Spinal Cord Injury Caused by Stab Wounds: Incidence, Natural History, and Relevance for Future Research

Home , Stab wound

JOURNAL OF NEUROTRAUMA 33:1416–1421 (August 1, 2016) ª Mary Ann Liebert, Inc. Original Articles DOI: 10.1089/neu.2015.4375

Euan J. McCaughey,1–3 Mariel Purcell,2,3 Susan C. Barnett,3,4 and David B. Allan2,3

Abstract Spinal cord injury caused by stab wounds (SCISW) results from a partial or complete transection of the cord, and presents opportunities for interventional research. It is recognized that there is low incidence, but little is known about the natural history or the patient’s suitability for long-term clinical outcome studies. This study aims to provide population-based evidence of the demographics of SCISW, and highlight the issues regarding the potential for future research. The database of the Queen Elizabeth National Spinal Injuries Unit (QENSIU), the sole center for treating SCI in Scotland, was reviewed between 1994 and 2013 to ascertain the incidence, demographics, functional recovery, and mortality rates for new SCISW. During this 20 year period, 35 patients with SCISW were admitted (97.1% male, mean age 30.0 years); 31.4% had a cervical injury, 60.0% had a thoracic injury, and 8.6% had a lumbar injury. All had a neurological examination, with 42.9% diagnosed as motor complete on admission and 77.1% discharged as motor incomplete. A total of 70.4% of patients with an American Spinal Injury Association Impairment Scale (AIS) level of A to C on admission had an improved AIS level on discharge. Nine (25.7%) patients have died since discharge, with mean life expectancy for these patients being 9.1 years after injury (20–65 years of age). Patients had higher levels of comorbidities, substance abuse, secondary events, and poor compliance compared with the general SCI population, which may have contributed to the high mortality rate observed post-discharge. The low incidence, heterogeneous nature, spontaneous recovery rate, and problematic follow-up makes those with penetrating stab injuries of the spinal cord a challenging patient group for SCI research.

Key words: epidemiology; rehabilitation; SCI; traumatic SCI

Introduction The aim of this study was to provide population-based evidence of the incidence, demographics, functional recovery, morbidity, n injury to the spinal cord is a debilitating and life- and mortality rates of patients with an SCISW, assisting in the changing event, leaving a patient with reduced motor func- A planning of future research pathways for spinal cord repair and tion, sensation, and an associated reduction in quality of life.1 regeneration. Spinal cord injury caused by stab wound (SCISW) is most com- monly inﬂicted with knives, and generally has a low incidence rate, accounting for only 0.3% of all SCIs in the United States.2 This low Methods incidence rate, combined with the challenges of long-term clinical Study setting follow-up, may be the reason for a lack of published literature documenting the demographics and functional recovery for this The Queen Elizabeth National Spinal Injuries Unit (QENSIU) patient group. Tabakow and coworkers3,4 investigated the use of a was built in 1993 to be the sole provider of initial treatment, re-

Downloaded by University Of New South Wales from online.liebertpub.com at 06/21/17. For personal use only. habilitation and lifelong care for patients with an SCI >12 years of multicomponent treatment consisting of injections of the patient’s age in Scotland; a devolved region of the United Kingdom National own olfactory ensheathing cells together with autologous periph- Health Service. It is the hub of a managed clinical network funded eral nerve graft and extensive rehabilitation in the management of by NHS Scotland. The unit provides care for a population of SCI. A signiﬁcant recovery was reported in one patient who had 5,300,000, and admits all patients who sustain traumatic spinal cord sustained a SCISW, suggesting the possible relevance of this group injury (TSCI). The etiology, gender, age, injury level, medical as a model for SCI repair. history, and degree of functional impairment of all new admissions

1Centre for Health Systems and Safety Research, Australia Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia. 2Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom. 3Scottish Centre for Innovation in Spinal Cord Injury, Glasgow, United Kingdom. 4Institute of Infection, Immunity, and Inﬂammation, University of Glasgow, Glasgow, United Kingdom.

1416 SCI CAUSED BY STAB WOUNDS 1417

are entered into the QENSIU database and have been published previously.5 The database does not include deaths caused by SCI before admission, but contains information on all new SCIs being treated and rehabilitated in Scotland, enabling a population-based review of SCISW. Scotland has a post-industrial mixed economy, and despite a high income per capita, has large health and socioeconomic variation.6 There is a tradition of knife crime, but strict gun laws are in place.7 The National Services Division of the Scottish Government granted approval for the collection and evaluation of data within the database.

Analysis Patients admitted between January 1, 1994 and December 31, 2013 were included in this study if they were assigned with the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision (ICD-9) diagnostic codes 806 (vertebral fracture with SCI) and 952 (SCI),8 with the etiology of injury being a stab wound (Fig. 1). The neurological level of injury and degree of impairment after SCI was defined according to the International Neurological Classification of Spinal Injury using the American Spinal Injury Association Impairment Scale (AIS).9 Admission and discharge AIS scores were assessed by SCI specialists who latterly com- pleted an International Standards for the Neurological Classifi- cation of Spinal Cord Injury (ISNCSCI) Instructional Course and an ISNCSCI Assessors Training Course for research purposes. No patients with an AIS score of E on admission; that is, stab wound with normal function, were admitted during the course of the study. The QENSIU medical records, current family physician, and the

National Patient Administration system were consulted as to the health of the subjects on the November 1, 2015.

Statistical analysis Incidence data are presented as the mean and standard deviation over a 5 year time block, as well as the mean values over the 20 year study duration.10 Crude annual incidence rates were calculated using the midyear population estimate for each year.11 Annual incidence of homicide, nonsexual crimes of violence, and crimes of possession of an offensive weapon in Scotland were obtained for the years 1994–2013 from data published by the Scottish government,12–15 and annual incidence of crimes of public possession of a bladed weapon were obtained for the years 2004– 2013 from these figures.12 All analysis was performed using MATLAB (version FIG. 1. Radiograph showing the blade of a knife embedded in R2013a, MathWorks, USA). the thoracic region of the spinal cord of a 28-year-old male. This stab wound resulted in the patient being discharged from the Results hospital with an injury level of T7 and American Spinal Injury Association Impairment Scale (AIS) score of A. Incidence of SCISW Between 1994 and 2013, 35 patients were admitted to the QENSIU with an SCISW, accounting for 2.1% of the 1638 TSCI study, whereas crimes for possession of an offensive weapon were admissions over this period. All SCISW were caused by assault. Downloaded by University Of New South Wales from online.liebertpub.com at 06/21/17. For personal use only. 50% greater between 2004 and 2009 than between 1994 and 1998 The mean annual incidence was 1.8 admissions per year (Table 1), (Table 1). There was a marked decrease in the mean annual inci- corresponding to an annual incidence rate of 0.4 incidents per dence of homicide (29.5%) (Fig. 2), nonsexual crimes of violence million population. A marked decrease in the incidence of SCISW (31.6%), possession of an offensive weapon (43.4%), and public was observed over the study duration (Fig. 2), and subsequently, no possession of a bladed weapon (30.5%) in the final 5 years of the patients were admitted to the QENSIU with an SCISW between study, compared with the previous 5 years. December 2010 and October 2015. Gender and age at injury Incidence of personal violence in Scotland Of the 35 patients admitted with an SCISW, 34 (97.1%) were The incidence of homicide and nonsexual crimes of violence in male. The average age at injury was 30.0 years (– 11.6 years [range: Scotland remained relatively stable over the first 15 years of the 16–55 years]). 1418 McCAUGHEY ET AL.

Table 1. Absolute Annual Incidence of Spinal Cord Injury Caused by Stab Wound (SCISW), Homicide14,15 Nonsexual Crimes of Violence, and Crimes of Possession of a Bladed or Offensive Weapon12,13 in Scotland between 1994 and 2013

1994–1998 1999–2003 2004–2008 2009–2013 1994–2013

SCISW 2.6 (1.3) 2.4 (1.8) 1.2 (0.4) 0.8 (1.1) 1.8 (1.4) Homicide 112.8 (20.4) 114.0 (9.4) 113.2 (16.9) 79.8 (17.5) 105.0 (21.3) Violent crime 14275.4 (632.2) 15501.2 (562.8) 13607.8 (871.8) 9302.8 (2109.5) 13171.8 (2643.0) Offensive weapon 6260.4 (636.8) 8654.2 (695.4) 9450.4 (476.9) 5353.2 (1415.3) 7429.6 (1902.7) Bladed weapon - - 3796 (203.0) 2693.4 (515.0) 3217.7 (712.6)

Results are presented as average values over a 5 year period, as well as over the entire study duration, with standard deviation shown in parentheses. Note that incidence of crimes of possession of a bladed weapon are only available from 2004 on.

Nature of injury and management Extent and outcome of paralysis The neurological deficit was associated in 11 (31.4%) patients All patients had an AIS assessment at both admission and dis- with an injury at the cervical level of the spinal cord, in 21 (60.0%) charge. On admission 15 (42.9%) had a motor complete injury (AIS it was associated with an injury at the thoracic level, and in 3 (8.6%) A or B), whereas the remaining 20 patients (57.1%) were motor it was associated with an injury at the lumbar level (Fig. 3). Three incomplete (AIS score C or D). (8.6%) patients, who had sustained injuries at C1/2, C3/4 and T8/9, Of the 27 patients who had an AIS score of A to C on admission, required mechanical ventilation for a period of 290, 14, and 19 (70.4%) had an improved AIS score on discharge (Table 2). 14 days, respectively. Eight (22.9%) patients were motor and sensory complete (AIS A) Anatomically, 15 (42.9%) patients sustained a single stab wound on admission, with three (37.5%) having an improved AIS score on and 20 (57.1%) patients sustained multiple wounds. There were a discharge. Seven (20.0%) patients were motor complete and sen- total of 96 incised wounds. The 12 single neck wounds resulted in sory incomplete on admission (AIS B), with six (85.7%) of these 11 cases of neurological injury. The 18 chest wounds in 10 patients patients motor incomplete on discharge. resulted in five deficits. None of the head (8 wounds in 7 patients), All patients underwent standard rehabilitation for their neuro- abdomen (12 wounds in 8 patients), or limb (10 wounds in 8 pa- logical level and severity of injury. Steroid administration was not tients) wounds caused spinal cord damage; however, there was one routinely advised at the time of the study for penetrating injuries. femoral nerve transection. The 24 patients with back wounds (5 Three patients (2 AIS A, 1 AIS D) had steroids administered, prior multiple) resulted in 19 cases of paralysis. to admission to the unit, with no improvement in their AIS score at Thirty-four (97.1%) patients with SWSCI had primary closure discharge. and one a delayed closure because of late presentation. Eleven (31.4%) patients required a chest drain, with two thoracotomies and Morbidity, mortality, and outcome two laparotomies were performed (liver laceration: mesenteric ar- tery division). Surgical explorations of the spine were required in By November 1, 2015, 9 (25.7%) of the 35 patients had died, six (17.1%) patients because of hematoma or a retained foreign with an average life expectancy from injury of 9.1 years (– 5.7 body. There were three cerebrospinal fluid (CSF) leaks and one years, range 0.8–16.7 years). The current life expectancy for a male infection reported. All limb wounds and fractures (two total) had in Scotland is 77 years.11 The mean age at death for the SCISW primary closure or fixation. patients was significantly lower, at 44.8 years. None of the deaths

3 120 Annual Incidence of Homicide 2.5 100

2 80

1.5 60 Downloaded by University Of New South Wales from online.liebertpub.com at 06/21/17. For personal use only.

1 40

Annual Incidence of SWSCI 0.5 20 SWSCI Homicide 0 0 1994−1998 1999−2003 2004−2008 2009−2013 Years

FIG. 2. Absolute annual incidence of spinal cord injury caused by stab wound (black) and homicide (gray)14,15 in Scotland between 1994 and 2013. Results are presented as average values over a 5 year period. SCI CAUSED BY STAB WOUNDS 1419

C1 2 C2 This rate is higher than in the United States (0.3%) and Europe C3 16 C4 (1.1%), but is much lower than in South Africa, where SCISW C5 17 C6 has been reported to be responsible for 26% of all TSCIs. The C7 T1 T2 variation in the proportion of TSCIs caused by SCISW will relate to T3 T4 cultural, economic, and political differences in combination with T5 T6 the availability of weapons. In the United States, gunshot wounds T7 T8 T9 were reported to be the cause of 5.8% of TSCIs between 1997 and T10 18 T11 2012. By comparison, in Scotland there were only 10 patients T12 L1 with TSCIs caused by gunshot wounds admitted between 1994 and L2 5 L3 2013, accounting for 0.6% of all TSCI admissions. Of these in- L4 012345juries, five were assaults (two of which were caused abroad), two Incidence were self-inflicted (one accidental and one deliberate self-harm), and three were caused during acts of war. FIG. 3. Injury level of 35 patients with a new spinal cord injury In 79% of cases of SCISW in Scotland, the patient lived in the caused by stab wound in Scotland between 1994 and 2013. In- Greater Glasgow area. This area, which has a population of juries to the lumbar region are shown in light gray, the thoracic region is shown in black, and injuries to the cervical region are 1,200,000 (accounting for less than a quarter of the Scottish pop- shown in dark gray. ulation) has been ranked as the United Kingdom’s most violent area,19 with a homicide rate between 2009 and 2013 of 1.5 per 100,000 people,14 compared with 1.0 across the United Kingdom as occurred during initial admission, and none are believed to be a a whole.20 However, unlike in the United States, where firearms direct consequence of SCI. The cause of death was available for six were responsible for *70% of homicides in 2010,21 firearms were of the nine patients. Two patients died from an overdose, the other only associated with 4.4% of homicides in Scotland between 2004 four patients died from pneumonia, bowel obstruction leading to and 2013.14 Instead, Glasgow has been notorious for knife crime, abdominal sepsis, acute pancreatitis, and sudden cardiac death, with 48.1% of homicides in 2010 committed using a knife, down respectively from 58% in 2008.7 This may be the reason for the large proportion Prior to their injury, 2 (5.7%) of the 35 patients were known to be of SCISW observed in this area. smokers, 11 (31.4%) had a drug addiction, 4 (11.4%) were alcohol Annual incidences of homicide, nonsexual crimes of violence, dependent, and 3 (8.6%) had hepatitis C. Of the 26 patients alive on and crimes of possession of both a bladed and offensive weapon all November 1, 2015, 14 (53.8%) were smokers, 11 (42.3%) had a decreased in the last 5 years of the study compared with the pre- significant history of depression, 9 (34.6%) had a drug addiction, 7 vious 5 years, with smaller reductions in both homicide and violent 12,14

(26.9%) were alcohol dependent, and 6 (23.1%) had hepatitis C. crime also observed in the penultimate 5 years of the study. The Despite national outreach clinics and a liaison nursing service, 14 reduction in homicide, assaults, and stabbings are likely linked to patients (53.9%) had been lost to follow-up, 5 (19.2%) had attended knife amnesties (1993 and 2006) and increased penalties for those all follow-up appointments since discharge, 6 (23.1%) had not at- caught carrying a knife, which were implemented in 2007.22 Si- tended the hospital for any appointments for >6 years, and 2 patients milar reductions have been subsequently reported elsewhere in the were in prison (7.7%). In 2014, these patients only attended 40 of 127 United Kingdom.23 (31.5%) scheduled hospital appointments (range: 15–100%). Gender and age at injury Discussion The population of Scotland in 2011 was 48.5% male and 51.5% This population-based study shows that SCISW has a low inci- female.11 The proportion of males sustaining an SCISW (97.1%), is dence, occurs primarily in young males, leads to greater sponta- disproportionate and is additionally far greater than the proportion of neous functional recovery, and has a higher morbidity and males in the general Scottish TSCI population (75.2% over the same mortality rate than that of the general SCI population. period),5 and is a consistent feature of all SCISW studies.17,24–27 The average age at injury for SCISW (30.0 years), was 17.2 Incidence years lower than that of the general TSCI population in Scotland, There were 35 cases of SCISW in Scotland between 1994 and who had an average age at injury of 47.2 years over the same 2013, representing *2% of all TSCIs in Scotland over this period.5 period.5 Young males have an increased likelihood of being

Table 2. American Spinal Injuries Association Impairment Scale (AIS) Scores on Admission and Discharge

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Discharge AIS A AIS B AIS C AIS D Admission Number % Number % Number % Number % Total

AIS A 5 62$5 2 25 - - 1 12$58 AIS B - - 1 14$3228$6457$17 AIS C - - - - 2 16$71083$112 AIS D ------7 100 7

A, no motor function or sensation; B, no motor function with sensation; C, severely compromised motor function with sensation; D, slightly compromised motor function with sensation. 1420 McCAUGHEY ET AL.

involved in episodes of violence and the age is mirrored in responsible for the early deaths of these patients with SCISW.34 fatal stabbings,28 nonfatal stabbings,29 general assault,30 and Tetrault and Courtois35 reported that pre-accident, 32% to 35% of SCISW.17,24–27 patients with a TSCI had been using illegal drugs, and Young and coworkers36 reported that 21% of patients with a TSCI were alcohol Nature of injury dependant. It was found that in Scotland, pre-stabbing, 31.4% of the SCISW population had been using illegal drugs, and 11.4% were The site of injury varies in general assault,29 fatal stabbings,28 alcohol dependant, increasing to 34.6% and 26.9% post-stabbing, and SCISW. In this study, the majority of SCISWs (60%) occurred respectively. in the thoracic region of the spinal cord (from wounds in the back) a In this group of SCISW patients, 42.3% had moderate to severe ﬁnding that has also been reported by Lipschitz27 (74% thoracic, depression, compared with the 25% found by Williams and co- 18% cervical) and Peacock and coworkers26 (64% thoracic: 30% workers37 in patients with TSCI. The reduced life expectancy, high cervical: 6% lumbar). The pattern of injury and low incidence of level of comorbidities, and poor follow-up attendance after SCISW lumbar injuries relates to the target areas in stabbing attacks with suggests that long-term outcome studies with this population may both the cervical and thoracic regions (front and back) within the be challenging to achieve. natural reach of the attacker.31 The spinal cord is vulnerable in the posterior triangle of the neck with the major vessels, trachea, and esophagus more accessible via the anterior triangle. There were no Relevance and limitations SCISWs between C6 and T3, and it is probable that this area is less Human models for research in SCI are challenging, and a accessible and that anterior penetrative injuries in this area lead to partial or full transection of the spinal cord with a minimum high levels of mortality because of vascular injury or injury to the shear or compression element offers advantages. There has been trachea.32 recent focus on the use of a combinational therapy involving cellular and structural implants plus rehabilitation to induce Extent and outcome of paralysis neural repair following a transection, such as that caused by a The proportion of motor complete injuries (AIS A or B) caused stab wound.3,4 by SCISW in Scotland between 1994 and 2013 (42.9%) agrees with The SCISW population represents a small proportion of those rates reported in the United States (37%)24 and Iran (43%),25 and is with TSCIs. They are generally of a young age, with a reduced life approximately equal to the rate in the general Scottish TSCI pop- expectancy and lifestyle options that may interfere with long-term ulation over the same period (39.7%).5 The proportion of patients compliance in rehabilitation, follow-up, and research review. The with an AIS A injury (23.5%) mirrors the ﬁndings of Peacock and patients also demonstrate a higher level of spontaneous functional coworkers26 who found that in South Africa 21% of patients with an recovery post-injury compared with the general TSCI population.

SCISW had a motor and sensory complete injury. The conversion These findings suggest that this patient group will present particular rate of motor complete to motor incomplete injuries over time challenges for experimental research. reported here (46.6%) agrees with a study in Iran, where 40% of A limitation of this study is the small sample size, caused by the patients who were motor complete on admission had improved infrequent nature of SCISW. Long-term multi-center studies may function at discharge.25 enable a more detailed analysis of the demographics and functional That 70.4% of patients had an improved AIS score on discharge recovery of patients with an SCISW. A further limitation is that agrees with Velmahos and coworkers,17 who found that 61% of MRI/CT scans were not available for every participant. Although patients in South Africa made significant recovery, characterized as imaging has historically played only a small role in interpreting the ability to walk unaided or with crutches. This is significantly neurological deficit and functional recovery after SCISW, this lack higher than the rate of recovery for the general TSCI population. of imaging meant that it was not possible to compare initial or Marino and coworkers33 found that of the 1626 patients with an AIS longitudinal changes in the spinal cord to neurological deficit or score of A to C on admission to Model Centres in the United States, functional recovery. an average of 39.9% of patients had an improved AIS score on discharge. This is also better than the recovery after gunshot Conclusion wounds (32%) and road traffic collisions (44%).17 The finding that This study demonstrates that SCISW in Scotland occur primarily three out of eight (37.5%) patients who had an AIS score of A on in young males. The incidence rate is low, and is currently de- admission were discharged with an improved AIS score is greater creasing in this region. Spontaneous functional recovery following than the rate reported in the general TSCI population, with Marino SCISW appears better than that for the general SCI population. and coworkers33 finding that of 981 patients admitted to Model There is a high mortality rate post-discharge, unrelated to the SCI, Centres in the United States with an AIS level of A on admission, with a poor life expectancy for these patients compared with their only 11% were discharged with an improved AIS score. The su-

Downloaded by University Of New South Wales from online.liebertpub.com at 06/21/17. For personal use only. peer groups. The patient group also has a range of comorbidities, perior functional recovery observed in patients with SCISW has including high levels of drug and alcohol dependence, and has poor important implications in long-term follow-up studies. rates of attendance at hospital follow-up. Although partial or full transection may provide a useful model for spinal cord repair, pa- Morbidity, mortality, and outcome tients with an SCI from a stab injury may be a particularly challenging group for experimental research studies. Strauss and coworkers34 predicted that a 25-year-old male patient with the most severe TSCI (C1–3, AIS A), who survived the Acknowledgments ﬁrst 3 years post-injury, would have a life expectancy of 25 years post-injury. However, for the nine patients who had died since The authors thank Dr. Alan McLean, Matthew Fraser, Ana Be- discharge in this study, the life expectancy was only 9.1 years. This wick, and the QENSIU staff for maintaining the database, and Dr. suggests that there are other medicosocio and economic factors Jim Guest for comments on the initial manuscript. SCI CAUSED BY STAB WOUNDS 1421

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