Nontraumatic spinal cord injury: demographic characteristics and complications

Rehabilitation of patients with nontraumatic spinal cord injury in the Netherlands: etiology, length of stay, and functional outcome

BACKGROUND

Patients with nontraumatic spinal cord injury (NTSCI) are different from patients with traumatic spinal cord injury. A better understanding of the characteristics of NTSCI and their influence on length of stay (LOS) and functional outcome might help professionals in planning rehabilitation and predicting outcomes in NTSCI.

OBJECTIVE

To describe personal and injury characteristics, etiology, LOS, and functional outcome after inpatient rehabilitation in patients with NTSCI.

METHODS

Retrospective single-center study including 124 patients who were discharged between 2006 and 2010 from their initial inpatient rehabilitation after onset of NTSCI. Information about personal and injury characteristics, LOS, and functional outcome was collected from medical files. Descriptive statistics were performed, and associations between etiology, LOS, and functional outcome were investigated.

RESULTS

Fifty percent of participants were male, and mean age was 54.9 years (SD 13.7). Most lesions were classified as American Spinal Injury Association Impairment Scale (AIS) D (68.8%) and paraplegic (76.6%). The most frequent etiologies were degeneration (25.8%), vascular disease (21.8%), benign tumor (16.1%), and malignant tumor (15.3%). Discharge destination was usually a private residence (84.6%). Median LOS in inpatient rehabilitation was 61.0 days (interquartile range [IQR], 38.3-111.8). Median functional status score was 47.5 (IQR, 30-70) at admission and 90 (IQR, 75-100) at discharge. Etiology was a significant predictor of LOS and functional status at admission and discharge, but not of functional improvement during inpatient rehabilitation.

CONCLUSION

Spinal degeneration, tumor, and vascular disease were the most common causes of NTSCI. All etiology groups improved during inpatient rehabilitation.

Incidence and prevalence of spinal cord injury in Canada: a national perspective

BACKGROUND

Despite decades of research, there are no national estimates of the incidence or prevalence of spinal cord injury (SCI) in Canada. Our objective was to utilize the best available data to estimate the incidence and prevalence of traumatic SCI (TSCI) and non-traumatic SCI (NTSCI) in Canada for 2010.

METHODS

Initial incidence (number of TSCIs at injury scene) and discharge incidence (number discharged into the community) were calculated using published TSCI rates from Alberta and NTSCI rates from Australia. Prevalence was estimated by applying TSCI and NTSCI discharge incidence rates to historical Canadian population demographics using a cohort survival model and age-specific mortality rates for tetraplegia and paraplegia.

RESULTS

The estimated 2010 initial incidence of TSCI is 1,785 cases per year, and the discharge incidence is 1,389 (41 per million). The estimated discharge incidence for NTSCI is 2,286 cases (68 per million). The prevalence of SCI in Canada is estimated to be 85,556 persons (51% TSCI and 49% NTSCI).

CONCLUSIONS

This study provides the first estimates of the incidence and prevalence of SCI in Canada. More population-based studies are needed, particularly for NTSCI, as an increasing number of Canadians are expected to be affected by SCI.

Spinal cord injury in Manitoba: a provincial epidemiological study

OBJECTIVE

To define the epidemiological trends and identify populations at risk of traumatic and non-traumatic spinal cord injury (NTSCI) for the province of Manitoba, Canada.

METHODS

We reviewed records retrospectively for subjects in three cohorts (1981-1985, 1998-2002, and 2003-2007). A total of 553 individuals with spinal cord injury (SCI) were studied for variables such as age, level of injury, severity of injury, First Nations (FN) status, and etiology of injury.

RESULTS

Incidence of overall SCi has increased from 22.0 to 46.5 per million (P< 0.001). Incidence of NTSCI increased from 3.12 per million to 16.7 per million (P < 0.001). Incidence of traumatic spinal cord injury (TSCI) has increased from the 17.1 per million to 25.6 per million (P<0.001). There was a significant increase in the mean age at injury from 30.23 to 45.768 years of age (P < 0.0001). Female and NTSCI have a higher mean and median age at injury. There was a significant (P = 0.0008) increase in the proportion of females with a most recent male/female ratio of 3.4:1. A temporal increase in incomplete injuries was observed (P < 0.0001). Incomplete and thoracic level injuries are more common with NTSCI.

CONCLUSION

The results demonstrate that there are significant differences between NTSCI and TSCI in Manitoba, and that Manitoba trends in SCI are in keeping with those seen on a national and an international level. There is a high risk of SCI in Manitoba FN, for which preventive strategies need to be put in place, and higher resource structure geared towards. Additionally, the trend of older age at injury has significant implications for structuring acute care and rehabilitation programs for these individuals, enhancing the need for treating older and more medically complicated individuals with SCI.

Effects of etiology on inpatient rehabilitation outcomes in 65- to 74-year-old patients with incomplete paraplegia from a nontraumatic spinal cord injury

OBJECTIVE

To examine differences in rehabilitation outcomes for older patients with a nontraumatic spinal cord injury (NT-SCI) for 5 etiologic diagnoses: degenerative spinal disease (DSD), malignant spinal tumor, benign spinal tumor, vascular ischemia, and spinal abscess.

DESIGN

Retrospective cohort study that used Medicare claims and assessment data.

SETTING

A total of 479 inpatient rehabilitation hospitals and units.

PATIENTS

A total of 1780 Medicare beneficiaries (65-74 years old) with incomplete paraplegia attributable to NT-SCI who were discharged from inpatient rehabilitation facilities from 2002 through 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

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

RESULTS

Demographic characteristics varied by etiology group. Mean +/- SD rehabilitation stays ranged from 13.3 +/- 7.7 days for DSD to 26.4 +/- 13.4 days for vascular ischemia. Adjusted data showed stays differed (P < .001) across etiology groups. Adjusted discharge mean self-care and mobility subscores revealed that patients with DSD and benign tumor were more independent (P < .001) than patients with a malignant tumor or spinal abscess. Patients with vascular ischemia were more dependent (P < .01) in mobility than the DSD and benign tumor groups. Etiologic differences (P < .01) in independence in discharge FIM modifiers for walking (FIM > or = 4), bladder (FIM > or = 6) and bowel management (FIM > or = 6) and bowel accidents/continence (FIM > or = 6), but not bladder accidents (FIM > or = 6), were present. The percent of patients discharged to a community residence ranged from 59.3% to 92.6%. Adjusted data showed that significantly larger percentages (P < .01) of patients in the DSD and malignant tumor groups than in the spinal abscess group were discharged to a community residence (versus nursing home).

CONCLUSION

There are etiologic differences in demographics, rehabilitation length of stay, functional outcomes, and discharge destination in elderly patients with NT-SCI.

Quality of life in adults with spinal cord injury living in the community

STUDY DESIGN

The study design used is cross-sectional descriptive survey.

OBJECTIVES

The aim of this study is to describe the subjective and objective quality of life (QoL) of adults with chronic non-traumatic spinal cord injury (NT-SCI) and to compare the objective and subjective QoL of adults with chronic NT-SCI with adults who have a chronic traumatic spinal cord injury (T-SCI) and the general population.

SETTING

Living in the general community (non-residential care), Australia.

PARTICIPANTS

The study included 443 adults with SCI (T-SCI, n=381) (NT-SCI, n=62), all SCI ≥6 months duration.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Objective and subjective QoL domains--Comprehensive QoL Scale for Adults, version 5 (COMQoL-A5); acceptance subscale--the Spinal Cord Lesion Coping Strategies Questionnaire, version 1 Australia (SCL CSQ v1.0 Australia).

RESULTS

Despite demographic differences, only the objective QoL domain material (higher in NT-SCI) and the subjective QoL domain health (lower in NT-SCI) were significantly different between the SCI subgroups. In contrast, five of the seven objective domains and four of the seven subjective domains were significantly lower in the SCI sample as a whole, compared with the general population. Post hoc analyses suggested that aetiology of the SCI was not responsible for QoL differences within the cohort with SCI.

CONCLUSION

On the whole, aetiology makes little difference to QoL outcomes after SCI. The QoL of adults with chronic T-SCI and NT-SCI fall significantly below that of the general population in most domains.

The costs and adverse events associated with hospitalization of patients with spinal cord injury in Victoria, Australia

STUDY DESIGN

Analysis of patient-level diagnostic and cost data from an administrative database.

OBJECTIVE

To describe complications and cost differentials for hospitalized patients with traumatic spinal cord injury (T-SCI) and nontraumatic spinal cord injury (NT-SCI).

SUMMARY OF BACKGROUND DATA

Numerous studies have reported costs for T-SCI, but few have involved NT-SCI.

METHODS

All patients with SCI admitted between June 1, 2003 and June 30, 2004 were identified using coding from the International Classification of Diseases and Related Health Problems 10th edition, Australian modification (ICD-10-AM). Analysis of database from 45 major acute care public hospitals included in the Victorian Cost Weights Study hospitals (n = 1605 episodes with a SCI). Complications were identified using the Victorian Department of Human Services C-prefix, assigned to hospital-acquired ICD-10-AM diagnoses.

RESULTS

Most (85.5%) SCI episodes involved NT-SCI. The ratio of acute to chronic admissions was high for T-SCI (1:0.05), but reversed for NT-SCI (1:1.36). Complications were documented in 38% of SCI episodes. T-SCI showed a higher rate of complications (56%) than NT-SCI (35%). SCI admissions with a complication were significantly more costly (mean, $A43,410) compared with those without a complication (mean, $A10,102). Length of stay was extended by an average of 32 days in the presence of a complication.

CONCLUSIONS

SCI entails costly hospital care and high risk of hospital-acquired illness. Some of these complications are preventable. Better understanding of the financial costs of these episodes can assist healthcare providers and funders to weigh the benefits of interventions to reduce the rates of complications in these vulnerable patients.

Factors associated with pressure ulcers in patients with complete or sensory-only preserved spinal cord injury: is there any difference between traumatic and nontraumatic causes?

Object

Pressure ulcers (PUs) are common complications in patients with complete spinal cord injury (SCI) or incomplete SCI in which sensory function is spared. Most studies analyzing associated factors of PU and SCI have been performed in cases of traumatic SCI and in just a few cases of nontraumatic SCI. This study was designed to look specifically at the differences in causative factors of PU in cases of traumatic and nontraumatic SCIs.

Methods

The authors performed a retrospective, cross-sectional study evaluating patients with complete and incomplete SCIs (American Spinal Injury Association Grades A and B) under the coverage of the financial, medicosocial, and rehabilitative support provided by the State Welfare Organization of Iran (SWOI). There were 3791 cases of traumatic SCI (63.2%) and 2110 cases of nontraumatic SCI (35.2%). For 94 patients (1.6%), sufficient data were not available.

Results

A PU was detected in 39.2% of all patients with an SCI (71.8% of those with traumatic SCI vs 28.2% of those with nontraumatic SCI). A univariate analysis showed a significant association between occupation, education, and the presence of PU in patients with a traumatic SCI (p < 0.05). This contrasted with nontraumatic SCI in which an association between PU and age was noted (p < 0.05).

Using logistic regression, traumatic cause, older age, an interval less than 1 year since the onset of SCI, male sex, and single status were found to significantly increase the risk of PU in all patients with an SCI. However, a higher education level had a preventive effect on PU.

Conclusions

This study revealed some risk factors for PU in the authors' setting. The authors' findings suggest a possible difference between the risk factors for PU in patients with both types of SCI. Further study on the pathoetiology of these differences is paramount in the future.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study

STUDY DESIGN

Retrospective cohort design.

OBJECTIVES

To compare socio-demographic, impairment characteristics and utilization (physician and emergency department (ED) visits) for non-traumatic (NTSCI) and traumatic (TSCI) spinal cord injury 1 year post inpatient rehabilitation.

SETTING

Ontario, Canada.

METHODS

Inpatient stays (2003-2006) were identified from the National Rehabilitation Registry System. Exclusions were: in-hospital mortality; discharge after 31 March 2006; death within 1 year after discharge. Multivariate logistic regression analyses were used to determine factors predicting high utilization.

RESULTS

NTSCI cases (n=1002) were greater than TSCI (n=560). NTSCIs were older (mean=61.6, s.d.=15.8) with more co-morbidities, paraplegic (39.5%) and female (P<0.001). NTSCI had higher FIM admission and discharge scores but lower change scores. Mean number of physician visits for NTSCI and TSCI were 31.2 (median=24) and 29.7 (median=22), with no significant differences in mean specialist visits (NTSCI 16.5: TSCI 17.0). Factors predicting 30 or more physician visits included age 60 years or above (OR=1.5; 95% CI=1.2-1.9), urban living (OR=1.59; 95% CI=1.12-2.22) and lowest quartile (18-88) discharge FIM (OR=1.8; 95% CI=1.4-2.3). Charlson score of 3 or more (OR=2.1; 95% CI=1.3-3.2), urban living (OR=1.92; 95% CI=1.3-2.86) and lowest quartile discharge FIM (OR=1.5; 95% CI=1.2-2.0) were associated with 20 or more specialist visits. Factors for high ED use were: rurality (OR=1.5; 95% CI=1.1-2.1), low income (OR=1.4; 95% CI=1.1-1.9) and low (18-88) discharge FIM (OR=1.7; 95% CI=1.3-2.2).

CONCLUSION

Both demonstrated significant health care utilization requiring attention to health care needs; particularly for those living in rural settings, with low income and/or low functional ability.

Comparison of depression, anxiety and stress in persons with traumatic and non-traumatic post-acute spinal cord injury

STUDY DESIGN

Community cross-sectional self-report survey of adults with spinal cord injury (SCI).

OBJECTIVES

The aim of this study was to examine the likelihood of depression, anxiety and stress in adults with non-traumatic SCI (NT-SCI) compared with adults with traumatic SCI (T-SCI).

SETTING

Victoria, Australia. Adults (N=443; NT-SCI n=62) living in the community and attending specialist SCI rehabilitation clinics.

METHODS

Participants completed a self-report survey by internet, telephone or hard copy. Items included demographic and injury-related characteristics and the short form Depression, Anxiety and Stress Scale (DASS-21).

RESULTS

Persons with NT-SCI were significantly more likely to be female (P<0.05), older (P<0.001) and have lower-level incomplete injuries (P<0.001). The probability of depression, anxiety or stress in respondents with NT-SCI did not differ from persons with T-SCI (P>0.05). Overall, the prevalence of adverse mental health problems defined by scoring above DASS-21 cutoffs, were depression 37%, anxiety 30%, and clinically significant stress 25%.

CONCLUSIONS

This study examined multiple mental health outcomes after NT-SCI in Australia. This study provides some evidence that the results of studies of depression, anxiety or stress in persons with T-SCI can be generalised to those with NT-SCI in the post-acute phase. NT-SCI patients are also at substantial risk of poor mental health outcomes. General demographic and injury-related characteristics do not seem to be important factors associated with the mental health of adults with SCI whether the SCI is traumatic or non-traumatic in origin.

Non-traumatic spinal cord lesions: epidemiology, complications, neurological and functional outcome of rehabilitation

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVE

To study epidemiology, complication, neurological and functional outcome in non-traumatic spinal cord lesions (NTSCL) after inpatient rehabilitation.

SETTING

Neurological rehabilitation unit of a tertiary research hospital.

METHODS

Sixty-four patients (M/F=28:36) with NTSCL admitted from June 2005 to January 2008 for multidisciplinary rehabilitation. Epidemiology, medical complications during stay in rehabilitation, admission and discharge--Barthel Index (BI) and American Spinal Injury Association (ASIA) impairment scale for functional and neurological recovery, respectively, were recorded and analyzed.

RESULTS

NTSCL constituted 60% (64 of 106) of the total SCL patients admitted for rehabilitation during the same period. Female patients outnumbered males (56.25%) in the study. Mean age, duration of illness and duration of stay in rehabilitation were 30.64+/-13.67 years (6-57), 7.09+/-9.15 months (1-48) and 55.75+/-40.91 days (14-193), respectively. The ratio of paraplegia and quadriplegia was 2:1. Forty-four patients (68.75%) had incomplete cord lesion according to the ASIA impairment scale. Spinal tumors (26.6%) were found to be the most common etiology, followed by Pott's spine (25%) and transverse myelitis (22%). Urinary tract infection was found to be the most common complication (50%), followed by spasticity (35.93%) and urinary incontinence (31.25%). The mean BI scores showed significant (P=0.000) functional recovery during rehabilitation using paired Student's t-test. The ASIA impairment scale showed significant neurological recovery (P=0.001) using the Wilcoxon non-parametric test.

CONCLUSIONS

NTSCL constitute a significant proportion of overall SCL. Female population, paraplegia and incomplete cord lesions are more common among NTSCL in this study. Patients with NTSCL recover significantly both neurologically and functionally with rehabilitation intervention.

Secondary conditions in spinal cord injury: results from a prospective survey

STUDY DESIGN

Prospective, self-report mail survey with two points of measurement one year apart.

OBJECTIVES

To determine significant predictors of pressure ulcers (PU) and urinary tract infections (UTI) in adults with spinal cord injury (SCI) over 2 years.

SETTING

Non-institutionalized adults with SCI living in the United States of America.

METHODS

Secondary data analysis from 2 consecutive years. Independent variables included demographic, healthcare-related, functional, access to care, and health behavior measures. Dependent variables were the occurrence of PU and UTI at Time 2.

RESULTS

Bivariate analyses showed significant associations between various independent variables and the occurrence of PU and UTI at Time 2. Separate logistic regression analyses for PU and UTI at Time 2 as dependent variables showed that PU at Time 1, not being married or cohabiting, not having access to primary care services when needed, and reporting a greater number of activities of daily living (ADL) requiring assistance were significant predictors of PU at Time 2. UTI at Time 1, a greater number of ADLs requiring assistance, and not engaging in weekly exercise are significant predictors of subsequent occurrence of UTI.

CONCLUSIONS

Findings support previous research, and indicate the need for increased efforts to provide SCI self-management education to at-risk subpopulations, including individuals with greater personal assistance needs and functional limitations.

Comparison of functional results in non-traumatic and traumatic spinal cord injury

PURPOSE

This study was conducted primarily to be a descriptive study about non-traumatic (NT) spinal cord injury (SCI) patients, in terms of their demographic and neurological features, and to investigate the complications and efficient results of rehabilitation in this group. The second aim of the study was to conduct a comparison between non-traumatic SCI patients and traumatic SCI patients.

MATERIALS AND METHODS

The design was a retrospective study at a Physical Medicine and Rehabilitation Training and Research center. The study was carried out with 194 patients, of whom 63 had non-traumatic SCI and 131 had traumatic SCI. Main outcome measures were: Demographics, etiology, Functional Independent Measure score, and level of injury.

RESULTS

A total of 32.47% (n = 63) of the patients in the study had a non-traumatic SCI. In traumatic SCI group, the proportion of male patients were significantly more than the proportion of female patients (p = 0.002). Admission FIM score of non-traumatic SCI group was better than the traumatic SCI group (p = 0.004). The comparison of discharge FIM scores between traumatic SCI and non-traumatic SCI groups did not yield any significant results (p = 0.303). However, the comparison of FIM gain between the two groups showed a significant difference (p = 0.03). The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (39.68%).

CONCLUSIONS

The present study showed that there are certain differences between NT and traumatic SCI patients. Therefore, not all SCI patients should be considered to be falling under a single category, and should be divided into groups on the basis of the etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program.

Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN

Retrospective, 3-year case series.

OBJECTIVE

To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI).

SETTING

Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI.

METHOD

Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores.

RESULTS

Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores.

CONCLUSIONS

Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.

The prevalence of neuropathic pain after non-traumatic spinal cord lesion

STUDY DESIGN

Retrospective register study.

OBJECTIVE

To investigate the predictive value of the following parameters for the development of neuropathic pain after non-traumatic spinal cord lesion: that is age at onset of spinal cord disease, gender, completeness of lesion, level of lesion, and aetiology.

SETTING

A unit for patients with post-acute traumatic and non-traumatic spinal cord lesions in the greater area of Stockholm, Sweden.

METHOD

All patients with non-traumatic spinal cord lesions visiting the unit between 1995 and 2000 were classified according to the following: that is neuropathic pain at or below lesion level according to IASP criteria, age at time of the onset of the spinal cord symptoms, injury level, complete/incomplete injury, and aetiology. Results were analysed with chi(2) - analysis and logistic regression.

RESULTS

In total, 38% had neuropathic pain, 15% had pain predominantly at the level of lesion, and 23% predominantly below the level of lesion. Of those with pain, 67% reported that the pain affected daily life. Women reported neuropathic pain below the level of lesion more often (40%) than men (13%). The prevalence was particularly high (64%) for patients with malignant spinal cord diseases. Neither age at onset of the spinal cord symptoms, nor complete/incomplete injury nor injury level had significant influence on the prevalence.

CONCLUSION

Neuropathic pain is common among patients with acquired non-traumatic spinal cord lesions regardless of aetiology, often causing severe problems in daily life.

Nontraumatic spinal cord lesions: a prospective study of medical complications during in-patient rehabilitation

STUDY DESIGN

Prospective study between 1st Jan 1995 and 31st Dec 1999.

OBJECTIVE

To document medical complications among subjects with Nontraumatic Spinal Cord Lesions (NTSCL) during in-patient rehabilitation.

SETTING

Bangalore, India.

METHODS

Persons with NTSCL admitted for in-patient rehabilitation were included in the study. Clinical evaluation was carried out according to The International Standards for Neurological and Functional classification of Spinal Cord Injury. Disability was quantified using Barthel index. All medical complications were documented.

RESULTS

A total of 297 subjects (154 men and 143 women) with NTSCL were included. The number of medical complications in each patient varied from 0 to 17 (mean=6.1+/-3.7). Common complications seen were urinary tract infections (184), spasticity (169), pain (149), urinary incontinence (147), depression (114), respiratory tract infections (101), constipation (92), pressure ulcers (89), contractures (52) and sleep disturbance (43). The number of medical complications correlated positively with duration of stay (Pearson's correlation coefficient r=0.5, P<0.01) and negatively with Barthel Index at admission (r=-0.2, P<0.05) and at discharge (r=-0.2, P<0.05). Complications were more frequent among people with tetraplegia than those with paraplegia (P<0.001).

CONCLUSIONS

Medical complications are frequent among subjects undergoing rehabilitation for NTSCL. Patients with severe disability at admission have more complications during rehabilitation. Conversely, individuals with more complications have greater disability at discharge.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1,962 and 2,000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study 1,211No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.22Reprints are not available from the author

OBJECTIVE

To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability.

DESIGN

Retrospective data analysis, 3-year case series.

SETTING

Tertiary medical unit specializing in nontraumatic SCI rehabilitation.

PARTICIPANTS

Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation.

INTERVENTION

Chart review.

MAIN OUTCOME MEASURES

Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores.

RESULTS

Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10 m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=-11.2; P<.000).

CONCLUSIONS

Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients' disability was usually significantly reduced during rehabilitation.

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs).

SUMMARY OF BACKGROUND DATA

NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce.

METHOD

The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs).

RESULTS

Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs.

CONCLUSIONS

The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation

BACKGROUND

Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH).

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To report on outcomes and factors affecting these.

SETTING

The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel.

SUBJECTS

A total of 158 patients with DH spinal neurological lesions (DHSNL).

METHOD

Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA.

RESULTS

The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time.

CONCLUSIONS

Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.

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.

Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To investigate the characteristics, predictors, and consequences of pressure ulcers in patients with nontraumatic spinal cord injury (SCI).

DESIGN

Retrospective, 3-year, case series.

SETTING

Tertiary medical unit specializing in SCI rehabilitation.

PARTICIPANTS

Consecutive sample of 134 adult inpatient referrals with nontraumatic SCI. Patients requiring initial rehabilitation or readmission were included.

INTERVENTION

Chart review.

MAIN OUTCOME MEASURES

Primary outcome measures were presence of pressure ulcers on admission to rehabilitation, incidence of new pressure ulcers developing during hospitalization, and any complications attributable to pressure ulcers during inpatient rehabilitation. Secondary objectives were to examine the predictability of risk factors for pressure ulcers, to assess the usefulness of a model previously developed for predicting pressure ulcers in patients with chronic SCI, and to estimate the effect of pressure ulcers on rehabilitation of nontraumatic SCI.

RESULTS

Prevalence of pressure ulcers among admissions was 31.3% (n=42). Only 2.2% (n=3) of patients developed a new pressure ulcer after admission. The length of stay (LOS) of patients admitted with a pressure ulcer was significantly longer than that of those without a pressure ulcer (geometric mean, 62.3 d for pressure ulcer vs 28.2 d for no pressure ulcer, P=.0001). Many previously identified risk factors for pressure ulcers in SCI patients did not apply to our nontraumatic SCI patients. It is estimated that the inpatient LOS for those patients with a significant pressure ulcer was increased by 42 days.

CONCLUSIONS

Pressure ulcers are a common complication for people with nontraumatic SCI who are admitted for rehabilitation, and they have a significant impact on LOS.