Functional outcome and discharge destination in elderly patients with spinal cord injuries

Decision Tree Analysis Accurately Predicts Discharge Destination After Spinal Cord Injury Rehabilitation

OBJECTIVES

To predict discharge destination after spinal cord injury (SCI) rehabilitation.

STUDY DESIGN

A retrospective, single-center study. We collected the following data from medical charts: age, sex, living arrangement before injury, acute length of stay (LOS), level of injury on admission, American Spinal Injury Association Impairment Scale (AIS) on admission, Upper Extremity Motor Score (UEMS) on admission, Lower Extremity Motor Score on admission (LEMS), Spinal Cord Independence Measure (SCIM) scores on admission and discharge, and discharge destination. A decision tree algorithm was used to establish prediction models in a train-test split manner using features on admission or discharge.

SETTING

A spinal center in Tokyo, Japan.

PARTICIPANTS

Participants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. The study included 210 participants divided into 2 groups: training (n=140) and testing (n=70). Random sampling without replacement was used.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prediction accuracy was evaluated with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating curve (AUC).

RESULTS

AIS was significantly different between the groups. The prediction model using total SCIM scores on discharge (D-Classification and Regression Tree [CART]) revealed that a cut-off value of 40 accurately predicted the discharge destination. In contrast, the prediction model using features on admission (A-CART) revealed that subtotal SCIM mobility scores of 5, age of 74 years, and UEMS of 23 were significant predictors. Sensitivity, specificity, PPV, NPV, and AUC of D-CART and A-CART were 0.837, 0.810, 0.911, 0.680, and 0.832 and 0.857, 0.810, 0.913, 0.708, and 0.869, respectively.

CONCLUSIONS

D-CART and A-CART showed comparable prediction accuracies. This suggests that, even during the early stages of rehabilitation, it is possible to predict the discharge destination.

Factors Affecting Home Discharge of Older Adults with Cervical Spinal Cord Injury in Japan Regional Population

Introduction

Older adults with cervical spinal cord injury (CSCI) often have a poor prognosis due to the high number of complications, decreased motivation to rehabilitation, and poor response to treatment. This study aimed to investigate the characteristics of CSCI in Japanese older adults and examined the factors influencing their discharge home.

Methods

In this retrospective cohort study, we extracted data on consecutive cases with CSCI between 2005 and 2020 from the study hospital's database. Patients over 65 years old who were admitted to the hospital within 14 days of injury were selected. A univariate analysis was performed between the home discharge and out-of-home discharge groups. In addition, binary logistic regression analysis of admission findings and patient background was performed to examine independent factors influencing home discharge.

Results

Of the 219 patients included, 90 (41.1%) were eventually discharged to home. Comparing home discharge and out-of-home discharge groups revealed significant differences in age at injury, length of hospital stay, neurological level of injury (NLI), percentage of American Spinal Injury Association (ASIA) Impairment Scale (AIS: A), percentage of living alone, ASIA motor score (AMS), and Spinal Cord Independence Measure (SCIM) at initial visit and discharge. Binary logistic regression analysis revealed that old age (over 75 years old) at injury (odds ratio [OR]: 0.31, 95% CI: 0.16-0.60, P<.001), living alone (OR: 0.22, 95% CI: 0.03-0.42, P<.01), high level of injury (i.e., NLI: C1-4; OR: 0.22, 95% CI: 0.09-0.53, P<.0001), and percentage of AIS: A at admission (OR: 0.09, 95% CI: 0.04-0.24, P<.001) were independent factors that influenced home discharge.

Conclusions

More than 50% older adults with CSCI were discharged to a place other than their own home. Age, percentage of AIS: A, living alone, and high level of injury at admission were independent factors that influenced home discharge.

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Spinal Cord Injury in Middle-aged and Older Adults Who Had Undergone Active Rehabilitation Treatment at a Remote Hospital: A Case Series

Background:

Middle-aged and older individuals with spinal cord injury (SCI) often require long-term care even after receiving rehabilitation treatment, making it difficult for them to return home. We retrospectively investigated our active rehabilitation treatment for patients with SCI.

Case:

Included in this case series were ten patients with SCI who were admitted to our general hospital (located in the southern part of Wakayama Prefecture) and who underwent active rehabilitation treatment. The participants were investigated retrospectively by access to electronic medical records. The Barthel index scores for discharged patients were determined at an outpatient clinic, and the community phase of rehabilitation management was recorded. The average age of the 10 patients was 67.4 ± 13.4 years, and the average period from onset to transfer to our hospital was 102.6 ± 69.9 days. The Barthel index scores significantly improved from 39.0 ± 30.9 at admission to 65.0 ± 28.2 at discharge (P<0.05). Among the seven patients who were discharged to their homes, six had cervical SCI. Some patients with American Spinal Injury Association impairment scale grades A and B at admission could be discharged home, and their Barthel index scores were maintained after discharge.

Discussion

: Even in a remote rural hospital, the activities of daily living of patients with SCI improved, and seven of the ten patients were discharged home. The activities of daily living of the discharged patients were maintained. To achieve these results, active rehabilitation treatment conducted by rehabilitation specialists is important.

Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury

STUDY DESIGN

Retrospective review of data from a prospective database of a Level 1 trauma center.

OBJECTIVES

This project aims to identify factors collected during the acute and rehabilitative care following a traumatic spinal cord injury (TSCI) associated with success and failure to return home after inpatient intensive functional rehabilitation (IFR).

SETTING

Level 1 trauma center specialized in TSCI care in Montreal, Canada.

METHODS

All eligible patients from our prospective database were separated into two groups according to discharge destination following IFR. Clinical variables collected during the acute and rehabilitative care as well as demographic variables were compared between patients who managed to return home (Group 1) and those who were discharged elsewhere (Group 2). Multivariable regression analyses were conducted with variables that were significant at the univariate level.

RESULTS

Out of the 193 patients included, 22 (11%) failed to return home following IFR. Six variables were associated with failure to return home at the univariate level: longer acute length of stay (LOS), longer rehabilitation LOS, living alone, higher neurological level of injury, having comorbidities, and having a pressure injury (PI) during acute care. Three variables remained significant at the multivariate level: living alone, increasing acute LOS and presenting a high cervical (C1-C4) neurological level of injury.

CONCLUSIONS

It is important that acute care clinicians recognize the aforementioned factors early after TSCI in order to optimize patients for community reintegration.

Predictors for Non-Home Patient Discharge Following Elective Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. The utilization of spinal surgery has increased and this trend is expected to continue. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement and reduce length of stay.

METHODS

The 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision diagnosis codes relevant to ASD. Patients were divided based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and hospital length of stay.

RESULTS

A total of 4552 patients met inclusion criteria, of which 1102 (24.2%) had non-home discharge. Multivariate regression revealed total relative value unit (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 1.00-1.01); female sex (OR = 1.54, 95% CI = 1.32-1.81); American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander versus black race (OR = 0.52, 95% CI = 0.35-0.78, P = .002); age ≥65 years (OR = 3.72, 95% CI = 3.19-4.35); obesity (OR = 1.18, 95% CI = 1.01-1.38, P = .034); partially/totally functionally dependent (OR = 2.11, 95% CI = 1.49-2.99); osteotomy (OR = 1.42, 95% CI = 1.12-1.80, P = .004) pelvis fixation (OR = 2.38, 95% CI = 1.82-3.11); operation time ≥4 hours (OR = 1.74, 95% CI = 1.47-2.05); recent weight loss (OR = 7.66, 95% CI = 1.52-38.65; P = .014); and American Society of Anesthesiologists class ≥3 (OR = 1.80, 95% CI = 1.53-2.11) as predictors of non-home discharge. P values were <.001 unless otherwise noted. Additionally, multivariate regression found non-home discharge to be a significant variable in prolonged length of stay.

CONCLUSIONS

The authors suggest these results can be used to inform patients preoperatively of expected discharge destination, anticipate patient discharge needs postoperatively, and reduce health care costs and morbidity associated with prolonged LOS.

Analysis of patients ≥65 with predominant cervical spine fractures: Issues of disposition and dysphagia

Background:

Cervical spine fractures occur in 2.6% to 4.7% of trauma patients aged 65 years or older. Mortality rates in this population ranges from 19% to 24%. A few studies have specifically looked at dysphagia in elderly patients with cervical spine injury.

Aims:

The aim of this study is to evaluate dysphagia, disposition, and mortality in elderly patients with cervical spine injury.

Settings and Design:

Retrospective review at an the American College of Surgeons-verified level 1 trauma center.

Methods:

Patients 65 years or older with cervical spine fracture, either isolated or in association with other minor injuries were included in the study. Data included demographics, injury details, neurologic deficits, dysphagia evaluation and treatment, hospitalization details, and outcomes.

Statistical Analysis:

Categorical and continuous data were analyzed using Chi-square analysis and one-way analysis of variance, respectively.

Results:

Of 136 patients in this study, 2 (1.5%) had a sensory deficit alone, 4 (2.9%) had a motor deficit alone, and 4 (2.9%) had a combined sensory and motor deficit. Nearly one-third of patients (n = 43, 31.6%) underwent formal swallow evaluation, and 4 (2.9%) had a nasogastric tube or Dobhoff tube placed for enteral nutrition, whereas eight others (5.9%) had a gastrostomy tube or percutaneous endoscopic gastrostomy tube placed. Most patients were discharged to a skilled nursing unit (n = 50, 36.8%), or to home or home with home health (n = 48, 35.3%). Seven patients (5.1%) died in the hospital, and eight more (5.9%) were transferred to hospice.

Conclusion:

Cervical spine injury in the elderly patient can lead to significant consequences, including dysphagia and need for skilled nursing care at discharge.

Factors Influencing Self-Care Behaviors in Persons with Spinal Cord Injuries and Disorders

Background: Individuals with spinal cord injury/disorder (SCI/D) must learn to adjust to and manage functional challenges after SCI/D onset. For these individuals, resilience (ie, the adaptive response to stressful events) may be related to their willingness and ability to conduct self-care behaviors. Objective: The study objectives were to examine the relationship between patient-reported perceptions of independence in performing self-care behaviors and resilience among Veterans with SCI/D and to examine variables (including resilience) associated with high self-care scores (controlling for confounders). Methods: In this cross-sectional survey, we conducted bivariate analyses to examine differences in demographic, injury, and health characteristics and resilience scores for individuals with SCI/D. We conducted a multivariate block-design linear regression to examine factors associated with ability to perform self-care. Results: Level of injury (β = 7.74, P < .0001), resilience (β = 0.08, P = .0216), marital status (β = 1.75, P = .0445), and living arrangement (β = 4.37, P < .0001) were positively related to higher self-care behaviors. Completeness of injury (β = -2.79, P < .0001), age (β = -0.09, P = .0052), age at injury (β = -0.05, P = .0129), and number of comorbid health conditions (β = -0.72, P < .0001) showed negative relationships with higher self-care. Conclusions: Self-care ability is related to multiple factors, including resilience. The positive relationship between resilience and self-care suggests that greater resilience, independent of injury level/severity, may contribute to improved self-care behaviors in individuals with SCI/D. Other factors that showed a positive relationship with self-care included younger age, living alone, paraplegic level injury, and fewer health conditions. Understanding the profile of persons with SCI/D with regard to self-care behaviors is important to the development of tailored interventions to improve self-care.

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.

An International Age- and Gender-Controlled Model for the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI)

Background. A quadratic formula of the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) has previously been published. This formula was based on a model of Spinal Cord Independence Measure (SCIM95), the 95th percentile of the SCIM III values, which correspond with the American Spinal Injury Association Motor Scores (AMS) of SCI patients. Objective. To further develop the original formula. Setting. Spinal cord injury centers from 6 countries and the Statistical Laboratory, Tel-Aviv University, Israel. Methods. SCIM95 of 661 SCI patients was modeled, using a quantile regression with or without adjustment for age and gender, to calculate SCI-ARMI values. SCI-ARMI gain during rehabilitation and its correlations were examined. Results. A new quadratic SCIM95 model was created. This resembled the previously published model, which yielded similar SCIM95 values in all the countries, after adjustment for age and gender. Without this adjustment, however, only 86% of the non-Israeli SCIM III observations were lower than those SCIM95 values ( P < .0001). Adding the variables age and gender to the new model affected the SCIM95 value significantly ( P < .04). Adding country information did not add a significant effect ( P > .1). SCI-ARMI gain was positive (38.8 ± 22 points, P < .0001) and correlated weakly with admission age and AMS. Conclusions. The original quadratic SCI-ARMI formula is valid for an international population after adjustment for age and gender. The new formula considers more factors that affect functional ability following SCI.

Epidemiology of spinal fractures among the elderly in Chongqing, China

OBJECTIVE

To illustrate the epidemiology of spinal fractures including traumatic spinal fractures and osteoporotic spinal fracture with no specific cause, spinal fracture caused by tumour and tuberculosis among the elderly.

DESIGN

We retrospectively reviewed hospital records on all patients who was 60 years of age or older with spinal fracture at two university-affiliated hospitals between January 2001 and May 2011 (n=996). Variables assessed included age, gender, incidence of hospital admission, mechanism of spinal fracture, anatomic distribution, neurologic deficit, therapeutic method, length of hospitalisation and hospitalisation cost.

SETTING

Two university-affiliated hospitals from January 2001 to May 2011.

RESULTS

A total of 996 patients with spinal fractures were identified, of whom 34.8% were males. The annual incidence of spinal fractures among the elderly was 24 cases per 100,000 hospital admission in 2001 and then gradually increased to 130 cases per 100,000 hospital admission in 2010. The causes of spinal fractures include traumatic spinal fractures (n=714, 71.7%), osteoporotic fracture with no specific cause (n=264, 26.5%) and spinal fracture caused by tumour and tuberculosis (n=18, 1.8%). The lumbar region was the most common region of spinal fracture (n=823, 48.8%), followed by the thoracic (n=724, 43.0%) and the cervical (n=138, 8.2%) regions. Lumbar spinal fractures and thoracic spinal fractures were more commonly seen as a result of accidental falls from low heights and osteoporotic spinal fractures respectively. Thirty-five (3.5%) patients exhibited a complete motor and sensory deficit and 151 (15.2%) an incomplete neurological deficit. The greatest number of complete motor and sensory neurological deficits was associated with cervical spinal fractures and accidental falls. A total of 87 (8.7%) patients had associated non-spinal injuries, of whom 26 (29.9%) sustained a head and neck injury, 28 (32.2%) patients suffered a thoracic injury and 19 (21.8%) patients suffered a fracture of a lower extremity.

CONCLUSION

Spinal fractures usually occur outdoors causing by accidental falls from low heights, most frequently happen on the road. The number of fall-induced injuries and sports injury increased steadily with age, may indicate that there is growing concern for the consequences of falls and sports in the elderly.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project

BACKGROUND/OBJECTIVE

Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.

METHODS

Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.

RESULTS

PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries.

CONCLUSION

Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

Occipitocervical fusion in elderly patients

BACKGROUND

Occipitocervical disease (OCD) in elderly patients will become increasingly common as the population ages. Our experience with occipitocervical fusions (OCF) in this population suggests mixed outcomes.

METHODS

Twenty consecutive patients over 65 years old underwent OCF between 1995 and 2005. A retrospective review of demographic, presentation, surgical and outcome data was performed.

RESULTS

Twenty patients averaging 75.3 years of age (range 65 to 91) were identified. All patients had evidence of myelopathy; however, the primary surgical indications were progressive spinal cord dysfunction (15), brainstem compression (3), and pain (2). Surgical approach was isolated posterior (9), or anterior transoral odontoidectomy followed by posterior stabilization (11). Overall, surgery improved function modestly; average modified Japanese Orthopedic Association functional score (improved 0.9 grades), average Ranawat Myelopathy Score (improved 0.4 grades), and average Nurick Myelopathy Grade (improved 0.6 grades). However, patients with poor preoperative functional assessment (Ranawat grade ≥ III) had greater neurologic improvement than those with good preoperative function, measured by Nurick grade improvement (1 vs. -0.28; P = .03) and Ranawat grade improvement (0.7 vs. -0.2; P = .03). Additionally, the posterior approach demonstrated significant improvement in Japanese Orthopedic Association functional assessment over patients with anterior/posterior approaches (2.2 vs. -0.3; P = .03), with fewer complications (posterior: 1 minor; anterior/posterior: 1 death, 2 major, 8 minor). Perioperative mortality occurred in 5%, and major morbidity in 10% of patients.

CONCLUSIONS

Preventing or stabilizing neurologic deficit in patients with OCD may require OCF, despite the patient's age. In the elderly population, our data favor using the posterior approach when possible, and demonstrate greater neurologic improvement in patients with poor preoperative function.