Traumatic spinal cord injury and concomitant brain injury: a cohort study

Concomitant traumatic brain injury as a determinant of survival, and neurological and functional outcomes after traumatic spinal cord injury: A retrospective cohort study

BACKGROUND

Although concomitant traumatic brain injury (TBI) is not infrequently associated with spinal cord injury (SCI), there is relatively scarce information about the effects of concomitant TBI on outcomes after SCI.

OBJECTIVE

To assess the impact of concomitant mild-to-moderate TBI on survival, and neurological and functional outcomes within the first year after acute traumatic SCI.

DESIGN

Retrospective cohort study.

SETTING

Acute spine trauma centers in the United States.

PARTICIPANTS

This study includes all individuals who were enrolled into the Third National Spinal Cord Injury Study (NASCIS-3). The study population was classified into SCI + TBI group and SCI-alone group. TBI was defined as a Glasgow Coma Scale score <15 on admission.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Both groups were compared regarding their survival and neurological outcomes (ie, NASCIS motor, sensory and pain scores) and functional outcome (ie, Functional Independence Measure score) within the first year following SCI. Data analyses were adjusted for major potential confounders.

RESULTS

There were 413 individuals in the SCI-alone group and 86 individuals in the SCI + TBI group (17.2%). Both groups were comparable regarding gender distribution (p = .621). However, the SCI + TBI group was older (p < .001), had a higher proportion of complete (p = .006) and cervical SCI (p = .003), and had a higher blood alcohol level (p < .001) than the SCI-alone group. The SCI + TBI group did not significantly differ from the SCI-alone group regarding survival within the first year after SCI (p = .768). Among the survivors, concomitant mild-to-moderate TBI did not significantly affect neurological and functional outcomes at 1 year after SCI in the multiple regression analyses after adjusting for major potential confounders.

CONCLUSIONS

The results of this study suggest that concomitant mild-to-moderate TBI did not have a significant impact on survival, neurological recovery, and functional outcomes at 1 year after SCI, even though there were some epidemiological differences between SCI-alone and SCI + TBI groups.

Incidence and outcomes of pediatric patients with dual diagnosis of traumatic spinal cord injury and brain injury on an inpatient rehabilitation unit

BACKGROUND

Traumatic brain injury (TBI) and spinal cord injury (SCI) are diagnoses commonly encountered on the pediatric rehabilitation unit. However, there is limited evidence in the literature addressing the incidence of or rehabilitation outcomes in pediatric patients with a dual diagnosis of TBI and SCI.

OBJECTIVE

To determine incidence and functional outcomes of the dual diagnosis population.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation unit within an academic pediatric hospital.

PATIENTS

Pediatric patients admitted to a single inpatient rehabilitation unit with a diagnosis of traumatic SCI between 2006 and 2019. Fifty-four patient records were identified and 26 met inclusion criteria.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Presence of concomitant TBI in patients with diagnosed SCI.

RESULTS

Seven of 26 patients were given a dual diagnosis of TBI and SCI during their initial rehabilitation hospitalization. After review of charts, authors identified 12 additional patients with suspected dual diagnoses based on injury characteristics and symptoms. There were no significant differences in functional outcomes across diagnosis groups.

CONCLUSIONS

Incidence of dual diagnosis among pediatric patients with traumatic SCI was initially found to be 27%; the retrospective review indicated that TBI may be underdiagnosed in this patient population, and the dual diagnosis incidence may be as high as 73%. All patients had improved functional outcomes during their rehabilitation stays regardless of presence or absence of TBI.

Characterization of Sleep, Emotional, and Cognitive Functions in a New Rat Model of Concomitant Spinal Cord and Traumatic Brain Injuries

Traumatic injuries to the spinal cord or the brain have serious medical consequences and lead to long-term disability. The epidemiology, medical complications, and prognosis of isolated spinal cord injury (SCI) and traumatic brain injury (TBI) have been well described. However, there are limited data on patients suffering from concurrent SCI and TBI, even if a large proportion of SCI patients have concomitant TBI. The complications associated with this "dual-diagnosis" such as cognitive or behavioral dysfunction are well known in the rehabilitation setting, but evidence-based and standardized approaches for diagnosis and treatment are lacking. Our goal was to develop and characterize a pre-clinical animal model of concurrent SCI and TBI to help identifying "dual-diagnosis" tools. Female rats received a unilateral contusive SCI at the thoracic level alone (SCI group) or combined with a TBI centered on the contralateral sensorimotor cortex (SCI-TBI group). We first validated that the SCI extent was comparable between SCI-TBI and SCI groups, and that hindlimb function was impaired. We characterized various neurological outcomes, including locomotion, sleep architecture, brain activity during sleep, depressive- and anxiety-like behaviors, and working memory. We report that SCI-TBI and SCI groups show similar impairments in global locomotor function. While wake/sleep amount and distribution and anxiety- and depression-like symptoms were not affected in SCI-TBI and SCI groups in comparison to the control group (laminectomy and craniotomy only), working memory was impaired only in SCI-TBI rats. This pre-clinical model of concomitant SCI and TBI, including more severe variations of it, shows a translational value for the identification of biomarkers to refine the "dual-diagnosis" of neurotrauma in humans.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI.

METHODS

Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status.

RESULTS

We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Epidemiology and Assessment of Traumatic Spinal Cord Injury With Concomitant Brain Injury: An Observational Study in a Regional Trauma Center

OBJECTIVE

: To analyze the epidemiological information of patients with traumatic spinal cord injury (SCI) and concomitant traumatic brain injury (TBI) and to suggest points to be aware of during the initial physical examination of patients with SCI.

METHODS

: This study was a retrospective, observational study conducted in a regional trauma center. All the records of patients diagnosed with traumatic SCI between 2016 and 2020 were reviewed. A total of 627 patients with confirmed traumatic SCI were hospitalized. A retrospective study was conducted on 363 individuals.

RESULTS

: The epidemiological data of 363 individuals were investigated. Changes in American Spinal Injury Association Impairment Scale (AIS) scores in patients with SCI were evaluated. The initial evaluation was performed on average 11 days after the injury, and a follow-up examination was performed 43 days after. Fourteen of the 24 patients identified as having AIS A and SCI with concomitant TBI in the initial evaluation showed neurologic level of injury (NLI) recovery with AIS B or more. The conversion rate in patients with SCI and concomitant TBI exceeded that reported in previous studies in individuals with SCI.

CONCLUSIONS

: Physical, cognitive, and emotional impairments caused by TBI present significant challenges in rehabilitating patients with SCI. In this study, the influence of concomitant TBI lesions could have caused the initial AIS assessment to be incorrect.

Concomitant spine trauma in patients with traumatic brain injury: Patient characteristics and outcomes

Objective

Spine injury is highly prevalent in patients with poly-trauma, but data on the co-occurrence of spine trauma in patients with traumatic brain injury (TBI) are scarce. In this study, we used the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) database to assess the prevalence, characteristics, and outcomes of patients with TBI and a concurrent traumatic spinal injury (TSI).

Methods

Data from the European multi-center CENTER-TBI study were analyzed. Adult patients with TBI (≥18 years) presenting with a concomitant, isolated TSI of at least serious severity (Abbreviated Injury Scale; AIS ≥3) were included. For outcome analysis, comparison groups of TBI patients with TSI and systemic injuries (non-isolated TSI) and without TSI were created using propensity score matching. Rates of mortality, unfavorable outcomes (Glasgow Outcome Scale Extended; GOSe &lt; 5), and full recovery (GOSe 7–8) of all patients and separately for patients with only mild TBI (mTBI) were compared between groups at 6-month follow-up.

Results

A total of 164 (4%) of the 4,254 CENTER-TBI core study patients suffered from a concomitant isolated TSI. The median age was 53 [interquartile range (IQR): 37–66] years and 71% of patients were men. mTBI was documented in 62% of cases, followed by severe TBI (26%), and spine injuries were mostly cervical (63%) or thoracic (31%). Surgical spine stabilization was performed in 19% of cases and 57% of patients were admitted to the ICU. Mortality at 6 months was 11% and only 36% of patients regained full recovery. There were no significant differences in the 6-month rates of mortality, unfavorable outcomes, or full recovery between TBI patients with and without concomitant isolated TSI. However, concomitant non-isolated TSI was associated with an unfavorable outcome and a higher mortality. In patients with mTBI, a negative association with full recovery could be observed for both concomitant isolated and non-isolated TSI.

Conclusion

Rates of mortality, unfavorable outcomes, and full recovery in TBI patients with and without concomitant, isolated TSIs were comparable after 6 months. However, in patients with mTBI, concomitant TSI was a negative predictor for a full recovery. These findings might indicate that patients with moderate to severe TBI do not necessarily exhibit worse outcomes when having a concomitant TSI, whereas patients with mTBI might be more affected.

Critical care for concomitant severe traumatic brain injury and acute spinal cord injury in the polytrauma patient: illustrative case

BACKGROUND

The occurrence of traumatic brain injury with spinal cord injury (SCI) in polytrauma patients is associated with significant morbidity. Clinicians face challenges from a decision-making and rehabilitative perspective. Management is complex and understudied. Treatment should be systematic beginning at the scene, focusing on airway resuscitation and hemodynamic stabilization, immobilization, and timely transport. Early operative interventions should be provided, followed by minimizing secondary pathophysiology. The authors present a case to delineate decision-making in the treatment of combined cranial and spinal trauma.

OBSERVATIONS

A 19-year-old man presented as a level I trauma patient after falling 30 feet as the result of scaffolding collapse. The patient was unresponsive and was intubated; he had an initial Glasgow Coma Scale score of 4. Computed tomography revealed multicompartmental bleeding and herniation, for which supra- and infratentorial decompressive craniectomies were performed. The patient also suffered from thoracic SCI that resulted in complete paraplegia. Multimodality monitoring was used. After stabilization and lengthy rehabilitation, the patient obtained significant functional improvement.

LESSONS

The approach to initial management of concomitant head and spine trauma is to establish intracranial stability followed by intraspinal stability. Patients can make considerable recovery, particularly younger patients, who are more likely to benefit from early aggressive interventions and medical treatment.

Diagnostic utility of point of care ultrasound in identifying cervical spine injury in emergency settings

Introduction

The evaluation of cervical-spine in a major trauma patient needs a bedside efficient tool to rule out cervical spine injury as the role of X-ray and Computed Tomography (CT) in this setting is limited. Point of care ultrasonography (POCUS) is being used as an adjunct during trauma resuscitation. The aim of this study was to evaluate the use of POCUS for identifying cervical spine injuries.

Methods

We recruited 84 cases with cervical spine injury based on CT scan after taking consent. POCUS was used as per the operational definition of study methods while maintaining manual in-line stabilisation. Statistical analysis was done by using STATA version 14.

Results

Normal cervical anatomy was visible through anterior approach in POCUS except for the 1^st and 2^nd cervical vertebrae. The sensitivity and specificity of POCUS vs CT scan for vertebral body listhesis were 84.52% (95% CI of 0.65-0.95) and 89.66% (95% CI 0.78-0.96) with p-value <0.0001. Sensitivity and specificity of POCUS vs CT for vertebral body fracture were 40.91% (95% CI of 0.20-0.63) and 96.77% (95% CI of 0.88-0.99) with p-value <0.0001. The overall sensitivity and specificity of POCUS were 45.83% and 83.33% (p = 0.06) and excluding isolated posterior column injuries, sensitivity and specificity were 70.21% and 83.33% (p < 0.05).

Conclusion

POCUS identified injuries such as fracture and listhesis. Because of high rate of missed injuries, ultrasound at present cannot be used as a screening or diagnostic tool for decision-making in cervical spine injury.

Trigonal-Sparing vs. Trigonal-Involved OnabotulinumtoxinA Injection for the Treatment of Overactive Bladder: A Systematic Review and Meta-Analysis

Objective: Overactive bladder (OAB) is a disease characterized by the presence of urinary urgency. We carried out a meta-analysis to assess the effectiveness and safety of trigonal-involved injection of onabotulinumtoxinA (BoNT-A) in comparison with the trigonal-sparing technique in cases with OAB [neurogenic detrusor overactivity (NDO) and idiopathic detrusor overactivity (IDO)]. Methods: Randomized controlled trials (RCTs) of BoNT-A injection for OAB were searched systematically by using EMBASE, MEDLINE, and the Cochrane Controlled Trials Register. The datum was calculated by RevMan version 5.3.0. The original references of relating articles were also reviewed. Results: In total, six RCTs involving 437 patients were included in our analysis. For OAB, the trigone-including group showed a different patient symptom score (p = 0.03), complete dryness rate (p = 0.002), frequency of incontinence episodes (p = 0.01), detrusor pressure at maximum flow rate (p = 0.01), and volume at the first desire to void (p = 0.0004) compared with the trigone-sparing group. Also, a trigone-including intradetrusor injection demonstrated a significant improvement in the patient symptom score (p = 0.0004), complete dryness rate (p = 0.0002), frequency of incontinence episodes (p = 0.0003), detrusor pressure at maximum flow rate (p = 0.01), and volume at the first desire to void (p = 0.00006) compared with the trigone-sparing group for treatment of NDO. The adverse events rates were similar in both groups. Conclusions: The meta-analysis has demonstrated that trigone-including BoNT-A injection was more effective compared with the trigone-sparing injection for the treatment of OAB, especially for NDO.

Cognitive Dysfunction in Persons with Chronic Spinal Cord Injuries

Cognitive dysfunction (CD) is pervasive in individuals who have chronic spinal cord injuries (SCI). Although classically associated with concomitant traumatic brain injuries, many other causes have been proposed, including premorbid neuropsychological conditions, mood disorders, substance abuse, polypharmacy, chronic pain and fatigue, sleep apnea, autonomic dysregulation, post-intensive care unit syndrome, cortical reorganizations, and neuroinflammation. The consequences of CD are likely widespread, affecting rehabilitation and function. CD in those with SCI should be recognized, and potentially treated, in order to provide the best patient care.

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.

Cognitive, Emotional, and Physical Functioning as Predictors of Paid Employment in People With Stroke, Traumatic Brain Injury, and Spinal Cord Injury

OBJECTIVE

Our objective was to examine demographic, cognitive, emotional, and physical factors that predict return to paid employment for people after neurological injury.

METHOD

Four hundred eighty adults with stroke (n = 149), traumatic brain injury (n = 155), and spinal cord injury (n = 176) completed an occupational outcome questionnaire and physical, emotional, and cognitive assessments at three rehabilitation facilities.

RESULTS

Odds of employment were predicted by being married or partnered, having more education, requiring fewer prompts for task sequencing, and having higher inhibitory control (but were not predicted by specific type of injury). Participants who returned to work within 3 mo were more likely to work with the same employer and to take a full-time position than those who returned later.

CONCLUSION

Executive functioning, in particular sequencing and inhibitory control, strongly predicts employment and highlights the importance of cognitive strategy training during occupational therapy with people who have sustained neurological injuries.

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.

Cognition among community-dwelling individuals with spinal cord injury

PURPOSE/OBJECTIVE

To compare the cognitive profiles of a well-characterized sample of adults with and without spinal cord injury (SCI) using the NIH Toolbox Cognition Battery NIHTB-CB. Research Method/Design: Participants were 156 community-dwelling individuals with SCI recruited from 3 academic medical centers, and 156 individuals without SCI selected from the NIHTB-CB normative database (N = 312). The main outcome measures were the demographically adjusted NIHTB-CB subtest and composite scores.

RESULTS

Individuals with and without SCI performed equivalently on the NIHTB-CB crystallized composite score, suggesting comparable premorbid functioning. Individuals with SCI produced lower scores on the NIHTB-CB fluid composite score by an average of 4.5 T-score points (Cohen's d = 0.50; a medium effect size). As a group, individuals with SCI had the most difficulty on tests of processing speed and executive functions, and some difficulty on a test of episodic memory, although effect sizes were small. These differences remained even after accounting for fine motor speed and dexterity. Individuals with tetraplegia produced lower scores than individuals with paraplegia on tests of processing speed and executive functioning.

CONCLUSION/IMPLICATIONS

Community-dwelling individuals with SCI are at elevated risk of mild cognitive difficulties, particularly on tasks that rely on processing speed and executive functions. The NIHTB-CB is relatively brief, samples important cognitive domains, has good normative data, and is appropriate for some individuals with SCI (those who have functional use of one hand). The battery has standardized accommodations for individuals with minor motor limitations, but timed tests are inaccessible for individuals who are unable to perform rapid button presses. (PsycINFO Database Record

Traumatic Brain Injury in Spinal Cord Injury: Frequency and Risk Factors

BACKGROUND

The frequency of traumatic brain injury (TBI) co-occurring with traumatic spinal cord injury (tSCI) is unclear despite a number of past studies; as well, limited research has examined predictors of co-morbid TBI in tSCI patients.

OBJECTIVES

(1a) To summarize past literature on comorbid diagnosis of TBI in tSCI in order to reexamine the frequency of dual diagnosis in a study designed to obviate past methodological limitations; (1b) to compare dual-diagnosis frequency with vs without the inclusion of diagnostically ambiguous cases; and (2) to measure risk factors for tSCI and comorbid TBI.

METHODS

Ninety-one of 135 eligible adults with tSCI, 3 to 6 months postinjury, were prospectively recruited from a tertiary inpatient tSCI rehabilitation program. TBI diagnosis was based on comprehensive, validated clinical neurological and neuroimaging measures.

RESULTS

Objective 1: 39.6% of the tSCI patients sustained a concomitant TBI, but when ambiguous cases were removed from analysis, frequency rose to 58.1%. Objective 2: Motor vehicle collisions were most likely to yield a comorbid TBI diagnosis, but 31.6% of falls also resulted in TBI. Patients with cervical and thoracic injuries showed a very similar frequency of comorbid TBI.

CONCLUSIONS

Varied methodological approaches, particularly the decision to include/exclude ambiguous cases, likely explain disparate past estimates of TBI in tSCI. However, even this study's lower frequency estimate, at nearly 40%, is clinically important. The prevailing assumption that dual diagnosis is less common in thoracic than cervical spine injuries was not supported. Finally, while comorbid TBI most frequently occurred in motor vehicle collisions, nearly a third of tSCIs sustained in falls resulted in comorbid TBI in our sample.

Validation of the NIH Toolbox in Individuals with Neurologic Disorders

OBJECTIVE

Individuals with spinal cord injury (SCI), traumatic brain injury (TBI), and stroke experience a variety of neurologically related deficits across multiple domains of function. The NIH Toolbox for the Assessment of Neurological and Behavioral Function (NIHTB) examines motor, sensation, cognition, and emotional functioning. The purpose of this paper is to establish the validity of the NIHTB in individuals with neurologic conditions.

METHODS

Community-dwelling individuals with SCI (n = 209), TBI (n = 184), or stroke (n = 211) completed the NIHTB. Relative risks for impaired performance were examined relative to a matched control groups.

RESULTS

The largest group differences were observed on the Motor domain and for the Fluid Cognition measures. All groups were at increased risk for motor impairment relative to normative standards and matched controls. Fluid cognitive abilities varied across groups such that individuals with stroke and TBI performed more poorly than individuals with SCI; increased relative risks for impaired fluid cognition were seen for individuals in the stroke and TBI groups, but not for those in the SCI group. All three neurologic groups performed normally on most measures in the Sensation Battery, although TBI participants evidenced increased risk for impaired odor identification and the stroke group showed more vision difficulties. On the Emotion Battery, participants in all three groups showed comparably poor psychological well-being, social satisfaction, and self-efficacy, whereas the TBI group also evidenced slightly increased negative affect.

CONCLUSIONS

Data provide support for the validity of the NIHTB in individuals with neurologic conditions.

Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps

Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.

Test-retest reliability at the item level and total score level of the Norwegian version of the Spinal Cord Injury Falls Concern Scale (SCI-FCS)

OBJECTIVES

Translation of the Spinal Cord Injury Falls Concern Scale (SCI-FCS), and investigation of test-retest reliability on item-level and total-score-level.

DESIGN

Translation, adaptation and test-retest study.

SETTING

A specialized rehabilitation setting in Norway.

PARTICIPANTS

Fifty-four wheelchair users with a spinal cord injury. The median age of the cohort was 49 years, and the median number of years after injury was 13. Interventions/measurements: The SCI-FCS was translated and back-translated according to guidelines. Individuals answered the SCI-FCS twice over the course of one week. We investigated item-level test-retest reliability using Svensson's rank-based statistical method for disagreement analysis of paired ordinal data. For relative reliability, we analyzed the total-score-level test-retest reliability with intraclass correlation coefficients (ICC2.1), the standard error of measurement (SEM), and the smallest detectable change (SDC) for absolute reliability/measurement-error assessment and Cronbach's alpha for internal consistency.

RESULTS

All items showed satisfactory percentage agreement (≥69%) between test and retest. There were small but non-negligible systematic disagreements among three items; we recovered an 11-13% higher chance for a lower second score. There was no disagreement due to random variance. The test-retest agreement (ICC2.1) was excellent (0.83). The SEM was 2.6 (12%), and the SDC was 7.1 (32%). The Cronbach's alpha was high (0.88).

CONCLUSION

The Norwegian SCI-FCS is highly reliable for wheelchair users with chronic spinal cord injuries.

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

OBJECTIVES

To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes.

DESIGN

Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI.

SETTING

Inpatient rehabilitation unit.

PARTICIPANTS

From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI.

RESULTS

Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%-93%), a specificity of 51% (95% confidence interval, 39%-64%), and a Youden Index of 0.3 (95% confidence interval, 0.2-0.5). Compared with those without TBI, those with chart review-determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes.

CONCLUSIONS

Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Not all neurogenic bladders are the same: a proposal for a new neurogenic bladder classification system

Neurogenic bladder (NGB) has long been defined as a clinical entity that describes a heterogeneous collection of syndromes. The common theme is a bladder disorder concomitant with a neurologic disorder. This definition does not give the clinician much information about the bladder disorder, nor how to treat it, or even what the natural history of the disorder is likely to be. It may be time for a new classification scheme to better define the bladder defect and prognosis, as well as inform treatment. We propose a classification system based on seven categories, each having a neurologic defect in a distinct anatomic location. This is termed SALE (Stratify by Anatomic Location and Etiology). In addition, the presence or absence of bowel dysfunction and autonomic dysreflexia will be reported. In the future, as more definite prognostic information can be gleaned from biomarkers, we anticipate adding urinary nerve growth factor (NGF) and urinary brain-derived neurotrophic factor (BDNF) levels to the definition. We expect the SALE system to efficiently describe a patient suffering from NGB and simultaneously inform the most appropriate treatment, follow-up regimen, and long-term prognosis.

Epidemiology of Pediatric Traumatic Spinal Cord Injury in a Population-Based Cohort, 1998-2012

BACKGROUND

Traumatic spinal cord injury (SCI) that occurs in children and adolescents who are still developing represents a different challenge than SCI in adults. However, information on the epidemiology and incidence of SCI in a population-based cohort is lacking.

OBJECTIVE

To describe the epidemiology of pediatric SCI in a population-based cohort in the United States and to assess trend in incidence over a 15-year period (1998-2012).

METHODS

Children and adolescents (0-21 years) with SCI were identified through the South Carolina SCI Surveillance Registry using hospital discharge records from 1998 to 2012. Overall age-adjusted incidence rates were calculated for each year, and incidence rates were stratified by age, gender, and race.

RESULTS

The overall age-adjusted incidence rate was 26.9 per million population, and there was a trend (P = .0583) toward decreasing incidence of pediatric SCI. When stratified by race, there was a significant decrease in incidence among Whites(P = .0052) but not among non-Whites. Younger participants were more likely to be female, to be injured through sports, and to be more likely to have concomitant traumatic brain injury. Since 1998, the proportion of older pediatric patients (16-22 years) with SCI has increased, as has the proportion of non-White patients.

CONCLUSIONS

Although there was an overall trend toward decreasing incidence in this population-based cohort, when stratified by race, this trend only occurred in the White population.

Combined detrusor-trigone BTX-A injections for urinary incontinence secondary to neurogenic detrusor overactivity

Objectives:

The objective of this study was to evaluate the effect and safety of trigonal injection of botulinum toxin A (BTX-A) for patients with neurological detrusor overactivity (NDO) with incontinence.

Methods:

A prospective, multicenter, single-blind and randomized controlled trial was conducted between June 2011 and June 2014. Spinal cord injury patients with urinary incontinence secondary to NDO overactivity were recruited. At a 1:1 ratio, patients randomly received 200 U BTX-A intradetrusor injections excluding the trigone (the control group) or 160 U intradetrusor and 40 U intratrigonal injections (the experimental group). Patients were evaluated at baseline and at 4 and 12 weeks after injection. The efficacy and safety outcomes included Incontinence-Specific-Quality-of-Life Instrument (I-QoL), voiding volume, urinary incontinence episodes, complete dryness, maximum detrusor pressure (P_detmax) and volume at first involuntary detrusor contraction (V_FIDC). Vesicoureteral reflux (VUR) and other adverse events were recorded.

Results:

Ninety-six patients were recruited and 91 of them completed the trial. Among the 91 patients, 47 were randomized to the experimental group and 44 to the control group. There were no significant differences in baseline evaluation items (gender, age, duration of spinal cord injury, level of neurological injury, AIS (the American Social Injury Association) scores) between the two groups. At 12 weeks, the improvement was significantly better in the experimental group compared with that in the control group for I-QoL (26.01 vs 18.75, P=0.01), mean urinary incontinence episodes (−5.22 vs −4.68 per day, P=0.01), complete dryness (13 vs 5, P=0.03), mean voiding volume (159.72 vs 139.07 ml, P=0.02), P_detmax (−33.34 vs −28.02 cmH₂O, P=0.04) and VFIDC (106.81 vs 97.86 ml, P=0.02), duration of first detrusor contraction (−41.54 vs −18.65 s, P=0.03) and the number of patients with detrusor contraction (−20 vs −9, P=0.02). In both the groups, no patients developed VUR.

Conclusions:

BTX-A intradetrusor and intratrigonal injections are more effective compared with those excluding the trigone for patients with NDO with incontinence. Intratrigonal injections do not induce VUR.

Endogenous TGFβ1 Plays a Crucial Role in Functional Recovery After Traumatic Brain Injury Associated with Smad3 Signal in Rats

Transforming growth factor-β 1 (TGFβ1) has a diverse role in astrogliosis and neuronal survival, but the underlying mechanism remains to be elucidated, especially in traumatic brain injury (TBI). Here, we show that the expression of TGFβ1 was increased in the pericontusional region, accompanied with astrogliosis and neuronal loss in TBI rats. Moreover, TGFβ1 knockdown not only reduced the number of neurons and inhibited astrogliosis but also resulted in a significant neurological dysfunction in rats with TBI. Subsequently, Smad3, a key downstream signal of TGFβ1, was involved in pericontusional region after TBI. These findings therefore indicate that TGFβ1 is involved in neuroprotection and astrogliosis, via activation of down stream Smad3 signal in the brain after injury.

Analysis of patients with spinal cord trauma associated with traumatic brain injury

Objective: Characterize victims of spinal cord injury (SCI) associated with traumatic brain injury (TBI) and risk factors. Methods: Study conducted with 52 victims of SCI associated with TBI. The variables studied were: sex; age; marital status; occupation; educational level; religion; etiology and the lesion area; neurological condition by the ASIA scale; associated injuries and potential risk factors. Results: The male (85%), aged between 21-30 years (25%), civil status stable union (56%), low level of education (69%) and the Roman Catholic religion (77%) presented the greater number of victims. Motor vehicle accidents (58%) were the main etiology. The cervical segment had higher injury risk (RR=3.48, p&lt;0.0001). The neurological status ASIA-E (52%), the syndromic neck pain (35%) and the rate of mild TBI (65%) were the most frequent. Complications occurred in 13 patients with increased frequency of pneumonia (62%). The length of hospital stay was significantly higher (20&#177;28 days) and 17% of patients died. Men (RR=2.14, p=0.028) and individuals exposed to motor vehicle accidents (RR=1.91, p=0.022) showed a higher risk of these lesions concurrently. Moreover, these patients had 2.48 (p&lt;0.01) higher risk of death than victims of SCI alone. Conclusion: The SCI associated with TBI was more frequent in men, young adults, and individuals exposed to motor vehicle accidents. The cervical spine is more likely to be affected. Furthermore, the length of hospitalization is significantly higher and the subjects analyzed have higher risk of death.

Impact of fatal cases on the epidemiology of traumatic spinal cord injury in Estonia

BACKGROUND AND PURPOSE

Most epidemiological studies on traumatic spinal cord injury (TSCI) have not included patients who die before hospitalization. The aim of the research was to study the incidence of TSCI by including the individuals who die at the scene of the accident in addition to data retrieved from all hospitals in Estonia.

METHODS

Medical records of patients with TSCI from all hospitals in Estonia from 2005 to 2007 were studied. With collaboration from the Estonian Forensic Science Institute the data of the victims of TSCI who died before hospitalization were included.

RESULTS

From 2005 to 2007, 391 TSCI cases were identified: 183 patients were found retrospectively from medical records and 208 cases were detected from autopsy reports. Fifty-three per cent of patients died before hospitalization. The annual incidence rate was 97.0 per million population (95% confidence interval 87.4-106.6). The mean age at injury was 44.4 ± 18.7 years. Motor vehicle accidents were the leading cause of TSCI amongst the individuals who died before hospitalization (75%). Falls accounted for the highest number of TSCIs (43%) amongst the patients who reached hospital.

CONCLUSIONS

Our study shows that, when the cases that die at the scene of the accident are included, the incidence of TSCI in Estonia rises from 39.7 to 97.0 per million population.

Combined SCI and TBI: recovery of forelimb function after unilateral cervical spinal cord injury (SCI) is retarded by contralateral traumatic brain injury (TBI), and ipsilateral TBI balances the effects of SCI on paw placement

A significant proportion (estimates range from 16 to 74%) of patients with spinal cord injury (SCI) have concomitant traumatic brain injury (TBI), and the combination often produces difficulties in planning and implementing rehabilitation strategies and drug therapies. For example, many of the drugs used to treat SCI may interfere with cognitive rehabilitation, and conversely drugs that are used to control seizures in TBI patients may undermine locomotor recovery after SCI. The current paper presents an experimental animal model for combined SCI and TBI to help drive mechanistic studies of dual diagnosis. Rats received a unilateral SCI (75 kdyn) at C5 vertebral level, a unilateral TBI (2.0 mm depth, 4.0 m/s velocity impact on the forelimb sensori-motor cortex), or both SCI+TBI. TBI was placed either contralateral or ipsilateral to the SCI. Behavioral recovery was examined using paw placement in a cylinder, grooming, open field locomotion, and the IBB cereal eating test. Over 6weeks, in the paw placement test, SCI+contralateral TBI produced a profound deficit that failed to recover, but SCI+ipsilateral TBI increased the relative use of the paw on the SCI side. In the grooming test, SCI+contralateral TBI produced worse recovery than either lesion alone even though contralateral TBI alone produced no observable deficit. In the IBB forelimb test, SCI+contralateral TBI revealed a severe deficit that recovered in 3 weeks. For open field locomotion, SCI alone or in combination with TBI resulted in an initial deficit that recovered in 2 weeks. Thus, TBI and SCI affected forelimb function differently depending upon the test, reflecting different neural substrates underlying, for example, exploratory paw placement and stereotyped grooming. Concurrent SCI and TBI had significantly different effects on outcomes and recovery, depending upon laterality of the two lesions. Recovery of function after cervical SCI was retarded by the addition of a moderate TBI in the contralateral hemisphere in all tests, but forepaw placements were relatively increased by an ipsilateral TBI relative to SCI alone, perhaps due to the dual competing injuries influencing the use of both forelimbs. These findings emphasize the complexity of recovery from combined CNS injuries, and the possible role of plasticity and laterality in rehabilitation, and provide a start towards a useful preclinical model for evaluating effective therapies for combine SCI and TBI.

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.