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

A robust paradigm for studying regeneration after traumatic spinal cord injury in zebrafish

BACKGROUND

Zebrafish are vertebrates with a high potential of regeneration after injury in the central nervous system. Therefore, they have emerged as a useful model system for studying traumatic spinal cord injuries.

NEW METHOD

Using larval zebrafish, we have developed a robust paradigm to model the effects of anterior spinal cord injury, which correspond to the debilitating injuries of the cervical and thoracic regions in humans. Our new paradigm consists of a more anterior injury location compared to previous studies, a modified behavioral assessment using the visual motor response, and a new data analysis code.

RESULTS

Our approach enables a spinal cord injury closer to the hindbrain with more functional impact compared to previous studies using a more posterior injury location. Results reported in this work reveal recovery over seven days following spinal cord injury.

COMPARING WITH EXISTING METHODS

The present work describes a modified paradigm for the in vivo study of spinal cord regeneration after injury using larval zebrafish, including an anterior injury location, a robust behavioral assessment, and a new data analysis software.

CONCLUSIONS

Our findings lay the foundation for applying this paradigm to study the effects of drugs, nutrition, and other treatments to improve the regeneration process.

Does stronger primary care improve access to health services for persons with spinal cord injury? Evidence from eleven European countries

OBJECTIVE

To determine the association between the strength of primary care and perceived access to follow-up care services among persons with chronic spinal cord injury (SCI).

DESIGN

Data analysis of the International Spinal Cord Injury (InSCI) cross-sectional, community-based questionnaire survey conducted in 2017-2019. The association between the strength of primary care (Kringos et al., 2003) and access to health services was established using univariable and multivariable logistic regression analysis, adjusted for socio-demographic and health status characteristics.

SETTING

Community in eleven European countries: France, Germany, Greece, Italy, Lithuania, the Netherlands, Norway, Poland, Romania, Spain and Switzerland.

PARTICIPANTS

6658 adults with chronic SCI.

INTERVENTION

None.

OUTCOME MEASURES

Share of persons with SCI that reported unmet healthcare needs as a measure of access.

RESULTS

Twelve percent of the participants reported unmet healthcare needs: the highest in Poland (25%) and lowest in Switzerland and Spain (7%). The most prevalent access restriction was service unavailability (7%). Stronger primary care was associated with lower odds of reporting unmet healthcare needs, service unavailability, unaffordability and unacceptability. Females, persons of younger age and lower health status, had higher odds of reporting unmet needs.

CONCLUSIONS

In all investigated countries, persons with chronic SCI face access barriers, especially with service availability. Stronger primary care for the general population was also associated with better health service access for persons with SCI, which argues for further primary care strengthening.

Predicting the Outcome and Survival of Patients with Spinal Cord Injury Using Machine Learning Algorithms: A Systematic Review

BACKGROUND

Spinal cord injury (SCI) is a significant public health issue, leading to physical, psychological, and social complications. Machine learning (ML) algorithms have shown potential in diagnosing and predicting the functional and neurologic outcomes of subjects with SCI. ML algorithms can predict scores for SCI classification systems and accurately predict outcomes by analyzing large amounts of data. This systematic review aimed to examine the performance of ML algorithms for diagnosing and predicting the outcomes of subjects with SCI.

METHODS

The literature was comprehensively searched for the pertinent studies from inception to May 25, 2023. Therefore, electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically searched with individual search syntax.

RESULTS

A total of 9424 individuals diagnosed with SCI across multiple studies were analyzed. Among the 21 studies included, 5 specifically aimed to evaluate diagnostic accuracy, while the remaining 16 focused on exploring prognostic factors or management strategies.

CONCLUSIONS

ML and deep learning (DL) have shown great potential in various aspects of SCI. ML and DL algorithms have been employed multiple times in predicting and diagnosing patients with SCI. While there are studies on diagnosing acute SCI using DL algorithms, further research is required in this area.

Disability, Unemployment, and Inequality: A Cross-Country Comparison of the Situation of Persons With Spinal Cord Injury

Unemployment and inequality are growing concerns that disproportionately affect people with disabilities. We compared unemployment rates and barriers to labor market participation for persons with spinal cord injury (SCI) as an exemplary case of disability with different socioeconomic positions and from a cross-national perspective across 20 countries worldwide. We showed that persons with SCI have much higher unemployment rates than the general population. While this situation is many times worse for those in low-income groups, persons with SCI in high-income groups are often in a position comparable to the general population. The main barriers to entering the labor market are health status, the impossibility of finding suitable jobs, and the lack of information about employment opportunities. This is the first study that quantifies the extent of inequality in the labor market for persons with SCI. Across the 20 countries analyzed, facing disability has a much higher impact on those in low-income groups. This reality is explained by the fact that people in lower-income groups face many more barriers to entering the labor market than those in higher-income groups.

A perioperative predictive model of early mortality in acute cervical spinal cord injury: A prospective cohort study

Background

Traumatic cervical spine injury is common among spinal cord injury which requires an intensive, multidisciplinary approach which can affect the immediate postoperative hospital survival rate. By identifying the risk factors leading to early mortality in cervical spine trauma patients, the prognosis of patients with TCSCI can be better predicted.

Objective

The study aims to analyze the variables influencing in-hospital mortality in cervical spine trauma patients treated at a Level I trauma Center.

Methods

Prospective study was conducted on subaxial cervical spine injuries from July 2019 to March 2022. Patients were divided into two groups: Group A, with in-hospital mortality, and Group B, who got discharged from hospital, and mortality predictors were reviewed and analyzed for as potential risk factors for in-hospital mortality.

Results

Out of 105 patients, 83.8 % were male with mean age of 40.43 ± 12.62 years. On univariate analysis, AIS (p-value: <0.01), ICU stay (p-value: <0.01), level of injury (p-value: <0.01), and MRI parameters like the extent of Parenchymal damage (p-value: <0.01), MSCC (p-value: <0.01), and MCC (p-value: <0.01) were potential risk factors for in-hospital mortality. On multivariate regression analysis AIS at presentation (p-value: 0.02) was the only significant independent parameter for in-hospital mortality.

Conclusions

AIS grading at presentation, duration of ICU stay, level of injury, rate of tracheostomy, and MRI parameters like the extent of parenchymal damage, MCC, and MSCC influence and predicts in-hospital mortality, whereas AIS is the only independent risk factor.

Incidence and Risk Factors of Pneumonia in Individuals With Acute Spinal Cord Injury: A Multi-national, Multi-center, Prospective Cohort Study

OBJECTIVE

To describe the occurrence of pneumonia in individuals with acute spinal cord injury (SCI) and identify its key predictors.

DESIGN

Multi-centric, longitudinal cohort study.

SETTING

10 specialized SCI rehabilitation units in Europe and Australia.

PARTICIPANTS

Eligible were 902 men and women with acute SCI, aged 18 years or older, with cervical or thoracic lesions and not dependent on 24-hour mechanical ventilation; 503 participated in the study (N=503).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We assessed demographics and lesion related parameters at study entry, and any pneumonia events throughout inpatient rehabilitation. Respiratory function, decubitus, and urinary tract infections were assessed at 1, 3, and 6 months post injury as well as at discharge from inpatient rehabilitation. Time to event (pneumonia) analyses were done using the Kaplan-Meier method, and potential predictors for pneumonia were analyzed with multivariable survival models.

RESULTS

Five hundred three patients with SCI were included, with 70 experiencing at least 1 pneumonia event. 11 participants experienced 2 or more events during inpatient rehabilitation. Most events occurred very early after injury, with a median of 6 days. Pneumonia risk was associated with tetraplegia (hazard ratio [HR]=1.78; 95% confidence interval [CI] 1.00-3.17) and traumatic etiology (HR=3.75; 95% CI 1.30-10.8) American Spinal Injury Impairment Scale (AIS) A (HR=5.30; 95% CI 2.28-12.31), B (HR=4.38; 95% CI 1.77-10.83), or C (HR=4.09; 95% CI 1.71-9.81) lesions. For every 10 cmH2O increase in inspiratory muscle strength, pneumonia risk was reduced by 13% (HR=0.87; 95% CI 0.78-0.97).

CONCLUSION

Pneumonia is a major complication after SCI with the highest incidence very early after injury. Individuals with traumatic or AIS A, B, or C tetraplegia are at highest risk for pneumonia.

The digital motor output: a conceptual framework for a meaningful clinical performance metric for a motor neuroprosthesis

In recent years, the majority of the population has become increasingly reliant on continuous and independent control of smart devices to conduct activities of daily living. Upper extremity movement is typically required to generate the motor outputs that control these interfaces, such as rapidly and accurately navigating and clicking a mouse, or activating a touch screen. For people living with tetraplegia, these abilities are lost, significantly compromising their ability to interact with their environment. Implantable brain computer interfaces (BCIs) hold promise for restoring lost neurologic function, including motor neuroprostheses (MNPs). An implantable MNP can directly infer motor intent by detecting brain signals and transmitting the motor signal out of the brain to generate a motor output and subsequently control computer actions. This physiological function is typically performed by the motor neurons in the human body. To evaluate the use of these implanted technologies, there is a need for an objective measurement of the effectiveness of MNPs in restoring motor outputs. Here, we propose the concept of digital motor outputs (DMOs) to address this: a motor output decoded directly from a neural recording during an attempted limb or orofacial movement is transformed into a command that controls an electronic device. Digital motor outputs are diverse and can be categorized as discrete or continuous representations of motor control, and the clinical utility of the control of a single, discrete DMO has been reported in multiple studies. This sets the stage for the DMO to emerge as a quantitative measure of MNP performance.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries

INTRODUCTION

As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS

All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS

A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION

The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

The effect of level of injury on diabetes incidence and mortality after spinal cord injury - a longitudinal cohort study

STUDY DESIGN

Retrospective longitudinal cohort study of veterans with SCI.

OBJECTIVES

Spinal cord injury (SCI) is associated with an increased risk of developing diabetes mellitus (DM), likely due to body composition alterations and autonomic nervous system dysfunction. These factors are more pronounced in persons with tetraplegia (TP) versus paraplegia (PP). However, the effect of level of injury (LOI) on DM incidence is largely unknown. Therefore, the objective is to examine the effect of LOI on DM incidence in persons with SCI.

SETTING

South Texas Veterans Health Care System.

METHODS

We obtained electronic record data on age, sex, race/ethnicity, LOI and HbA1c concentration from January 1st 2001 through December 31st 2021. Cox proportional hazard regression analyses were used to assess the association between LOI, DM and all-cause mortality.

RESULTS

Among 728 non-diabetic veterans with SCI (350 TP/ 378 PP, 52 ± 15 years, 690 male/38 female) 243 developed DM, of which 116 with TP and 127 with PP. Despite chronological variations between TP and PP, DM risk over the entire follow-up did not differ between the groups (hazard ratio (HR): 1.06, 95% CI: 0.82-1.38). Mortality was higher in TP versus PP (HR: 1.40, 95% CI: 1.09-1.78). However, developing DM did not increase the risk of death, regardless of LOI (HR: 1.07, 95% CI: 0.83-1.37).

CONCLUSION

Despite chronological variations between both groups, the level of injury had minimal effect on long-term DM development in this cohort of veterans with SCI. Sponsorship NIH (DK105379; MS), RR&D SPiRE (I21RX003724-01A1; MT and SH).

Multivariable Prediction Models for Traumatic Spinal Cord Injury: A Systematic Review

Background

Traumatic spinal cord injuries (TSCI) greatly affect the lives of patients and their families. Prognostication may improve treatment strategies, health care resource allocation, and counseling. Multivariable clinical prediction models (CPMs) for prognosis are tools that can estimate an absolute risk or probability that an outcome will occur.

Objectives

We sought to systematically review the existing literature on CPMs for TSCI and critically examine the predictor selection methods used.

Methods

We searched MEDLINE, PubMed, Embase, Scopus, and IEEE for English peer-reviewed studies and relevant references that developed multivariable CPMs to prognosticate patient-centered outcomes in adults with TSCI. Using narrative synthesis, we summarized the characteristics of the included studies and their CPMs, focusing on the predictor selection process.

Results

We screened 663 titles and abstracts; of these, 21 full-text studies (2009-2020) consisting of 33 distinct CPMs were included. The data analysis domain was most commonly at a high risk of bias when assessed for methodological quality. Model presentation formats were inconsistently included with published CPMs; only two studies followed established guidelines for transparent reporting of multivariable prediction models. Authors frequently cited previous literature for their initial selection of predictors, and stepwise selection was the most frequent predictor selection method during modelling.

Conclusion

Prediction modelling studies for TSCI serve clinicians who counsel patients, researchers aiming to risk-stratify participants for clinical trials, and patients coping with their injury. Poor methodological rigor in data analysis, inconsistent transparent reporting, and a lack of model presentation formats are vital areas for improvement in TSCI CPM research.

Nitric oxide-induced lipophagic defects contribute to testosterone deficiency in rats with spinal cord injury

Introduction

Males with acute spinal cord injury (SCI) frequently exhibit testosterone deficiency and reproductive dysfunction. While such incidence rates are high in chronic patients, the underlying mechanisms remain elusive.

Methods and results

Herein, we generated a rat SCI model, which recapitulated complications in human males, including low testosterone levels and spermatogenic disorders. Proteomics analyses showed that the differentially expressed proteins were mostly enriched in lipid metabolism and steroid metabolism and biosynthesis. In SCI rats, we observed that testicular nitric oxide (NO) levels were elevated and lipid droplet-autophagosome co-localization in testicular interstitial cells was decreased. We hypothesized that NO impaired lipophagy in Leydig cells (LCs) to disrupt testosterone biosynthesis and spermatogenesis. As postulated, exogenous NO donor (S-nitroso-N-acetylpenicillamine (SNAP)) treatment markedly raised NO levels and disturbed lipophagy via the AMPK/mTOR/ULK1 pathway, and ultimately impaired testosterone production in mouse LCs. However, such alterations were not fully observed when cells were treated with an endogenous NO donor (L-arginine), suggesting that mouse LCs were devoid of an endogenous NO-production system. Alternatively, activated (M1) macrophages were predominant NO sources, as inducible NO synthase inhibition attenuated lipophagic defects and testosterone insufficiency in LCs in a macrophage-LC co-culture system. In scavenging NO (2-4-carboxyphenyl-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (CPTIO)) we effectively restored lipophagy and testosterone levels both in vitro and in vivo, and importantly, spermatogenesis in vivo. Autophagy activation by LYN-1604 also promoted lipid degradation and testosterone synthesis.

Discussion

In summary, we showed that NO-disrupted-lipophagy caused testosterone deficiency following SCI, and NO clearance or autophagy activation could be effective in preventing reproductive dysfunction in males with SCI.

Impact of Specialized Versus Non-Specialized Acute Hospital Care on Survival Among Patients With Acute Incomplete Traumatic Spinal Cord Injuries: A Population-Based Observational Study from British Columbia, Canada

Given the complexity of care necessitated after an acute traumatic spinal cord injury (SCI), it seems intuitively beneficial for such care to be delivered at hospitals with specialized SCI expertise. Demonstrating these benefits is not straightforward, however. We sought to determine whether specialized acute hospital care influenced the most fundamental outcomes after SCI: mortality within the first year of injury. We compared survival among patients with incomplete tSCI admitted to a single quaternary-level trauma hospital with a specialized acute SCI program versus those admitted to trauma hospitals without specialized acute SCI care. We performed a population-based retrospective observational cohort study using administrative and clinical data linked from multiple sources in British Columbia (BC) from 2001 to 2017. Among a cohort of 1920 patients, there were 193 deaths within one year. We failed to identify a significant overall benefit for survival after adjusting for potential confounders, and the confidence intervals (CIs) were compatible with both benefit and harm (odds ratio [OR] 1.01, 95% CI 0.17 to 6.11, p = 0.99). Significant associations were observed with age greater than 65 (OR 4.92, 95% CI 1.66 to 14.57, p < 0.01), Charlson Comorbidity Index (OR 1.61, 95% CI 1.42 to 1.83, p < 0.01), Injury Severity Score (OR 1.08, 95% CI 1.06 to 1.11, p < 0.01), and traumatic brain injury (OR 2.12, 95% CI 1.32 to 3.41, p < 0.01). Among patients with acute tSCI, admission to a hospital with specialized acute SCI care was not associated with improved overall one-year survival. Subgroup analyses, however, suggested heterogeneity of effects, with little benefit for older patients with less polytrauma and substantial benefit for younger patients with greater polytrauma.

Finite element analysis of electric field distribution during direct current stimulation of the spinal cord: Implications for device design

Spinal cord injury (SCI) arises from damage to the spinal cord, often caused by trauma or disease. The resulting sensorimotor dysfunction is variable and dependent on the extent of the injury. Despite years of research, curative options for SCI remain limited. However, recent advancements in electric field stimulated axonal regrowth have shown promise for neuronal regeneration. One roadblock in the development of therapeutic treatments based on this is a lack of understanding of the exogenous electric field distribution in the injured tissue, and in particular, how this is influenced by electrode geometry and placement. To better understand this electric field, and provide a means by which it can be optimized, we have developed a finite element model of such spinal cord treatment. We investigate the impact of variations in electrode geometry, spinal cord size, and applied current magnitude as well as looking at several injury models in relation to clinically observed outcomes. Through this, we show that electrode shape has little effect on the induced electric field, that the placement of these electrodes has a noticeable influence on the field distribution, and that the magnitude of this field is governed by both the applied current and the spinal cord morphology. We also show that the injury modality influences the induced field distribution and that a stronger understanding of the injury will help decide treatment parameters. This work provides guidance in the design of electrodes for future clinical application in direct current electric field stimulation for axonal regeneration.

Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study

BACKGROUND AND OBJECTIVES

Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs.

METHODS

A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction).

RESULTS

Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up.

CONCLUSION

This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.

Research priorities to enhance life for people with spinal cord injury: a Swedish priority setting partnership

STUDY DESIGN

Mixed-method consensus development project.

OBJECTIVE

To identify the top ten research priorities for spinal cord injury (SCI).

SETTING

Nationwide in Sweden in 2021-22.

METHODS

The PSP process proposed by the James Lind Alliance was used. It comprises two main phases: question identification and priority selection. People living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI were included.

RESULTS

In the first phase, 242 respondents provided 431 inputs addressing potentially unanswered questions. Of these, 128 were beyond the scope of this study. The remaining 303 were merged to formulate 57 questions. The literature review found one question answered, so 56 questions proceeded to the prioritisation. In the second phase, the interim prioritisation survey, 276 respondents ranked the 56 questions. The top 24 questions then proceeded to the final prioritisation workshop, at which 23 participants agreed on the top ten priorities.

CONCLUSIONS

This paper reveals issues that people living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI find difficult to get answered. The top-priority questions for people living with SCI in Sweden concern specialist SCI care and rehabilitation, followed by a number of questions addressing physical health. Other topics, from the 56 key questions include Mental health, Ageing with SCI, Community support and personal care assistance, and Body functions. This result can guide researchers to design appropriate studies relevant to people with SCI.

SPONSORSHIP

The project was funded by the Gothenburg Competence Centre for Spinal Cord Injury and the Swedish Association for Survivors of Accident and Injury (RTP).

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

In-hospital mortality rate in subaxial cervical spinal cord injury patients: a systematic review and meta-analysis

PURPOSE

To determine existing trends concerning in-hospital mortality in patients with traumatic subaxial cervical spinal cord injury (SCI) over the last four decades.

METHODS

We searched MEDLINE and EMBASE to assess the role of the following factors on in-hospital mortality over the last four decades: neurological deficit, age, surgical decompression, use of computed tomography (CT) and magnetic resonance imaging (MRI), use of methylprednisolone in the acute post-injury period, and study location (developing versus developed countries).

RESULTS

Among 3333 papers after deduplication, 21 studies met the eligibility criteria. The mortality rate was 17.88% [95% confidence interval (CI): 12.9-22.87%]. No significant trend in mortality rate was observed over the 42-year period (meta-regression coefficient = 0.317; p = 0.372). Subgroup analysis revealed no significant association between acute subaxial cervical SCI-related mortality when stratified by use of surgery, administration of methylprednisolone, use of MRI and CT imaging, study design (prospective versus retrospective study), and study location. The mortality rate was significantly higher in complete SCI (20.66%, p = 0.002) and American Spinal Injury Association impairment scale (AIS) A (20.57%) and B (9.28%) (p = 0.028).

CONCLUSION

A very low level of evidence showed that in-hospital mortality in patients with traumatic subaxial cervical SCI did not decrease over the last four decades despite diagnostic and therapeutic advancements. The overall acute mortality rate following subaxial cervical SCI is 17.88%. We recommend reporting a stratified mortality rate according to key factors such as treatment paradigms, age, and severity of injury in future studies.

Stem Cell Therapy in Spinal Cord Injury-Induced Neurogenic Lower Urinary Tract Dysfunction

Spinal cord injury (SCI) is a devastating condition that enormously affects an individual's health and quality of life. Neurogenic lower urinary tract dysfunction (NLUTD) is one of the most important sequelae induced by SCI, causing complications including urinary tract infection, renal function deterioration, urinary incontinence, and voiding dysfunction. Current therapeutic methods for SCI-induced NLUTD mainly target on the urinary bladder, but the outcomes are still far from satisfactory. Stem cell therapy has gained increasing attention for years for its ability to rescue the injured spinal cord directly. Stem cell differentiation and their paracrine effects, including exosomes, are the proposed mechanisms to enhance the recovery from SCI. Several animal studies have demonstrated improvement in bladder function using mesenchymal stem cells (MSCs) and neural stem cells (NSCs). Human clinical trials also provide promising results in urodynamic parameters after MSC therapy. However, there is still uncertainty about the ideal treatment window and application protocol for stem cell therapy. Besides, data on the therapeutic effects regarding NSCs and stem cell-derived exosomes in SCI-related NLUTD are scarce. Therefore, there is a pressing need for further well-designed human clinical trials to translate the stem cell therapy into a formal therapeutic option for SCI-induced NLUTD.

Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

To identify five-year longitudinal changes in employment, health, participation, and quality-of-life outcomes (QOL) among participants with chronic spinal cord injury (SCI) and to compare the amount of change in these outcomes between those surviving and those not surviving until follow-up.

METHODS

Participants were 1157 individuals from the SCI Longitudinal Aging Study, who have completed at least two self-report assessments separated by five-year intervals. The main outcome measures were 13 indicators related to employment, health, participation, and QOL/psychosocial indicators. Survival status measured at follow-up.

RESULTS

Those who survived to follow up had a history indicating a greater likelihood of employment, better health, participation, and QOL/psychosocial indicators. Among survivors, longitudinal declines were limited to the percent employed and participation indicators, whereas those deceased by follow-up had significant undesirable changes in employment, participation, health, and QOL/psychosocial indicators. More specifically, compared to the survivors, those deceased by follow-up experienced a greater increase in hospitalizations, decreases in nights away from home, and declines in global satisfaction over the five-year interval.

CONCLUSIONS

Longitudinal declines in employment and some aspects of participation are common among long-term survivors and may be part of the natural course of outcomes after SCI. However, more dramatic increases in hospitalizations, fewer nights away from home, and declining satisfaction may be red flags for declining longevity.

A dynamic nomogram for predicting the probability of irreversible neurological dysfunction after cervical spinal cord injury: research based on clinical features and MRI data

BACKGROUND

Irreversible neurological dysfunction (IND) is an adverse event after cervical spinal cord injury (CSCI). However, there is still a shortage of objective criteria for the early prediction of neurological function. We aimed to screen independent predictors of IND and use these findings to construct a nomogram that could predict the development of neurological function in CSCI patients.

METHODS

Patients with CSCI attending the Affiliated Hospital of Southwest Medical University between January 2014 and March 2021 were included in this study. We divided the patients into two groups: reversible neurological dysfunction (RND) and IND. The independent predictors of IND in CSCI patients were screened using the regularization technique to construct a nomogram, which was finally converted into an online calculator. Concordance index (C-index), calibration curves analysis and decision curve analysis (DCA) evaluated the model's discrimination, calibration, and clinical applicability. We tested the nomogram in an external validation cohort and performed internal validation using the bootstrap method.

RESULTS

We enrolled 193 individuals with CSCI in this study, including IND (n = 75) and RND (n = 118). Six features, including age, American spinal injury association Impairment Scale (AIS) grade, signal of spinal cord (SC), maximum canal compromise (MCC), intramedullary lesion length (IMLL), and specialized institution-based rehabilitation (SIBR), were included in the model. The C-index of 0.882 from the training set and its externally validated value of 0.827 demonstrated the model's prediction accuracy. Meanwhile, the model has satisfactory actual consistency and clinical applicability, verified in the calibration curve and DCA.

CONCLUSION

We constructed a prediction model based on six clinical and MRI features that can be used to assess the probability of developing IND in patients with CSCI.

Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.

Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10^-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.

The prevalence and profile of spinal cord injury in public healthcare rehabilitation units in Gauteng, South Africa

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

To determine the prevalence and describe the profile of person with SCI (PWSCI) admitted in the public healthcare sector in Gauteng, South Africa.

SETTING

Specialized public healthcare rehabilitation units in Gauteng, South Africa.

METHODS

Medical records of PWSCI admitted to public healthcare rehabilitation units between 01 January 2018 and 31 December 2019 were perused. Data were collected anonymously and then summarised using descriptive and inferential statistics. Significance was set at p < 0.05.

RESULTS

386 of 998 participants (38.7%) were admitted following SCI and the mean age was 36.9 years. Most participants were male (69.9%), with females significantly more likely to sustain a NTSCI (p < 0.001), which was the least common cause of SCI (34.9%). Those sustaining a TSCI were found to be significantly younger than their NTSCI counterparts (p < 0.001). Assault was the leading cause of injury (35.2%), and a positive HIV status with the presence of comorbidities were found to be significant risk factors for developing a NTSCI (p < 0.001). Most injuries were between T7-T12 (39.9%) and were complete (56.9%). The rehabilitation length of stay 85.6 days, with a mortality rate of 6.48%.

CONCLUSIONS

Gauteng has among the highest global proportion of TSCI due to assault. Of interest, more females sustained a NTSCI than their male counterparts. There is a need to strengthen SCI prevention strategies, particularly targeting assault in young males and infectious causes in females and older populations. Further epidemiological and outcomes-based research is required for PWSCI.

Cost-effectiveness analysis of hydrophilic-coated catheters in long-term intermittent catheter users in the UK

OBJECTIVE

To estimate the cost-effectiveness of single-use hydrophilic-coated intermittent catheters (HCICs) versus single-use uncoated intermittent catheters (UICs) for urinary catheterization.

METHODS

The evaluation took a UK national health service (NHS) perspective. The population of interest were people using intermittent catheters, with either a spinal cord injury or multiple sclerosis. A Markov model was developed that estimated costs and clinical evidence over the lifetime of a hypothetical cohort and applied health-related quality-of-life estimates. Model inputs were sourced from published evidence, including a network meta-analysis to inform the treatment effect (reduction in catheter-associated urinary tract infections [CAUTIs]), and were supported by expert opinion. The model outputs included per-patient lifetime costs, quality-adjusted life years (QALYs), and the incremental cost effectiveness ratio (ICER). Event counts were also produced.

RESULTS

Using HCICs instead of UICs could prevent seven CAUTI events per patient over a lifetime horizon (1.8 requiring secondary care). Overall, lifetime use of HCICs is £3,183 more expensive than use of UICs per patient. However, for these additional costs, 0.55 QALYs are gained. The ICER is £5,755 per additional QALY gained. Key drivers of the model results were identified and subject to sensitivity analyses. The results were found to be robust to parameter uncertainty.

CONCLUSION

HCICs are likely to be a cost-effective alternative to UICs, a result driven by substantial reductions in the number of CAUTIs. Their adoption across clinical practice could avoid a substantial number of infections, freeing up resources in the NHS and reducing antibiotic use in urinary catheter users.

Incidence and mortality of spinal cord injury from 2008 to 2020: a retrospective population-based cohort study in the Piedmont Region, Italy

STUDY DESIGN

Retrospective population-based cohort study.

OBJECTIVES

To determine the incidence and mortality of spinal cord injuries (SCI) in the Piedmont Region of Northwestern Italy.

SETTING

Publicly-funded SCI rehabilitation centres in the Piedmont Region.

METHODS

Administrative databases were used to identify individuals at their first admission to a SCI rehabilitation centre from January 1st, 2008 to December 31st, 2020. Cases were stratified by age and aetiology (traumatic SCI, TSCI; non-traumatic SCI, NTSCI). Age- and aetiology-specific incidence rate and person-year mortality rates were calculated for each year. Case lethality was reported as deaths among prevalent cases for each year.

RESULTS

A total of 892 cases were identified (56.4% TSCI). The average annual crude incidence rate was 17.9 per million population, decreasing from 26.0 in 2008 to 10.8 in 2020. Young adults and the elderly represented the majority of TSCI and NTSCI cases, respectively. Of the 235 individuals who died during the study period, 58.3% had NTSCI. The mortality rate per 1000 person-years decreased from 16.3 in 2009 to 8.5 in 2020, while case lethality more than tripled (from 17.2 in 2009 to 57.1 in 2020).

CONCLUSIONS

We identified a decreasing trend in SCI incidence and mortality rates, with an increased case lethality over the study period, especially in NTSCI. Given these changes in the epidemiology of SCI, community services offered after rehabilitation should be strengthened to enhance their effectiveness and contribute to increased survival in this population.

Advances in Spinal Cord Stimulation

Neuromodulation, specifically spinal cord stimulation (SCS), has become a staple of chronic pain management for various conditions including failed back syndrome, chronic regional pain syndrome, refractory radiculopathy, and chronic post operative pain. Since its conceptualization, it has undergone several advances to increase safety and convenience for patients and implanting physicians. Current research and efforts are aimed towards novel programming modalities and modifications of existing hardware. Here we review the recent advances and future directions in spinal cord stimulation including a brief review of the history of SCS, SCS waveforms, new materials for SCS electrodes (including artificial skins, new materials, and injectable electrodes), closed loop systems, and neurorestorative devices.

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

PURPOSE

International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool.

MATERIALS AND METHODS

A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round.

RESULTS

Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool.

CONCLUSIONS

Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.

Macrophage Extracellular Traps Exacerbate Secondary Spinal Cord Injury by Modulating Macrophage/Microglia Polarization via LL37/P2X7R/NF-κB Signaling Pathway

Persistent inflammation in the secondary spinal cord injury (SCI) is an important reason for the failure of nerve repair, which is partly due to the continuous activation of local M1-like macrophage/microglia. It is reported that extracellular trap (ET) has been a new way of cell death, which can be released by macrophages and named macrophage extracellular trap (Met). Furthermore, it exists widely in the pathophysiological process of many diseases, but it has been rarely studied in the field of SCI. In this study, we constructed a spinal cord contusion model and assessed the function outcome of SCI rats. We used immunofluorescence, flow cytometry, and transmission electron microscope (TEM) to demonstrate the existence of Mets. Besides, some related experiments had also been employed to explore the relationship between Mets and M1 polarization of macrophage/microglia. We also performed Co-IP and Western blotting to reveal a new extracellular proinflammatory signal pathway. Finally, we made a linear regression analysis between the concentrations of specific markers of Mets in human serum and ASIA scores. Briefly, our results suggested that macrophages infiltrated in SCI area could induce macrophage/microglia to differentiate into M1-like cells by releasing Mets, which may be achieved partly through LL37-P2X37-NF-κB signal pathway. However, limiting Mets could effectively inhibit M1 polarization and promote function recovery. In addition, the concentrations of Met related proteins in human serum showed high correlation with ASIA scores and could be applied to reflect the severity of SCI. In conclusion, Mets may be a new target for SCI therapy and a promising index for SCI assessment.

Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries

OBJECTIVE

We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs.

METHODS

A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages.

INCLUSION CRITERIA

published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods.

RESULTS

Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44-2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27-4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140).

CONCLUSIONS

Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.

Endocrinological and inflammatory markers in individuals with spinal cord injury: A systematic review and meta-analysis

Spinal cord injury (SCI) can lead to dramatic physiological changes which can be a factor in developing secondary health conditions and might be reflected in biomarker changes in this elevated risk group. We focused specifically on the endocrine and inflammation profile differences between SCI and able-bodied individuals (ABI). Our aim was to determine the differences in inflammatory markers and endocrine profiles between SCI and ABI. We systematically searched 4 electronic databases for relevant studies. Human observational (cross-sectional, cohort, case-control) studies that compared biomarkers of interest between SCI and ABI population were included. Weighted mean difference between SCI and ABI was calculated using random-effects models. Heterogeneity was computed using I² statistic and chi-squared test. Study quality was evaluated through the Newcastle-Ottawa Scale. The search strategy yielded a total of 2,603 studies from which 256 articles were selected for full-text assessment. Sixty-two studies were included in the meta-analysis. SCI individuals had higher levels of pro-inflammatory C-reactive protein and IL-6 than ABI. Creatinine and 25-hydroxyvitamin D₃ levels were lower in SCI than ABI. Total testosterone levels and IGF-1 were also found to be lower, while cortisol and leptin levels were higher in SCI when compared to ABI. Accordingly, meta-regression, subgroup analysis, and leave-one-out analysis were performed, however, they were only able to partially explain the high levels of heterogeneity. Individuals with SCI show higher levels of inflammatory markers and present significant endocrinological changes when compared to ABI. Moreover, higher incidence of obesity, diabetes, osteoporosis, and hypogonadism in SCI individuals, together with decreased creatinine levels reflect some of the readily measurable aspects of the phenotype changes in the SCI group. These findings need to be considered in anticipating medically related complications and personalizing SCI medical care.

Video-urodynamics efficacy of sacral neuromodulation for neurogenic bladder guided by three-dimensional imaging CT and C-arm fluoroscopy: a single-center prospective study

To assess the efficacy of sacral neuromodulation (SNM) for neurogenic bladder (NB), guided by intraoperative three-dimensional imaging of sacral computed tomography (CT) and mobile C-arm fluoroscopy through video-urodynamics examination. We enrolled 52 patients with NB who underwent conservative treatment with poor results between September 2019 and June 2021 and prospectively underwent SNM guided by intraoperative three-dimensional imaging of sacral CT and mobile C-arm fluoroscopy. Video-urodynamics examination, voiding diary, quality of life questionnaire, overactive bladder symptom scale (OABSS) scoring, and bowel dysfunction exam were completed and recorded at baseline, at SNM testing, and at 6-month follow-up phases. Finally, we calculated the conversion rate from period I to period II, as well as the treatment efficiency and the occurrence of adverse events during the testing and follow-up phases. The testing phase of 52 NB patients was 18–60 days, with an average of (29.3 ± 8.0) days. Overall, 38 patients underwent SNM permanent electrode implantation, whose follow-up phase was 3–25 months, with an average of (11.9 ± 6.1) months. Compared with baseline, the voiding times, daily catheterization volume, quality of life score, OABSS score, bowel dysfunction score, maximum detrusor pressure before voiding, and residual urine volume decreased significantly in the testing phase. The daily voiding volume, functional bladder capacity, maximum urine flow rate, bladder compliance, and maximum cystometric capacity increased significantly in the testing phase. Besides, the voiding times, daily catheterization volume, quality of life score, OABSS score, bowel dysfunction score, maximum detrusor pressure before voiding, and residual urine volume decreased further from the testing to follow-up phase. Daily voiding volume, functional bladder capacity, maximum urine flow rate, bladder compliance, and maximum cystometric capacity increased further from testing to follow-up. At baseline, 10 ureteral units had vesicoureteral reflux (VUR), and 9 of them improved in the testing phase. Besides, there was 1 unit that further improved to no reflux during the follow-up phase. At baseline, 10 patients had detrusor overactivity (DO), and 8 of them improved in the testing phase. Besides, 1 patient’s symptoms further improved during the follow-up phase. At baseline, there were 35 patients with detrusor-bladder neck dyssynergia (DBND); 14 (40.0%) of them disappeared during the testing phase. Among 13 cases who had DBND in the testing phase, 6 (46.2%) disappeared during the follow-up phase. Of the 47 patients with detrusor-external sphincter dyssynergia (DESD) at baseline, 8 (17.0%) disappeared during the testing phase. Among 26 cases who had DESD in the testing phase, 6 (23.1%) disappeared during the follow-up phase. The effective rate of this study was 88.5% (46/52), and the conversion rate from phase I to phase II was 73.1% (38/52). Additionally, the efficacy in a short-term follow-up was stable. SNM guided by intraoperative three-dimensional imaging of sacral CT and mobile C-arm fluoroscopy is an effective and safe treatment option for NB in short time follow-up. It would be well improved in the bladder storage function, sphincter synergetic function and emptying efficiency by video-urodynamics examination in this study.

Trial registration: Chinese Clinical Trial Registry. ChiCTR2100050290. Registered August 25 2021. http://www.chictr.org.cn/index.aspx.

Temporal changes in demographic and injury characteristics of traumatic spinal cord injuries in Nordic countries - a systematic review with meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To explore temporal changes in incidence rates, demographic and injury characteristics of incident traumatic spinal cord injury (TSCI) in Nordic countries.

METHODS

Peer-reviewed publications and periodic reports about epidemiology of TSCI in the Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) are identified, reviewed and included in the meta-analysis. Data are stratified into 20-year intervals to allow for chronological comparisons. Pooled estimates are derived using random effects meta-analysis.

RESULTS

Twenty-three data sources are included presenting a total of 5416 cases. The pooled incidence rate for 2001-2020 is 15.4 cases/million/year compared to 17.6 and 18.3 cases/million/year during the two previous 20-year intervals. The proportion of cases with TSCI in the 15-29 age-group decreases from 50% (1961-1980) to 20% (2001-2020), while it increases from 9% to 35% in 60+ age-group. Transportation-related injuries decrease from 44% (1961-1980) to 27% (2001-2020). Conversely, fall-related injuries increase from 32% (1961-1980) to 46% (2001-2020). The proportion of individuals with incomplete tetraplegia increases from 31% (1961-1980) to 43% (2001-2020), while complete paraplegia decreases from 25% to 16%.

CONCLUSION

The characteristics of TSCI in the Nordic countries have changed drastically over the last six decades, in line with clinical experiences, and limited research evidence from other countries. These changes indicate the need for adapting research focus, prevention strategies, design and provision of care, rehabilitation and community services towards older individuals, fall-related injuries, and incomplete injuries in Nordic countries and other settings internationally where such changes occur.

Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

Previous research has indicated that socioeconomic factors affect longevity after traumatic spinal cord injury (SCI). Our purpose was to evaluate whether social participation mediates the relationship between socioeconomic factors and survival status after SCI.

SETTING

Medical university in the southeastern United States.

METHODS

Participants (N = 1540) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and having residual impairment from SCI. The main outcome measures were a) survival status as of December 31, 2019, identified by the National Death Index (NDI) search, b) socioeconomic status (SES), measured by education, employment status, and family income, and c) participation, measured by marital/relationship status, hours out of bed per day, days leaving home per week, and nights away home during the past year.

RESULTS

Thirty nine percent of participants (n = 602) were decreased by the end of 2019. Socioeconomic factors were associated with longevity controlling for demographic, injury characteristics, and health status. However, the association of SES with longevity was mediated by three social participation mobility indicators (hours out of bed, days out of house, and nights away from home), such that SES was no longer significantly related to longevity after inclusion of the participation variables.

CONCLUSIONS

Although socioeconomic factors are related to longevity, their relationship appears to be mediated by social participation mobility indicators. Intervention studies are needed to address the modifiable factors that may promote longevity, including promoting an active lifestyle.

Comparison of Different Tidal Volumes for Ventilation in Patients with an Acute Traumatic Cervical Spine Injury

Background

There is scant literature comparing high tidal volume ventilation (HTV) over low tidal volume (LTV) ventilation in acute traumatic cervical spinal cord injury (CSCI).

Objective

The aim of this prospective randomized controlled parallel-group, single-blinded study was to compare the effect of two different tidal volumes (12-15 mL/kg and 6-8 mL/kg) in CSCI on days to achieve ventilator-free breathing (VFB), PaO2/FIO2 ratio, the incidence of complications, requirement of vasopressor drugs, total duration of hospital stay, and mortality.

Materials and Methods

We enrolled patients with acute high traumatic CSCI admitted to the neurotrauma intensive care unit within 24 h of injury, requiring mechanical ventilation. Participants were randomized to receive either HTV, 12-15 mL/kg (group H) or LTV, 6-8 mL/kg (group L) tidal volume ventilation.

Results and Conclusions

A total of 56 patients, 28 in each group were analyzed. Patient demographics and injury severity were comparable between the groups. VFB was achieved in 23 and 19 patients in groups H and L, respectively. The median number of days required to achieve VFB was 3 (2, 56) and 8 (2, 50) days, P = 0.33; PaO2: FIO2 ratio was 364.0 ± 64 and 321.0 ± 67.0, P = 0.01; the incidence of atelectasis was 25% and 46%, P = 0.16, respectively, in group H and group L. The hemodynamic parameters and the vasopressor requirement were comparable in both groups. There was no barotrauma. The duration of hospital stay (P = 0.2) and mortality (P = 0.2) was comparable in both groups. There was no significant difference in days to achieve ventilator-free breathing with HTV (12-15 mL/kg) ventilation compared to LTV (6-8 mL/kg) ventilation in acute CSCI. The PaO2:FiO2 ratio was higher with the use of 12-15 mL/kg. No difference in mortality and duration of hospital stay was seen in either group.

Baseline predictors of in-hospital mortality after acute traumatic spinal cord injury: data from a level I trauma center

Comorbidity scores are important predictors of in-hospital mortality after traumatic spinal cord injury (tSCI), but the impact of specific pre-existing diseases is unknown. This retrospective cohort study aims at identifying relevant comorbidities and explores the influence of end-of-life decisions. In-hospital mortality of all patients admitted to the study center after acute tSCI from 2011 to 2017 was assessed. A conditional inference tree analysis including baseline data, injury characteristics, and Charlson Comorbidity Index items was used to identify crucial predictors. End-of-life decisions were recorded. Three-hundred-twenty-one patients were consecutively enrolled. The median length of stay was 95.7 days (IQR 56.8-156.0). During inpatient care, 20 patients (6.2%) died. These patients were older (median: 79.0 (IQR 74.7-83.2) vs. 55.5 (IQR 41.4-72.3) years) and had a higher Charlson Comorbidity Index score (median: 4.0 (IQR 1.75-5.50) vs. 0.0 (IQR 0.00-1.00)) compared to survivors. Pre-existing kidney or liver disease were identified as relevant predictors of in-hospital mortality. End-of-life decisions were observed in 14 (70.0%) cases. The identified impairment of kidney and liver, important for drug metabolism and elimination, points to the need of careful decisions on pharmaceutical treatment regimens after tSCI. Appropriate reporting of end-of-life decisions is required for upcoming studies.

Hybrid high-intensity interval training using functional electrical stimulation leg cycling and arm ski ergometer for people with spinal cord injuries: a feasibility study

Aim

The aim was to assess safety and feasibility of Hybrid High-Intensity Interval Training (HIIT) using Functional Electrical Stimulation (FES) leg cycling and arm ski ergometer in people with Spinal Cord Injuries (SCI).

Method

Eight outpatients (mean age 42.8 years; 7 men) with stable SCI paraplegia (mean 14.5 years since injury) participated in hybrid HIIT (90% peak watts; 4 × 4–min intervals), three times a week (over 8 weeks). Primary outcomes were Adverse Events (AE), participant acceptability, shoulder pain, training intensity (% peak watts), and attendance.

Secondary outcomes were effect on peak oxygen uptake (VO₂peak) during FES hybrid poling, mean watts, self-reported leisure time physical activity, quality of life, and fatigue.

Results

No serious AE occurred; acceptability with the training modality was high, while shoulder pain increased by 9% (SD 95.2). During training, 50% of the participants reached > 90% peak watts during the intervals, three with the legs (FES cycle) and one with the arms (Ski-Erg). Overall, mean training intensity (% peak watts) was 92% (SD 18.9) for legs and 82% (SD 10.3) for arms. Proportion of fulfilled training minutes was 82% (range 36–100%); one participant dropped out after 6 weeks due to back pain. Mean VO₂peak increased by 17% (SD 17.5). Participants reported increased leisure time physical activity and health-related quality of life, besides reduced fatigue.

Conclusion

Hybrid HIIT was safe for people with SCI paraplegia. The majority of the criteria for feasibility were met with acceptable attendance rate, limited drop out, participants enjoyed training, and increased VO₂peak and mean watts. However, the intensity of 90% peak watts was reached by < 60% of the participants despite high RPE ratings during training. The method of measuring and calculating intensity needs to be studied further before a study using this HIIT protocol is undertaken.

Trial registration

Clinicaltrials.gov, NCT04211311, registered 12 December 2019 retrospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00997-2.

Electroactive Scaffolds to Improve Neural Stem Cell Therapy for Spinal Cord Injury

Spinal cord injury (SCI) is a serious condition caused by damage to the spinal cord through trauma or disease, often with permanent debilitating effects. Globally, the prevalence of SCI is estimated between 40 to 80 cases per million people per year. Patients with SCI can experience devastating health and socioeconomic consequences from paralysis, which is a loss of motor, sensory and autonomic nerve function below the level of the injury that often accompanies SCI. SCI carries a high mortality and increased risk of premature death due to secondary complications. The health, social and economic consequences of SCI are significant, and therefore elucidation of the complex molecular processes that occur in SCI and development of novel effective treatments is critical. Despite advances in medicine for the SCI patient such as surgery and anaesthesiology, imaging, rehabilitation and drug discovery, there have been no definitive findings toward complete functional neurologic recovery. However, the advent of neural stem cell therapy and the engineering of functionalized biomaterials to facilitate cell transplantation and promote regeneration of damaged spinal cord tissue presents a potential avenue to advance SCI research. This review will explore this emerging field and identify new lines of research.

Development of a machine learning algorithm for predicting in-hospital and 1-year mortality after traumatic spinal cord injury

BACKGROUND CONTEXT

Current prognostic tools such as the Injury Severity Score (ISS) that predict mortality following trauma do not adequately consider the unique characteristics of traumatic spinal cord injury (tSCI).

PURPOSE

Our aim was to develop and validate a prognostic tool that can predict mortality following tSCI.

STUDY DESIGN

Retrospective review of a prospective cohort study.

PATIENT SAMPLE

Data was collected from 1245 persons with acute tSCI who were enrolled in the Rick Hansen Spinal Cord Injury Registry between 2004 and 2016.

OUTCOME MEASURES

In-hospital and 1-year mortality following tSCI.

METHODS

Machine learning techniques were used on patient-level data (n=849) to develop the Spinal Cord Injury Risk Score (SCIRS) that can predict mortality based on age, neurological level and completeness of injury, AOSpine classification of spinal column injury morphology, and Abbreviated Injury Scale scores. Validation of the SCIRS was performed by testing its accuracy in an independent validation cohort (n=396) and comparing its performance to the ISS, a measure which is used to predict mortality following general trauma.

RESULTS

For 1-year mortality prediction, the values for the Area Under the Receiver Operating Characteristic Curve (AUC) for the development cohort were 0.84 (standard deviation=0.029) for the SCIRS and 0.55 (0.041) for the ISS. For the validation cohort, AUC values were 0.86 (0.051) for the SCIRS and 0.71 (0.074) for the ISS. For in-hospital mortality, AUC values for the development cohort were 0.87 (0.028) and 0.60 (0.050) for the SCIRS and ISS, respectively. For the validation cohort, AUC values were 0.85 (0.054) for the SCIRS and 0.70 (0.079) for the ISS.

CONCLUSIONS

The SCIRS can predict in-hospital and 1-year mortality following tSCI more accurately than the ISS. The SCIRS can be used in research to reduce bias in estimating parameters and can help adjust for coefficients during model development. Further validation using larger sample sizes and independent datasets is needed to assess its reliability and to evaluate using it as an assessment tool to guide clinical decision-making and discussions with patients and families.

Epidemiology of traumatic spinal cord injury: a large population-based study

STUDY DESIGN

A retrospective population-based study.

OBJECTIVES

Describe the incidence of traumatic spinal cord injury (TSCI) and mortality risks, based on the characteristics of the patient, anatomical level of the lesion, setting/cause of the injury, and type of healthcare support received within the regional trauma network (highly specialized trauma center or spoke hospital).

SETTING

Between 2011 and 2020, 1303 patients with incident TSCI were identified in a population of 4.9 million inhabitants.

METHODS

Hospital discharge records and mortality records were used to identify patients and outcomes. Cox regression models were fitted to estimate mortality risks across several subgroups.

RESULTS

Over the past decade, age-sex-standardized TSCI incidence rates remained stable with 26.5 cases (95% CI, 25.0-27.9) per 1,000,000 inhabitants (mean age 59.2 years) and most cases were males (68.3%). Incidence was directly associated with age while the male to female ratio was inversely related. Most TSCIs were cervical lesions (52.1%), and the most common cause of injury were traffic crashes (29.9%) followed by occupational accidents (29.8%). Sex, cause of the trauma, or inpatient hospital management were not associated with an increased risk of death. Mortality rates were greater for cervical lesions, and increased with age, remaining stably high among older individuals even 12 months after the accident. One-month mortality risk was significantly higher at ≥75 years compared to <55 years (adjusted HR 9.14 (95% CI, 4.17-20.03)).

CONCLUSION

Public health policies should aim at reducing preventable TSCIs, and special attention should be drawn to long-term management of elderly patients in the attempt to decrease mortality rates.

In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI).

SETTING

The study was performed at the Indian Spinal Injuries Centre, New Delhi.

METHODS

Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression.

RESULTS

Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality.

CONCLUSION

Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.

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

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

Trends and external causes of traumatic brain injury and spinal cord injury mortality in south China, 2014-2018: an ecological study

BACKGROUND

The epidemiological evidence of traumatic brain injury (TBI) and spinal cord injury (SCI) mortality in mainland China is lacking. We aimed to assess the trends of TBI and SCI mortality, and their association with sex, age, location and external causes of injury in south China.

METHODS

Mortality data were derived from the Disease Surveillance Points (DSPs) system of Guangdong province between 2014 and 2018. We examined the trends in mortality with Cochran-Armitage trend test, and the association between the socio-demographic factors and the TBI and SCI mortality by using negative binomial models. Subgroup analysis was performed by stratifying the external causes of TBI and SCI.

RESULTS

The age-standardized TBI mortality remained relatively stable (from 11.6 to 15.4 per 100,000), while the SCI mortality increased by 148.3% from 2014 to 2018. Compared with females and urban residents, the adjusted mortality rate ratios of males and rural residents were 2.3 and 2.0 for TBI, and 2.2 and 4.6 for SCI, respectively. TBI and SCI mortality increased substantially with age. Motor vehicle crashes and falls were the leading causes of TBI mortality in residents aged under 75 years and over 75 years, respectively. Falls were the most important external cause for SCI death of all ages.

CONCLUSIONS

Being male, rural and elderly residents are at higher risk of dying from TBI and SCI. The substantial burden of TBI and SCI caused by road traffic crashes and falls has called for the urgent need to improve injury prevention, pre-hospital aid, hospital treatment and recovery.

A systematic review of cardiovascular risk factors in patients with traumatic spinal cord injury

Objective: The main risk factors for cardiac events, and particularly for the development of atherosclerosis, are diabetes mellitus, arterial hypertension, dyslipidemia and smoking. Patients with a traumatic spinal cord injury (SCI) may present with autonomic nervous system dysfunction depending on their level of spinal cord injury. Studies have found a rise in cardiovascular mortality. A systematic review was conducted that focused on this patient group's predisposition to vascular risk. Methods: We performed a PubMed and Cochrane database search. After applying specific search criteria, 42 articles were included in our analysis out of a total of 10,784 matches. The articles were selected with the aim of establishing cardiovascular risk factors in patients with traumatic spinal cord injury. Results: Patients with SCI are at an increased risk for peripheral artery disease even in the absence of cardiovascular risk factors. Major vascular changes to the arteries of patients with SCI include: a reduction in lumen size, increased vessel wall tension, higher vascular stiffness, an impaired reactive hyperemic response, and a lack of reduced vascular resistance. The findings for carotid atherosclerosis were inconclusive. This group of patients also has a higher disposition for diabetes mellitus, lipid metabolism disorders and coronary artery disease. Paraplegics are more likely to suffer from dyslipidemia, obesity and PAD, while tetraplegics are more likely to have diabetes mellitus. Conclusions: Patients with SCI are more likely to have cardiovascular risk factors and have cardiovascular disease compared to the normal population. Peripheral circulatory disorders are particularly common. Patients with SCI are now considered to be a new risk group for cardiovascular disease; however, large epidemiological studies are needed to verify in more detail the cardiovascular risk profile of this patient group.

Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis

Background. Venous thromboembolism is a frequent complication and an important cause of death in patients with paralysis. We aimed to investigate predictors of pulmonary embolism (PE) and the impact of PE on the survival of patients with paralysis in comparison to those with deep venous thrombosis or thrombophlebitis (DVT). Methods: Patients were selected by screening the German nationwide inpatient sample (2005–2017) for paralysis, and were stratified for venous thromboembolism (VTE) and the VTE-sub-entity PE (ICD-code I26). Impact of PE on mortality and predictors for PE were analyzed. Results: Overall, 7,873,769 hospitalizations of patients with paralysis were recorded in Germany 2005–2017, of whom 1.6% had VTE and 7.0% died. While annual hospitalizations increased (2005: 520,357 to 2017: 663,998) (β 12,421 (95% CI 10,807 to 14,034), p < 0.001), in-hospital mortality decreased from 7.5% to 6.7% (β −0.08% (95% CI −0.10% to −0.06%), p < 0.001). When focusing on 82,558 patients with paralysis hospitalized due to VTE (51.8% females; 58.3% aged ≥ 70 years) in 2005–2017, in-hospital mortality was significantly higher in patients with paralysis and PE than in those with DVT only (23.8% vs. 6.3%, p < 0.001). Cancer (OR 2.18 (95% CI 2.09–2.27), p < 0.001), heart failure (OR 1.83 (95% CI 1.76–1.91), p < 0.001), COPD (OR 1.63 (95% CI 1.53–1.72), p < 0.001) and obesity (OR 1.42 (95% CI 1.35–1.50), p < 0.001) were associated with PE. PE (OR 4.28 (95% CI 4.07–4.50), p < 0.001) was a strong predictor of in-hospital mortality. Conclusions: In Germany, annual hospitalizations of patients with paralysis increased in 2005–2017, in whom VTE and especially PE substantially affected in-hospital mortality. Cancer, heart failure, COPD, obesity and acute paraplegia were risk factors of PE.

Traumatic spinal cord injury mortality from 2006 to 2016 in China

Purpose: To report on the national traumatic spinal cord injury (TSCI) mortality of China population, and assess sex-, age-, location-, and cause-specific mortality rates, respectively.Methods: A population-based longitudinal study based on mortality data from the Disease Surveillance Points system of China, 2006-2016. TSCI was defined according to the 10th International Classification of Disease. Negative binomial regression was used to test the significance of the change in overall and subgroup mortality rate.Results: Age-adjusted TSCI mortality rate increased by 64% from 2006 to 2016, ranging from 0.19 to 0.34 per 100,000 population. The crude mortality was 0.31 per 100,000 population in 2016. Males and rural residents had higher TSCI mortality rates than females and urban residents. The age-adjusted TSCI mortality rate increased 53% for males, 107% for females, 75% in an urban area, and 59% in a rural area. In comparison with insignificant change in the age group of 0-44 years, TSCI mortality increased 56% and 147% in age groups of 45-64 years and 65 years. Falls accounted for 45.4% of total mortality.Conclusions: TSCI mortality rates were higher in males and in rural residents than in females and in urban residents during the study time period. TSCI mortality increased quickly as age increased; adults aged 65 years and older had the highest mortality rate. Falls and motor vehicle crashes were the two most common causes of TSCI mortality. More prevention efforts are needed to reduce a number of deaths from TSCI injury considering a substantial increase in TSCI mortality.

Getting in touch with your senses: Mechanisms specifying sensory interneurons in the dorsal spinal cord

The spinal cord is functionally and anatomically divided into ventrally derived motor circuits and dorsally derived somatosensory circuits. Sensory stimuli originating either at the periphery of the body, or internally, are relayed to the dorsal spinal cord where they are processed by distinct classes of sensory dorsal interneurons (dIs). dIs convey sensory information, such as pain, heat or itch, either to the brain, and/or to the motor circuits to initiate the appropriate response. They also regulate the intensity of sensory information and are the major target for the opioid analgesics. While the developmental mechanisms directing ventral and dorsal cell fates have been hypothesized to be similar, more recent research has suggested that dI fates are specified by novel mechanisms. In this review, we will discuss the molecular events that specify dorsal neuronal patterning in the spinal cord, thereby generating diverse dI identities. We will then discuss how this molecular understanding has led to the development of robust stem cell methods to derive multiple spinal cell types, including the dIs, and the implication of these studies for treating spinal cord injuries and neurodegenerative diseases. This article is categorized under: Neurological Diseases > Stem Cells and Development.

Health inequalities and income for people with spinal cord injury. A comparison between and within countries

Income and health are related in a bi-directional manner, whereby level of income affects health and vice versa. People in poorer households tend to experience worse health status and higher mortality rates than people in wealthier households, and, at the same time, having poor health could restrict workability leading to less income. This gap exists in almost every country, and it is more pronounced in more unequal countries and in vulnerable populations, such as people experiencing disability. The goal of this paper is to estimate the health-income gap in people with a Spinal Cord Injury (SCI), which is a chronic health condition often associated with multiple comorbidities that leads to disability. As data on mortality is inexistent, to estimate the health-income gap for persons with SCI, this paper uses two health outcomes: the number of years a person has lived with the injury, and a comorbidity index. Data was obtained from the International Spinal Cord Injury survey (InSCI), which is the first worldwide survey on community-dwelling persons with SCI. To compare across countries, the health outcomes were adjusted through hierarchical models, accounting for country fixed-effects, individual characteristics such as age and gender, and injury characteristics (cause, type and degree). Our results suggest that for the years living with SCI, the gap varies from 1 to 6 years between the lowest and the highest income groups. The main driver of such a difference is the cause of injury, where injuries caused by work accidents showed the biggest gap. Similarly, for the comorbidity index, persons with SCI in poorer deciles reported significantly more comorbidities, forty times more, than people in richer deciles.

A community-based intervention to prevent serious complications and death 2 years after discharge in people with spinal cord injury in Bangladesh (CIVIC): a randomised trial

STUDY DESIGN

Randomised controlled trial.

OBJECTIVES

To determine the effectiveness of a sustainable community-based intervention designed to prevent serious complications and death 2 years after discharge in people with spinal cord injury in Bangladesh.

SETTING

Bangladesh.

METHODS

A pragmatic randomised controlled trial was undertaken. People who had sustained a spinal cord injury in the preceding 2 years, were wheelchair-dependent, and were about to be discharged from hospital in Bangladesh were recruited and randomised to an Intervention or Control group using a concealed allocation procedure stratified by level of lesion (tetraplegia/paraplegia). Participants in the Intervention group received 36 phone calls and three home visits over the first 2 years following discharge. All participants received usual post-discharge care. Survival status and date of death were determined by blinded assessors 2 years after randomisation.

RESULTS

Between July 2015 and March 2018, 410 participants were randomised (204 to Intervention, 206 to Control). There was no loss to follow up. At 2 years, 15 (7.4%) participants in the Intervention group and 16 (7.8%) participants in the Control group had died (hazard ratio from unadjusted Cox model = 0.93 [95% CI, 0.46 to 1.89]; p from log rank test 0.85). There were no clinically important or statistically significant average causal effects of intervention on the incidence or severity of complications.

CONCLUSION

A program of community-based care for people with recent spinal cord injury in Bangladesh involving frequent phone contact and occasional in-person contact with a health professional after discharge from hospital is no better at preventing death at 2 years than usual care.