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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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NeurologicalOutcomesTrends
Thepercentageofhighcervicalinjurieshasincreasedoverthelastfivedecades,
whilethepercentage of low cervical injuries has decreasedandthatofT1–S3
injuries has remained relatively constant (Table 4.2). The percentage of
neurologicallycompleteinjuries(AISA)hasdecreased,whilethepercentageof
motorincompleteinjuries(AISC,D,orE)hasincreasedfrom36.4%to56.4%.
Theincrease inthepercentage ofAIS D andE injuries wasparticularly noted
amongthoseaged≥46years(38.4%inthe1970sand55.3%inthe2010s)and
amongalletiologiesexceptviolence(35).Thepercentageofpersonsdischarged
ventilator-dependentdoubledfrom2.2%inthe1970sto4.6%inthe1990sand
4.2%inthe2000sbeforedecliningto2.2%during2015to2017.
Thesetrends are likely due toadvancesin acute management ofSCIfrom
pre-hospitaltoacuteandrehabilitationcare(42)andimprovedacutesurvivalof
high cervical injuries (43), as well as changes in demographics, etiology,and
referralpatternsofSCIModelSystemsCenters.Forexample,olderpersonsare
mostlikelyinjuredinfallsonthesamelevelthatresultintetraplegiaandAISD
injuries. Additionally,firearm-related SCIs have declined in the past decades,
and these typically result in complete paraplegia. Pre-hospital care such as
appropriate stabilization of the spinal cord during transfer, early surgical
intervention,aswellastheuseofmethylprednisoloneandothermedicationsare
notdocumentedintheNSCID,thustheircontributionthereoftothedecreasein
neurologicallycompleteinjuriescannotbeevaluated.
AssociatedInjuries
SCI is often accompanied by other significant injuries. Among 3,389 persons
withacuteSCIbetween1998and2009whowereincludedinapopulation-based
sample,20.0%,17.9%,and14.9%hadconcomitantinjuriesinvolvingone,two,
and≥3otherbodyregion(s),respectively(44).Thebodyregionsmostfrequently
involved were the abdomen and pelvis (20.3%), thoracic cavity and the bony
structures(19.0%),skinandsubcutaneoustissues(17.4%),andthecraniumand
brain(15.8%).
Comorbid traumatic brain injury (TBI) has been reported to occur among
peoplewithacuteSCIatafrequencybetween16%and74%(45), andis most
commonamongSCIsresultingfrommotorvehiclecrashesandfallsandamong
personswithcervicalinjuries.Ina recentstudyof 155personswithacuteSCI
admittedtoarehabilitationhospitalduring2012to2014,theestimatedincidence
ofTBIwas33%byphysicianreviewofmedicalrecords,but60%basedonself-
reportedTBIscreeningquestions(46),whichraisesconcernoverthediagnostic
accuracyofself-reportedcomorbidTBIinthispatientpopulation.
The International SCI Core Data Set recommends reporting the cooccurrencewithSCIofthefollowingmajorinjuries:(47)(a)moderatetosevere
TBI(GlasgowComaScale≤12),(b)nonvertebralfracturesrequiringsurgery,(c)
severe facial injuries affecting sense organs, (d) major chest injury requiring
chesttubeormechanicalventilation,(e)traumaticamputationofanarmorleg,
orinjuriessevereenoughtorequiresurgicalamputation,(f)severehemorrhage,
(g) brachial plexus injury, and (h) damage to any internal organ requiring
surgery.Overall,38.6%ofpersonsenrolledintheNSCIDhaveoneormoreof
these major injuries along with SCI, and this percentage remained consistent
overthecourseofdatacollectionfromOctober2006toSeptember2017(Table
4.4).Thepresenceoftheseassociatedinjurieswasparticularlycommonamong
persons with SCI caused by violence (60.1%) and motor vehicle crashes
(49.2%),butwasless common among persons injured in sports (25.4%), falls
(23.2%),andmedical/surgicalcomplications(9.5%).
VertebralInjury
IncompliancewiththeInternationalSCICoreDataSet(47),theNSCIDbegan
todocumentinOctober2016thedetectionofanySCI-relatedspinalfractureor
dislocation,definedasanybreak,rupture,orcrackthrough/betweenanypartsof
thevertebralcolumnfromtheocciputtothecoccyx.Overall,vertebralinjuryhas
beendocumentedin80.4%ofpeoplewithacuteSCIenrolledintheNSCID,and
thepercentageincreasedslightlyfrom2006to2017(Table4.4).Vertebralinjury
ismostcommonamongthosewithSCIasaresultofvehicularcrashes(92.1%),
followed by sports (85.8%), violence (80.5%), falls (74.1%), and
medical/surgicalcomplications(15.3%).
SpinalSurgery
The NSCID also documents whether any of the following spinal surgical
procedureswereperformedatanypointduringtheinpatienthospitalizationafter
SCI: laminectomy, neural canal restoration, open reduction,spinal fusion, and
internalfixationofthespine(47).Thespinalsurgeryrateis79.6%overalland
also increased slightly from 2006 to 2017 (Table 4.4). These procedures are
morecommonlyperformedinacuteSCIscausedbyvehicularcrashes(91.9%),
sports-relatedinjuries(90.9%),andfalls(85.9%),butlessfrequentlyperformed
in those caused by acts of violence (34.0%) or,more specifically, penetrating
injuries (gunshot or stab wounds, 19.6%) (48). Stabilization surgery is not
typically required for patients with penetrating SCI because most penetrating
injuries are not associated with instability of the spine. However, debate
continues over whether or not surgical decompression, including bone and
projectile removal, in patients with penetrating SCI provides any benefit for
neurologicalfunctioncomparedwithnonsurgicaltreatment(48).
Regarding individual surgical procedures, data from the US Nationwide
InpatientSamplerevealedthat15.9%ofpeoplewithacuteSCIduring2010 to
2012 underwent intervertebral disc excision, 15.9% underwent spinal canal
decompression,and 14.8% underwent spinal fusion. The percentage of people
whoreceivedthesesurgicaltreatmentsduringacuteinpatientcarehasincreased
byabout5%since1993(22).
LengthofStay
The NSCID also documents the declining length of stay during initial
hospitalizationoverthelastfivedecades.AsshowninTable4.4,daysspentin
theacutecareunitdecreasedfromamedianof24daysduring1972to1979toa
medianof11daysduring2015to2017,andmedianlengthofrehabilitationstay
alsodroppedfrom91daysto42daysduringthesameperiod.Suchdeclineis
notedinallneurological impairment groups, but with a differentpace(29).A
numberoffactorsaccountforthesedecreasesinthelengthofstay,particularly
theimplementationofmanagedcareandothercost-containmentmeasures(49–
51).
Assuggestedbypreviousstudies,earlyadmissiontoanSCIrehabilitation
unitasaresultofashorteracutecarestaymightimprovefunctionaloutcomesat
discharge. (52). Rehabilitation facilities seem to adapt to the changing
reimbursementpatternsby improving the efficiencyofinpatientcare (53) and
utilizingpost-dischargeservicesto replacesome inpatienttreatments(54).Itis
notknown,however,howshortistoo short before patients with SCI begin to
experience negative outcomes and healthcare delivery becomes less efficient,
withhighercostsresultingfromthetreatmentofcomplications.
DischargePlacement
Overall,amongpersonsdischargedalivefromtheSCIModelSystemsCenters,
90.9% have historically been discharged back into the community, either in a
privateresidenceorgrouplivingsituation.Asinpatientrehabilitationlength of
stayhasdecreasedandageatinjuryhasincreased,thepercentageofpeoplewho
aredischargedtoanotherhospital,nursinghome,orassistedlivinghasincreased
from5.7%inthe1970stogreaterthan10.0%since2000(Table4.4).Anumber
of factors are associated with nursing home discharge, including having a
cervical AIS A, B, or C injury; being ventilator dependent; older age; being
unmarried;being unemployed; being from a region of theUnited Statesother
than the southeast; having an indwelling urethral catheter or external catheter
bladder drainage; having either Medicaid or health maintenance organization
insurance; being dependent in performing activities of daily living; and being
nonambulatory(55).
MORTALITY
Data from the statewide surveillance systems and from the nationwide
administrativedatasetsintheUnitedStatesindicatethatapproximately5.7%to
8.0% of people with SCI die before discharge from acute hospital care
(21,22,44,56). The in-hospital mortality rates in the SCI population overall
increasedfrom6.6% in 1993 to 1996 to 7.5% in 2010to2012,butdecreased
overthesameperiodfrom24.2%to20.1%amongpeopleaged≥85years(22).
There is also consistence across studies regarding a high risk of in-hospital
mortality associated with advancing age (≥ 65 years), motor vehicular crash,
high cervical injury, polytrauma, multiple comorbidities, and multiple
complicationssuchasvenousthromboembolismandTBI(21,22,44).
EstimatesderivedfromtheNSCIDthrough2017(29)showthattheannual
mortalityriskisabout4.6%duringthefirstyearofinjuryand2.4%duringthe
secondyear.Forthosewhosurvivethesecondpost-injuryyear,theannualdeath
rate averages about 2.1% and gradually increases over timebecause ofaging.
Thecumulativesurvivalrateis95.6%for1year,88.4%for5years,81.1%for
10years,73.8%for15 years,and 66.7%for20yearsafterinjury. Medianlife
expectancy(50%)forthetotalNSCIDsampleis31.30±0.15years,butvaries
considerably by age, level and completeness of injury, ventilator use, sex,
race/ethnicity, and socioeconomic factors (57–60). Mortality odds during the
firstyear of injuryhaveimproved by approximately54%since the 1970s,but
among those surviving the first year of injury, annual mortality has remained
relativelyconstantsince the1980s (Figure4.5). Asa result,lifeexpectancyof
personswithSCIremainsbelowthatinthegeneralpopulation(29,61).
FIGURE 4.5 Mortality odds ratios by calendar years of follow-up
(reference group: 1973–1979) for post-injury year 1 and for postinjuryyear2andbeyond.Theoddsratioswereadjustedforage,sex,
race, education, insurance type, injury etiology, and neurological
category.
ThelatestlifeexpectancyestimatesfromtheNSCID,beginningatthefirst
anniversary of injury, are presented in Table 4.5. Life expectancy is almost
normalforpersonswithanAISDinjury,butdeclinessteadilyasinjuryseverity
increases. Interestingly, in general, as age increases within each neurologic
category,lifeexpectancydecreases.Forexample,amongpersonswithaC1–C4
AISA, B, or C injury who survive the first year,lifeexpectancyis 63.4% of
normalfor10-year-olds,56.7%ofnormalfor30-year-olds,52.5%ofnormalfor
50-year-olds,and48.4%ofnormalfor70-year-olds.TheNationalSCIStatistical
Centerupdatesthedetailedlifeexpectancytablesonanannualbasis(29),andits
website provides an interactive tool for projecting life expectancy after SCI
based on personal demographic and injury characteristics
(www.nscisc.uab.edu/Public_Pages/LifeExp).
Standardized mortality ratio has been used to illustrate the differences in
mortalityriskbetweentheSCIandgeneralpopulations(29,58,62)bycomparing
theobservednumberofdeathsamongpersonswithSCItoanexpectednumber
of deaths should those with SCI have the same mortality rate as the general
population.BasedondatafromNSCIDthrough2017,thestandardizedmortality
ratiosrangefrom1.5to104.3(29).Forexample,amongthosesurvivingthefirst
yearofinjury,personswhoareventilator-dependentandyoungerthan31years
have51.8timesgreatermortalitythanpersonswithoutSCIofthesameage,sex,
andrace,whereaspersonswhohaveanAISDinjuryandareolderthan60years
have 1.5 times greater mortality than similarly matched counterparts without
SCI.
CauseofDeath
Examining the common causes of death after SCI may offer some clues
regarding the lack of progress in life expectancy after SCI. Diseases of the
respiratorysystem(primarilypneumonia)constitutetheleadingcauseofdeath,
accountingfor21.9%ofthetotal12,673deathsreportedtoNSCIDthrough2015
(29). The second leading cause of death is infectious and parasitic diseases
(12.0%), which are usually cases of septicemia (90.0%) and associated with
pressure ulcers (now called pressure injuries), urinary tract infections, or
respiratory infections. Cancer ranks third (10.2%), closely followed by
hypertensive and ischemic heart disease (10.0%). Specific locations of cancer
includelung(26.2%),bladder(9.0%),colon/rectum(8.8%),prostate(5.5%),and
liver (4.1%). Other heart disease ranks fifth (8.4%) and is often unexplained
heartattacks(38.5%,ICD-10-CMcodeI46.9),whichmightnotrepresentatrue
underlyingcauseofdeathbutratherreflectpoorqualityofcause-of-deathdata
and reporting practices on many death certificates of people with SCI. As a
result,mortalityfromotherheartdiseaseisprobablyoverestimated.
Unintentionalinjuries are also arelativelycommon cause of death(6.6%),
followed by diseases of the digestive system (4.8%), cerebrovascular disease
(3.6%), suicide (3.1%), and diseases of pulmonary circulation (3.1%).
Pulmonary emboli account for 91.4% of the deaths caused by the diseases of
pulmonary circulation and usually occur during the initial hospital care. The
suicidemortalityrateafterSCIdecreasedoverthreeinjurycohorts(1973–1979,
1980–1989, and 1990–1999), but is still about three times that for persons of
comparable age, sex, and race in the general population (63). Suicide risk is
higherduringthefirst6yearsafterSCI,forpersonswithparaplegicAISA,B,or
Cinjury,andfornon-Hispanicwhites.
PREVALENCE:HOWMANYPEOPLELIVING
WITHSCI
Prevalence reflects the number of persons with SCI who are currently alive,
whichisprimarilyafunctionofincidence(numberofnewcaseseachyear)and
mortality(numberofdeceasedcaseseachyear).BecauseSCIisarelativelyrare
condition, estimating prevalence by surveying the population requires a very
largerandomsample.Asaresult,veryfewattemptshavebeenmadetoestimate
prevalencebysamplingpopulationsintheUnitedStates.Duringthe1970s,the
prevalence of SCI was estimated by mathematical modeling of incidence and
survival (64,65). Prevalence in the 1980s was estimated by studies that
extrapolated data from a regional disability survey (66), used data from the
National Health Interview Survey (67), or involved a nationwide probability
sample of small geographic areas and institutions (68). The prevalence rates
derivedfromthesestudiesrangedfrom525casespermillionpopulationin1975
to1,124casespermillionpopulationin1981.
More recently, utilizinga complex mathematical model includingage-sexspecificincidence,survival,andbaselineprevalence,Lasfarguesetal.estimated
that 250,000 persons were living with SCI in 2004 in the United States and
projectedthatnumberwouldincreaseto270,000in2014becauseofimproved
lifeexpectancy(69). ByextrapolatingthemodelusedbyLasfarguesetal.,the
numberof people withSCI who arecurrentlyalive in2018is estimatedtobe
288,000 (or 880 cases per million), with a range from 247,000 to 358,000
persons(70).
The 2013 Paralysis Prevalence and Health Disparities Survey, funded
throughaco-operativeagreementbetweentheCentersforDiseaseControland
Prevention and the Christopher and Dana Reeve Foundation, unveiled a
staggeringSCIprevalenceintheUnitedStates(71).Theresultshavealsobeen
posted on the foundation’s website (www.christopherreeve.org/living-with-
paralysis/stats-about-paralysis). This study involved a national random-digit-
dialedtelephonesurveyoftheciviliannoninstitutionalizedpopulationthatasked
participantswhethertheyoranypersonsintheirhouseholdhaveanydifficulty
movingarmsorlegs andthecauseofthemovementdifficulty,aschosenfrom
15qualifyingdiagnoses,includingSCI,stroke,multiplesclerosis,cerebralpalsy,
andothers.Theestimatederivedfromthisstudyindicatesthatin2013morethan
1,462,000 people (or 4,641 persons per million population) were living with
paralysiscausedbytraumaticornontraumaticSCIintheUnitedStates,whichis
considerablyhigherthananyotherestimatesofSCIprevalenceanywhereinthe
world. Using Canada as an example, the prevalence rate of traumatic and
nontraumaticSCIisestimatedat2,525personpermillionin2010(72).
DemographiccharacteristicsoftheprevalentSCIpopulationreportedbythis
studyalsoappeartobeoutoflinewithexistingknowledge.Forexample,there
werenopeopleunderage 18yearsreported.Asacknowledgedbythe authors,
this estimate was based on self- or family-reported data without independent
confirmation. Therefore, although overall results describing the prevalence of
paralysisasdefinedinthestudymaybevalid,resultsreflectingtraumaticSCI
fromthisstudyrequireconfirmationbyanotherstudywithmore rigorouscase
ascertainmentprocedures.
DemographicProfileofChronicSCI
InthereportpublishedbyBerkowitzetal.,theageofallpersonslivingwithSCI
intheUnitedStates,includingnewandexistingcases,wasestimatedat41years
in 1988, which is about 10 years older than the average age of new cases
reportedintheNSCIDatthattime(73).Becausewomenusuallyhavealonger
lifeexpectancythanmen,theoverallmaletofemaleprevalenceratiowasfound
to be lower than the ratio observed among new SCI cases (2.6 vs. 4.0). The
whitetononwhiteprevalenceratioamongpersonswith SCIwhowerealivein
1988was1.5,similartotheratioamongnewcases.
CharacteristicsoftheprevalentSCIpopulationwereestimatedbyanalyzing
datafromtheNSCIDandNationalShrinersSCIDatabase(74).Among45,442
peoplelivingwithSCIin2008,theaverageageoftheprevalentpopulationwas
higher than that of the incident population (45.0 years vs. 37.1 years). This
differencewasnotedforallneurologicalcategories.Withincreasingseverityof
injury,meanagedecreasesandtheage gapincreases asa resultof differential
survivalratesbyageandneurologicalimpairment.Contrarytoexpectations,the
percentage of persons who were older than 60 years was virtually identical
betweenprevalentand incidentcases (13.7%vs13.2%),andthepercentageof
femaleswasalsoidentical(21.7%).Comparedwithnewlyinjuredpersons,those
intheprevalentpopulationhad higher injury levels (C1–C4 injury: 17.0% vs.
27.2%),lesslikelihoodof ventilator-dependency(4.6%vs. 1.1%),and reduced
likelihoodof residingin anursinghome (10.8%vs. 4.6%).Thesefindingsare
similartothoseinBerkowitz’s1988reportandthoseofarecentstudyconducted
inFinland(73,75).
In data analyzed from 12,456 participants enrolled in the NSCID during
2000to2017,socio-demographiccharacteristicsofpeoplelivingwithSCIwere
further examined by post-injury years. Among those who were single and at
least15 years of ageatthe time of injury, about 60.7% remainedsingle/never
married15yearsafterSCI.Previousresearchshowedtheannualmarriagerate
after SCI is 59% below that for persons of comparable age, sex, and marital
status(nevermarriedvs.previouslymarried)inthegeneralpopulation(76).The
annualdivorcerateduringthefirst3yearsafterSCIis2.3timesnormal,andfor
thosemarriagesthatoccurafterinjury,thedivorcerateisstill1.7timesnormal
(77).
AmongpersonsenrolledintheNSCIDwhowereinthe9thtothe11thgrade
atthetimeoftheirinjury,46.8%earnedahighschooldiplomawithin5yearsof
injury.Amongthosewhohadahighschooldiplomaatthetimeoftheirinjury,
only28.9%receivedapost-highschooldegreewithin10years.Thelowlevels
ofeducational attainment might magnifythedifficulty inadjustingto physical
disabilityandobtainingsubsequentemployment.
Forpersonsaged16to59yearsatthetimeoffollow-up,thepercentageof
persons with tetraplegia who are employed in the competitive labor market
increases steadily with time, from 14.2% at the 1st anniversary of injury to
30.5% at the 15th anniversary of injury. Among those with paraplegia, the
percentage employed in the competitive labor market is only slightly higher,
rangingfrom17.1%atthe1stanniversaryto36.6%atthe15thanniversary.The
most common types of jobs that persons with SCI obtain are professional
specialty (31.7%); management, business, and financial occupations (23.2%);
office and administrative support (11.2%); and sales and related occupations
(8.8%)(29).
INTERNATIONALPERSPECTIVES
The work in understanding the global epidemiology of SCI has been prolific
(78–80). The foremost work is the recent establishment of a living data
repository structure by the International Spinal Cord Society to allow
documentationandmappingofSCIincidence,etiology,and prevalencearound
theworld(81,82).AnothergreatexampleisthepublicationoftheWorldHealth
Organization’s International Perspectives on Spinal Cord Injury in 2013 that
summarizedinformationonSCI,includingepidemiology,throughouttheworld
(83).
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