Bulletin 16 - Clinical information
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Clinical information
The clinical picture of persisting cases of SCI was affected by incomplete
reporting.
There were 62 cases for whom the neurological level of injury at discharge was
not reported and a further one case for whom the extent of injury was not
reported. Analysis of the characteristics of these cases compared with the
other 177 cases for whom neurological level and extent of injury was reported
revealed no significant nor substantial differences on the basis of the
neurological level of injury at admission, the extent of injury at admission,
age group, and length of stay in hospital. Given that there was no evidence of
unrepresentativeness, the following discussion of the neurological level,
extent of injury and length of hospital stay was based on the 177 cases for
whom neurological level and extent of injury was reported.
ASIA impairment category was not reported at discharge for 42 of the 240
persisting cases of SCI. Comparison of these cases with the 198 cases for whom
that information was reported, revealed no significant nor substantial
differences on the basis of neurological level of injury at admission, extent
of injury at admission, age group, length of stay in hospital, and ASIA
impairment category at admission. Given that there was no evidence of
unrepresentativeness, the following discussion of the ASIA impairment category
at discharge was based on the 198 cases for which those data were reported.
Figure 6 presents the neurological level at discharge (n=177). The most
commonly injured segments of the spinal cord were C5 (21%), C6 (15%), C4 (9%),
L1 (7%), T12 (6%) and C7 (6%). Fifty-two per cent of the cases (n=92) had an
injury to the cervical segments, resulting in `Tetraplegia'. With Tetraplegia,
there is impairment of function in the arms as well as in the trunk, legs, and
pelvic organs. Forty-eight per cent of the cases (n=85) had an injury to the
thoracic, lumbar or sacral (but not cervical) segments of the spinal cord,
resulting in `Paraplegia'. With Paraplegia, arm functioning is spared, but,
depending on the level of injury, the trunk, legs, and pelvic organs may be
involved. For Paraplegia, the most common level of injury was L1, followed by
T12 and T1.
Note: Neurological level was not reported for 63 cases
The overall severity of SCI is usually measured by a combination of both the
neurological level and extent of injury. The standard combination involves the
creation of five neurologic categories: incomplete paraplegia, complete
paraplegia, incomplete tetraplegia, complete tetraplegia, and complete
recovery.[10] In the context of a discussion of persisting cases of SCI the last category is excluded.
Table 1 presents the counts and column percentages for neurologic level and
extent of injury (n=177). Complete injury was a more prominent feature of
injury to the thoracic segments of the spine (n=24, 49%), than it was for the
cervical (n=34, 37%), lumbar (n=7, 23%), or sacral (n=1, 20%) segments of the
spine. Complete cord injuries are relatively common among patients with
thoracic fractures and dislocations because the spinal canal in this region is
small in relation to the size of the cord.[13]
[14]
[15]
[16]
Based on all cases, the most common
neurologic category (for all cases, n=177) was incomplete Tetraplegia (n=58,
33%), followed by incomplete Paraplegia (n=53, 30%), complete Tetraplegia
(n=34, 19%), and complete Paraplegia (n=32, 18%).
Table 1: Incidence of persisting SCI from traumatic causes by neurological
level (major grouping) and extent of injury at discharge, Australia 1995/96
(counts and column percentages)
| Extent of injury |
Tetraplegia |
Paraplegia |
Total |
| Cervical |
Thoracic |
Lumbar |
Sacral |
All Paraplegia |
|
Count |
% |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
| Complete |
34 |
37 |
24 |
49 |
7 |
23 |
1 |
20 |
32 |
38 |
66 |
37 |
| Incomplete |
58 |
63 |
25 |
51 |
24 |
77 |
4 |
80 |
53 |
62 |
111 |
63 |
| Total |
92 |
100 |
49 |
100 |
31 |
100 |
5 |
100 |
85 |
100 |
177 |
100 |
Note: Neurologic category was not reported for 63 cases out of the 240 persisting
cases of SCI
The external cause of injury for persisting cases of SCI from traumatic causes
is presented by neurological level of injury in Table 2. Motor vehicle
occupants were most likely to suffer from injury to the cervical segments of
the spinal cord. Complete injury occurred to 40% (n=19) of the occupants.
Unprotected road users were most likely to suffer from injury to the thoracic
segments of the spine. Complete injury occurred to 32% (n=8) of the unprotected
road users. Whereas Tetraplegia was most common amongst motor vehicle
occupants, Paraplegia was most common amongst unprotected road users. Low falls
(i.e. falls on the same level or from less than one metre in height)
exclusively resulted in cervical level damage. Cervical level damage to the
spinal cord was also common in high falls (i.e. falls from a height of one
metre or higher). Complete injury occurred to 18% (n=2) of the low falls cases
and to 41% (n=21) of the high falls cases.
Table 2: Incidence of persisting SCI from traumatic causes by external cause
(major groupings), and neurological level, of injury at discharge, Australia,
1995/96 (counts and row percentages)
| Extent of injury |
Tetraplegia |
Paraplegia |
Total |
| Cervical |
Thoracic |
Lumbar |
Sacral |
All Paraplegia |
|
Count |
% |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
| Motor vehicle occupants |
29 |
62 |
10 |
21 |
6 |
13 |
2 |
4 |
18 |
38 |
47 |
100 |
| Unprotected road users |
9 |
36 |
12 |
48 |
4 |
16 |
0 |
0 |
16 |
64 |
25 |
100 |
| Low falls |
11 |
100 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
11 |
100 |
| High falls |
25 |
49 |
14 |
28 |
11 |
22 |
1 |
2 |
26 |
51 |
51 |
100 |
| Other causes |
18 |
42 |
13 |
30 |
10 |
23 |
2 |
5 |
25 |
58 |
43 |
100 |
| Table Total |
92 |
52 |
49 |
28 |
31 |
18 |
5 |
3 |
85 |
48 |
177 |
100 |
Note: Neurological level and extent of injury was not reported for 63 cases out of
the 240 persisting cases of SCI
To measure the change in the degree of impairment of cases in response to the
combined effects of treatment in the acute care facility, rehabilitation and
other factors, the ASIA impairment category[5]
of each case was recorded at both admission and discharge. This measure of impairment was
derived from the Frankel cord injury scale.[17]
[18] The categories relevant to an assessment
of persisting cases of SCI are presented below:
- A = Complete.
- No sensory or motor function is preserved in the sacral segments S4-S5.
- B = Incomplete.
- Sensory but not motor function is preserved below the
neurological level and extends through the sacral segments S4-S5.
- C = Incomplete.
- Motor function is preserved below the neurological
level, and the majority of key muscles below the neurological level have a
muscle grade less than 3.
- D = Incomplete.
- Motor function is preserved below the neurological
level, and the majority of key muscles below the neurological level have a
muscle grade greater than or equal to 3.
A comparison of the ASIA category at admission and discharge is presented in
Table 3. This information facilitates an assessment of the degree of change in
impairment between admission and discharge. The ASIA category was reported at
discharge for 198 cases but for four of these it was not reported at admission.
The table is therefore based on the 194 cases for whom that information was
reported both at admission and discharge.
For the majority of cases (n=141, 73%), there was no change in the degree of
impairment between admission and discharge. This was particularly true for the
admission ASIA categories of `A' and `D'. For a small number of cases (n=4, 2%)
there was an apparent increase in the extent of impairment between admission
and discharge. This could reflect a coding error either at admission or
discharge, rather than a real increase in impairment, but warrants a further
assessment. For one quarter of the cases (n=49, 25%) there was a reduction in
the extent of impairment. Numerically, this reduction was particularly strong
from a category `C' at admission to a category `D' at discharge (n=19, 10%),
indicating a clinically significant improvement in muscle functioning for these
cases. The reduction in impairment from category `A' at admission to category
`D' at discharge (n=7, 4%) is clinically very significant. It demonstrates an
improvement from a state of no sensory or motor functioning in the sacral
segments S4-S5, to sensory preservation and useful motor functioning in the
majority of key muscles below the neurological level of injury.
Table 3: Incidence of persisting SCI from traumatic causes by ASIA impairment
category at admission and discharge, Australia 1995/96 (counts and percentages)
| |
ASIA category at admission |
|
A |
B |
C |
D |
Total reported |
ASIA category
at discharge |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
Count |
% |
| A |
62 |
32 |
1 |
1 |
1 |
1 |
0 |
0 |
64 |
33 |
| B |
7 |
4 |
16 |
8 |
0 |
0 |
1 |
1 |
24 |
12 |
| C |
3 |
1 |
8 |
4 |
25 |
13 |
1 |
1 |
37 |
19 |
| D |
7 |
4 |
5 |
3 |
19 |
10 |
38 |
20 |
69 |
36 |
| Total reported |
79 |
41 |
30 |
16 |
45 |
24 |
40 |
22 |
194 |
100 |
Note: ASIA impairment category was not reported at admission and/or discharge for 46
cases.
Table 4 presents information on the average length of stay (ALOS) in hospital,
from the date of injury to the date of discharge from the SU, by neurologic
category for the 177 cases for which neurologic category was reported. It shows
that the ALOS was much longer for Tetraplegia than for Paraplegia. The ALOS was
longest for complete Tetraplegia, followed by complete Paraplegia, incomplete
Tetraplegia, and incomplete Paraplegia. The ALOS decreased with a decrease in
the neurological level of injury, from the cervical through to the sacral
segments of the spine, for both complete and incomplete injuries.
Table 4: Incidence of persisting SCI from traumatic causes by neurological
level (major grouping) and extent of injury at discharge, Australia 1995/96
(counts and average length of stay)
| Extent of injury |
Tetraplegia |
Paraplegia |
Total |
| Cervical |
Thoracic |
Lumbar |
Sacral |
All Paraplegia |
|
|
Count |
ALOS (days) |
Count |
ALOS (days) |
Count |
ALOS (days) |
Count |
ALOS (days) |
Count |
ALOS (days) |
Count |
ALOS (days) |
| Complete |
34 |
252 |
24 |
160 |
7 |
97 |
1 |
53 |
32 |
143 |
66 |
199 |
| Incomplete |
58 |
119 |
25 |
95 |
24 |
60 |
4 |
27 |
53 |
74 |
111 |
98 |
| Total |
92 |
168 |
49 |
127 |
31 |
68 |
5 |
32 |
85 |
100 |
177 |
135 |
|
Note: Neurologic category was not reported for 63 cases out of the 240 persisting
cases of SCI
|
[5] American Spinal Injury Association. International standards for neurological and functional classification of spinal cord injury. Chicago:
American Spinal Injury Association, 1992.
[10] Stover SL, DeLisa JA, Whiteneck GG. Spinal cord injury: clinical
outcomes from the Model Systems. Maryland: Aspen Publishers, 1995.
[13] Bauer, RD, Errico, TJ. Thoracolumbar
spine injuries. In: Errico TJ; Bauer, RD, Waugh, T. (Eds). Spinal trauma.
Philadelphia: J.B. Lippincott, 1991, pp. 195-269.
[14] Bohlman, HH. Treatment of fractures and dislocations of the thoracic and lumbar spine. J Bone Joint Surg Am 1985; 67: 165-169.
[15] Bohlman, HH, Freehafer, A, Dejak, J. The results of treatment of
acute injuries of the upper thoracic spine with paralysis. J Bone Joint Surg Am
1985; 67: 360-369.
[16] White A, Panjabi M. Clinical biomechanics of the spine. Second
Edition. Philadelphia: JB Lippincott Company, 1990, p. 333.
[17] Frankel HL, Hancock DO, Hyslop G et al.
The value of postural reduction in the initial management of closed injuries of
the spine with paraplegia and tetraplegia. Paraplegia 1969; 7(3): 179-192.
[18] Tator CH, Rowed DW, Schwartz ML. (eds): Sunnybrook cord injury
scales for assessment of neurological injury and neurological recovery in early
management of acute spinal cord injury. New York: Raven Press, 1982: 7.
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