Comorbid Traumatic Brain Injury and Spinal Cord Injury: Screening Validity and Effect on Outcomes

Acute non-traffic traumatic spinal cord injury in the aging population: Analysis of the National Inpatient Sample 2005-2018

BACKGROUND

This study aimed to determine risk factors for poor in-hospital outcomes in a large cohort of older adult patients with acute non-traffic traumatic spinal cord injury (tSCI).

METHODS

This is a population-based, retrospective, observational study. Data of older adults ≥65 years with a primary discharge diagnosis of acute non-traffic tSCI were extracted from the US National Inpatient Sample (NIS) database 2005-2018. Traffic-related tSCI admissions or patients lacking complete data on age, sex and outcomes of interest were excluded. Univariate and multivariate logistic regression analysis was used to determine associations between variables and in-hospital outcomes.

RESULTS

Data of 49,449 older patients (representing 246,939 persons in the US) were analyzed. The mean age was 79.9 years. Multivariable analyses revealed that severe International Classification of Disease (ICD)-based injury severity score (ICISS) (adjusted odds ratio [aOR] = 3.14, 95% confidence interval [CI]: 2.77-3.57), quadriplegia (aOR = 2.79, 95%CI: 2.34-3.32), paraplegia (aOR = 2.60, 95%CI:1.89-3.58), cervical injury with vertebral fracture (aOR = 2.19, 95%CI: 1.90-2.52), and severe liver disease (aOR = 2.33, 95%CI: 1.34-4.04) were all strong independent predictors of in-hospital mortality. In addition, malnutrition (aOR = 3.19, 95% CI: 2.93-3.48) was the strongest predictors of prolonged length of stay (LOS).

CONCLUSIONS

Several critical factors for in-hospital mortality, unfavorable discharge, and prolonged LOS among US older adults with acute non-traffic tSCI were identified. In addition to the factors associated with initial severity, the presence of severe liver disease and malnutrition emerged as strong predictors of unfavorable outcomes, highlighting the need for special attention for these patient subgroups.

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome.

METHODS

The TraumaRegister DGU® was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined.

RESULTS

12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%).

CONCLUSIONS

The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.

Myokines may target accelerated cognitive aging in people with spinal cord injury: A systematic and topical review

Persons with spinal cord injury (SCI) can suffer accelerated cognitive aging, even when correcting for mood and concomitant traumatic brain injury. Studies in healthy older adults have shown that myokines (i.e. factors released from muscle tissue during exercise) may improve brain health and cognitive function. Myokines may target chronic neuroinflammation, which is considered part of the mechanism of cognitive decline both in healthy older adults and SCI. An empty systematic review, registered in PROSPERO (CRD42022335873), was conducted as proof of the lack of current research on this topic in people with SCI. Pubmed, Embase, Cochrane and Web of Science were searched, resulting in 387 articles. None were considered eligible for full text screening. Hence, the effect of myokines on cognitive function following SCI warrants further investigation. An in-depth narrative review on the mechanism of SCI-related cognitive aging and the myokine-cognition link was added to substantiate our hypothetical framework. Readers are fully updated on the potential role of exercise as a treatment strategy against cognitive aging in persons with SCI.

Difficulties capturing co-occurring traumatic brain injury among people with traumatic spinal cord injury: a population-based study

STUDY DESIGN

This is a population-based prospective cohort study.

OBJECTIVES

Traumatic brain injury (TBI) is common among people with traumatic spinal cord injury (TSCI), but rates vary across studies associated with variable approaches to diagnosis. We aimed to determine if a published diagnostic algorithm could be consistently applied to capture co-occurring TBI among persons sustaining TSCI.

SETTING

One of two spinal centres in New Zealand (NZ), the Burwood Spinal Unit (BSU) captures approximately 45% of NZ TSCI admissions.

METHODS

Adults (age 16+) with TSCI admitted to the BSU between 1 January 2021 and 31 August 2021 (n = 51) were included. Clinical notes were audited prospectively to identify co-occurring TBI.

RESULTS

We identified co-occurring TBI in 39% of TSCI cases with a small number of additional suspected TBI cases where TBI could not be confidently ruled in or out. Including all TBI cases, suspected or otherwise resulted in up to 55% of the sample having sustained co-occurring TBI. There were difficulties applying the published algorithm, associated with inconsistent documentation of TBI indicators from acute to rehabilitation contexts.

CONCLUSIONS

In this study, the feasibility of a TBI diagnostic algorithm for the TSCI population was low. Alternative approaches to screening for TBI among people sustaining TSCI are needed. Greater consistency in documenting TBI across the continuum of care will ensure TBI if present, is included in treatment planning.

Concomitant Brain Injury and Spinal Cord Injury Management Strategies: A Narrative Review

Spinal cord injury (SCI) is a catastrophic event with multiple comorbidities including spastic paralysis, sensory loss, autonomic dysfunction with sympathetic blunting, neurogenic orthostatic hypotension, neurogenic restrictive and obstructive lung disease, neuropathic pain, spasticity, neurogenic bladder, neurogenic bowel, immobilization hypercalcemia, osteopenia/osteoporosis, neurogenic obesity, and metabolic dysfunction. Cervical and thoracic SCI is all too often accompanied by traumatic brain injury (TBI), which carries its own set of comorbidities including headaches, seizures, paroxysmal sympathetic hyperactivity, aphasia, dysphagia, cognitive dysfunction, memory loss, agitation/anxiety, spasticity, bladder and bowel incontinence, and heterotopic ossification. This manuscript will review the etiology and epidemiology of dual diagnoses, assessment of both entities, and discuss some of the most common comorbidities and management strategies to optimize functional recovery.

Influence of age on acute traumatic spinal cord injury in Saint Petersburg, Russia

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate influence of age after traumatic spinal cord injury (TSCI).

SETTING

13 specialized hospitals with neurosurgical departments of Saint Petersburg, Russia.

METHODS

Charts of all patients admitted with TSCI to the city hospitals 2012-2016. Demographic and clinical characteristics, surgical interventions, complications, mortality rate, and hospital stays were recorded.

RESULTS

311 patients with TSCI were included. TSCI was more common in younger age. Mean age (SD) was 42.4 (16.8) years. Patients were divided into four age groups: 18-29, 30-44, 45-59 and ≥60 years. The group ≥60 years had the lowest percentage of concomitant traumatic brain injury (TBI), 25%, versus 43% in TSCI < 60 years, p < 0.05. Low falls were the most frequent cause in patients aged 60 years and older, and led to less severe neurological deficits (p < 0.05). Complications were most frequent in motor complete TSCI (AIS A and AIS B) and in persons with combined TSCI and TBI at older age. Total complication rate was 67% at the age of ≥60 years versus 38% <60 years in TSCI with TBI (p < 0.05). Respiratory complications occurred in 67% ≥45 years versus 45% <45 years, p < 0.05. In-hospital mortality rate after TSCI was higher in the oldest age group.

CONCLUSIONS

Respiratory complications are common and the in-hospital mortality is higher among elderly people. Older patients with TSCI and TBI are at high risk for complications.

The Neural Mechanisms Underlying Processing Speed Deficits in Individuals Who Have Sustained a Spinal Cord Injury: A Pilot Study

Our objective was to determine differences in brain activation during a processing-speed task in individuals with SCI compared to a group of age-matched healthy controls and to a group of older healthy controls. Ten individuals with cervical SCI (C3-C5), 10 age-matched healthy controls and 10 older healthy controls participated in a cross-sectional study in which performance on neuropsychological tests of processing speed and brain activation were the main outcome measures. The brain areas used by the individuals with SCI during the processing-speed task differed significantly from the age-matched healthy controls, but were similar to the older control cohort, and included activation in frontal, parietal and hippocampal areas. This suggests that individuals with SCI may compensate for processing-speed deficits by relying on brain regions that classically support control cognitive processes such as executive control and memory.

The Impact of a Comorbid Spinal Cord Injury on Cognitive Outcomes of Male and Female Patients with Traumatic Brain Injury

INTRODUCTION

Evidence of the effect of comorbid spinal cord injury (SCI) on cognitive outcomes in persons undergoing rehabilitation following newly diagnosed traumatic brain injury (TBI) is limited. We conducted a population-based study to investigate this effect.

OBJECTIVE

To compare cognitive outcomes in patients with TBI with and without a comorbid SCI.

SETTING/PARTICIPANTS

Adult patients diagnosed with TBI were identified and followed for 1 year through provincial health administrative data; those who entered inpatient rehabilitation were studied.

DESIGN

A retrospective matched cohort study using the National Rehabilitation Reporting System data of all acute care and freestanding rehabilitation hospitals in Ontario, Canada.

MAIN MEASURES

The exposure was a comorbid SCI in patients with diagnosed TBI. Exposed patients were matched to unexposed (TBI-only) on sex, age, injury severity, and income, in a ratio of one to two. Gain differences in the cognitive subscale of the Functional Independence Measure were compared between exposed and unexposed patients using multivariable mixed linear model, controlling for comorbidity propensity score, gains in motor function, and rehabilitation care indicators.

RESULTS

Over the first year post injury, 12 750 (0.84%) of all TBI patients entered inpatient rehabilitation, of whom 1359 (10.66%) had a comorbid SCI. A total of 1195 exposed patients (65.4% male, mean age 50.9 ± 20.6 for male and 61.8 ± 21.8 for female patients) were matched to 2390 unexposed patients. Controlling for confounding, exposed patients had lower cognitive gain (beta -0.43; 95% CI -0.72, -0.15), for both male (beta -0.39; 95% CI -0.75, -0.03) and female (beta -0.51; 95% CI -0.97, -0.05) patients. The adverse effects of comorbid SCI were driven largely by lower gains in problem solving and comprehension.

CONCLUSIONS

Adult patients with TBI and comorbid SCI showed a lower cognitive domain response to inpatient rehabilitation than patients with TBI alone. Identifying patients at risk for worse cognitive outcomes may facilitate the development of targeted strategies that improve cognitive outcomes.

Complications and mortality after acute traumatic spinal cord injury in Saint Petersburg, Russia

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

We studied complications during early rehabilitation and their relation to length of stay (LOS) in the hospital as well as to survival in people with traumatic spinal cord injury (TSCI).

SETTING

All specialized hospitals of Saint Petersburg.

METHODS

We analysed all charts of patients admitted with acute TSCI to the city hospitals, 2012-2016. Patient characteristics, complications, time and cause of death, and LOS were recorded. Mean values with standard deviations and t-tests were used. We analysed mortality rate using the Kaplan-Meier method and calculated relative risks (RRs).

RESULTS

A total of 311 patients with TSCI were included. Complications occurred in 34% of patients; most were respiratory complications and pressure ulcers. Complications occurred more often in those with concomitant traumatic brain injury (TBI) (RR = 1.4, 95% CI: 1.2-1.8). All complications prolonged LOS (median, 11 days) and increased mortality in the acute phase (p < 0.001). In the early phase, 15% died, with a median time to death of 13 days. Respiratory complications markedly increased the death rate (RR = 18, 95% CI: 15-22). Mortality rate correlated also with age, TSCI severity and level, and concomitant TBI. Alcohol/drug consumption before TSCI increased the likelihood for complications (RR = 1.7, 95% CI: 1.3-2.1) and mortality (RR = 2.2, 95% CI: 1.6-3.1).

CONCLUSION

Focus on prevention as well as early and optimal treatment of complications, together with no or low alcohol/drug consumption may reduce mortality in the early phase after TSCI and at the same time shorten LOS.

Sex-specific incident dementia in patients with central nervous system trauma

Introduction

Despite evidence that central nervous system (CNS) trauma, including traumatic brain injury and spinal cord injury, can cause sustained neurocognitive impairment, it remains unclear whether trauma-related variables are associated with incident dementia independently of other known risk factors.

Methods

All adults without dementia entering the health-care system with diagnoses of CNS trauma were examined for occurrence of dementia. All trauma-related variables were examined as predictors in sex-specific Cox regression models, controlling for other known risk factors.

Results

Over a median follow-up of 52 months, 32,834 of 712,708 patients (4.6%) developed dementia. Traumatic brain injury severity and spinal cord injury interacted with age to influence dementia onset; women were at a greater risk of developing dementia earlier than men, all other factors being equal.

Discussion

Risk stratification of patients with CNS trauma by sex is vital in identifying those most likely to develop dementia and in understanding the course and modifying factors.

Incidence of adult traumatic spinal cord injury in Saint Petersburg, Russia

STUDY DESIGN

Retrospective population-based cohort study.

OBJECTIVES

To characterise the epidemiology of traumatic spinal cord injury (TSCI) among the inhabitants of Saint Petersburg, Russia.

SETTING

All hospitals in Saint Petersburg.

METHODS

Charts for all individuals admitted to city hospitals from 1st January 1 2012 to 31st December 2016 with acute TSCI were reviewed. Incidence rates were calculated for the whole period and for each year separately. Gender-specific and age-specific incidence rates were calculated, and epidemiological characteristics and possible risk factors were analysed.

RESULTS

A total of 361 people were identified. The average annual incidence rate was 17.6 per million, varying from 21.2 (2013) to 13.6 (2016), and 70.9% were men. Mean age at injury was 42.1 years. Injuries from falls represented 49.8% of cases, and motor vehicle accidents 18.9%. The male:female ratio in the low-falls group was 1.2:1, and among the elderly patients, it was 0.5:1. Lesions at the cervical level were involved in 49.3%, thoracic in 24.7%, and lumbar/sacral in 23.5%. TSCI was complete in 16.9%. Concomitant injuries occurred in 47.2% of cases, and traumatic brain injuries in 37.7%.

CONCLUSION

TSCI incidence decreased during the observation period and was 2.4 times more common among men than women. In half of the cases, injuries involved the cervical level, and a fall was the most frequent injury cause. Elderly women more often had falls from a low height than men. Multiple injuries-most frequently traumatic brain injuries-were common.

Patterns of cognitive deficits in persons with spinal cord injury as compared with both age-matched and older individuals without spinal cord injury

Context/Objective: Cognitive deficits can impact as many as 60% of individuals with spinal cord injury (SCI). In an effort to identify the nature of cognitive deficits in SCI, we examined neuropsychological test performance in individuals with SCI, age matched healthy controls and older healthy controls.Design: Participants completed a motor-free neuropsychological test battery assessing attention, working memory, information processing speed, new learning /memory and executive control.Setting: Outpatient rehabilitation research facility.Participants: Participants included 60 individuals with chronic spinal cord injury [SCI; 32 with paraplegia (T2-T12) and 28 with tetraplegia (C3-T1)], 30 age-matched healthy controls (AMHC; 30-40 years old) and 20 older healthy controls (OHC; 50-60 years old).Outcome Measures: Wechsler Intelligence Scale - 3^rd edition (WAIS-III) Digit Span and Letter-Number Sequencing; Symbol Digit Modalities Test (SDMT) - oral version; California Verbal Learning Test-II; Paced Auditory Serial Addition Test (PASAT); Wechsler Abbreviated Scale of Intelligence (WASI); Delis-Kaplan Executive Function System; Verbal Fluency subtest.Results: Significant differences were noted between the SCI and AMHC groups on measures of information processing speed, new learning and memory, and verbal fluency. No significant differences were noted between the groups on tests of attention or working memory.Conclusion: The current study documented differences in specific realms of cognitive functioning between a chronic SCI sample and AMHC. Implications for cognitive rehabilitation and overall quality of life are discussed. Additional research is needed utilizing a more comprehensive battery of motor-free neuropsychological tests that avoid the confound of upper limb motor limitations on cognitive performance.

Prevalence of concomitant traumatic cranio-spinal injury: a systematic review and meta-analysis

The biomechanical relationship between cranial and spinal structures makes concomitant injury likely. Concomitant cranio-spinal injuries are important to consider following trauma due to the serious consequences of a missed injury. The objective of this review was to estimate the prevalence of concomitant cranio-spinal injury in the adult trauma population. A systematic search of MEDLINE and EMBASE databases to identify observational studies reporting the prevalence of concomitant cranio-spinal injury in the general adult trauma population was conducted on 21 March 2017. The prevalence of concomitant cervical spinal injury in patients with a traumatic brain injury (TBI); the prevalence of concomitant spinal injury in patients with a TBI; the prevalence of concomitant TBI in patients with a cervical spinal injury; and the prevalence of concomitant TBI in patients with a spinal injury were calculated by meta-analysis. Twenty-one studies met the inclusion criteria and were included in this review. The prevalence of concomitant cervical spinal injury in patients with a TBI was found to be 6.5% (95% CI 6.0-7.1%); the prevalence of concomitant spinal injury in patients with a TBI to be 12.4-12.5%; the prevalence of concomitant TBI in patients with a cervical spinal injury to be 40.4% (95% CI 33.0-48.0%); and the prevalence of concomitant TBI in patients with a spinal injury to be 32.5% (95% CI 10.8-59.3%). This review reports the prevalence of concomitant cranio-spinal injury and highlights the importance of considering concomitant injury in patients with a cranial or spinal traumatic injury.