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4
EpidemiologyofSpinalCordInjury
YuyingChenandMichaelJ.DeVivo
INTRODUCTION
Spinal cord injury (SCI), typically definedas an acute traumatic lesionof the
spinal cord resulting in any degree of sensory/motor deficit or bladder/bowel
dysfunctiontemporarilyorpermanently(1),onlyaccountsforasmallproportion
of all injuries; but the associated disabilities, life changes, and economic
consequencesmakeSCIoneofthemostcatastrophicinjuries.Asdisabilitiesare
typically permanent and there is currently no cure, the importance of primary
prevention of SCI cannot be stressedenough. Understanding the risk and risk
factorsofSCIisessentialforinjurypreventionandcontrol.Knowledgeoftrends
inSCIepidemiologycanalsohelpassessfuturehealthcareneedsthroughoutthe
regionandcountry.InformationoncostsofcareisvaluabletopersonswithSCI,
lifecareplanners,casemanagers,lawyers,andinsurancecompanies,whomust
ensurethatadequateresourcesaresetasidetomeettheneedsofanindividual
withSCIovertheremainderofhisorherlifetime.
Thegoalofthischapteristoprovideanoverviewofthedemographic,injury,
and clinical profiles of people with acute SCI and the characteristics of those
currentlylivingwithSCI.TheeconomicimpactsofSCIarediscussedaswell.In
additionto reviewing literature worldwide, data from the National SCI Model
SystemsDatabase(NSCID)intheUnitedStates(2)havebeenutilizedtofurther
illustratethetrendsindemographicandinjuryprofilesoverthelastfivedecades.
The NSCID contains baseline and follow-up information on persons with
traumaticSCIwhoreceivedinitialhospitalcarefromoneofthe29SCIModel
Systems Centers since the early 1970s; it currently captures data from
approximately6%ofnewSCIsintheUnitedStates(2).AsofNovember2017,
thereare32,727personswhowere injuredbetween1972 and2017enrolledin
theNSCID.
INCIDENCE:HOWMANYPEOPLESUSTAINSCI
EVERYYEAR
Annualincidenceisameasureofthenumberofnewcasesthatoccurduringa1yearperiod. To betterestimate theimpactofSCI,during the1980s and1990s
many states in the United States established a population-based surveillance
systemandmandated by law the reporting of new caseswithSCIto the state
healthdepartment(1). Hospitals were the primary sources of information, but
some states also required reporting from public/private health and social
agencies, physicians, emergency medical services staff, and chief medical
examiners.BasedonreportspublishedbythesestateSCIregistries(3–14),the
annual incidence of SCI varies from a low of 25.0 new cases per million
populationinWestVirginiain1985to1988(3)toahighof83.0newcasesper
millionpopulationinAlaskain1991to1993(14)(Table4.1).Otherpopulationbased studies conducted in the United States from the 1970s to 1990s at the
regional(15–18)andnationallevel(19,20)showedasimilarrangeofvariation
(Table4.1).Differencesintheseincidenceestimatesareduetoacombinationof
factors, including regional differences in population characteristics (e.g., age,
sex, and race) and research methodology (e.g., case definition, eligibility,
reporting procedures, and completeness of case ascertainment). Overall, SCI
incidencewasknownformanyyearstoaverageabout40newcasespermillion
populationperyearuntilmostrecently.
Anestimate derived from an ongoingstatewidetraumaticSCI surveillance
and follow-up registry indicates an overall incidence rate of 70.8 per million
populationperyearfrom1998through2012amongpersonsolderthan21years
inSouthCarolina (23).Given theincreasingavailabilityofadministrativedata
setsandimprovedanalytictechniques,SCIincidencefigureswerealsorecently
updatedwithdatafromlargenationwidesamples(Table4.1).Basedonthedata
from the Nationwide Emergency Department Sample, the largest all-payer
emergency department database in the United States (21), it is estimated that
between 2007 and 2009, 56 per million adults (aged ≥ 18 years) visited
emergency departments for acute SCI each year. Another study utilizing data
from the Health Care Cost and Utilization Project—Nationwide Inpatient
Sample(22)—reportsacomparablefigure,54cases(95%CI:53–55cases)per
millionpeople aged ≥ 16 years received inpatient care for acute SCIin 2012.
This corresponds to approximately 17,700 new SCI cases eachyear giventhe
current population size of 327 million people in the United States. Because
administrativedataareoriginallyintendedforbillingpurposes,multipleinherent
limitations(24,25)cannotbeoverlookedininterpretingtheabovereportssolely
onthebasisoftheadministrativedata.Forexample,giventhatthesetwostudies
heavilyrelied onprincipaldiagnosis codestoidentify SCIcases,it ispossible
that people with chronic SCI receiving emergency or inpatient care for other
reasonswere giventheprincipal diagnosisof SCI byclinicians if theSCI had
morefinancialincentivesthanthelessseveresecondaryconditions.Asaresult,
theSCIincidenceratesmighthavebeenoverreported.
Becausechildrenwereexcludedfromtherecentincidencestudiesmentioned
earlierandalsobecausetheriskofSCIislowerinchildren,theoverallincidence
rate of SCI (including all ages) in the United States might have been
overestimated by these reports that were based on the adult population. The
incidence rate of SCIis typically less than10 new cases permillion children
aged0to15yearsandabout20to25newcasespermillionchildrenaged0to
19yearseachyearintheUnitedStates.(3,9–14,19,26–28)Childrenyoungerthan
16yearsaccountforabout3%to5%oftotalSCIsthatoccureachyear.
Mostof the SCIincidenceestimates didnotinclude those whodiedat the
siteofthe incidentthat causedtheSCI.Theincidence rateof pre-hospitalSCI
deaths,reportedbyalimitednumberofstudies(12,13,17,18),rangesfromfour
casespermillion(9.3%oftotalSCIs)inUtahin1989to1991to21cases per
million(39.7%oftotalSCIs)inNorthernCaliforniain1970to1971.
ExternalCausesofInjury
External causes of SCI are often grouped into five categories: motor vehicle
crashes, violence, sports/recreational activities, falls,and all other causes. The
NSCID also records the impairment of spinal cord function resulting from
adverseeffectsofmedical,surgical,ordiagnosticproceduresandtreatmentsfor
nonspinal cord conditions as the sixth category. The NSCID’s 2017 Annual
StatisticalReport(29)andTable4.2showthatmotorvehiclecrashescontinueto
betheleadingcauseofSCI,althoughthepercentagedeclinedfrom47.0%inthe
1970sto 38.3% during 2015to2017. The percentageofSCIs due to fallshas
increased gradually and persistently over the last five decades and currently
(2015–2017) accounts for 31.6% of all SCIs reported to the NSCID. Acts of
violence,primarilyfirearminjuries,arealsoarelativelycommoncauseofSCI
(13.8%),followedbysports/recreationalactivities(8.2%),medicalandsurgical
complications (4.6%), and all others (3.5%), including hit or stuck by
objects/othersandpedestrianinjuries.
ComparedwiththeNSCIDreports,recentstudiesusingadministrativedata
reportedfewercategoriesofinjuryetiologiesandnotedslightlydifferentfigures.
AmongadultsvisitingtheemergencydepartmentsforacuteSCIduring2007to
2009,the most commoncauseof injury wasfalls(41.5%), followed bymotor
vehicular collision (35.5%), other unclassed (14.9%), struck by others/objects
(4.3%),andfirearms(3.8%)(23).Datafromthe2012inpatientsampleshowed
that40.4%ofSCIswerecausedbyunintentionalfalls,31.0%bymotorvehicle
crashes,and5.4%byfirearms(21).
ThepercentageofviolentetiologiesintheNSCIDishigherthanwhat was
reportedbystudiesofadministrativedatabecauseoftheurbanlocationofmany
of the SCI Model Systems Centers that contribute data to the database. The
under-representation of fall etiology in the NSCID is partly explained by the
NSCID eligibility criteria that call for neurological deficits and completed
rehabilitation with some exceptions. In other words, those with minimal
neurologicaldeficitswho neverreceivedrehabilitationareexcluded,andmany
of them are likely to be older patients with fall etiologies. The National SCI
StatisticalCenterwebsiteprovidesaninteractivetoolforthepublictobuildan
NSCID etiology profile by demographics and multiple timeframes
(www.nscisc.uab.edu/Public_Pages/LeadingCauses).
RiskFactors
Age-SpecificRiskandCauseofInjury
TheincidenceofSCIwashistoricallyknowntobe thelowestforthepediatric
group(youngerthan16years)andhighestforpersonsintheirlateteensand20s,
withthisknowledgesupportedbyvirtuallyallincidencestudiesconductedinthe
1970sto1990s(Figure4.1A).Recentreportslookedintotheolderagegroups(≥
65 years) in further detail and noted an increased risk with advancing age
(Figure 4.1B) (21–23). This change in age-specific incidence rates over time
suggeststhatpersons65to84yearsoldarecurrentlymoreactivethanthosewho
wereinthatagegroupinthe1970sto1990s,andincreasedactivitycontributes
totheincreasedriskofSCIinthisagegroup.
FIGURE4.1 Annualincidence rate ofSCI(per million)byage and
sex in Oklahoma 1988–1990 (A) and based on the Nationwide
InpatientSamplein2012(B).
SCI,Spinalcordinjury.
External causes of injury vary substantially by age (9,11,30,31). Injuries
resultingfrom recreationalsport mishaps arecommon amongpersonsyounger
than15years(29).Violentetiologiesdeclinewithadvancingage,whereasSCIs
resultingfrom fallsand medical/surgicalcomplicationsincreaseproportionally.
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