How to prevent early mortality due to spinal cord injuries? New evidence & update

According to the most recent report by the World Health Organization, between 250,000 and 500,000 people suffer from a traumatic spinal cord injury (SCI) every year1. The leading causes are road traffic accidents, falls and violence1. In this issue, Lalwani et al2 describe the mortality profile of patients with spinal cord injuries in New Delhi, in order to identify factors predictive of an increased mortality risk. This knowledge will improve patient care, guide injury prevention activities, target staff education programmes, as well as directing research efforts. They studied computerized patient records and autopsy reports from the department of Forensic Medicine at a level I trauma care centre in New Delhi, India, and identified 341 patients with traumatic SCI who died between January 2008 and December 2011.

There are large variations in the published studies worldwide on traumatic SCI with regard to incidence, prevalence, gender distribution, mechanism of injury, level of injury, and completeness of injury3. Most follow up studies of traumatic SCI are from rehabilitation centres that receive patients many months after the time of injury. Many studies, therefore, choose to exclude all those who die within one year after their injury, and define one year after injury, as the distinction between early and late death3. Only a few studies include pre-hospital deaths456.

Epidemiology of traumatic spinal cord injuries in India

Lalwani et al2 identified 84.5 per cent males and 15.6 per cent females. Most deceased (73%) were in the age group 25-64 yr, followed by young adults between 16 and 24 yr (19.4%). The level of injury was cervical in 76 per cent, thoracic in 16.4 per cent and thoraco-lumbar in 7.6 per cent of the deceased. The most common cause of injury was high energy falls 44.3 per cent, followed by road traffic accidents 41.9 per cent.

The published research on epidemiology of traumatic SCI in India is very limited. Chacko et al7 reported 125 patients with SCI admitted to a rural hospital in India during the previous seven years. In this population, 92.6 per cent were men and 7.4 per cent women, and 60.5 per cent were in the 3^rd and 4^th decades. Fifty five per cent were admitted within 24 h after injury. Cervical spine injuries comprised 8.6 per cent whereas thoracic and lumbar spine comprised 32.3 and 59.1 per cent respectively7.

Singh et al8 reported 483 traumatic SCI in Haryana during 2000-2001. The average age at time of injury was 35.4 yr and 74.4 per cent were men. Fall from height was the most frequent cause of trauma (44.5%), followed by motor vehicle accidents (34.7%). Among the 447 patients with neurological deficits, 36.7 per cent were tetraplegics and 63.3 per cent paraplegics. The most common levels of injury were first lumbar and fifth cervical vertebra8.

Agarwal et al9 identified 107 patients with a traumatic SCI in a retrospective descriptive analysis of data of patients with SCI admitted to a tertiary medical centre during 2003-2004. Of these, 50.5 per cent had a cervical injury, 24.3 per cent thoracic and 25.2 per cent lumbar injury, and 83.4 per cent were men. Fall from height was the major cause of injury (59.3%), followed by motor vehicle accidents (21.2%) and fall of weight (10.2%). Motor vehicle accidents were more common in men and fall of weight in women9.

Pandey et al10. identified 60 patients with traumatic SCI admitted for rehabilitation between August 2005 and May 2006. Of these, 85 per cent were men, the mean age was 34 yr, and 48.3 per cent were due to fall from height.

The data from the study by Lalwani et al2 are comparable to the published studies with regard to gender and age distribution. Level of injury was also similar among the studies. Of the deceased in the present study, most had a cervical injury, comparable to only a few of the surviving patients in the previous published studies had a cervical injury. Falling from a height is the most common cause of injury in India. However, it seems that high energy falls often result in a cervical injury and death, while falling from a low height results in surviving patients with more diverse injuries. In the study by Lalwani et al2 the percentages of patients who died from a motor vehicle accident was higher than previous reports. This could be due to the fact that the study was performed in the capital city of India.

Knowledge of pre-hospital deaths of traumatic spinal cord injuries worldwide

Lalwani et al2 identified the majority of deaths (51.6%) to occur during phase IV (secondary to tertiary complications of trauma i.e. >1 wk); 40 patients (11.7%) died during phase I (brought dead on-arrival or surviving <3 h), 55 (16.1%) during phase II (>3 h to 24 h) and 70 (20.5%) during phase III (> 24 h to 7 days). Among the 95 patients (27.9%) who survived less than 24 h, 86.3 per cent had associated injury while only 28.5 per cent of patients who survived more than 24 h sustained associated injuries2.

There are only a few studies on the relationship between time of death after a traumatic SCI, level of injury and cause of injury.

Kraus et al6 identified 619 patients with traumatic SCI in a study from North California between 1970 and 1971, among these were 299 deaths. Almost 79 per cent of the persons were dead on-arrival at the hospital emergency room or taken directly to the county morgue (38.0% of the total population). Sixty four (21.4 %, or 10.3% of the total population) died during hospitalization6.

Martins et al4 studied traumatic SCI in Portugal during the period 1989-1992. They identified 398 new traumatic SCI, of which, 77 per cent were male and 23 per cent female. The average age was 50.5 yr. Sixty four (16%) were dead upon arrival at hospital, and 159 (40%) died during hospitalization. The death rate was high during the first week, especially during the first 24 h4.

Surkin et al11 identified 395 patients with traumatic SCI in Mississippi from 1992-1994. Among these patients, 40.7 per cent were dead by the end of the study period. Among those who died, 56.5 per cent (23% of the 395 patients) died before reaching a hospital11.

Dryden et al5 identified 450 cases of traumatic SCI in Canada during 1997-2000. Of these, 15.8 per cent died prior to hospitalization. The percentages of patients with traumatic SCI brought dead to hospitals in published studies are 11-38 per cent.

The number of deaths due to road traffic accidents in India has increased during the last 10 years according to the Ministry of Road Transport and Highways, Transport Research Wing, Government of India12. These numbers call for increased surveillance and prevention measurements regarding road traffic accidents in India. However, as Lalwani et al2 found, the 86.3 per cent of the patients who survived less than 24 h had associated injuries, while only 28.5 per cent of patients who survived more than 24 h had associated injuries. The outcome after a trauma depends not only on the injury, but also on the victim's health condition at the time of injury, associated injuries and the energy of trauma13.

This study adds new knowledge to mortality and survival after traumatic SCI. Whether this is a common finding worldwide is yet to be confirmed by similar studies.