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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана
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Infact, fallscurrently accountforapproximately65%of allSCIs occurringin
people aged ≥ 65 years (22,23) and 76% of SCIs in people aged > 75 years
(www.nscisc.uab.edu/Public_Pages/LeadingCauses). Utilizing the International
Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
code,theaccidentalfallsarefurtherclassifiedinto19types.AmongSCIsinthe
elderly(olderthan60 years)reportedtotheNSCIDduring2005 to2014,falls
onthesamelevel(30%)werethemostcommonmechanismofaccidentalfalls,
followed by falls from stairs and steps (22%) and other
slipping/tripping/stumbling,suchasfallsfromoroffthetoiletandintheshower
oremptybathtub (11%)(31,32).By contrast,among youngerindividuals,falls
from a building (21%), ladder (8%), or tree (7%) were the most common
mechanisms of accidental falls; about 39% of these falls were work-related.
Similarage-specificpatternsassociatedwith the types of accidentalfalls were
alsonotedinthestudyofadultemergencyvisitsforacuteSCIbetween2007and
2009(21).
ThereportedSCIetiologyprofileacrossdifferentagegroupsisafunctionof
thefrequencyofparticipationineachactivityaswellastheriskofSCIforeach
activity. For example, a smaller percentage of sports-related SCIs occurring
among the elderly does not necessarily suggest that participation in sports is
saferforthisagegroupthanforothers.Rather,itislikelybecauseparticipation
insportsdeclinessubstantiallywithadvancingage.
Sex-SpecificRiskandCauseofInjury
MalesexperienceahigherriskofSCIthanfemales(Figure4.1).Whenallages
areconsidered,the maleto femaleincidencerateratiois about4.0 to1(Table
4.1).ThesexdifferenceintheSCIriskismuchsmalleramongyoungchildren
and the elderly (aged ≥75 years), with a male to female incidence rate ratio
usually below 2.0 (3,11,21–23,28). The higher incidence rate in males is
presumablyrelatedtotheincreasedrisk-takingbehaviortheyexhibitafterearly
childhood.Forexample,astheygrowintoadulthood,malesmaybemorelikely
thantheirfemalecounterpartsaretoparticipateinactsofviolenceand contact
sportsaswellastoown/driveacar.AsreportedbytheNationalSCIStatistical
Center’s web-based query tool on the leading causes of SCI, the major sex
differencessince2015lieintheproportion(malevs.female)offirearminjuries
(14.9% vs. 4.9%), motorcyclecrashes (8.3% vs. 3.1%), and recreational sport
mishaps(8.9%vs.5.7%).
Race/Ethnicity-SpecificRiskandCauseofInjury
TheSCIincidenceratesarehigherforblacksthanforwhites,especiallyamong
males and for violence-related SCI. The black to white incidence rate ratio
rangesfrom1.4to2.0overall(9,11,12,15,18,19,23)butfrom6.3to17.8foran
SCI resulting from violence (6,9,11,12). Since 2015, firearm injuries have
accounted for 39.4% and 29.0% of total SCIs among non-Hispanic black and
Hispanicmales,respectively,butonlyaccountedfor1.9%ofSCIsamongwhite
males enrolled in the NSCID
(www.nscisc.uab.edu/Public_Pages/LeadingCauses).
OtherRiskFactors
Approximately22%to50%ofnewpatientswithSCIreportusingalcoholortest
positive for blood alcohol at the time of injury (3,9,11–15,27,33). The
associationwithalcoholconsumptionisparticularlycommonamonginjuriesin
Native Americans, occurring between 10 p.m. and 4 a.m., pedestrian injuries,
andcervicalinjuries(11,14,33).
MoreSCIsoccuronweekendsthanonanyotherday(9,21,30),particularly
thoseinjuriescausedbydivingincidentsandmotorcyclecrashes(ofwhich57%
and50%,respectively,occuronSaturdayandSunday)(30).Theexceptionisfor
SCIsresultingfrommedical/surgicalcomplications,alargerpercentageofwhich
occuronMonday(20%)andTuesday(31%)thanonSaturday(6%)andSunday
(5%), which might be largely due to the scheduling of more procedures on
MondaysandTuesdaysthanonotherdays.
TheincidenceofSCIalsoincreasesduringthewarmweathermonths,with
fewerSCIsinFebruary(6.3%),followedbyasteadyincreaseuntilJuly(10.9%)
andthenasteadydeclineuntilthenextFebruaryintheUnitedStates(9,30).This
seasonal variation seems to parallel the increase of motorcycle- and divingrelatedSCIsoccurringinthewarmermonths.
LevelandCompletenessofInjury
The NSCID classifies the preserved neurologic function of people with SCI
according to the International Standards for Neurological Classification of
Spinal Cord Injury (34). As shown in Table 4.2, at time of discharge from
inpatient rehabilitation between 2015 and 2017,a cervical level of injury was
most common (C1–C4, 32.8% and C5–C8, 26.1%), followed by thoracic
(32.2%)and lumbosacrallevels(8.2%). Themost commonneurologicallevels
were C4 (19.9%) and C5 (13.7%), followed by C6 (6.3%), C3 (6.0%), T4
(4.4%),T10(4.3%),C7(3.9%),T12(3.9%),andL1(3.9%)(Figure4.2).
Among the same 2015 to 2017 injury cohort, about 31.8% had
neurologically complete injuries (American Spinal Injury Association
ImpairmentScale[AIS]A),11.9%hadincompleteinjurieswithsensorysparing
(AIS B), 16.7% had incomplete injuries with nonfunctional motorcapabilities
belowthe lesionlevel(AIS C), 38.9%had incomplete injurieswith functional
motor capabilities below the lesion level (AIS D), and 0.8% had essentially
complete neurologic recovery (AIS E). The most frequent combination was
incomplete tetraplegia (47.2%), followed by incomplete paraplegia (20.4%),
completeparaplegia(20.2%),andcompletetetraplegia(11.5%;Table4.2).
Thestudyofthe NationwideEmergencyDepartment Sampleduring 2007–
2009definedthelevelofinjury (cervical,thoracic, lumbosacral,multisite, and
other/unspecified) and complete versus incomplete injuries by the ICD-9-CM
code and reported a trend similar to that in the NSCID, with predominantly
cervical(57.4%)andincomplete(89.0%)injuries(21).
External causes of injury have a meaningful role in determining the
preservedneurologicfunction(9,29,30,35).Among peoplewithfirearm-related
SCIreportedtotheNSCIDandthecomparableNationalShrinersSCIDatabase
(36) during 2005 to 2011, 71.6% had paraplegia and 63.6% had complete
injuries(30). By contrast, 96.4%ofdiving-related SCIs resulted in tetraplegia
and72.7%resultedinmotorcompleteinjuries(41.8%AISAand30.9%AISB
injuries). Another study of fall-induced SCI among people enrolled in the
NSCID between 2005 and 2014 noted that high falls, such as falls from
buildings and ladders, were likely to result in thoracic (~47%) and complete
(~42%)injuries,whereaslowfalls,suchasfallsonthesamelevelorstairs,were
commonlyassociatedwithcervical(~88%)andAISD(~60%)injury(32)
FIGURE 4.2 Percentage of persons enrolled in the NSCID by
neurologicallevelatdischargeduring2015–2017.
NSCID,NationalSCIModelSystemsDatabase.
TrendsandCurrentProfileofAcuteSCI
BasedonthedatafromtheNationwideInpatientSample,Jainetal.reportedthat
the overall incidence rate of SCI remained relatively consistent from 1993 to
2012, at approximately 54 cases per million population (22). Age-specific
incidence rates, however, varied over this period, with increased rates for the
olderagegroupsanddecreasedratesfortheyoungeragegroups,whichapplied
tobothmalesandfemales(Figure4.3).Asimilarage-specifictrendissupported
byestimatesderivedfromtheNationwideEmergencyDepartmentSample(21–
28)anddatafromtheSouthCarolinaSCISurveillanceRegistry(23).Jainetal.
alsoreported thatthe meanage atinjuryincreasedfrom40.5 yearsin 1993to
50.5 years in 2012, while the percentage of females increased slightly from
26.5%to29.3%overthistimeframe(22).
Becauseof the hospital-based (not population-based)nature,theNSCID is
notappropriateforstudyingSCIincidenceratesorrisks.Nevertheless,because
of its longevity and standardized prospective data collection, the NSCID
provides important insight into the relative contribution of personal
characteristics to the occurrence of SCI since the early 1970s that no other
studieshavebeenabletoattain.
TheprofilesofacuteSCIreportedhereareprimarilybasedondatafromthe
NSCIDand largelyreflect thechangesin thegeneralpopulation intheUnited
States(e.g.,advancingageandincreasingracial/ethnicdiversity).Changesinthe
age-,sex-,andrace-specificSCIincidenceratesoverthelastfivedecadescould
also affect the demographic composition of new SCI cases over time. These
trends could also be attributable to periodic changes in the identities and
locations of participating SCI Model Systems Centers, changes in referral
patterns to SCI Model Systems Centers, and changes in eligibilitycriteria for
inclusionintheNSCID.
AgeatInjury
AsgiveninTable 4.3,the averageage atinjury hasincreasedfrom28.7years
duringthe1970sto43.0yearsduring2015to2017,whichisyoungerthanwhat
wasreportedintheincidencestudybyJainetal.(50.5years).Theageatinjury
might has been overestimated in this latter study because of the potential
countingofreadmissionsofpeoplewithchronicSCIandexclusionofchildren
younger than 16 years. The age difference could also be attributed to the
NSCID’s over-representation of violent etiologies and eligibility criteria that
potentiallyexcludeolder patientswithfalletiologiesand minimalneurological
deficitswhoneverreceivedrehabilitation.
AsshowninFigure4.4,thedistributionofageattimeofinjuryforpersons
enrolled in the NSCID has changed substantially over the last five decades.
Although people aged 16–30 years are still the most common age group, the
percentagesdropped from 62.0% in the 1970s to 34.3%during2015–2017 of
totalSCIcasesreportedtotheNSCID.
ThepercentageofnewSCIcasesaged≥65yearsalsoincreasedfrom3.1%
duringthe1970sto15.6%during2015to2017(Table4.3),whilethepercentage
of people aged ≥65 years in the general population increased from 9.8% to
15.2%over the same period. The currentaverageageat injury (43.0 years) is
about5years older than the median age of the U.S. population in 2016 (37.9
years).BothfindingssuggestafasteragingofnewSCIcasesthanofthegeneral
U.S. population over the last five decades, a concept supported by the trends
towardincreasingSCIincidenceintheoldergroupsanddecliningincidencein
theyoungergroups,asshownearlierinFigure4.3(22).
FIGURE4.3 Annualincidence rate ofSCI(per million)byage and
calendar year (1993 vs. 2012) in males and females based on the
NationwideInpatientSample.
SCI,spinalcordinjury.
Thereisatrendtowardincreasingageatinjuryforbothsexesandallraces,
withthe greatestincreasein ageat injury inwhite females,followedby white
males,Hispanicfemales,blackfemales,Hispanicmales,andblackmales(35).
Thegradualincreaseinageatinjuryisalsoobservedwithinalletiologygroups
exceptactsofviolence.
Sex
AccordingtodatafromtheNSCID,amongtheSCIpopulation,thepercentageof
females increased from 18.2% in the 1970s to 22.0% in 2015 to 2017 (Table
4.3),an upward trend similar to that reported by Jain et al. (21). This finding
reflectsafasterincreaseinthenumberofwomenthanmenwhoareaged≥75
yearsinthe general population and an increase of injuriesamongolderadults
overall,aswellasasmallerdifferenceinSCI riskbetween malesand females
amongtheelderlythanamongteenagersandyoungadults.
RaceandEthnicity
Inlinewiththecontinuedgrowthofminoritypopulations,especiallyHispanics,
in the United States, the NSCID also observes an increasing percentage of
HispanicethnicityintheSCIpopulationoverthelastfivedecades,from6.0%to
12.8%(Table4.3).Thisfindinghighlightstheneedforstaffdiversificationand
culturalcompetencytrainingtoavoidracialbiasinhealthcareandhealth(37).
FIGURE 4.4 Age of persons enrolled in the NSCID at the time of
injuryduring1972–1979andduring2015–2017.
NSCID,NationalSCIModelSystemsDatabase;SCI,spinalcordinjury.
OtherDemographicCharacteristics
Thepercentageofpeoplewithabachelor’sorhigherdegreeatthetimeofinjury
hasincreasedfrom 7.0% to 24.6% over the last five decades (Table4.3). The
increasededucation levelis noted inall agegroupsstarting at16years ofage
(35).Willthisincreasingtrendineducation attimeofinjuryleadtoimproved
post-injuryemploymentandotheroutcomes?(38)Itdeservesfurtherstudy.
With increasing age at injury, the percentage of people who were retired
(2.6%vs.14.2%),married(31.9%vs. 39.1%),divorced orwidowed (9.4%vs.
12.9%)increased,whilethepercentageofpeoplewhoweresingle/nevermarried
decreased(54.0%vs.46.0%)overthelastfivedecades(Table4.3).However,the
percentageofsingle/nevermarriedincreasedwithineachagegroup(16–30,31–
45, and 46–60 years) over the last five decades (35), which parallels the
decreasingmarriagerateinthegeneralpopulationintheUnitedStates.Asthe
marriage rate is usually lower in the SCI population than in the general
population, and marriage is associated with favorable psychosocial outcomes
(39,40),itis importantto knowwhetherthelowermarriage rateat thetimeof
injurywilladverselyaffectthemarriagerateandoverallqualityoflifeafterSCI.
InjuryEtiologyTrends
ThepercentageofSCIsduetomotorvehicularcrasheshasdeclined(Table4.2),
while the percentage of injuries due to falls has increased steadily over time,
particularlyamongthoseolderthan45years(35).ThepercentageofSCIsdueto
violence peaked in the 1990s (24.8%) but has since declined (13.8% during
2015–2017).Sports-relatedSCIsdeclinedfrom14.4%duringthe1970sto8.2%
during2015to2017.Amongthoseaged46to60years,however,thepercentage
ofSCIsasaresultofsports-relatedactivitiesincreasedfrom2.2%inthe1970s
to 7.2% during 2010 to 2014, which is consistent with the observation of
increasing age for sports-related SCI, from 21.1 yearsto34.3 years, over this
timeframe(35).
Diving mishaps account for the largest subgroup (41.3%) among the 499
peoplewithsports-relatedSCIreportedtotheNSCID from2010to2017(41).
Snowskiingrankedsecondat10.8%, followedbyother wintersports(suchas
sledding, snow tubing, tobogganing, ice hockey, and snowboarding) at 7.6%,
surfing at 7.0%, horseback riding at 4.6%, air sports at 3.8%, and football at
3.0%.SincetheinitiationoftheNSCIDintheearly1970s,SCIsduetodiving,
football, and trampoline mishaps have declined markedly, while those due to
snowskiing,wintersports,andsurfinghaveincreased.Thedeclineoffootballrelated SCIs is, in large part, as a result of a rule change made in 1976 that
banneddeliberateuseofthehelmetastheinitialpointofcontactintacklingor
blocking. Similarly, removal of trampolines from schools in some states has
undoubtedlycontributedtothedeclineintrampoline-relatedSCIs.
Itisimportant to keep in mind that those recreationalsportsactivitiesthat
accountforthemostSCIsarenotnecessarilythemostriskyactivities.Toassess
risk,wemustknowtheunderlyingrateofexposuretothatactivity.Forexample,
gymnasticscausesfewSCIs(1.6%)butalsohasfewparticipants,whereashigh
school and college football cause more SCIs (3.0%) but also have more
participants.
The proportional nature of these statistics can only reflect the relative
importanceofthecontributionoftheseexternalfactorstothecausationofSCI,
butmightnotrepresentunderlyingchangesinthecause-specificincidenceover
time.Forexample,therecentdeclineinthepercentageofnewSCIcasescaused
byvehicularcrashes couldbe duetoadecreaseintheunderlying incidenceof
vehicular-relatedSCI.Thepercentageofvehicular-relatedSCIswouldalsodrop
if the underlying incidence rate rises but at a slower rate than that of other
causes. However, provided that the statistics are interpreted with some
understanding of how the data have been collected and analyzed, the trends
reportedherearerelevanttoserviceproviders,policymakers,andresearchers.
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