of sternocleidomastoid and scalene muscles in tetraplegic subjects during respiration

An electromyographic investigation of inspiratory respiratory muscles was carried out in six tetraplegic and two normal subjects using needle electrodes. When the normal subjects were using tidal breathing there was no activity present. In the majority of tetraplegic subjects, activity was present in the scalene muscle during tidal breathing. This activity became more marked during deep inspiration. The muscles were hypertrophied and these muscles filled an important respiratory role.

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.