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Vol. 28. Num. 1.January - February 2017Pages 1-50
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Vol. 28. Num. 1.January - February 2017Pages 1-50
Clinical Research
DOI: 10.1016/j.neucie.2017.01.001
Epidemiology of traumatic spinal cord injury in Gran Canaria
Epidemiología de la lesión medular de origen traumático en Gran Canaria
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Enrique Bárbara-Batallera,
Corresponding author
ebb31604@hotmail.com

Corresponding author.
, José Luis Méndez-Suáreza, Carolina Alemán-Sáncheza, Teresa Ramírez-Lorenzob, Manuel Sosa-Henríquezc
a Unidad de Lesionados Medulares, Servicio de Rehabilitación, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
b Unidad de Investigación, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
c Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Grupo de Investigación en osteoporosis y metabolismo mineral, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Figures (1)
Tables (4)
Table 1. Gender, aetiology and work-related accident by time period.
Table 2. Level, type and neurological classification by time period.
Table 3. ASIA and Neurological Classification by time period.
Table 4. Surgical intervention by neurological level.
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Abstract
Objective

To evaluate the epidemiological and clinical trends in acute traumatic spinal cord injuries.

Material and methods

A retrospective study was conducted of traumatic spinal cord injury patients in Gran Canaria (Canary Islands, Spain) from 2000 to 2014. Demographic and spinal injury severity trends were analysed by year of injury grouped into 3 periods: 2000–2005, 2006–2010, and 2011–2014.

Results

The sample included 141 patients. The mean incidence for the entire period was 12 cases/million/year. There was a decrease in cases in the second and third period. While the male/female ratio was 3.8/1 and was maintained in all periods, the mean patient age increased from 38.8 in 2000–2005 to 54.5 years in 2011–2004 (p<.05). Falls have been the leading cause of spinal cord injury (48.2%), followed by traffic accidents (37.6%). Falls have increased, especially in the older population. Incomplete tetraplegia has been the most prevalent group (30.5%). A vertebral fracture was suffered by 70.3% of all patients, with 93.2% of them requiring surgery.

Conclusions

There has been a decrease in the incidence of traumatic spinal cord injury in recent years. The target population has changed, and the older population is currently the most affected. This reality suggests the need to change the local prevention campaigns for spinal cord injury in the elderly.

Keywords:
Traumatic spinal cord injury
Epidemiology
Incidence
Aetiology
Resumen
Objetivo

Determinar la tendencia de la incidencia del paciente con una lesión medular de origen traumático y describir las características epidemiológicas y clínicas de esta población.

Material y métodos

Se ha realizado un estudio descriptivo retrospectivo de los pacientes que han sufrido una lesión medular de origen traumático en la isla de Gran Canaria (islas Canarias, España) desde el año 2000 al 2014. Para estudiar la tendencia se han dividido los pacientes en 3 periodos según el año de la lesión: 2000-2005, 2006-2010 y 2011-2014.

Resultados

El número de casos ha sido de 141 pacientes. La incidencia media para todo el periodo ha sido de 12 casos/millón/año con una disminución de los casos en el segundo y tercer periodo. Mientras la relación hombre/mujer de 3,8/1 se ha mantenido, la edad media del paciente ha aumentado de 38,8 años entre el año 2000-5 a 54,5 años en el 2011-14 (p<0,05). La caída, que ha sido la principal causa de lesión medular (48,2%) seguida de los accidentes de tráfico (37,6%), ha aumentado especialmente en la población de mayor edad. La lesión incompleta ha predominado sobre la completa, siendo la tetraplejía incompleta el grupo más prevalente (30,5%). El 70,3% de los lesionados medulares tenían una fractura vertebral y de ellos han sido intervenidos quirúrgicamente el 93,2%.

Conclusiones

En los últimos años ha habido una disminución de la incidencia de la lesión medular de origen traumático con un cambio en la población diana, afectando principalmente a la población de mayor edad. Estos hallazgos muestran la necesidad de replantear las campañas de prevención local de la lesión medular en el anciano.

Palabras clave:
Lesión medular traumática
Epidemiología
Incidencia
Etiología
Full Text
Introduction

Spinal cord injuries are one of the most significant traumatic events a person can suffer. This type of injury causes a series of physical, mental, family, social and economic dysfunctions that affect not only the patient, but also their environment. The physical consequences of these injuries are often permanent, and as there is currently no cure, prevention is of great importance. Knowing the incidence and aetiology is essential for planning prevention campaigns.1

There are several reviews in the literature on the incidence of traumatic spinal cord injuries. The reported incidence varies widely, ranging between 4.5 and 83 cases per million people/year (c/m/y) in the review by Wyndaele et al.,2 or between 15 and 39c/m/y in the review by Cripps et al.3 These differences in the incidence are primarily due to: (a) differences in the databases, which are sometimes national and other times regional, hospital or simply a series without a clear methodological delimitation; (b) differences in the patient definition, criteria and identification processes: whether or not paediatric patients are included, whether the patients are included from the site of the accident or from admission, whether or not fatalities in the early hours are included, or inclusion due to coding processes, among other; and lastly, (c) differences between countries: sociocultural or economic variations, variations in public health, healthcare systems, or prevention policies.1

Traditionally, the typical patients admitted into the specialised units for handling these patients were young males who had suffered a road traffic accident.4 In recent years, a change in the patient profile has been observed, with an upward trend in the mean age, with falls being the main cause. As the impact intensity decreases, the number of fractures related to spinal cord injury decreases.

We present in this study the changes that we have observed in the incidence and the epidemiological and clinical characteristics of patients who have suffered a traumatic spinal cord injury.

Material and methodsStudy population

A retrospective, descriptive study was conducted of all patients who had suffered a traumatic spinal cord injury on the island of Gran Canaria and who were admitted to a specialised unit. The Spinal Cord Injury Unit at the Hospital Universitario Insular de Gran Canaria has been a regional referral centre for the entire Canary Islands Community since it opened in November 2000. The Canary Islands are composed of 7 islands, and Gran Canaria and Tenerife are the most populous. According to the Canary Islands Statistics Institute, the population of the island of Gran Canaria was 741,161 people in 2000 (study start) and 851,157 people in 2014 (study end).5

Inclusion and exclusion criteria

All patients who were admitted to the Spinal Cord Injury Unit for an acute traumatic spinal cord injury on the island of Gran Canaria from 1 November 2000 to 31 December 2014 were included. Patients who died before admission to our Unit, traumatic spinal cord injuries occurring outside of Gran Canaria, patients admitted for medical spinal cord injuries, for other reasons, or readmissions, and patients under 14 years of age were excluded.

Source of information

The information was obtained from the hospital database, the patients’ medical records during the admission and follow-up period, and the patient or their family members were contacted when necessary.

Variables

Several types of variable were collected:

  • Sociodemographic: gender and age.

  • Spinal cord injury-related variables: aetiology, work-related accident, injury level, injury type, injury severity according to the American Spinal Injury Association (ASIA) classification,6 neurological classification, vertebra fractures and surgical intervention.

To describe the population trend, 3 periods were established according to the year of injury: 2000–2005, 2006–2010 and 2011–2014.

Statistical analysis

SPSS v. 19.0 was used to analyse the data. A descriptive analysis was used for the main variables included in the study: the relative and absolute frequencies were found for the qualitative variables, and the mean and standard deviation for the quantitative variables.

In addition to the descriptive analysis for each of the variables, a bivariate statistical analysis was performed to determine possible correlations between the different variables considered: for correlations between two qualitative variables, the Chi-squared or Fisher's exact test were used; to determine the influenced of the different qualitative variables on the patients’ age, analysis of covariance techniques were used.

A hypothesis test was considered statistically significant when the corresponding p-value was below 0.05.

ResultsIncidence

During the 15 years of the study, 141 patients with an acute traumatic spinal cord injury occurring on the island of Gran Canaria were admitted to our Unit. By period, 66 patients were admitted between 2000 and 2005; 41 patients from 2005 to 2010; and 34 patients from 2011 to 2014.

The annual incidence of acute traumatic spinal cord injury was 12c/m/y during the study period. By time period, the incidence was 17.8 cases between 2000 and 2005; during the second period the incidence fell to 9.7c/m/y (2005–2010); and in the third it remained at 9.9c/m/y (2011–2014).

The mean age was 43.7 years. By period, a clear upward trend in the mean patient age was observed, as it was 38.8 years in the first period, 42.7 years in the second and 54.5 years in the third (p<0.05). By gender, the male/female ratio during the study period was 3.8/1, and by period it was 2.6/1, 9.2/1 and 3.8/1, respectively. The gender variable was correlated to age, and in patients aged 31–40 years, the ratio was 2.7/1 while in patients aged 41–60 years, the ratio was 5.3/1.

Aetiology

The main cause was falls (48.2%), followed by road traffic accidents (37.6%). By period, it was observed that while road traffic accidents were the main cause of spinal cord injury in the first period, this cause decreased in the subsequent periods. In contrast, the proportion of falls rose progressively in the different periods (Table 1). If we correlate age and aetiology in each period, we observe that while the mean age does not change for road traffic accidents, it increases significantly for falls in the second and third period (p=0.002) (Fig. 1). If gender is correlated with aetiology, falls were the main cause of spinal cord injury in women during the 3 periods, and in our series all the diving injuries occurred in men.

Table 1.

Gender, aetiology and work-related accident by time period.

  Time period
  2000–20052006–20102011–2014Total %  p-Value 
  Count  Count  Count     
Gender
Male  48  72.7  37  90.2  27  79.4  79.4  0.093 
Female  18  27.3  9.8  20.6  20.6   
Total  66  100  41  100  34  100     
Aetiology
RTA  31  47  14  34.1  23.5  37.6  0.183 
Fall  25  37.9  20  48.8  23  67.6  48.2   
Dive  6.1  4.9  2.9   
Other  9.1  12.2  5.9  9.2   
Total  66  100  41  100  34  100     
Work-related accident
Yes  11  16.7  11  26.8  5.9  17  0.055 
No  55  83.3  30  73.2  32  94.1  83   
Total  66  100  41  100  34  100     
Fig. 1.
(0.11MB).

Mean age by aetiology and time period.

Although not significant, the drop in work-related accidents in the third period stands out (Table 1). A large number of these accidents were from falls and were related to a T11-L2 spinal cord injury. In our series, no injuries occurred at this level during the third period (45-45-0%, respectively).

Spinal cord injury characteristics

By injury level, cervical injuries were more prevalent than thoracic and lumbar injuries, which remained constant over the 3 periods (Table 2). Eighty-five percent of the cervical injuries were found among the C4–C6 spinal cord segments, with 33% of the injuries at the C4 level, 24.6% at C5 and 29% at C6. By period, there was a slight uptick in high cervical injuries and a decrease in C7-T1 injuries.

Table 2.

Level, type and neurological classification by time period.

  Time period
  2000–20052006–20102011–2014Total %  p-Value 
  Count  Count  Count     
Level
Cervical  31  47  22  53.7  16  47.1  48.9  0.666 
Thoracic  25  37.9  12  29.3  15  44.1  36.9   
Lumbar  10  15.2  17.1  8.8  14.2   
Total  66  100  41  100  34  100     
Injury type
Complete  27  40.9  18  43.9  18  52.9  44.7  0.515 
Incomplete  39  59.1  23  56.1  16  47.1  53.3   
Total  66  100  41  100  34  100     

By lesion type, incomplete spinal cord injuries were more common overall (55.3% vs 44.7%). By period, there was an increase in complete spinal cord injuries in the second and third periods (Table 2).

Among the ASIA classifications, ASIA A spinal cord injuries were most prevalent (47.7%) followed by ASIA D injuries (23.8%). By period, an increase in complete spinal cord injuries was observed while the other groups decreased (Table 3).

Table 3.

ASIA and Neurological Classification by time period.

  Time period
  2000–20052006–20102011–2014Total %  p-Value 
  Count  Count  Count     
ASIA
27  44.3  18  47.4  17  54.8  47.7  0.246 
1.6  13.2  6.5  6.2   
10  16.4  15.8  19.4  16.9   
20  32.8  15.8  16.1  23.8   
4.9  7.9  3.2  5.4   
Total  61  100  38  100  31  100     
Neurological classification
CQ  11  16.7  22  17.6  18.4  0.808 
IQ  20  30.3  13  31.7  10  29.4  30.5   
CP  16  24.2  22  12  35.3  26.2   
IP  19  28.8  10  24.4  17.6  24.8   
Total  66  100  41  100  34  100     

CP: complete paraplegia; CQ: complete quadriplegia; IP: incomplete paraplegia; IQ: incomplete quadriplegia.

By combining the injury type (complete or incomplete) with the neurological level (quadriplegia and paraplegia), 4 groups are defined: complete quadriplegia, incomplete quadriplegia, complete paraplegia and incomplete paraplegia. Overall, the most prevalent group is incomplete quadriplegia (30.5%). While the percentage of quadriplegia injuries remained constant in the different periods, an increase in complete paraplegia injuries in the third period stands out (Table 3).

Vertebral fractures and surgical intervention

In terms of the number of fractures, there was a progressive decrease over the different study periods. If we correlate vertebral fractures by level, we observe that, as expected, the most common fractures were thoracic spinal cord injuries (92.3%), followed by lumbar injuries (75%) and then cervical (58%). If we correlate vertebral fractures with the neurological classification in the different periods, while there is a high percentage of fractures (77.1%) for incomplete paraplegias, of the 43 incomplete quadriplegias, only 39.5% had fractures.

Overall, there was a decrease in the number of surgeries that is directly correlated with the number of vertebral fractures. Of the 103 spinal cord injuries with vertebral fractures, 93.2% underwent surgery (p<0.05), a percentage that remained constant over the different periods (94-90.6-95.2%). If we correlate surgeries with the neurological level, we observe that while 86.5% of thoracic spinal cord injuries underwent surgery, 59.4% of cervical spinal cord injuries underwent surgery (p<0.05) (Table 4).

Table 4.

Surgical intervention by neurological level.

  Neurological level, n (%)Total  p-Value 
  Cervical  Thoracic  Lumbar     
Surgery
Yes  41 (40.6)  45 (44.6)  15 (14.9)  101 (100)  0.004 
No  28 (70)  7 (17.5)  5 (12.5)  40 (100)   
Total  69 (48.9)  52 (36.9)  20 (14.2)  141 (100)   
Discussion

This study has shown the incidence of acute traumatic spinal cord injuries in Gran Canaria and its trend over 14 years. Similarly, the main epidemiological and clinical characteristics of these patients have been described. Our low incidence (12c/m/y), similar to that of other studies such as the one by Ahoniemi et al.7 in 2008 (13.8c/m/y), contrasts with other published incidences (4.5–83).2,3,8 In contrast, the downward incidence trend does coincide with similar studies published in recent years.4,9,10 In the same vein, in our series there is an upward trend in the mean age of the patients which coincides with the existing literature.1,4,7,9,11,12

The decreasing incidence and increasing mean age can be explained by the changes in the aetiology of spinal cord injuries. Until 2000, spinal cord injuries mainly affected young patients between 20 and 40 years of age who had been in a road traffic accident. With improvements in prevention campaigns, car and roadway safety, and deterrent measures (license points, speed cameras, harsher punishments), a 55% decrease in roadway morbidity and mortality was achieved.4 Furthermore, the generalised increase in life expectancy associated with an ageing population in our setting is causing fall-related spinal cord injuries to increase. This is becoming the main cause of spinal cord injuries in developed countries.1,10,11,13–16

Despite living in an ever more egalitarian society for both sexes, the male/female ratio for spinal cord injuries has not changed substantially in our study, as also happened in other papers. A slight increase has been observed in the proportion of women in other studies. This is due to the fact that the male/female ratio is more equal for falls. In 2004, Jackson et al. observed a slight rise in the proportion of women, increasing from 18.2% in 1970 to 21.8% in 2000, attributable to falls.17 The difference in the incidence between the sexes can be attributed, on the one hand, to women still not participating equally in high-risk activities, and on the other, that when they do participate, they are safer than men.1,13

Another aspect to highlight in our study is the decrease in work-related accidents in the third period. This reduction is related to a decrease in the number of falls in the younger population. This fact can be explained by the improvements in preventing work-related accidents and by the slump in construction in Spain since 2008.

As for the injury level and degree, in our study there was an initial upward trend for incomplete cervical injuries that coincides with most studies.1,15 However, in the third period, there is a peak in the incidence of complete paraplegia. This piece of data, which deviates from the general trend in most studies, is due to a one-off increase in patients with complete thoracic spinal cord injuries (15 out of 34 patients), which changed the trend from the second period. In most studies, there is an upward trend for cervical spinal cord injuries.7,14 Although this is not as clear in our sample, there is an increase in cervical injuries in the literature that is occurring at the expense of high cervical injuries, versus low cervical injuries which are decreasing.9 This is seen in a broad study spanning the period 1935–2008, which showed an increase in C1–C4 injuries from 12.3% to 27.2% while C5–C8 injuries fell from 35.9% to 29%.11 This means an increase in the discharge of ventilator-dependent patients, a fact that we have also observed in our Unit. In our series, complete injuries were mainly associated with road traffic accidents, falls from heights and diving, while incomplete injuries were associated with falls in the elderly, a piece of data that coincides with recent studies.7,9,17 Lenehan et al. also correlate it with the type of injury and observe that most thoracolumbar injuries occur in young patients due to high-energy impact injuries; women are affected by low-impact, incomplete high cervical injuries; and older male patients suffer low-impact cervical injuries that usually do not require surgery.

Along the same line, the decrease in road traffic accidents and high-energy falls in the young population explains the progressive decrease in the number of fractures. Falls from heights in the elderly have lower energy than the above, but these patients are vulnerable to spinal cord injuries due to different causes: osteoporosis, narrow cervical spinal canal, sensory deterioration and adverse effects from medication.1

As expected and for the same reason, the number of patients treated conservatively increased in the last period. As the number of fractures decreased, the number of patients undergoing surgery fell as happened in the various published reviews.9,18,19

It seems clear that the spinal cord injury prevention campaigns, which until not long ago were focused on preventing road traffic accidents, require a broader focus that includes falls, mainly in the elderly population. Different lines of prevention appear in the literature, based on20,21: (a) improving an individual's physical condition focusing on strength, balance, coordination and gait training; (b) patient safety at home: adequate night-time lighting, removing structural barriers, avoiding slippery or mobile surfaces such as rugs, placing handrails and supports and assessing the adaptations; (c) decreasing the individual's medication as much as possible and paying attention to its adverse effects, especially for psychoactive drugs; (d) regular medical follow-up with special emphasis on controlling blood pressure, vision, hearing and balance; (e) proper nutrition with moderate alcohol consumption; and lastly, (f) ensuring proper footwear and orthopaedic aids.

With the increase in falls in the elderly population and the decrease among younger people and road traffic accidents in general, we are now encountering a decrease in the incidence of traumatic spinal cord injuries in our setting. There is a trend towards low-energy traumatic spinal cord injuries, with a lower proportion of fractures, and the injuries tend to be cervical and incomplete. These findings show the need to rethink local spinal cord injury prevention campaigns in the elderly to promote their safety.

The limitations of our study include: despite being a regional referral unit, our database is a hospital database, so some patients who may have been transferred to another specialised unit elsewhere in the country could have been lost. However, should this have occurred, we consider it to be an isolated case. When collecting our sample, patients may have been lost prior to admission due to death or severe polytrauma whose primary malady was not spinal cord injury and whose transfer was not considered.

Another limitation is the sample size, which only refers to Gran Canaria and which mainly affected the third study period. This bias could be offset with larger studies that include the entire Autonomous Community or the entire country.

Conflicts of interest

The authors declare that they have no conflicts of interest.

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Please cite this article as: Bárbara-Bataller E, Méndez-Suárez JL, Alemán-Sánchez C, Ramírez-Lorenzo T, Sosa-Henríquez M. Epidemiología de la lesión medular de origen traumático en Gran Canaria. Neurocirugía. 2017;28:15–21.

Copyright © 2016. Sociedad Española de Neurocirugía
Neurocirugía (English edition)

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