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Study Design: Observational cohort study., Objectives: To understand differentials in the force of mortality with increasing time since injury according to key spinal cord injury (SCI) characteristics., Setting: Specialized rehabilitation centers within Switzerland., Methods: Data from the Swiss Spinal Cord Injury (SwiSCI) cohort study were used to model mortality in relation to age, sex, and lesion characteristics. Hazard ratios (HRs) and adjusted survival curves were estimated using flexible parametric survival models of time since discharge from first rehabilitation to death or 30 September 2011, whichever came first., Results: 2 421 persons were included that incurred a new TSCI between 1990 and 2011, contributing a total time-at-risk of 19,604 person-years and 376 deaths. Controlling for attained age, sex, decade, and etiology, there was more than a four-fold higher risk of mortality for complete tetraplegia compared to incomplete paraplegia (HR = 4.27; 95% CI 2.72 to 6.69). Survival estimates differed according to SCI characteristics, with differentials steadily increasing with time since injury., Conclusion: This study provides evidence of disparities in mortality and survival outcomes according to SCI characteristics that increases with increasing time since injury. These results lend support to the hypothesis of a progressive and disproportionate accumulation of allostatic load according to SCI characteristics. Future research should investigate cause-specific mortality for insight into potentially modifiable secondary health conditions contributing to these disparities.

Aim: To assess the in-hospital mortality rate in adult patients suffering acute traumatic complete quadriplegia and determine the possible predictors of mortality in these patients., Material and Methods: A review of all complete quadriplegics treated from January 1996 through March 2004 in a regional spine injuries unit measuring in-hospital mortality and other factors that might contribute to increased mortality. Multivariate logistic regression analysis was performed to explore these possible predictors of mortality., Results: We identified 126 cases of cervical spinal cord injury treated at our hospital from January 1996 to March 2004 and identified only 62 cases of complete quadriplegia. Of 62 patients, 11 (17.7%) died in the hospital. Age, gender, injury mechanism and medical co-morbidity showed only trends towards a higher mortality. Age and pre-injury medical co-morbidity were found to be significant independent predicting factors for mortality. Gender, mechanism of injury, neurological level and injury severity score were not the predictors of mortality in these patients., Conclusion: Despite the limitations of the current evidence, advanced age and pre-existing medical co-morbidity are likely predictors of hospital mortality in the traumatic quadriplegia population.

Introduction: In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh., Methods and Analysis: A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete., Ethics and Dissemination: Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences., Trial Registration Numbers: ACTRN12615000630516, U1111-1171-1876., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To assess the survival in persons with traumatic spinal cord injury (SCI) receiving structured follow-up in South India., Design: Retrospective study., Setting: Rehabilitation center., Participants: Persons with traumatic SCI (N=490) residing within a 100-km radius of the institute who were managed and regularly followed up by the rehabilitation center between the years 1981 and 2011., Interventions: Not applicable., Main Outcome Measures: Survival rates and mortality risk factors. Measures were estimated using the product limit (Kaplan-Meier) method and the Cox model., Results: The survival rate after SCI was 86% after 5 years, 71% after 15 years, and 58% after 25 years. Survival of persons with complete high cervical injury is substantially low compared with other levels of SCI. Level of injury and extent of lesion (Frankel classification and/or American Spinal Injury Association Impairment Scale) play a significant role in predicting survival of this population., Conclusions: Survival rates of regularly followed-up persons with SCI from this study show promising results, though survival rates are lesser when compared with studies from developed countries. Better understanding of the predictors, causes of deaths, comprehensive rehabilitation, community integration, and regular follow-up could possibly assist in improving survival rates., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective chart review., Objectives: The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI)., Setting: Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany., Methods: All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination., Results: A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients., Conclusions: Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

Background: Case series suggest that atlanto-occipital dissociation (AOD) is a potentially survivable injury. Intuitively, a significant neurologic injury, a high degree of initial distraction, and more severe associated injuries would decrease the likelihood of survival. However, this has never been demonstrated for this injury pattern in a statistically meaningful way. The purpose of this study was to assess the relationship of atlanto-occipital distraction, presence of a complete neurologic injury, and Injury Severity Score (ISS) to the rate of survival in AOD., Methods: One thousand one hundred seventy-four patients from 2005 to 2009 comprehensive trauma database were retrospectively reviewed. Fourteen patients diagnosed with AOD were included in the study. Outcome measures assessed included survival, neurologic status, and ISS. The basion-dens interval (BDI) was measured on the computed tomography scan. Fisher's exact test and Wilcoxon's test were used to evaluate possible associations., Results: Six patients died with complete, high cervical, spinal cord injuries. Follow-up for survivors ranged from 6 months to 2 years. Mortality was associated with the presence of complete neurologic deficit (p = 0.0047), a high basion-dens interval (>16 mm, p = 0.015), and a high ISS (p = 0.0373)., Conclusions: AOD is a potentially survivable injury; however, there may be identifiable subsets of patients where the injury is so severe that treatment is unlikely to change the outcome. This is the first study to show that the ISS and the presence of a complete neurologic injury correlate with nonsurvivability of this devastating injury. A larger case series would help to generalize the results, given the small sample size.

As there are only few reliable data concerning mortality of SCI patients, this retrospective monocentric cohort study was carried out. Despite essential improvements in intensive medical care from the accident scene to clinic life, comprehensive rehabilitation, and implementation of a lifelong aftercare system, the life expectancy of SCI patients is still reduced. Especially patients with high tetraplegia die significantly earlier from pulmonary complications. The longer the onset of SCI is survived, the more patients die from age-related diseases. In old paraplegic patients, pressure sores are the only major SCI-related complication. Successful social reintegration and professional care are the most important factors for an expanded lifespan after occurrence of a SCI. Hence, the special impact of lifelong treatment of SCI patients ("comprehensive care") is confirmed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Study Design: Longitudinal study with mortality follow-up., Objective: Identify predictive factors for long-term mortality following tetraplegic spinal cord injury (TSCI)., Setting: The Tetrafigap survey is a multi-centre epidemiological survey on the long-term outcome of persons with TSCI, initiated in France in 1995 with the participation of 35 rehabilitation centres., Methods: The mortality follow-up involves 1241 persons with TSCI who were admitted to one of the study rehabilitation units at the initial phase and who completed the initial self-administered questionnaire. There were 226 observed deaths (18.2%) during an 11-year period. Logistic regression methods, with estimates of odds ratios (ORs), incorporating clinical, functional and social participation data were used to determine the factors related to mortality. This was followed by multivariate analysis to determine the best predictive factors for long-term mortality., Results: Risk of death increases significantly with age but not with the time elapsed since the accident. The risk of death is higher in men. Interestingly, clinical variables are not the best predictors of long-term mortality. Instead, the significant effect of poor social participation (being single, infrequent contact with friends) and functional limitations (full assistance required with dressing or eating) persists after adjustment for other variables., Conclusion: Once the medical situation becomes more stable, factors related to the long-term mortality of persons with TSCI are not exactly identical to those observed in the short acute-phase and during the first year after the accident. Social participation has a significant effect on mortality.

Guillain-Barré syndrome often follows an antecedent gastrointestinal or respiratory illness but, in rare cases, follows vaccination. This study was conducted to identify preceding events, demographic, clinical characteristics and prognostic factors of childhood Guillain-Barré syndrome after post-poliomyelitis eradication era in Egypt. This is a prospective study of all children with GBS (no = 50) admitted to pediatric Cairo University Hospital between January 2006 and June 2007 (70.42% of all acute flaccid paralysis patients during this period). Upper respiratory infection was the most common preceding event (24%) while only 4 patients (8%) reported antecedent oral polio vaccine. Motor deficit was frequent and severe (quadriparesis in 92% and paraparesis in 8%). Autonomic dysfunction was recorded in 32% of patients. Forty two percent of patients had poor outcome with 16% deaths. Presence of severe disability on admission and on nadir, cranial nerve affection or the need for mechanical ventilator were found to be significant predictors for poor outcome., (Copyright © 2010 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

Spinal cord injury (SCI) leading to neurological deficits produces long-term effects that persist over a lifetime. Survival analysis of patients with SCI, at individual and population level, is important for public health management and the assessment of treatment achievements. The current study evaluated survival following traumatic and non-traumatic SCI worldwide. A systematic review was conducted, and all included papers were assessed for quality using a purposely designed assessment form. Survival data were presented in Kaplan-Meier curves and compared using the log-rank test. Sixteen studies were included of which 11 concerned traumatic SCI, four non-traumatic SCI, and one both. Crude standard mortality rates (SMRs) revealed that overall mortality in SCI is up to three times higher than in the general population. Survival rates were statistically significantly lower in non-traumatic SCI than in traumatic SCI (log-rank p = 0.000). Age at injury, neurological level, extent of lesion, and year of injury have been described as predictors of survival. Causes of death stem from secondary complications, with failure of the respiratory system being the leading cause. This is the first systematic literature review on survival analysis following SCI worldwide. An increase in survival over time was found. However, the SMRs of individuals with SCI still exceed those of an age-matched non-disabled population, mainly due to secondary complications. Lower survival rates were observed in non-traumatic SCI compared with traumatic SCI.

Study Design: Retrospective clinical study., Objective: The aim of this study was to examine whether the Tokuhashi score correlates with the neurologic outcome in early surgical treatment in metastatic spinal cord compression (MSCC). A retrospective analysis of 35 consecutive incomplete tetraplegic and paraplegic patients with vertebral metastases (VM) and spinal cord compression (SCC) was performed., Summary of Background Data: MSCC is a challenging problem in VM and constitutes an oncologic emergency. The Tokuhashi score has been modified recently and seems to constitute the best method of prediction for real survival in patients with VM. Until now the influence of the neurologic status as a prognostic factor has been discussed controversially., Methods: Data of 35 patients with VM and incomplete tetraplegia or paraplegia, who underwent surgical treatment, were reviewed retrospectively from 2005 to 2006 at our hospital. All patients were classified among the American Spinal Injury Association (ASIA) Impairment Scale (AIS) before and after surgery and at the follow-up. Data were analyzed with SPSS 15.0 and correlation coefficients (Spearman rho) were computed., Results: Analysis showed that 19 patients (54.3%) with an average Tokuhashi score of 9 showed an improvement in the AIS, whereas 12 (34.3%) patients with an average score of 8 had no change and 4 (11.4%) patients with a score of 7 had deterioration. AIS changes showed a positive correlation with Tokuhashi score (r = 0.33; P = 0.048)., Conclusion: Our clinical observation suggests that patients with spinal metastases and a high Tokuhashi score benefit from surgical treatment with moderate improvement in sensomotoric function even in a heterogenic collective.

The objective of this study was to examine the factors which influence discharge disposition in patients with severe physical disability, due to the Locked-in Syndrome (LIS). This retrospective case series of patients with LIS, examines the extent of recovery, the processes involved in achieving discharge and the discharge destination following rehabilitation at the National Rehabilitation Hospital (NRH), Dublin. Nine LIS patients, 4 male and 5 female, have been referred to the NRH since 1995. Six of the 9 returned to live at home with their families. One patient with LIS, due to metastatic tumour, has since died. The factors which appear to determine the place and timing of discharge in LIS patients are the extent of neurological recovery, input from a specialist rehabilitation team, patient and family wishes, and the financial resources available for home care in the health service area concerned.

Introduction: The Locked-In syndrome (LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor); (ii) preserved awareness; (iii) aphonia or hypophonia; (iv) quadriplegia or quadriparesis; and (v) a primary mode of communication that uses vertical or lateral eye movement or blinking. Acute ventral pontine lesions are its most common cause. Following such brainstem lesions patients may remain comatose for some time and then gradually awaken, remaining paralyzed and voiceless, superficially resembling the vegetative state., Background: It has been shown that more than half of the time physicians fail to recognize early signs of awareness in LIS. Given appropriate medical care, life expectancy may be several decades but the chances of good motor recovery remain small. Eye-controlled computer technology now allows LIS patients to communicate and control their environment. Recent studies show that most LIS patients self-report meaningful quality of life and the demand for euthanasia is infrequent., Conclusion: Patients suffering from LIS should not be denied the right to die--and to die with dignity--but also they should not be denied the right to live--and to live with dignity and the best possible pain and symptom management and revalidation.

Objective: To review and reassess the findings of Krause and colleagues on the effect of economic and other risk factors on life expectancy after spinal cord injury, using an expanded and updated database., Design: Pooled person-year analysis., Setting: Model Spinal Cord Injury Systems hospitals., Participants: A total of 7331 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and received an evaluation between November 1995 and December 2005., Interventions: Not applicable., Main Outcome Measures: Mortality, determined by routine follow-up supplemented by information from the Social Security Death Index. Logistic regression models based on the predictor variables were developed to estimate the chance of dying in a given year., Results: As in the Krause study, life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. However, the positive effect of favorable economics was much less than previously reported, largely because having health insurance coverage through workers' compensation was no longer a powerful (or statistically significant) predictor of survival., Conclusions: The beneficial effect of favorable economics appears to be much less than previously reported. Further, the interpretation of the effects of modifiable factors (such as economics and social integration) is complicated by questions of cause and effect.

Background: When venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE), patients with acute traumatic spinal cord injury (SCI) have the highest incidence of VTE among all hospitalized groups, with PE the third most common cause of death. Although low-molecular-weight heparin (LMWH) outperforms low-dose unfractionated heparin (LDUH) in other patient populations, the evidence in SCI remains less robust., Objective: To determine whether the efficacy for LMWH shown in previous SCI surveillance studies (eg, routine Doppler ultrasound) would translate into real-world effectiveness in which only clinically evident VTE is investigated (ie, after symptoms or signs present)., Methods: A retrospective cohort study was conducted of 90 patients receiving LMWH dalteparin (5,000 U daily) or LDUH (5,000 U twice daily) for VTE prophylaxis after acute traumatic SCI. The incidence of radiographically confirmed VTE was primarily analyzed, and secondary outcomes included complications of bleeding and heparin-induced thrombocytopenia., Results: There was no statistically significant association (p = 0.7054) between the incidence of VTE (7.78% overall) and the type of prophylaxis received (LDUH 3/47 vs dalteparin 4/43). There was no significant differences in complications, location of VTE, and incidence of fatal PE. Paraplegia (as opposed to tetraplegia) was the only risk factor identified for VTE., Conclusions: There continues to be an absence of definitive evidence for dalteparin (or other LMWH) over LDUH as the choice for VTE prophylaxis in patients with SCI. Novel approaches to VTE prophylaxis are urgently required for this population, whose risk of fatal PE has not decreased over the last 25 years.

Trauma of the infant or juvenile spine is a very rare occurrence (less than 2%). Nevertheless, it is almost always dramatic. In 21 years 1630 patients with spinal cord injuries were treated. Of these, 21.7% (357 patients) had injuries in the area of the cervical spine. 23 patients (1.4%) were younger than 17.5 years, 8 of them were younger than 10 years. In 10 cases the cause was a traffic accident, in 7 cases it was a jump in too shallow water. In 4 times other leisure activities were the cause. A fall from a window sill and a falling tree were further reasons. Neck segment C0 to C3 was involved eight times, segment C3 to C7/Th1 was involved 15 times. The average age of the group with injuries in C0 to C3 was 5.6 years, in the group with injuries of segments C3 to C7/Th1 it was 15.8 years. In 11 cases the trauma caused complete tetraplegia, in six cases the paralysis was partial. In six further cases no neurological deficit occurred. 14 cases were treated surgically, six were treated conservatively. Four children younger than 10 years with complete tetraplegia died. In seven cases tetraplegia persisted; out of six patients with incomplete neurological deficit three improved and three patients recovered completely.

Objective: To determine the long-term outcome of patients with stable locked-in syndrome., Setting: The community., Design: Retrospective phone survey. This study was further follow-up on a previously reported cohort., Participants: Twenty-nine persons with locked-in syndrome were included in an initial cohort 11 years prior to the current study. Records or contact with family showed that 16 were deceased. Telephone interviews were made with 1 living patient and the caregivers of 11 others. Public records documented survival of 1 nonrespondent., Outcome Measures: Survival, codified responses regarding functional activities, social activities, and satisfaction with life., Results: Five-, 10-, and 20-year survival were 83%, 83%, and 40%, respectively. Ten subjects had not been hospitalized in the previous year. Eight lived with family. Little change in impairment occurred, but care was simplified. Improvements in communication related to technology, including computer and Internet access. Eleven left home at least monthly. Caregivers reported seven expressed satisfaction with life; five were occasionally depressed. No deaths could be attributed to euthanasia and no survivor had a "no code" status. One patient wished to die, seven had never considered euthanasia, six had considered and rejected it., Conclusions: Persons with initially stable locked-in syndrome can have prolonged survival, can live in the community if there is enough support, and have some measure of quality of life.

Seventy patients with ALS using tracheostomy positive pressure ventilation (TPPV) were evaluated for impaired communication. Severely impaired communication is divided into the totally locked-in state (TLS) and the minimal communication state (MCS). TLS occurred in 8 of 70 (11.4%). In the 33 patients on TPPV for more than 5 years, TLS developed in 6 (18.2%) and MCS in 11 (33.1%). Respiratory management for ALS allows long-term survival if mechanical ventilation is used.

Background: We surveyed survival and prognosis factors in tetraplegic spinal cord injured persons (TSCI) after their admission to a physical medicine and rehabilitation center., Methods: This multicenter study included 697 individuals, the entire cohort of patients admitted to three of the principal French centers caring for spinal cord injured persons from 1949 to 1997. The data set was drawn from the medical files and included data on the accident and its complications, social and demographic features, and the characteristics of the spinal injury. Survival data were obtained for all subjects from the official registries of their place of birth. Univariate (Kaplan-Meier) and multivariate (Cox regression) analysis was made to study links between these data and survival., Results: Univariate analysis indicated that the principal variables significantly related to survival were: level of the lesion, age at the time of the accident, the cause of the accident, and the presence of a permanent tracheotomy or a depressive syndrome requiring medical care. Multivariate analysis showed that the risk of dying was 82% lower for persons who did not have a permanent tracheotomy. The risk declined by 92%, 89% and 69% for TSCI aged 20 years or less, 20-39 years and 40-59 years respectively at the time of the accident compared with those aged more than 60 years. This risk was 37% lower for TSCI without depressive syndrome and 52% lower for persons injured at levels C6, C7, C8 compared with those injured at levels C2, C3, C4., Conclusion: Multivariate analysis showed that the principal prognosis factors for survival are the presence of a permanent tracheotomy, the age at the time of the accident, the presence of a depressive syndrome and the level of the lesion. No statistical improvement of survival was observed related with time (corresponding to the year of inclusion) but, over the study period, there was an increasing number of spinal cord injured person who survived with high lesions.

Study Design: Mortality review was undertaken of patients who suffered traumatic spinal cord injury (SCI) between 1955 and 1994 inclusive., Objectives: The study objective was to provide evidence of reasons for the observed reduction in long-term life expectancy for the SCI population., Setting: Patients were those who had most, if not all, of their inpatient and outpatient care at Royal North Shore Hospital, Spinal Injuries Unit, Sydney, New South Wales, Australia., Methods: Data on causes of death for 195 patients fitting the inclusion criteria were analysed by actuarial methods using ICD9CM classifications., Results: The incidence of death in the spinal cord injured, from septicaemia, pneumonia and influenza, diseases of the urinary uystem and suicide, are significantly higher than in the general population. The findings confirm variations in potentially treatable causes of death depending on neurological impairment, attained age and duration since injury. Unlike septicaemia and pneumonia, which have shown a significant reduction since 1980, the death rate for suicide alone has risen., Conclusion: This analysis identified complications which affect mortality and morbidity in patients suffering from the effects of SCI.

Patients with chronic tetraplegia are prone to develop unique clinical problems which require readmission to specialised centres where the health professionals are trained specifically to diagnose, and treat the diseases afflicting this group of patients. An appraisal of the readmission pattern of tetraplegic patients will provide the necessary data for planning allocation of beds for treatment of chronic tetraplegic patients. Hospital records of patients with tetraplegia readmitted to the Regional Spinal Injuries Centre, Southport, UK between 1 January 1994 and 31 December 1995 were analyzed to find out the number of tetraplegic patients who required readmission, reasons for readmission, duration of hospital stay, and mortality among patients readmitted. During the 2-year period, 155 tetraplegic patients were readmitted and 44 of them (28.4%) required more than one readmission (total readmission episodes: 221); these patients occupied 4.5 beds which is equivalent to 11.5% of the total bed capacity of the spinal unit. Among the reasons for the readmissions, evaluation and care of urinary tract disorders topped the list with 96 readmission episodes (43.43%) involving 70 patients; the median hospital stay was 3 days, and 18 patients (26%) required more than one readmission during this period. One hospital bed was occupied by the tetraplegic patients requiring treatment/evaluation of urinary tract disorders. Assessment and treatment of cardio-respiratory diseases was the second most common reason for readmission with 51 readmission episodes pertaining to 27 patients having a median hospital stay of 6 days; 13 patients (48%) were readmitted more than once within this 2-year period. Treatment of cardio-respiratory diseases in chronic tetraplegic patients required 1.2 hospital beds yearly. Only five tetraplegic patients were readmitted for treatment of pressure sore(s); however they had a prolonged hospital stay (median duration: 101 days). Social reasons accounted for 13 readmission episodes concerning nine patients who stayed in the hospital for varying periods (median: 6.5 days; mean: 35 days). Four tetraplegic patients readmitted with acute chest infection expired. An 81 year-old tetraplegic died of myocardial infarction. Urinary sepsis, renal insufficiency, respiratory failure and intra-cerebral haemorrhage accounted for the demise of a 41 year-old tetraplegic patient following surgical removal of a large, impacted stone at the pelviureteric junction. A tetraplegic patient who was admitted with haematuria subsequently underwent cystectomy for squamous cell carcinoma of the urinary bladder; he developed secondaries and expired 5 months later. As more patients with high cervical spinal cord injury survive the initial period of trauma, and as the life expectancy of tetraplegic patients increases, it is likely that greater numbers of tetraplegic patients will be requiring readmission to spinal injuries centre. Although it may be possible to prevent some of the complications of spinal cord injury and hence the need for a readmission, progress in medicine and rehabilitation technology will create additional demands for readmissions of chronic tetraplegic patients in order to implement the newer therapeutic strategies. Thus a change in the pattern of readmission of chronic tetraplegic patients is likely to be the future trend and this should be taken into account while making plans for providing the optimum care to chronic tetraplegic patients.

Respiratory failure plays a major role in morbidity and mortality after high cervical spine injury. Initially the patients are threatened by acute loss of motor function of the respiratory muscles and the development of neurogenic pulmonary edema. In the further course alterations in the mechanical properties of the respiratory system, changes in lung function, pulmonary infections and airway problems are the main reasons for life threatening respiratory failure. Early surgical stabilization, careful weaning from mechanical ventilation, meticulous search and treatment of infections, aggressive posturing and mobilization and support of impaired mechanical functions by physiotherapy, muscle training, noninvasive respiratory support and in some cases electrophrenic pacing increase survival and independency of quadriplegic patients.

This study analyzed the mortality in 1453 spinal cord injured patients admitted early after injury to a specialised Spinal Injuries Unit within a University teaching hospital over a 40-year period. The cohort comprised 55.3% patients with cervical lesions and 44.7% patients with thoracic/lumbar lesions. Those patients who died within 18 months of the spinal injury (132) were excluded from the final analysis. Standardised Mortality Ratios, survival rates and life expectancy ratios were calculated for specific ranges of current attained age and duration since injury with reference to level and degree of spinal cord injury. The projected mean life expectancy of spinal cord injured people compared to that of the whole population was then estimated to approach 70% of normal for individuals with complete tetraplegia and 84% of normal for complete paraplegia (Frankel grade A). Patients with an incomplete lesion and motor functional capabilities (Frankel grade D) are projected to have a life expectancy of at least 92% of the normal population.

A study of 3178 individuals injured in Britain between 1943 and 1990 and surviving the first year post-injury was conducted to evaluate the homogeneity of mortality risk ratios within groups based on varying degrees of neurological injury level and completeness of the injury. The study shows that it is less than optimal to combine individuals into neurological groupings of C1-C4 ABC, C5-C8 ABC and T1-S5 ABC since the risk ratios are not homogeneous within these groups. Similarly, combining individuals into neurological groupings of tetraplegia complete, tetraplegia incomplete, paraplegia complete and paraplegia incomplete may not be appropriate for the same reasons. The consequence of performing a survival analysis using either of the traditional sets of groups is to dilute the risk ratios for a subset of individuals within a particular group, thereby providing less discrimination between neurological groups. Cox proportional hazards regression was employed to determine a set of neurological groupings with homogeneous risk ratios within a group while providing better differentiation between groups.

The aims of this study were to examine long-term survival in a population-based sample of spinal cord injury (SCI) survivors in Great Britain, identify risk factors contributing to deaths and explore trends in cause of death over the decades following SCI. Current survival status was successfully identified in 92.3% of the study sample. Standardised mortality ratios (SMRs) were calculated and compared with a similar USA study. Relative risk ratio analysis showed that higher mortality risk was associated with higher neurologic level and completeness of spinal cord injury, older age at injury and earlier year of injury. For the entire fifty year time period, the leading cause of death was related to the respiratory system; urinary deaths ranked second followed by heart disease related deaths, but patterns in causes of death changed over time. In the early decades of injury, urinary deaths ranked first, heart disease deaths second and respiratory deaths third. In the last two decades of injury, respiratory deaths ranked first, heart related deaths were second, injury related deaths ranked third and urinary deaths fourth. This study also raises the question of examining alternative neurological groupings for future mortality risk analysis.

While our understanding of aging and mortality in spinal cord injury is evolving, precise estimates are still not available for expectations of life and health following a spinal cord injury. In order to derive these estimates, information about mortality and health must be combined into a single estimate. Health expectancy estimates have been widely used in the literature of the last decade to try to understand the relationship between population health and survival, both in the general population and in special populations. This study brought the benefit of this methodology to the question of long-term survival following spinal cord injury. Specifically, the study aimed to calculate life and health expectancy in a population of spinal cord injured individuals; and to estimate the effect of factors associated with survival and health. The study involved a retrospective cohort, all of whom sustained a spinal cord injury between the ages of 25 and 34 years, and between 1945 and 1990. The study predicted a median survival time of 38 years post-injury, with 43% surviving at least 40 years. These findings suggest an increase in life expectancy of about 5 years over previous research on the same cohort. Factors affecting survival were age at injury, level and completeness of lesion. Expectations of health found in the present study are similar to those found in studies of the general population. This study showed seven remaining years of poor health expected at injury, and five remaining years expected at 40 years post injury, presumably occurring at the end of life.

A retrospective review was carried out to determine the morbidity and mortality of abdominal aortic aneurysm repair in patients with previous spinal cord injury. A population-based study utilizing computer records on all patients in Department of Veterans' Affairs medical centers from 1987-1991 identified 31 patients with spinal cord injury who underwent subsequent infrarenal abdominal aortic aneurysm repair. Additional information was obtained from individual medical records. Some twenty patients (65%) were paraplegics and 11 (35%) were quadriplegics. Aneurysms were most commonly discovered incidentally during work-up of other conditions. All patients had no symptoms referable to their abdominal aortic aneurysm. In total, 29 patients (94%) underwent elective operations. The complication rate (57%) involved mostly pulmonary, cutaneous or urinary tract morbidity. The 30-day mortality rate was 3% for elective abdominal aortic aneurysm repair. Two patients were operated upon as emergencies for rupture, with one operative death. Long-term follow-up revealed a median survival duration of 5.4 years after aneurysm repair. In conclusion, abdominal aortic aneurysm repair in patients with previous spinal cord injury has a low mortality rate. Postoperative complications are often related to spinal cord injury and are potentially preventable; thus, such injury should not preclude surgical intervention for abdominal aortic aneurysm.

The aim of this study was to determine the benefits of patients admitted early to the specialist spinal injuries centre. The results show a significant reduction in the incidence of pressure sores in the early admitted patients and demonstrate the lowered incidence of both preventable and non preventable complications, as well as reduction of hospitalisation time.

Although spinal cord injury is devastating and can compromise the respiratory system, particularly when the cervical cord is injured, aggressive use of noninvasive respiratory muscle aids can reduce the otherwise commonly seen complications of pneumonia, bronchial mucous plugging, atelectasis, and respiratory failure. Accessory muscle function can also usually be improved and the muscles then recruited to help maintain adequate alveolar ventilation during the acute spinal cord injury recovery period. Noninvasive assisted ventilation can be successful for patients with compromised lung function during the acute rehabilitation period as well as on a long-term basis. Removal of an indwelling tracheostomy tube results in improved quality of life from many points of view, a decreased number of local tracheostomy complications, a decreased number of serious respiratory infections, an improved ability to communicate, and an increased ability to use the mouth for functions such as operating computers and wheelchairs.

We present a life-table analysis of a cohort of 29 locked-in syndrome (LIS) patients followed for a minimum of five years, and we report on the status of the chronic LIS patient. Twenty-nine LIS patients who remained locked-in for more than one year were identified. Inpatient charts were reviewed for demographic, medical, and functional data. Telephone followup was obtained to examine medical complications after discharge, survival, neurologic recovery, care issues, and permanent disposition. A life-table analysis was performed on survival data. Cerebrovascular disease was the most common cause of LIS. Survival ranged from 2.02 to 18.15 years. Twenty of the 26 patients available for five-year followup survived; hence, five-year survival was 81%. An alternative method of communication and emotional stress for the patient's caregiver was the key issue in patient care. Most patients were cared for in their own homes. Although minimal late neurologic recovery occurs in chronic LIS, survival may, nonetheless, be prolonged with adequate supportive care. Modern computerized technology offers LIS patients the ability to interact with their environment. This information may assist physicians in making ethical and long-term care decisions with the patient rather than for the patient with LIS.

The authors present a prospective analysis of the functional outcome in 99 patients with traumatic tetraplegia consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 29% death rate. Eighteen months after injury, 33% of the patients were dependent (not able to perform activities of daily living without the presence of a helping individual), 38% were independent. Two predictors of independence (age and initial Yale Scale Score) were found by a statistical analysis of the course of the disorder.

Seventy-four deaths during treatment at the orthopedic university hospital Homburg/Saar between 1965 and 1981 are reported, causes and basic diseases are analyzed. Deathrate was 0,22% at our hospital comparing 0,61% average standard deathrate at West-German orthopedic hospitals. Main risk groups are patients with para--or tetraplegia (28 cases), patients following total hip replacement (16 cases), bone tumors (18 cases - 4 of these cases are figured as well in the first group because of the clinical sign of paraplegia). All other patients (about 29 000) are represented with 16 deaths. Comparing literature deathrate of paraplegia and total hip replacement are detailed discussed.

In the 1940s major amputation in paraplegic and tetraplegic patients was performed mainly for the complications of pressure sores. With the increased understanding of paraplegia, life expectancy has greatly improved, with the consequence that the chief indication for amputation is now gangrene due to atherosclerosis. The special problems of the spinal-cord-paralysed amputee are reviewed.

This retrospective study of 5131 persons who sustained a spinal cord injury between 1973 and 1980 sought to determine the overall seven-year survival rate and the effect of several prognostic factors on survival. All study subjects had been treated at one of seven federally designated Model Regional Spinal Cord Injury Care Systems and each had survived at least 24 hours after injury. The cumulative seven-year survival was 86.7%. Advancing age at time of injury and being rendered a neurologically complete quadriplegic were significant prognostic factors. The cumulative seven-year survival among neurologically complete quadriplegics who were at least 50 years of age when injured, was only 22.7%. Spinal cord injury mortality rates ranged from 3.26 to 20.78 times higher than corresponding rates for nonspinal injured persons. Although mortality rates for spinal cord injury patients have declined dramatically since World War II, life expectancies for these patients are still substantially below normal.

The present study was conducted on 1510 persons between 1 December 1973 and 31 December 1980. Of these, 1478 (97.9 per cent) were traced by questionnaire. Of those traced, 1252 were male and 226 were female. There were 194 deaths of whom 160 were male and 34 female. The main causes of death are cardiovascular, renal, respiratory, suicide and neoplastic. Compared with the 1973 study, there has been a marked decrease in deaths due to renal disease and a marked increase in deaths due to suicide and liver disease and the abuse of alcohol. A study of the new deaths allowed one to note a relative mortality rate to be 186 per cent for partial paraplegics, 209 per cent for partial tetraplegics; 318 per cent for complete paraplegics and 767 per cent for complete quadriplegics. The approximate application of these rates to current (1975-77) mortality tables permitted the calculation of theoretically derived life expectation at various ages. These indicated an improved life expectation for all categories.

Mean survival of 110.5 months (9 yr. 2.5 months) for spinal cord-injured persons who died between 1963 to 1976 compared favorable with the figure of 52.8 months (4 yr, 4.8 months) calculated in 1955 by Dietrick and Russi [1]. If suicides were not considered, then mean longevity for the deceased patients would be 126 months (10 yr, 6 months). The leading causes of death were related to the cardiovascular system, respiratory system, suicide and the urinary tract.

We compared retrospectively consecutive series of patients with cervical dislocation treated at two Australian centres. In Perth, 82 patients were treated by closed reduction and postural nursing. In Adelaide, 85 patients had closed reduction and early surgical stabilisation by interbody fusion. There were 46 bilateral dislocations, 101 unilateral dislocations, and 20 anterior subluxations. On admission 30 patients had complete tetraplegia, 17 incomplete tetraplegia, and 120 had minimal or no neurological loss. Our results indicated that closed manipulation under general anaesthesia is a safe and effective means of reduction in the acute stage. There was a high mortality rate for acute surgery in patients with complete tetraplegia. Early surgical stabilisation by dowel fusion reduced bed and hospital stay in patients with no neurological loss, but seemed to impair neurological recovery in patients with a neurological deficit on admission. Conservative management after reduction of bilateral dislocation or anterior subluxation led to a higher incidence of instability in patients with minimal or no neurological loss; in such cases surgery to stabilise the injured segment is indicated.

In a group of 520 patients with injury to the spine and spinal cord 125 died within 10 years. The highest fatality rate (76.0 +/0 3.8) is recorded in the first year after the injury. In the following 10 years the fatality rate was uniform and ranged between 1.6 and 4.1%. This value increases with the patient's age, the severity of the spinal cord injury, and the degree of damage to the spinal ligamento-bursal apparatus. Among the total number of injured, 76% have a survival period of more than 10 years.

This paper reviews the medical records of 100 consecutive patients with tetraplegia owing to diving injury. Their high survival characteristics, plus youth on presentation, create the problem of an expanding population of chronically disabled patients.

The locked-in syndrome is a severe disability consisting of quadriplegia and anarthria with preserved consciousness. No large series of cases have been reported and very few cases of long-term survival have been described. We present a follow-up of 27 patients "locked-in" for more than one year. Twenty-four were still alive up to 12.5 years after onset, with a mean survival of 4.9 years. Significant recovery was noted in only a few patients. Seventeen patients lived at home at the time of study. Eight were never hospitalized after the initial event. Gastrostomy and tracheostomy tubes and indwelling catheters were eventually removed from many patients. Electronic devices were used by ten patients to facilitate communication. We conclude that rehabilitation and medical care must be planned carefully, given the length of survival shown in this group.

The records of 363 patients presenting to the Spinal Unit of Royal Perth Rehabilitation Hospital with traumatic tetraplegia are reviewed. Mortality rates in both short and long terms are tabulated and correlated with the level of the lesion, age of the patient at the time of injury and completeness of the lesion. The mortality rate for patients sustaining a complete lesion above C5 at the end of 1 year after injury was 20 per cent if under the age of 45 years and 75 per cent if over the age of 45 years. The mortality rate of patients sustaining a complete lesion below C5 at the end of 1 year after injury was 8 per cent if under the age of 45 years and 66 per cent if over the age of 45 years.

Traumatic spinal cord injuries frequently result in respiratory insufficiency. With intensive medical support, many of these patients live productive lives in spite of severe neurologic deficit. A ten-year review of ventilator-dependent quadriplegic patients at Craig Rehabilitation Hospital was undertaken to determine the number of patients who could be weaned from mechanical ventilation and their long-term survival rate. Ventilator dependency is defined as requiring continuous mechanical ventilatory support for 30 or more days. Of the 134 patients that were included in the study, 76 were weaned during initial hospitalization. Factors which adversely affected ability to wean include: 1) high level of neurologic injury, 2) age greater than 50 years, and 3) other associated injuries. Of the ventilator-dependent patients surveyed after leaving the hospital, survival rate at one year was 90 percent (37 of 41), 56 percent (14 of 25), at three years and 33 percent (7 of 21) at five years. We conclude that vigorous medical support and maximal efforts to wean these patients from mechanical ventilation should be undertaken to: minimize the financial and emotional burden of long term institutional care, reduce ventilator dependency, and improve overall quality of life.