Neurological recovery, mortality and length of stay after acute spinal cord injury associated with changes in management.

Based on epidemiological data from two populations of patients with acute spinal cord injury (ASCI), three outcome measures were compared to evaluate the effectiveness of management of ASCI patients in a regional, specialized acute spinal cord injury unit (ASCIU). The two populations consisted of a pre-ASCIU group of 351 patients managed from 1947-73 before the establishment of the ASCIU, and an ASCIU group of 201 patients managed in an ASCIU from 1974-81. The three outcome measures were mortality rate, length of stay (LOS) during first hospitalization, and neurological recovery. Linear regression and multiple regression analyses were used to determine whether differences in the outcome measures were attributable to differences in admission variables in addition to the influence of the ASCIU. The results showed that the patients treated in the ASCIU had a significant reduction in the mortality rate of almost 50% (P = 0.022), a significant reduction in the LOS of almost 50% (P < 0.001), and a significant increase in neurological recovery consisting of a doubling of the neurological recovery scale utilized (P < 0.001). Multiple regression analysis showed that the reduction in mortality rate was significantly influenced by differences in the admission variables between the two groups. However, the establishment of the ASCIU was associated with a significant reduction in LOS and a significant improvement in neurological recovery. Thus, these results support the view that management of ASCI patients in a regional, multidisciplinary unit is medically advantageous and can reduce the LOS.

Complications and costs of management of acute spinal cord injury.

This study examined the complications and costs of management of patients with acute spinal cord injury (ASCI) in a regional, multidisciplinary acute spinal cord injury unit (ASCIU). Data were available to compute length of stay (LOS) on 191 of the first 220 consecutive patients managed in this unit from 1974 to 1981. Specific formulae for assessing hospital and medical costs were developed based on a systems analysis approach. The statistical analysis included multiple regression analysis for determining the effect of the principal admission characteristics of ASCI patients, the main types of complications, and the methods of management. The effects of these variables on LOS, costs per day (CPD), and costs per stay (CPS) were determined. Age at admission, sex, and cause of accident had no effect on costs. As expected, increasing severity of injury to the spinal cord and to the vertebral column caused a significant increase in the mean LOS and CPS, and increasing total trauma load resulted in a significant increase in LOS and CPS. The LOS was shorter for patients admitted sooner after trauma. Respiratory, gastrointestinal, thromboembolic and genitourinary complications and decubitus ulceration were all associated with marked increases in LOS and CPS. The annual mean CPS decreased dramatically during the period of the study from 1974-81 due mainly to a decrease in LOS. Multiple regression analysis showed that severity and level of the spinal column and spinal cord injury, and the presence of complications had the most significant effects on duration and cost of care. The study also suggests that a specialized, multidisciplinary regional unit for ASCI patients is associated with a reduction in LOS and cost of care.

Changes in epidemiology of acute spinal cord injury from 1947 to 1981.

The aim of this study was to determine whether there have been epidemiologic changes in acute spinal cord injury. Two groups of patients injured in the same geographic area were compared: the first group of 351 patients was injured between 1947 and 1973; and the second group of 201 patients between 1974 and 1981. The results showed that there were indeed major epidemiologic changes in spinal cord injury between the two study periods. Most importantly, the more recently injured group were younger, arrived sooner, had less severe cord injuries, and higher frequencies of motor vehicle, and sports and recreational accidents, but fewer work-related injuries.

Comparison of surgical and conservative management in 208 patients with acute spinal cord injury.

The role of surgery in the management of acute spinal cord or cauda equina injuries remains controversial. The present study analyzed ten admission features and three outcome variables in 208 patients treated in an Acute Spinal Cord Injury Unit, 116 (56%) of whom underwent at least one spinal operation. The surgical and non-surgical groups showed no significant differences in the following seven clinical features: age, sex, distance travelled to the Unit, time interval between trauma and admission, type of accident, severity of injuries to the spinal cord, and severity of associated injuries. However, the two groups showed significant differences in level and type of vertebral column injury, and in the frequency of pre-existing spinal abnormalities. These differences were due to management policies which selected certain injuries for surgical or non-surgical treatment. One-third of the operative procedures were performed primarily for neural decompression, one-third primarily for reduction of bony structures and one-third for fusion. However, 95% of the operative patients had a fusion at the initial operation. Operative treatment was associated with a lower overall mortality rate (6.1%) than non-operative (15.2%), despite a higher frequency of thrombo-embolic complications in the surgical group. Overall, there was no difference between operated and non-operated patients in length of stay or neurological recovery. Surgical management of patients with acute spinal cord injury appears safe in terms of mortality rate and neurological recovery, but it has not been proven to improve the latter.