Epidemiology of Spinal Cord Injury and Traumatic Brain Injury: the Scope of the Problem
Epidemiology of SCI and TBI 1 Epidemiology of Spinal Cord Injury and Traumatic Brain Injury: The Scope of the Problem
Elie Elovic and Steven Kirschblum Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 Traumatic injury to the central nervous system (CNS) is one of the most important issues concerning the health care system in the 1990s and will likely remain so into the next millenium. In the United States, there are 10,000 hospital admissions each year secondary to spinal cord injury (SCI), while there are more than 250,000 hospital admissions each year secondary to traumatic brain injury (TBI). The majority of SCIs occur in the young, and 55% of traumatic SCIs are sustained by people between 16 and 30 years old. A similar trend is noted in TBI with the highest incidence rate reported for those who are between 15 and 24 years old. Motor vehicle accidents (MVAs) and falls are the two most common causes of traumatic injuries to the CNS. Recent advances have lessened the incidence of MVAs related to the CNS, while there has been an increased rate of injury secondary to violence in both SCI and TBI. The issue of dual diagnosis of SCI and TBI is an important one. It is far more common for the patients with an SCI to also have a TBI diagnosed, with a rate between 24% and 50% reported. The converse of SCI diagnosed after a primary TBI is much less common with single digit rates between 1.2% and 6% reported. Key words: epidemiology, spinal cord injury, traumatic brain injury
N TODAY’S WORLD, trauma has be- the person involved, their family and friends, come all too common. Injury to the and society at large. Only during the past I central ner vous system (CNS) is per- half-century have persons with SCI been haps the most critical, because of the extreme given hope for survival. The earliest refer- deficits that can result from dysfunction of the ence to SCI was made approximately 5,000 brain and spinal cord, coupled with their lim- years ago by an unknown Egyptian physician ited potential for regeneration. As a result, in the so-called Edwin Smith Papyrus as “an there have been extensive resources dedicated ailment not to be treated.”1 Prior to World to the study and medical management of these disorders. Efforts at treatment and prevention have been very successful, minimizing indi- Elie Elovic, MD, is Associate Medical Director, Cen- vidual deficits as well as financial costs to ter for Head Injuries, JFK Johnson Rehabilitation society. The efficacy and direction of these Institute, Edison, New Jersey, and Clinical Assistant efforts require information about incidence, Professor, Department of Physical Medicine and Re- prevalence, and the populations at risk for habilitation, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, sustaining injury to the CNS. This article will New Brunswick, New Jersey. discuss the critical epidemiological informa- tion about traumatic spinal cord and brain Steven Kirschblum, MD, is Associate Professor, De- injury. We hope that the readers will gain a partment of Physical Medicine and Rehabilitation, better understanding of this vital material. University of Medicine and Dentistry New Jersey, Newark, New Jersey, and Director of Spinal Cord Injury Program and Director of Ventilator Program, Epidemiology of Spinal Cord Injury Kessler Institute for Rehabilitation, West Orange, New Jersey. Spinal cord injury (SCI) is a clinical con- Top Spinal Cord Inj Rehabil 1999;5(2):1–20 dition that has a devastating consequence for © 1999 Thomas Land Publishers, Inc.
1 2TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
War II, life expectancy of persons with SCI 30-year-old age group.2,5,11 The mean age at was rarely greater than 2 years; most of them injury, which currently is 31.7 years accord- died due to septic infections, renal failure, ing to Model System data, 5 has risen slowly and pressure sores. Remarkable progress has since 1973, while the median and mode age been made toward effectively preventing and at time of injury is 26 and 19 years, respec- managing the numerous medical complica- tively. The increase in mean age in part Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 tions of SCI, as a result, the life expectancy of results from the increased median age of the persons with SCI has increased significantly. general population, but it is also due to the In addition, early provision of comprehen- almost doubling in the proportion of persons sive rehabilitation services has helped per- who are older than 60 years of age who sons who sustained SCI to regain at least sustain an SCI; this is an increase from 4.7% limited self care and mobility skills. This for the 1973 to 1977 period to 9.7% since usually permits them to seek reintegration 1990. 2,5 In addition, there is an increasing into their communities. survival rate for older persons with SCI.12
Incidence and prevalence Etiology Excluding deaths at the scene of injury, the Since the inception of the SCI Model System annual incidence of SCI in the United States data collection in 1973, almost half of the persons is estimated to be between 30 and 40 new enrolled were injured in motor vehicle accidents cases per million populations.2–8 Based on (MVAs) (44.5%), followed by falls (18.1%), acts the current US population, there should be of violence (16.6%), and recreational sports ac- roughly 10,000 new cases of traumatic SCI tivities (12.7%).5 In MVAs, roughly half of the presenting to the hospital each year.2 There injured individuals are the driver and 28% are the may be as many as 5,000 spinal-cord-injured passengers; approximately 16% of the individu- persons who die before being admitted to the als are injured in motorcycle accidents.11 There hospital.3,5 Estimated incidence varies some- have been noteworthy changes in the pattern of what from state to state, and figures from causes of injury since 1990. The proportion of SCI other countries are often quite different. (since 1992) caused by MVAs has declined to There have not been any recent incidence 37.2% and the proportion of SCI caused by studies in the United States and therefore it is recreational sports fell to 7.1%. SCI caused by unclear if the incidence has changed in the acts of violence has increased to 26.8%, and last few decades. As life expectancy has fall-related injuries have risen to 21%.2 improved, the prevalence of traumatic SCI The causes of SCI vary by age, gender, and has increased and is estimated to be between racial/ethnic background. MVAs are the 183,000 and 230,000 persons.5,9,10 leading cause of SCI up to age 45, when falls become the leading cause. Both sports activi- Age at injury ties and acts of violence decline steadily with The incidence of SCI appears to be in- advancing age, while the reverse is true for creasing among older individuals, although falls. The age groups at greatest risk for injuries still remain concentrated at the violence-related SCI are 15- to 24-year-old younger end of the age spectrum; 55% of males and 25- to 39-year-old females.13 The traumatic SCI occurs in persons in the 16- to younger age groups are at greatest risk for Epidemiology of SCI and TBI 3
sports injuries. The most striking difference (17%); 50% of the accidents result in a neu- between males and females is the proportion rologically complete injury.17 of sports-related SCI, which is 14% in males versus 6.6% in females. There is a higher Gender and ethinicity proportion of SCI from MVAs in females Virtually all demographic data reveal that than in males (56% versus 42%).5 roughly 80% of persons sustaining a trau- Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 The etiology of SCI also varies by the matic SCI are male. As previously men- racial/ethnic background.5,14–16 According to tioned, females are significantly involved in Model System data, 5 the frequency of SCI in more MVAs than males, whereas males are rank order for whites is MVAs (50%), fol- involved in more falls and sports-related in- lowed by falls (18%), sports activities (16%), juries.18 Females are more reliant on Medic- and acts of violence (7%). For African aid in the long term, whereas males have Americans, acts of violence are the most more Medicare and workers’ compensation common cause (42%), followed by MVAs coverage.18 Females are more likely to have (27%), falls (20%), and sports activities a paid attendant as a caregiver, whereas (4%). Population-based studies have shown males are more likely to have their spouse or that the incidence of SCI due to violence is parents assist.18 much higher among African Americans than With respect to racial composition, sig- among whites. 14–16 nificant changes have been noted during the SCI is most often seasonal; the incidence past 20 years. According to the Model Sys- increases as daylight hours and the tempera- tem data5 that compared ethnicity of persons ture increase. SCI is most common during the who sustained SCI between 1973 and 1977 to summer months (July and August) and on those injured between 1990 and 1992, whites weekend days. Almost 40% of injuries occur were 77% versus 57% of injuries, respec- on Saturday and Sunday.5 The fewest amount tively; African Americans were 14% versus of injuries occur in February. Seasonal varia- 30%; Hispanics were 6% versus 11.2%; and tion is less in regions of the country with less Asians were 0.8% versus 1.6% (Table 1). temperature fluctuations. Racial trends in the general population of the Specific sports that cause SCI include div- United States are not sufficient to account for ing (8.5%), followed by football (0.7%), this change.11 However, the Model System snow skiing (0.5%), horseback riding and data, based on the location of many of the surfing (0.4% each), and gymnastics and wrestling (0.3% each).5 Diving accidents Table 1. Model Systems data relating to per- represent the fourth leading cause overall of centage of ethnicity of persons with SCI in two SCI and account for almost two thirds of all time periods sports-related SCI. Diving accidents usually occur in males between 15 and 25 years of Ethnicity 1973–1977 1990–1992 age, in below-ground pools, in shallow water Caucasian 77 57 (less than 4 ft), and in pools without depth African American 14 30 markers. Diving accidents usually cause a Hispanic 6 11.2 neurological level of injury at the C5 level Asian 0.8 1.6 (35%), followed by C6 (26.8%) and C4 xxx 4TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
centers, reflect a higher urban proportion than is present in the United States as a Trends over the last 20 years indicate a whole, and the urban environment has a rising proportion of persons with greater percentage of violence.11 According neurologically incomplete paraplegia to the sample study by Berkowitz et al.,11 the and a diminishing proportion of rate of SCI among whites and nonwhites persons with complete tetraplegia. Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 closely resembles the demographic compo- sitions of the United States at large, so this aspect is still not completely clarified. earnings of SCI individuals than on earnings of individuals in the general population.22 Educational, occupational, and marital status Neurologic level and extent of injury Based on data from the Model Systems,5 at Most studies show that a slight majority of the time of injury, most persons with traumatic persons with SCI have tetraplegia. Trends SCI are at least high school graduates (59.3%) over the last 20 years indicate a rising propor- and are employed (63.5%). The majority are tion of persons with neurologically incom- single at the time of injury (53.6%) and less plete paraplegia and a diminishing propor- than one third (31%) are married.2 The likeli- tion of persons with complete tetraplegia. hood of a marriage remaining intact after SCI This may be partly explained by a rising is slightly lower when compared to the general incidence of gunshot wounds as a cause of population. The likelihood of getting married SCI, because such wounds usually result in after SCI is also reduced. paraplegia (69%) as compared to injuries A number of factors affect the rate of from MVAs (45%) and sports (9%).5 An- employment 10 years postinjury, but the rate other explanation may be the decline in is estimated to be approximately 35% in sports-related injuries that generally result in patients with paraplegia and 23% in patients tetraplegia. Since 1990, incomplete tetraple- with tetraplegia. Specific factors that influ- gia (29.6%) is the most frequent neurologic ence higher rates of employment for paraple- category, followed by complete paraplegia gia relative to tetraplegia are incomplete in- (28.1%), incomplete paraplegia (21.5%), juries relative to complete injuries, younger and complete paraplegia (18.6%).2 For pa- age at onset, longer time postinjury, greater tients older than 46, the incidence of incom- preinjury educational status, nonminority plete tetraplegia increases rapidly. Patients groups, and a history of preinjury employ- older than 60 years of age have a greater than ment.19,20 Completion of a vocational pro- 60% incidence of incomplete tetraplegia.5 gram postinjury also increases the chance of The most common neurologic level of future employment.19 Individuals with a injury (NLI) at discharge from a Model Sys- modified vehicle and the ability to drive have tem program is C5, followed by C4, C6, T12, a higher employment rate. Younger persons C7, and L1.5 There may be a greater percent- have a higher reemployment rate postinjury age of higher level NLI in Model System than older individuals with SCI.19,21 Com- data, because non-Model System hospitals puter knowledge has a stronger effect on and programs may care for patients with Epidemiology of SCI and TBI 5
lower level of injuries and may refer the spend up to $1 million, depending on their higher level and more severely affected indi- level of injury. The monetary costs do not viduals to more specialized SCI programs. include losses in satisfaction, utility, or wel- fare of others around them.22 Associated injuries According to DeVivo,23 average lifetime
A major trauma capable of causing SCI is costs also vary by the etiology of the injury, Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 often accompanied by associated injuries to with the highest first year costs for sports- other body parts and organ systems, which related injuries, followed by MVAs, vio- may lengthen the initial hospitalization and lence, and falls. He reported the first year negatively affect rehabilitation outcome. costs in 1995 dollar values at $233,947 for The most commonly associated injuries in- MVAs, $217,868 for violence, $295,643 for clude extremity fractures (29.3%), loss of sports, $185,019 for falls, and $208,762 for consciousness (28.2%), pneumohemothorax other causes. Recurring annual charges were (17.8%), and traumatic brain injury affecting highest for MVAs, followed by sports, falls, cognitive or emotional functioning (11.5%).5 and then violence-related injuries. Average Persons injured from a MVA have the great- lifetime costs averaged $969,659, $613,345, est risk for fractures and head injuries, $950,973, $630,453, and $673,749, respec- whereas persons injured from acts of vio- tively.23 Average initial and annual charges lence are most likely to suffer a pneumotho- are high for sports-related injuries because rax and/or hemothorax. they occur in younger persons and more often result in tetraplegia.5 Initial charges are Estimated costs lowest for falls because they often result in The cost of SCI to the individual and to relatively incomplete neurologic injuries. society is staggering. With advancing medical However, annual charges rank third for falls technology and increasing life expectancies, because they typically occur among the eld- the costs of SCI are increasing at a rapid pace.2 erly who are more likely to need attendant SCI costs the nation more than $9.73 billion care and nursing home services. Annual per year, including direct ($7.136 billion) and charges are lowest for violence-related SCIs indirect ($ 2.591 billion) costs.21 This is simi- because they usually result in paraplegia. lar to the figures of DeVivo23 who reported in However, their initial costs are higher be- 1995 dollars a direct cost for all causes of SCI cause of increased concomitant internal inju- in the United States at $7.736 billion. ries associated with the acute event.23 First year costs (initial hospital costs and rehabilitation) are estimated at $223,261 per Life expectancy injury, or $2.367 billion per year with an Life expectancy for patients with SCI has estimated incidence of 40 per million. Fur- been increasing, but it is still below that of the ther annual medical care averages $9,000 per non-SCI population. Mortality rates are sig- year, or $1.624 billion per year based on nificantly higher during the first year after 180,400 persons with SCI who survive be- injury than during the subsequent years, par- yond 1 year. Over the course of a lifetime ticularly for severely injured persons. Model postinjury, an SCI individual can expect to System data5 report mortality rates of 3.8% 6TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
during the first year postinjury, 1.6% during may include educating persons at risk by the second year, and approximately 1.2% per reinforcing safe behavior, increasing the use year over the next 10 years. Life expectancies of self-protective measures, and modifying for postinjury by severity and age at time of the environment (i.e., safety features in auto- injury have been developed and published.2,24 mobiles, highways, and pools). An example
Life expectancy is less when there is a higher is THINK FIRST (THINK FIRST Founda- Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 level of injury, a greater age at injury, a tion, Park Ridge, IL), which is a prevention greater degree of completeness of the injury, program established by the American Asso- and ventilator dependence. 24–28 The pro- ciation for Neurological Surgeons and the jected mean life expectancy of persons sur- Congress of Neurological Surgeons to pre- viving 18 months, as compared to the non- vent injuries to the head and spine. The SCI population, is 70% for complete program describes personal vulnerability tetraplegia, 84% for complete paraplegia, and the consequences of excessive risk-tak- and at least 92% for individuals with incom- ing behavior. The program is presented to plete injuries.25 Current figures do not take middle and high school students who are into account the possibility of any present deemed particularly at risk. Descriptions re- and future medical advances that would in- garding pool safety have been recom- crease the survival of individuals with SCI.28 mended.17,31,32 DeVivo17 reported that with- Previously, renal failure was the leading out considering the substantial value of lost cause of death in SCI individuals. However, productivity, a program that prevents a single significant advances in urological manage- SCI due to a MVA can save money if it can ment and preventive care have resulted in be conducted for under $969,659, because shifts in the leading causes of death. Al- this is the estimated lifetime cost per indi- though there is a variation based on the age vidual. Because most prevention programs groups and on the severity and level of lesion, are not specific for SCI, other types of inju- respiratory complications followed by heart ries that are prevented as a result of the disease are the leading causes of death. Unin- programs would generate additional savings. tentional deaths (i.e., suicide) are higher in SCI individuals than in the general popula- Epidemiology of Traumatic Brain tion, especially in patients under 25 years of Injury age. For incomplete paraplegia, the leading causes of death are cancer and suicide; The discussion of the epidemiology of whereas for complete paraplegia, it is suicide traumatic brain injury (TBI) is always a chal- followed by heart disease.5 Lower quality of lenging issue. Many of the landmark studies life is also a predictor of mortality. Activity, of the past had very different inclusion crite- social and vocational, is positively associ- ria, which makes direct comparisons prob- ated with survival in multiple studies.29,30 lematic. Also, inclusion criteria are set by the investigators who collect them, but the crite- Prevention ria are not the same as a definition of TBI. It Prevention of SCI should be a focus of all is beyond the scope of this article to exhaus- centers caring for these patients. Prevention tively discuss the subject, but pertinent infor- Epidemiology of SCI and TBI 7
mation is included in Table 2 and the refer- Incidence ence list.33 The Centers for Disease Control and Pre- The actual incidence of TBI in the United vention (CDC) estimated that 1.5 million States has been studied in numerous works. Americans survive a TBI every year.34 At the The first attempt at quantifying the problem more severe end of the spectrum, there are of brain injury was the National Health Inter- Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 approximately 230,000 hospital admis- view Survey.39 A survey was sent to over sions35 and 50,000 deaths every year in the 41,000 households, and 111,000 households United States as a result of TBI.36 This ac- were contacted each year to obtain an esti- counts for one third of all injury-related mate of TBI incidence. For the survey, any- deaths in the United States. In addition, on a one who was either medically attended or yearly basis, 80,000–90,000 individuals de- limited in activity for 1 day as a result of an velop a long-term disability resulting from accident or an act of violence was considered TBI. The vast majority of people survive injured. Using this information, Caveness40 their injury, and the CDC estimates that there estimated that 4% of the US population had are 5.3 million survivors of TBI in the United sustained a head injury every year with more States.37 The financial costs of TBI can be than 1 million people each year sustaining a staggering. Max38 estimated the costs in the major injury. A major injury was defined as United States due to TBI in 1985 and re- a head injury that had the potential to be a ported a total loss of $37.8 billion: $4.5 brain injury. There were obvious problems billion was spent in direct care costs, $20.6 with this study; there was no verification of billion in work loss and disability, and $12.7 injury and there was a very loose definition of billion in lost income from premature death. injury that included facial lacerations and With the increase in health care costs and contusions. Although it was clearly flawed, general inflation, the current financial loss this study was the first work that demon- must be staggering. The need to study and strated the magnitude of the problem. prevent the consequences of TBI is obvious. There have been numerous studies since The federal government has committed itself that time that have looked at the incidence of to this activity and, as a result of the Trau- TBI.34,41–56 Based on the inclusion criteria, matic Brain Injury Act of 1996 (Pub L No. time period, location, and demographics of 104-166), is providing $3 million per year of the population studied, there has been a wide funding for state surveillance systems. As a disparity between the numbers obtained by result, data collection is now occurring in an the researchers. The highest rate was re- organized fashion in over 15 states.37 ported by Gutierrez et al.,48 who reported a rate of 676 per 100,000 in Cali, Columbia, during 1990. Tiret et al.47 reported a rate of 281 per 100,000. Most recently, Koskinen et On a yearly basis, 80,000–90,000 al.53 published data from Finland with a much individuals develop a long-term lower incidence of 95–100 per 100,000 in disability resulting from TBI. Finland for the years 1991–1995. There is similar variation noted in the US 8TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
Table 2. Inclusion criteria for brain injury studies
Study Population Inclusion criteria
Annegers et al. 198041 Olmstead County Head injury with presumed brain involvement Kalsbeek et al. 198039 United States Head injuries admitted for inpatient care; prehospital deaths excluded Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 Klauber et al. 198142 San Diego County Hospital admissions and deaths with diagnosis of head injury by International Classification of Diseases; gun- shots, bruises, and lacerations excluded Cooper et al. 198343 Bronx urban Residency, onset of injury <24 h, loss of consciousness >10 min, skull fracture, neurologic sign or seizure Jagger et al. 198444 Virginia rural Residency; hospitalized > 15 h; 99% had loss of conscious- ness, skull fracture, or posttraumatic amnesia; prehospital deaths excluded Desai 198395 Chicago urban Injury < 7 days old, blow to face or head with change in consciousness Kraus et al. 198446 San Diego Physicians diagnosed brain injury, blunt and penetrating included; facial and skull fractures without brain injury excluded Tiret et al. 199047 Aquitaine, France Head injuries including contusions, lacerations, skull fractures, brain injuries, loss of consciousness; admissions and immediate deaths Thurman et al. 199654 Utah Hospital admissions by ICD-9 and death certificates with TBI listed first or second CDC 199752 Colorado, Missouri, Hospital admissions by ICD-9 and death certificates with Oklahoma, and Utah TBI listed first or second Gabella et al. 199751 Colorado Hospital admissions by ICD-9 and death certificates with TBI listed first or second
Note: ICD-9 = International Classification of Diseases, Ninth Revision. studies. The highest rates were reported by a rate of 102 per 100,000 for the years 1990– Cooper et al.43 and Whitman et al.45 1993 (Table 3).52 Cooper’s group reported a rate of 249 per As mentioned earlier, the Traumatic Brain 100,000 in the Bronx, New York, whereas Injury Act of 1996 provides funding for state Whitman reported a rate as high as 403 per registries to monitor the incidence of TBI. 100,000 for inner city blacks. Fife et al.,49 on This signals a major shift in the means of data the other hand, reported a rate of 152 per collection. Prior to this, most studies in the 100,000. More recently, data from state United Sates were based on case series or trauma registries from three states reported epidemiological studies in one specific loca- Epidemiology of SCI and TBI 9
tion. As a result of this funding, the develop- What is the actual incidence of TBI in the ment of a national surveillance method has United States and why are there major differ- now becoming a possibility. The CDC began ences in incidence rates among different the process for TBI in 1989 when federal studies? In 1980, there were 500,000 admis- funding was provided after a Federal Inter- sions to the hospital resulting from TBI. agency Head Injury Task Force report iden- Today, admissions have dropped to less than Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 tified the need.57 At first, 4 states were half of that. Part of this decline may result involved in the data collection; however, from decreased incidence and increased effi- data collection has been broadened and 15 cacy of prevention measures. There has been states are now involved. a drop of 20% in TBI-related mortality.37
Table 3. Incidence of traumatic brain injury per 100,000 and male to female ratio
Study Incidence Male to female ratio
Annegers et al. 198041 270 Male 2.3:1 116 Female Kalsbeek et al. 198039 272 Male 2.1:1 132 Female 200 Total Klauber et al. 198142 295 Total 1.3:1 to 2.8:1 Cooper et al. 198343 391 Male 2.8:1 142 Female 249 Total Jagger et al. 198444 208 Total 2.4:1 Whitman et al. 198445 403 Inner city 2.5:1 394 Suburban African American 2.8:1 196 Suburban white 2.3:1 Kraus et al. 198446 247 Male 2.2:1 111 Female 180 Total Tiret et al. 199047 384 Male 2.1:1 185 Female 281 Total CDC 199752 140 Male 2.1:1 66 Female 102 Total CDC 1999 (unpublished 124 Male 2.1:1 data from 7 states) 59 Female 91 Total xxx 10 TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
However, this does not explain the 50% drop Table 4. Becker’s (1989)62 grading of injury from the 200 per 100,000 that Kraus58,59 dis- severity based on neurological condition of cussed to the 100 per 100,000 that is cur- patient on arrival to the emergency room rently being reported by the state registries. Grade Neurological condition These registries obtain their information
from death certificates and hospital admis- I Awake and alert, nonfocal neurologic Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 sion records. Information about patients who examination are seen and discharged from the emergency II Awake with focal neurologic examina- room is not being captured and is not being tion or decreased level of consciousness entered into the TBI database. This accounts but follows commands for the major difference in incidence be- III Unable to follow one-step commands tween current information and some of the IV Without evidence of brain function or historical reports. Unpublished data from brain dead 1988 from the Missouri trauma registry,60 which does not include emergency room xxx information, show a lower incidence of TBI as well. cal condition of the patient upon arrival to the emergency room was published in Becker’s Injury severity Textbook of Head Injury.62 Grade I patients Discussing injury severity scientifically is are alert and oriented with no focal lesion; quite challenging because the literature is grade II patients have decreased level of difficult to interpret. There are many differ- consciousness but can follow simple com- ent tools for assessing severity of TBI, and mands or have a focal neurologic deficit; there is no uniformity in the scales used by grade III patients are unable to follow a investigators. To critically review an article, simple one-step command; and grade IV the reader must be aware of which injury patients are brain dead (Table 4). scale the authors used. We will briefly dis- Ommaya and Gennarelli63 in 1974 pub- cuss the most commonly used scales in the lished a scale from grades I to VI based on following paragraphs; a more extensive dis- severity of injury after a blow to the head. cussion can be found in the reference list.33 Grades I through III are injuries that cause no The most well-known scale is the loss of consciousness; grades IV through VI Glasgow Coma Scale (GCS).61 First pub- involve loss of consciousness with increasing lished in 1974, it is the most widely used injury up to death (Table 5). In 1982, scale because of ease of use and prognostic Gennarelli64 published the results of his pri- value. This scale tests three parameters: best mate research that graded the severity of in- motor score, eye opening, and verbal respon- jury based on evidence of diffuse axonal in- siveness. The lowest possible score is 3 and jury (DAI). Grade 0 has no evidence of DAI; the highest possible score is 15. A score of 3– grade 1 has DAI primarily in the parasagittal 8 is considered a severe injury, 9–12 is a white matter; grade 2 has DAI also in the moderate injury, and 13–15 is a minor injury. corpus callosum; and grade 3 has DAI also in A grading system based on the neurologi- the superior cerebellar peduncle (Table 6). Epidemiology of SCI and TBI 11
Table 5. Ommaya and Gennarelli’s (1974)63 Posttraumatic amnesia (PTA) has long grading of injury severity based on severity of been considered an effective measure in as- injury after a blow to the head sessing injury severity. Russell68,69 was one of the first authors to recognize the relation- Grade Neurological condition ship between the two. There is literature that
I Confusion, no amnesia has linked the length of PTA to Glasgow Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 II Confusion and posttraumatic amnesia Outcome Scale70 and IQ performance.71 The III Confusion and antegrade amnesia length of PTA is considered to be the time IV Loss of consciousness V Coma to vegetative state that passes prior to the patient being able to 72 VI Coma to death form new continuous memory. Levin et al. developed a scale called the Galveston Ori- xxx entation and Amnesia Test (GOAT) that can be used to objectively assess the duration of Table 6. Gennarelli’s (1982)64 grading of amnesia. When patients consistently score severity of injury based on evidence of diffuse 75 of 100, they are out of PTA. axonal injury (DAI) Distribution of injury severity Grade Location of DAI Some of the first major epidemiological 0 No evidence work in the United States was the work done 1 Primarily in the parasagittal white matter by Annegers et al.41 Their research revealed 2 Also in corpus callosum that 55%–60% of the survivors sustained 3 Also in superior cerebellar peduncle minor injuries, 30% sustained moderate inju- ries, and roughly 10% sustained severe inju- xxx ries. Recent studies suggest that there has been a shift toward more minor injuries; There are numerous injury scales that have Tiret, Whitman, Kraus, and Chiu report an been designed to assess injury severity. The incidence of approximately 80% minor brain most commonly used scales include the Ab- injury.45–47,56 The data from the trauma regis- breviated Injury Scale (AIS), Injury Severity tries will be difficult to interpret because the Score (ISS), and the Revised Trauma Score registries are missing the majority of minor (RTS). 65–67 With the AIS, injuries of indi- injuries that are not being admitted to the vidual organ systems are rated from 1 to 6 hospital. In 1996, Sosin et al.34 published (mild to causing death). The ISS is a deriva- their estimate that 1.5 million US civilians tive of the AIS; ISS is calculated by adding sustain a nonfatal brain injury that does not the squares of the three most severely injured require hospitalization; this is an incidence organ systems. The RTS looks at three of 618 per 100,000 (Table 7). parameters: GCS, systolic blood pressure, and respiratory rate. Each of these param- Mortality eters is rated from 0 to 4. The sum of these Kraus73 estimated that in 1990, TBI ac- three parameters can be useful in triage and in counted for 75,000 deaths, which was 52% of prognostication. the 148,480 injury-related deaths. This esti- 12 TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
Table 7. Distribution of severity by study incidence per 100,000
Study Location of study Fatal Severe Moderate Minor/trivial
Annegers 198041 Olmstead County M 35 17 69 149
F 10 6 29 71 Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 Whitman 198445 Chicago ICB 32 14 34 328 SB 19 32 6 303 SW 11 15 20 118 Kraus 198446 San Diego 30 14 15 131 Tiret 199047 Aquitaine, France M33 F12 T 22 23 28* 227†
Note: M = male; F = female; ICB = inner city black; SB = suburban black; SW = suburban white; T = total. *Includes hospital admissions with minor head injury and TBIs not admitted to hospital. †Estimate calculated by using the percent of each injury group reported by multiplied by the (total incidence – fatalities). Source: Modified and reprinted with permission from Elovic E, Antoinette T. Epidemiology and primary prevention of traumatic brain injury. In: Horn LJ, Zasler ND, eds. Medical Rehabilitation of Traumatic Brain Injury. Philadelphia, PA: Hanley & Belfus; 1996. mate was based on the TBI-related death rate 100,000. Throughout all the studies, there is of 30 per 100,000. The most recent informa- the general trend of higher male-to-female tion on TBI mortality comes from the Na- mortality (2:1–5:1) and a higher mortality for tional Center for Health Statistics for the lower socioeconomic groups (Table 8). years 1980 through 1994.74 In 1994, 51,350 people died in the United States because of Gender differences and TBI TBI; the vast majority of these deaths re- There are major differences between sulted from firearm- or transportation-re- males and females relative to TBI. This is lated events. There was a 20% decrease in true relative to incidence of both fatal and TBI-related mortality during that time pe- nonfatal injuries and in causes of TBI. Men riod, with a rate of 24.7 per 100,000 in 1980 are far more likely to suffer a TBI and to die declining to 19.8 per 100,000 in 1994.37 from their injury. The ratio of males to Review of the literature shows substantial females differs study to study; but in the variation among the different studies but these civilian population, the ratio for incidence is variations are in line with the aforementioned 2:1–3:1 overall. The ratio of mortality may numbers. The highest rate of 30 per 1,000 was even be higher with the male-to-female ratio reported by Kraus et al.46 Sosin et al.,36 who of 2:1–5:1. Possible reasons for the differ- reviewed information on deaths in the United ence may be different exposure risks to States using the national multiple cause of MVAs, interpersonal violence, alcohol use, death tapes, reported the lowest rate of 19 per and participation in contact sports.73 Epidemiology of SCI and TBI 13
major source of TBI-related mortality for The etiology of TBI-related deaths ages 17 and 74. Falls are the major source of differs between the sexes. TBI-related mortality for women older than age 75 and for men older than age 85.
Socioeconomic influences and race Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 The etiology of TBI-related deaths differs Although studies have shown that there between the sexes. Information from the are differences in incidence and mortality CDC35 highlights these differences. For data between the races, there has been no males, firearms are the major source of TBI- clear study that shows that the difference is related mortality for ages 15 to 84. For fe- race specific and not related to some other males, transportation-related events are the confounding variable such as lower in-
Table 8. Mortality of traumatic brain injury
Study Location of study Rate per 100,000 Male to female ratio
Annegers et al. 198041 Olmstead County 35 Male 3.5:1 10 Female Klauber et al. 198142 San Diego County 32 Male 2.7:1 12 Female 22 Total Cooper et al. 198343 Bronx, New York 50 Male 5.0:1 10 Female 28 Total Whitman et al. 198445 Chicago 32 Inner city 4.6:1 19 Suburban African American 2.6:1 11 Suburban white 2.3:1 Kraus et al. 198446 San Diego 45 Male 3.0:1 15 Female 30 Total Sosin et al. 198977 United States 26 Male 3.0:1 09 Female 17 Total Tiret et al. 199047 Aquitaine, France 33 Male 2.75:1 12 Female 22 Total Sosin et al. 199536 United States 19 Total 3.4:1
CDC 199752 Colorado, Missouri, 23.2 Total calculated Not reported Oklahoma, and Utah
CDC 1998 United States 30.7 Male 3.3:1 (unpublished data) 9.3 Female 19.8 Total xxx 14 TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
come.42 The relationship between lower Age and TBI median family income and an increase in TBI incidence and mortality has been well Age has consistently been one of the most documented.44,75,76 Recently, TBI-based important variables in determining risk and mortality is showing some differences be- etiology of injury. Many studies have shown tween the races. Sosin’s original review of that 15 to 24 year olds often have the highest Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 the multiple cause of death tapes showed no incidence of TBI.33,43,44 Two reports51,52 from difference between African Americans and the state registries stated that the individuals whites,77 however his later review34 demon- over 75 years old had the highest incidence of strated a divergence between the two rates TBI and individuals who were 15 to 24 years with a drop in white male mortality to 29 per old had the second highest incidence. Falls 100,000 and an increase in African Ameri- were the number one cause of TBI for the can male mortality to 42 per 100,000. The over 75 age group, while transportation was unpublished analysis of the CDC35 is sup- the leading cause for the 15 to 24 year olds. portive of the later review; it reports the Relative to mortality, individuals older than mortality rate for TBI as 25.5 per 100,000 75 years have the highest TBI mortality, and for African Americans, 19.0 per 100,000 for 15–24 year olds have the second highest whites, and 15.3 per 100,000 for others. mortality. The CDC data from 1994 show Again, race may be secondary to financial that the leading cause of TBI for males who or geographic issues in causing much of the are 15–84 years old is firearms. This is prob- divergence, because past studies have often ably due to the lethality of firearm-related shown that there is a higher incidence of TBI. In individuals who are under 15 years TBI in the urban regions. Recently, Gabella old, transportation is the leading cause of et al.51 reported on data from the Colorado death. For males over 84 years old, the lead- data registry, which contradicted the trend ing cause of death is falls. For females up to of a higher incidence of TBI-based mortal- age 74, transportation is the leading cause of ity in urban versus rural populations. They TBI mortality. For 30- to 54-year-old fe- reported that in Colorado there is a higher males, firearms are almost identical to trans- incidence of TBI-based mortality in rural portation in causing mortality. For females versus urban regions (172.1 versus 97.8, over 75 years old, falls are the major source respectively). of TBI-related mortality.37, 52
Previous injury Cause of injury Previous studies have demonstrated that a Numerous studies have looked at the etiol- past history of TBI does increase the risk of ogy of TBI. For prevention efforts to be a repeat event.43, 74 The literature is unclear effective, the cause of injury must be known. whether this is due to some disability or Transportation-related events remain the deficit from the initial injury or whether it is leading cause of TBI incidence, and falls are a result of behavioral preselection for some the second most frequent cause.35,37,41,44,46,47,60 risk factor, such as alcohol or risk-taking In selected populations, such as the inner behavior. city, interpersonal violence plays a much Epidemiology of SCI and TBI 15
larger part and can be the second most or even all injuries with mortality rates of greater possibly the leading cause of TBI. 43,45,78 In than 90% (Table 9).41,78,79 TBI-related mortality, there has been a dras- tic change in the leading cause. Prevention Dual Diagnosis efforts such as airbags and seat belts have decreased transportation-related TBI deaths Up to this point, we have discussed TBI Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 by 38%, from an incidence of 11.1 per and SCI as separate entities. However, the 100,000 in 1980 to 6.9 per 100,000 in 1994. two injuries can occur concurrently. In the During that same time period, firearm-re- remainder of this article, we will report on the lated mortality increased 11% from 6.9 per literature when the two diagnoses are sus- 100,000 to 8.4 per 100,000 and is now the tained simultaneously. leading cause of TBI-related mortality.37 SCIs are commonly associated with TBI. Data from the Spinal Cord Model Systems Lethality of injury report that 28.2% of SCI patients have at least Tremendous efforts have been made to a minor brain injury with loss of conscious- reduce the lethality of transportation-related ness whereas 11.5% have a TBI severe TBI deaths. Airbags, seat belts, and helmets enough to demonstrate cognitive or behav- have substantially reduced the mortality. ioral changes.5 Many other studies have Falls, which are relatively low-energy inju- shown that patients who have sustained a SCI ries, have a low lethality. Firearm-induced are at high risk for having sustained a TBI as TBI, on the other hand, is the most lethal of well. When SCI is the primary injury, studies
Table 9. Percentage distribution of traumatic brain injury by cause of injury
Study Vehicle Falls Violence Recreation Other
Annegers et al. 198041 46 29 6 9 9 Cooper et al. 198343 28 32 34 NR 7 Kraus et al. 198446 49 21 18 10 4 Whitman et al. 198445 Inner city African American 31 20 40 3 6 Suburban African American 32 21 26 11 10 Suburban white 39 31 10 14 6 Jagger et al. 198444 55 20 11 NR 14* Sosin et al. 198977 57 12 15 NR 13 Gennarelli et al. 198978 66 15 19 NR 0 Missouri 198860 48 29 7 NR 17 Tiret et al. 199047 60 33 7 NR 1 CDC 199752 48 23 18 3 10 CDC 1999 (unpublished data) 49 26 16 NR 8
Note: NR = not reported. *Other includes some pedestrian accidents, whereas other studies include them as transportation accidents. 16 TOPICS IN SPINAL CORD INJURY REHABILITATION/FALL 1999
Table 10. Percentage of traumatic brain injury Table 11. Percentage of spinal cord injury re- reported with primary spinal cord injury ported with primary traumatic brain injury
Study Percentage Study Percentage
Meinecke 196784 31% calculated Gbaanador et al. 198689 1.2% 85 90 Harris 1967 44% cervical Bayless & Ray 1989 1.7% Downloaded from http://meridian.allenpress.com/tscir/article-pdf/5/2/1/1985025/v75j-re76-20gh-x7by.pdf by guest on 30 September 2021 23% dorsal Michael et al. 198986 6% 26% lumbar Soicher & 3.5% cervical 33% total Demetriades 199191 Silver 197381 50% Kach et al. 199392 5.8% stable cervical Shrago 197382 53% with C1-C2 2.9% unstable cervical 9% with
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