Survival after spinal cord injury in Australia

International comparison: Spinal cord injury in the USA and UK

BACKGROUND

Long-term survival after spinal cord injury (SCI) has been extensively studied in the US and UK.

OBJECTIVE

To compare SCI epidemiology and survival results between the US and UK for the same time period and patient groups.

METHODS

We restricted attention to persons injured at ages 18 and older who had survived at least 2 years post injury and were not ventilator dependent. We performed survival analysis using logistic regression on person-year data with time-dependent covariates. The resulting mortality rates were used to construct life tables in order to obtain life expectancies.

RESULTS

The average age at injury, percentage male, and level/grade of injury were rather similar between the two countries. After adjustment for risk factors, UK mortality was 85% of that in the US (95% c.i. 80% to 91%, p < 0.0001). Mortality increased by 0.3% per year over the 1980 to 2012 study period (HR = 1.003); this was not statistically significant (p = 0.44). The US and UK life expectancies are nearly the same percentage of their respective general population values, differing by at most 2%.

CONCLUSION

Long-term mortality after SCI in the UK is roughly 15% lower than that in the US. The general population mortality in the UK is also approximately 15% lower, however, and thus the percentages of normal life expectancy in the two countries prove to be strikingly similar.

A New Scale for Predicting the Risk of In-hospital Mortality in Patients With Traumatic Spinal Cord Injury

Purpose

To analyze the relative factors influencing in-hospital mortality in patients with traumatic spinal cord injury (TSCI), and develop a score scale for predicting the risk of in-hospital mortality.

Method

We reviewed the medical records from 59 spine centers in mainland China from 1 January 2018 to 31 December 2018. The inclusion criteria were (1) confirmed diagnosis of TSCI, (2) hospitalization within 7 days of injury, and (3) affecting neurological level from C1 to L1. The exclusion criteria were (1) readmission, and (2) incomplete data. Included patients were classified into the survival and non-survival groups according to their status at discharge. Univariate and multivariate logistic regressions were performed to identify the factors related to in-hospital mortality in patients with TSCI. A new scale was developed, and the mortality rate in each risk group was calculated.

Results

Of the 3,176 participants, 23 (0.7%) died in the hospital, and most of them died from respiratory diseases (17/23, 73.9%). After univariate and multivariate logistic regression analysis, cervical spinal cord injury [odds ratio (OR) = 0.264, 95% confidence interval (CI): 0.076–0.917, P = 0.036], abdominal visceral injury (OR = 3.778, 95% CI: 1.038–13.755, P = 0.044), the American Spinal Injury Association (ASIA) score on admission (A: reference; B:OR = 0.326, 95% CI: 0.093–1.146, P = 0.081; C:OR = 0.070, 95% CI: 0.016–0.308, P < 0.001; D:OR = 0.069, 95% CI: 0.019–0.246, P < 0.001), and surgery (OR = 0.341, 95% CI: 0.146–0.796, P = 0.013) were significantly associated with in-hospital mortality. Scores for each of the four factors were derived according to mortality rates. The sum of the scores from all four factors was included in the scoring system and represented the risk of in-hospital mortality. The in-hospital mortality risk of the low-risk (0–3 points), moderate-risk (4–5 points), and high-risk groups (6–8 points) was 0.3, 2.7, and 9.7%, respectively (P < 0.001).

Conclusions

Cervical spinal cord injury, abdominal visceral injury, ASIA score on admission, and surgery were significantly associated with in-hospital mortality in patients with TSCI and stable condition. The scale system may be beneficial for clinical decision-making and for communicating relevant information to patients and their families.

Long-Term Survival and Causes of Death in Patients below the Age of 60 with Traumatic Spinal Cord Injury in Germany

To study the mortality, cause and risk indicators of death in German patients with traumatic spinal cord injury, patients with traumatic spinal cord injury admitted to Berufsgenossenschaftliches Trauma Hospital Hamburg between 1 January 1997 and 31 December 2018, aged between 16 and 60 with a minimal survival of one year after injury, were included. Further criteria were the absence of life-limiting comorbidities at the time of injury. 223 deceased patients with traumatic spinal cord injury were identified, investigated on and partly compared to the surviving subjects. We aimed to discover specific complications that were related to Spinal Cord Injury and responsible for a possibly limited life expectancy. Data collection was performed during in- and outpatient treatment. A statistical analysis was performed to compare groups. The post-injury life expectancy was 25.0 years with a significant correlation regarding the level of lesion and severity of injury. The leading causes of death were cardiovascular diseases and pneumonia. Bladder cancer was the most common fatal malignant tumor. The life expectancy of patients suffering from traumatic spinal cord injury is limited. The longer a patient survives after injury and the lower the level of lesion, the more likely an age-related cause of death becomes. Bladder cancer is significantly more frequent when compared to the overall distribution of tumor diseases in Germany.

Pharmacologic and Regenerative Cell Therapy for Spinal Cord Injury: WFNS Spine Committee Recommendations

This is a review article examining the pharmacologic and regenerative cell therapy for spinal cord injury. A literature search during last 10 years were conducted using key words. Case reports, experimental (nonhuman) studies, papers other than English language were excluded. Up-to-date information on the pharmacologic and regenerative cell therapy for spinal cord injury was reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. Pharmacologic and regenerative cell therapy for spinal cord injury have long been an interest of many experimental and clinical researches. Clinical studies with methylpredinisolone have not shown clear cut benefit. Other drugs such as Rho inhibitor, minocycline, riluzole, granulocyte colony-stimulating factor have also been tried without significant benefits. Regenerative cell therapy using different types of stem cells, different inoculation techniques, and scaffolds have undergone many trials highlighting the efficacies of cells and their limitations. This review article summarizes the current knowledge on pharmacologic and regenerative cell therapy for spinal cord injury. Unfortunately, there is a need for further experimental and human trials to recommend effective pharmacologic and regenerative cell therapy.

Age as a determinant of inflammatory response and survival of glia and axons after human traumatic spinal cord injury

Despite the shift in the demographics of traumatic spinal cord injury (SCI) with increased proportion of injuries in the elderly, little is known on the potential effects of old age on the pathobiology of SCI. Since there is an assumption that age adversely affects neural response to SCI, this study examines the clinically relevant question on whether age is a key determinant of inflammatory response, oligodendroglial apoptosis and axonal survival after traumatic SCI. This unique study includes post-mortem spinal cord tissue from 64 cases of SCI (at cervical or high-thoracic levels) and 38 control cases without CNS injury. Each group was subdivided into subgroups of younger and elderly individuals (65 years of age or older at the SCI onset). The results of this study indicate that age at the SCI onset does not adversely affect the cellular inflammatory response to, oligodendroglial apoptosis and axonal survival after SCI. These results support the conclusion that elderly individuals have similar neurobiological responses to SCI as younger people and, hence, treatment decisions should be based on an assessment of the individual patient and not an arbitrary assumption that "advanced age" should exclude patients with an acute SCI from access to advanced care and translational therapies.

Time-related changes in quality of life in persons with lower limb amputation or spinal cord injury: protocol for a systematic review

BACKGROUND

Experiencing a lower limb amputation (LLA) or spinal cord injury (SCI) is a life-changing event, affecting physical and systemic function as well as having psychological and social impacts. However, the severity of the physical impairment and/or motor disability demonstrates a poor relationship with patient-reported quality of life, suggesting that other factors determine such outcomes. As such, holistic health-related quality of life (QoL) assessment is an important tool to monitor long-term outcomes. While there are some studies that have assessed the influence of variables such as age at time of injury occurrence and time since injury on changes in QoL, there are no systematic reviews which synthesise this evidence.

METHODS/DESIGN

All follow-up study designs will be included, where data from multiple time points are presented. Searches will target both SCI and LLA populations where a validated measure of QoL has been used: Medical Outcome Study Short-Form 36/12 or the World Health Organization Quality of Life instruments 100 and BREF. Studies must include adult participants (≥ 18 years at time of injury) and detail time since injury event and patient age. The primary objective is to establish the effects of participant age and time since injury on QoL scores. Secondary objectives include determining between-group effects (i.e. LLA vs. SCI). We will search PubMed, Embase and Web of Science databases, supplemented by hand-searching references within existing review articles and experimental studies. Reviewer pairs will conduct screening and quality assessment of included papers. Results will be stratified by impairment, QoL tool, age/time since injury and additional variables such as sex, race, comorbidity or disease aetiology, as appropriate. If sufficient high-quality data exist, a meta-analysis will be conducted.

DISCUSSION

The results of this systematic review will summarise evidence of how QoL changes across the life course, relative to both patient age and time since injury, for both LLA and SCI populations. By enabling a direct comparison of different chronic conditions, disability-specific differences in QoL changes over the life course can be identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096633 .

Mortality Rate and Predicting Factors of Traumatic Thoracolumbar Spinal Cord Injury; A Systematic Review and Meta-Analysis

Objective

To estimate the summation of mortality rate and the contributing factors in patients with traumatic thoracolumbar spinal cord injuries (TLSCI).

Methods

A systematic search of observational studies that evaluated the mortality associated with TLSCI in MEDLINE and EMBASE was conducted. The study quality was evaluated using a modified quality assessment tool previously designed for observational studies.

Results

Twenty-four observational studies involving 11,205 patients were included, published between January 1, 1997, and February 6, 2016. Ten studies were of high quality, thirteen were of moderate quality, and one study was of low quality. Seventeen reports described risk factors for mortality and eleven of these studies used a multiple regression models to adjust for confounders. The reported mortality rate ranged from 0 to 37.7% overall and between 0 and 10.4% in-hospital. The sum of mortality for in-hospital, 6-month, and 12-month were 5.2%, 26.12%, 4.3%, respectively. The mortality at 7.7 years follow-up was 10.07% and for 14 years follow-up reports ranged from 13.47% to 21.46%. Associated data such as age at injury, male to female ratio, pre-existing comorbidities, concomitant injuries, duration of follow-up, and cause of death have been underreported in studies investigating the mortality rate after TLSCI.

Conclusion

There is no study was found that accurately assessed mortality in the thoracolumbar spine, while there is general agreement that traumatic thoracolumbar spinal cord injuries are important.

A safe and effective multi-day colonoscopy bowel preparation for individuals with spinal cord injuries

CONTEXT/OBJECTIVE

Colonoscopy with polypectomy is associated with a reduced risk of colorectal cancer (CRC), but poor bowel cleansing limits the diagnostic yield of the procedure. Patients with spinal cord injury (SCI) frequently have suboptimal bowel cleansing with standard pre-colonoscopy bowel preparation regimens. We aimed to assess the safety, tolerability, and efficacy of a multi-day inpatient bowel preparation regimen in a population of patients with SCI.

DESIGN

Retrospective case series.

SETTING

VA Puget Sound SCI Center.

PARTICIPANTS

All patients with SCI (n = 53) who underwent inpatient colonoscopy at the VA Puget Sound from July 12, 2013 to February 12, 2015.

OUTCOME MEASURES

Patient characteristics, tolerance of full bowel preparation, pre- and post-bowel preparation electrolyte values, adverse events, and adequacy of bowel cleansing were abstracted.

RESULTS

Sixty-eight percent of patients had a cervical level of injury and the majority were either American Spinal Injury Association Impairment Scale A (41%) or D (43%). The full bowel preparation was tolerated by 91% of inpatients. In those with pre- and post-bowel preparation laboratory testing, there were small, but statistically significant decreases in serum calcium and phosphate. No patient had symptoms associated with electrolyte abnormalities or required treatment. Five out of 53 inpatients experienced autonomic dysreflexia (AD) during bowel preparation. Eighty-nine percent of patients had adequate bowel cleansing at colonoscopy.

CONCLUSIONS

We demonstrate a safe and effective inpatient bowel preparation regimen in a SCI population. The regimen was associated with mild, asymptomatic hypophosphatemia and hypocalcemia. AD was an uncommon event, predominantly occurring in patients who experienced frequent AD episodes at baseline.

The association between bladder-emptying methods and health-related quality of life among Iranian individuals with spinal cord injury

OBJECTIVES

In this study, we compared the health-related quality of life (HRQoL) among patients with spinal cord injury (SCI) using different bladder emptying methods including normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization.

DESIGN

Cross-sectional.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Patients referred to Brain and Spinal Cord Injury Research Center between 2012 and 2014.

OUTCOME MEASURES

HRQoL was assessed by Short Form Health Survey (SF-36). Hierarchical regression analysis with adjustment for probable confounders (demographic and injury-related variables) was performed to assess the relationship between bladder-emptying method and total SF-36 score.

RESULTS

Patients with injury at cervical sections had significantly lower scores in domain of physical functioning (PF), physical component summary (PCS) and total score (P: 0.001, <0.0001 and 0.027, respectively). Longer time since injury was associated with better scores of PCS, Mental component summary (MCS) and total score (P: 0.002, <0.0001 and 0.003, respectively). Regression analysis showed that the effect of bladder-emptying method on total score of SF-36 was significant (P < 0.0001) and this relationship remained significant after adjustment for probable confounders in the second step of hierarchical regression analysis (R: 0.923, R²: 0.852, Adjusted R²: 0.847, P < 0.0001). Patients with NSM had the highest scores in SF-36 instrument and individuals with indwelling catheterization had the poorest HRQoL in all domains.

CONCLUSION

This study shows that the type of bladder management method affects HRQoL significantly in patients with SCI. Intermittent catheterization are recommended to be administered instead of indwelling catheterization to improve HRQoL.

Factors predictive of survival and estimated years of life lost in the decade following nontraumatic and traumatic spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To identify factors predictive of survival after spinal cord injury (SCI).

SETTING

Tertiary care institution.

METHODS

Multiple-variable Cox proportional hazards regression analysis for 759 patients with SCI (535 nontraumatic and 221 traumatic) included age, sex, completeness of injury, level of injury, functional independence measure (FIM) scores, rehabilitation length of stay and SCI cause. Estimated years of life lost in the decade after injury was calculated for patients vs uninjured controls.

RESULTS

Median follow-up was 11.4 years. Population characteristics included paraplegia, 58%; complete injury, 11%; male sex, 64%; and median rehabilitation length of stay, 16 days. Factors independently predictive of decreased survival were increased age (+10 years; hazard ratio (HR (95% CI)), 1.6 (1.4-1.7)), male sex (1.3 (1.0-1.6)), lower dismissal FIM score (-10 points; 1.3 (1.2-1.3)) and all nontraumatic causes. Metastatic cancer had the largest decrease in survival (HR (95% CI), 13.3 (8.7-20.2)). Primary tumors (HR (95% CI), 2.5 (1.7-3.8)), vascular (2.5 (1.6-3.8)), musculoskeletal/stenosis (1.7 (1.2-2.5)) and other nontraumatic SCI (2.3 (1.5-3.6)) were associated with decreased survival. Ten-year survival was decreased in nontraumatic SCI (mean (s.d.), 1.8 (0.3) years lost), with largest decreases in survival for metastatic cancer and spinal cord ischemia.

CONCLUSIONS

Age, male sex and lower dismissal FIM score were associated with decreased survival, but neither injury severity nor level was associated with it. Survival after SCI varies depending on SCI cause, with survival better after traumatic SCI than after nontraumatic SCI. Metastatic cancer and vascular ischemia were associated with the greatest survival reduction.

Mortality and longevity after a spinal cord injury: systematic review and meta-analysis

BACKGROUND/AIMS

Mortality and longevity studies of spinal cord injury (SCI) are essential for informing healthcare systems and policies. This review evaluates the current evidence among people with SCIs worldwide in relation to the WHO region and country income level; demographic and lesion characteristics; and in comparison with the general population.

METHODS

A systematic review of relevant databases for original studies. Pooled estimates were derived using random effects meta-analysis, restricted to traumatic SCI.

RESULTS

Seventy-four studies were included. In-hospital mortality varied, with pooled estimates of 24.1% (95% confidence interval (CI) 14.1-38.0), 7.6% (95% CI 6.3-9.0), 7.0% (95% CI 1.5-27.4), and 2.1% (95% CI 0.9-5.0) in the WHO regions of Africa, the Americas, Europe and Western Pacific. The combined estimate for low- and middle-income countries was nearly three times higher than for high-income countries. Pooled estimates of first-year survival were 86.5% (95% CI 75.3-93.1), 95.6% (95% CI 81.0-99.1), and 94.0% (95% CI 93.3-94.6) in the Americas, Europe and Western Pacific. Pooled estimates of standardized mortality ratios in tetraplegics were 2.53 (2.00-3.21) and 2.07 (1.47-2.92) in paraplegics.

CONCLUSION

This study found substantial variation in mortality and longevity within the SCI population, compared to the general population, and between WHO regions and country income level. Improved standardization and quality of reporting is needed to improve inferences regarding the extent to which mortality outcomes following an SCI are related to healthcare systems, services and policies.

Predictors of mortality in veterans with traumatic spinal cord injury

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine the predictors of mortality in veterans with traumatic spinal cord injury (tSCI).

SETTING

Tertiary clinic in the state of Oklahoma.

METHODS

One hundred and forty-seven patients with tSCI who were enrolled in our Spinal Cord Injury program from 1 January 2000 to 31 December 2011 were retrospectively studied. The study sample was divided into two groups, based on the survival status by 31 December 2011.

RESULTS

In this sample of 147 patients with tSCI, survival at the end of the 12-year study period was 60%. There were three major causes of death: infection-related, such as pneumonia (21%), urinary infection (14%), and infection of the pressure ulcers (11%); cardiovascular-related, such as congestive heart failure (16%), coronary arterial disease (13%), and atrial fibrillation (2%); and cancer-related (16%). In veterans with complete SCI, deaths were mainly infection-related and occurred in the hospital (51%), while deaths in veterans with incomplete SCI were primarily cardiovascular and cancer-related and occurred in the community. A Cox regression analysis showed the age at the time of injury to be the main predictor of SCI-related mortality.

CONCLUSION

This study suggests that an older age at the time of injury is a significant predictor of mortality following tSCI with patients more likely to die from cardiovascular deaths than the general population. These findings support the need for preventative strategies, including a focus on cardiovascular risk factor management, in order to decrease long-term mortality.

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.

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.

Epidemiology of traumatic spinal cord injury: trends and future implications

STUDY DESIGN

Review supplemented by inception cohort.

OBJECTIVES

To review trends in the incidence, prevalence, demographic characteristics, etiology, injury severity and selected treatment outcomes of traumatic spinal cord injury (SCI).

SETTING

International review and US model systems cohort.

METHODS

An extensive literature review was conducted to identify all relevant studies of descriptive epidemiology of traumatic SCI. This review was supplemented by analyses of trends in US SCI epidemiology that are reflected in the National Spinal Cord Injury Statistical Center and Shriners Hospital Spinal Cord Injury databases.

RESULTS

Incidence and prevalence of traumatic SCI in the United States are higher than in the rest of the world. Average age at injury is increasing in accordance with an aging general population at risk. The proportion of cervical injuries is increasing, whereas the proportion of neurologically complete injuries is decreasing. Injuries due to falls are increasing. Recent gains in general population life expectancy are not reflected in the SCI population. Treatment outcomes are changing as a result of increasing age and changes in US health care delivery.

CONCLUSION

Within the prevalent population, the percentage of elderly persons will not increase meaningfully until the high mortality rates observed among older persons significantly improve. Those who reach older ages will typically have incomplete and/or lower level injuries, and will have relatively high degrees of independence and overall good health.

[Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care]

OBJECTIVE

To evaluate the impact of age (<or≥65 ans) on hospital mortality in traumatic spinal cord injury requiring intensive care.

DESIGN

Retrospective, monocenter.

PATIENTS AND METHODS

A total of 131 patients greater or equal to 15 years (<65 years, n=109 and ≥65 years, n=22) was analyzed (cervical, n=71; thoracolumbar, n=60), over a 10 years period (1998-2008). The hospital and long-term mortality were studied. The risks factors of death were searched by a uni- and multivariate analysis. Intensive care unit (ICU) discharge and long-term neurological recovery, and long-term functional independence measure (FIM) were assessed.

RESULTS

Hospital mortality was increased in patients greater or equal to 65 years (41% vs 6%, P<0.001) and long term mortality was not different between the two groups (31% vs 12%, P=0.150). The risks factors of death were age (HR=3.44; IC 95%: 1.53-7.72, P=0.028), previous coronary disease (HR=3.64; IC 95%: 1.25-10.65; P=0.018) and fall injury (HR=2.40; IC 95%: 1.15-5.00, P=0.020). Among survivors, incompletes forms (Frankel B, C, D, E) were significantly more frequent in older patients at ICU discharge and long term follow up. At long term, FIM was similar in the two groups except a better sphincter control in patient greater or equal to 65 years.

CONCLUSION

Mortality rate of older people (≥65 years) were greater than those in younger people, mainly caused by an increased hospital mortality. Among survivors, the neurological recovery was better in patients' greater or equal to 65 years, and was associated with a functional status at least comparable than in the youngest patients.

The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home

PURPOSE

To open a discourse on the concept of autonomy as a precursor for participation in individuals with Spinal Cord Injury (SCI) by exploring the experiences about their perceived autonomy in their transition period from hospital to home.

METHOD

Based on the 'grounded theory' approach; in-depth, semi structured interviews were conducted with 11 SCI-patients. A theoretical sampling strategy was used and the data was analysed according to the constant comparative method.

RESULTS

To capture this complexity of autonomy, the results have been structured in themes with regard to the self of the patient and his independency. The analysis showed four different typologies of how autonomy is perceived; (1) the active agent, (2) the active follower, (3) the passive follower and (4) the passive victim.

CONCLUSION

Rehabilitation professionals can help individuals in disconnecting their internalised ideal of independency to avoid the illusion of being autonomous and can gain insight in the patients' typology and empower patients to avoid the paradox of being autonomous. If the ultimate goal of rehabilitation is participation; empowering the patient to achieve a 'sense of agency' instead of autonomy is the central goal for rehabilitation professionals. Empowerment and agency are key topics for the patient to gain mastery over his own life.

Predictive factors of long-term mortality of persons with tetraplegic spinal cord injury: an 11-year French prospective study

STUDY DESIGN

Longitudinal study with mortality follow-up.

OBJECTIVE

Identify predictive factors for long-term mortality following tetraplegic spinal cord injury (TSCI).

SETTING

The Tetrafigap survey is a multi-centre epidemiological survey on the long-term outcome of persons with TSCI, initiated in France in 1995 with the participation of 35 rehabilitation centres.

METHODS

The mortality follow-up involves 1241 persons with TSCI who were admitted to one of the study rehabilitation units at the initial phase and who completed the initial self-administered questionnaire. There were 226 observed deaths (18.2%) during an 11-year period. Logistic regression methods, with estimates of odds ratios (ORs), incorporating clinical, functional and social participation data were used to determine the factors related to mortality. This was followed by multivariate analysis to determine the best predictive factors for long-term mortality.

RESULTS

Risk of death increases significantly with age but not with the time elapsed since the accident. The risk of death is higher in men. Interestingly, clinical variables are not the best predictors of long-term mortality. Instead, the significant effect of poor social participation (being single, infrequent contact with friends) and functional limitations (full assistance required with dressing or eating) persists after adjustment for other variables.

CONCLUSION

Once the medical situation becomes more stable, factors related to the long-term mortality of persons with TSCI are not exactly identical to those observed in the short acute-phase and during the first year after the accident. Social participation has a significant effect on mortality.

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.

Risk and protective factors for mortality after spinal cord injury

Our purpose was to systematically review research on postacute risk and protective factors for mortality after spinal cord injury including psychological, environmental, behavioral and health factors. A theoretical risk model was used to identify these sets of predictive factors and to structure this article. The majority of research identifies basic demographic (age and race) and injury factors (severity). More limited research has indicated that personality, purpose in life, income, social support and negative risk behaviors predict mortality. In terms of health factors and secondary conditions, pressure ulcers, amputations, depressive diagnosis and need for treatment also predict mortality. Interventions are needed that diminish the risk of secondary conditions and early mortality.

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.

Risk of mortality after spinal cord injury: relationship with social support, education, and income

Study Design

Prospective cohort study.

Objective

To identify the association of social support and socioeconomic factors with risk of early mortality among persons with SCI.

Setting

Participants were identified from a large specialty hospital in the Southeastern United States.

Methods

Data was collected by mailed survey, and mortality status was ascertained approximately 8 years later. The outcome was time from survey to mortality or censoring. Mortality status was determined using the National Death Index and the Social Security Death Index. There were 224 observed deaths (16.2%) in the full sample (n = 1,386). Due to missing data, the number of deaths used in the final analysis was 188 (out of 1249 participants).

Results

Cox proportional hazards modeling was used to build a comprehensive predictive model. After controlling for biographic and injury related factors, two of four environmental predictors were retained in the final model including low income and general social support. Years of education and the upsets scale, another aspect of social support, were not retained in the final model. Inclusion of these variables resulted in only modest improvement in the prediction of survival compared with biographic and injury variables alone, as the pseudo-R² increased from .121 to .134 and the concordance from .730 to .751.

Conclusion

Environmental factors are important predictors of mortality after SCI.

Developing core sets for persons with spinal cord injuries based on the International Classification of Functioning, Disability and Health as a way to specify functioning

OBJECTIVE

The objective of this paper is to outline the proposed development process for the ICF Core Sets for Spinal Cord Injury (SCI) and to invite clinical and consumer experts to actively participate in this process. ICF Core Sets are selections of categories of the International Classification of Functioning, Disability and Health (ICF) that are relevant to persons with a specific condition or in a specific setting.

METHOD

The project is a cooperation between the ICF Research Branch of the World Health Organization (WHO) Collaboration Centre of the Family of International Classifications (DIMDI, Germany), the Classification, Assessment and Terminology (CAT) team and the Disability and Rehabilitation (DAR) team at WHO, the International Spinal Cord Society (ISCoS) and International Society for Physical and Rehabilitation Medicine (ISPRM) and partner institutions across the world. The project will consist of four worldwide studies to be conducted from 2006 to 2007 with a proposed ICF Core Set Consensus Conference to be held in 2007. ICF categories relevant for SCI are to be identified by means of (I) an empirical study, (II) a systematic review of outcomes and measures used in SCI research (III) an expert survey and (IV) focus groups and semistructured interviews with persons with SCI. Consensus about items that have to be part of a Comprehensive and of a Brief ICF Core Set for SCI will be reached in a final ICF Core Set Consensus Conference. Subsequent field testing will be necessary to validate this first version of ICF Core Sets for SCI.

INVITATION FOR PARTICIPATION

The development of ICF Core Sets is an inclusive and open process. Anyone who wishes to actively participate in this process is invited to contact the project coordinator (Monika.Scheuringer@med.uni-muenchen.de or http://www.icf-research-branch.org/research/spinalcord-injuries.htm). Individuals, institutions and associations can be formally associated as partners of the project.

A follow-up study of patients with spinal cord injury in Sierra Leone

Over an 18-month period, 24 patients were admitted with spinal cord injuries in a non-governmental organization hospital in one of the world's poorest countries, Sierra Leone. Seven patients died while in hospital. Follow-up data was available for 13 of the 17 survivors an average of 17.4 (10-28) months after discharge. Five patients were still alive.

Forecasting of spinal cord injury annual case numbers in Australia

OBJECTIVES

To forecast annual numbers of cases of spinal cord injury (SCI) and to assess the effect on case mix.

DESIGN

Cohort of incident cases from 1986 to 1997, with forecasting to 2021.

SETTING

Australian cases registered by treatment centers for the acute care and rehabilitation of SCI patients.

PARTICIPANTS

A total of 2959 SCI patients, aged 15 years and over, identified through the Australian Spinal Cord Register.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence and case mix.

RESULTS

If the recent trends in SCI continue (ie, a 6.21% per annum rate increase in elderly men and a 2.8% per annum rate decrease in young men), the annual number of cases will increase from 253 in 1997 to 464 in 2021. In addition, the case mix would change substantially and the number and proportion of elderly persons with SCI would increase from 32 cases per annum in 1997 (13% of cases) to 233 per annum in 2021 (47% of cases). In addition, there would be a 143% increase in the number of cases of incomplete tetraplegia, from 88 cases per annum in 1997 to 214 cases per annum in 2021. Substantial increases would occur even if the age-specific rates of SCI were stable over the period.

CONCLUSIONS

Population growth, and aging, plus increasing rates of SCI in the elderly will have profound effects on the expected number of SCI patients and their case mix. Treatment centers in Australia will need to plan for these changes. At the same time, there should be increased efforts to prevent SCI in order to ameliorate the problem.