create the summary of the findings of "MATERIALS AND METHODS
This cross-sectional study was performed on TSCI patients referred to Brain
and Spinal Injury Research Center center, which began its services since 2005
for TSCI subjects. The center had been introduced to TSCI patients, and acute
care spine centers, as a specialized facility for rehabilitation since 2007. These
cases had been referred from all provinces over the country for outpatient
rehabilitation programs, monitoring of health indices and chronic complications of TSCI. Most of these cases had not undergone the early optimal
postacute rehabilitation program. Also, prognostication of neurological outcome was an important question for many of these cases. In this center,
patients had the opportunity to participate in multidisciplinary outpatient and
inpatient programs for TSCI. The outpatient multidisciplinary team studied
patients recruited from September 2011 to March 2015 among those referred
for rehabilitation programs from 32 provinces. Institutional Review Board of
Tehran University of Medical Sciences had approved the study.
All the participants had informed consent for participation in the study, and
a medical record for documenting their TSCI, and were assured that their
information would remain confidential. Demographic and background data as
well as neurological status were obtained from the patients by two separate
trained research assistants. Data recheck was performed to ensure prevention of
possible random errors. Each case was examined by two neurosurgeons for at
least 30 min to determine detailed neurological characteristics of injury
including level and American Spinal Injury Association Impairment Scale
(AIS). Meanwhile, classification of spinal injury mechanism based on either
sub-axial injury classification and severity score17 or thoracolumbar injury
classification and severity score18 was performed according to imaging and
medical records. Patients were registered in the database, regardless of their
willingness to join the outpatient or inpatient rehabilitation programs. The
patients’ data were recorded in the registration software (Microsoft Office
Access 2007, Redmond, WA, USA) on presentation. Missing parameters of the
patients’ records were completed in their consecutive visits. The geographical
distribution of the provincial residence of our patients was recorded, and the
referral frequencies from 31 different provinces were recorded. As a sampling
method, we employed the capture–recapture technique, to estimate point
prevalence of TSCI in Tehran province. The study cases formed the first
sample, and the second sample was obtained from the database of ‘Protection
Center of Spinal Cord Disabled of Iran’.
Variables included gender, age, marital status, etiology, education level,
occupational status, duration of injury, neurological level, spinal pathology,
severity of injury and complications. The neurological level and severity of TSCI
were categorized according to standard protocols recommended by Wyndaele19
and Burns.20 Complications were evaluated as follows: neuropathic pain by
Visual Analogous Scale, spasticity by Modified Ashworth Scale, depression
categories by Beck Depression Index and pressure ulcers (PUs) graded from I to
IV by the classification scheme of Ennis and Sarmiento. We used the Petersen
statistic for population size estimation in the capture–recapture method. Point
prevalence of TSCI in Tehran province was calculated according to the
following formula:
^t ¼ y
x ´ X(estimation of total number of TSCI in Tehran province)
P^ ¼ Estimation of total number of TSCI in Tehran province
Total poppulation in Tehran province
In these formulae, ^t represents estimated total number of TSCI in Tehran
province; x represents the number of overlapped cases between the two
samples; y and x represent the total number of cases in each sample, and finally
P^ represents the estimated prevalence of TSCI in Tehran province.
Clinically relevant associations between categorical variables were assessed by
χ2 or Fisher’s Exact test, if indicated. The data analyses were performed with
SPSS software version 22 (IBM, Chicago, IL, USA). A P-value o0.05 was
considered as significant.
RESULTS
Among a total of 1215 patients with TSCI referred to Brain and Spinal
Injury Research Center center, 78 cases were excluded because of
Figure 1 Geographic distribution of spinal cord injury patients in 31 Iranian provinces.
Epidemiological study of traumatic spinal cord injuries
N Derakhshanrad et al
902
Spinal Cord
either non-traumatic SCI (68 cases) or a lack of informed consent for
the study (10 cases). The study was performed on 1137 cases with
TSCI. Missing parameters of 12 cases were completed in their
consecutive visits. The geographical distribution of relative frequency
(number of referred cases/province population) of referred TSCIs has
been depicted in Figure 1.
By the capture–recapture sampling method, the point prevalence of
TSCI in Tehran province was estimated. The number of cases in our
series from Tehran province was 218 cases. The second sample for
capture–recapture analysis was obtained from ‘Protection Center of
Spinal Cord Disabled of Iran’ database for Tehran province
(1256 cases). The two centers overlapped in 95 cases. Peterson
statistics in our cases for ^t and P^ yielded the following:
^t ¼ 1256
95 ´ 218 ¼ 2882 (estimation of total number of TSCI in
Tehran province)
P^ ¼ 2882
12 183 391 ¼2.36 (in 10 000 population, 95% confidence
interval=2.02–2.71).
Dividing the number of our cases from Tehran province, by the
total estimation of the province (see Results), shows that we are
reporting about one-thirteenth of the TSCI population of Tehran
province (218/2882).
The demographic and background data have been shown in
Table 1. The mean age of our cases was 29.1 (s.d.=11.2) years,
50% of them being between ages 21.6 and 35.7 years, and 79.2% were
males (M/F=3.8/1). There was not a significant age difference
between the males and females (P=0.615). As seen in Figure 2,
histogram of frequency for age at the time of injury shows a unimodal
pattern. The mean duration of TSCI in our patients was 29.3 months
(s.d.=27.7). The mean education year was 9.54 years (range: 0–19
years), and ~ 7.0% were illiterate (Table 1). As shown in Table 1,
~ 56.8% of patients were married. Regarding the impact of TSCI on
marital status at the time of assessment, the percentage of divorce
and/or emotional separation was 6.5% in males and 9.3% in
females after TSCI. This figure was 0.67% for males and 1.4% for
females in the Iranian general population (410 years of age;
http://www.amar.org.ir/; 2011). As seen that the prevalence of divorce
in TSCI is much more than general population. The mean age of
divorced cases was significantly lower than that of non-divorced cases
(32.8 vs 34.8 years; P=0.037). The higher the level of injury, the more
was the divorce percentage (P=0.097). Multiple logistic regression
analysis revealed that females had 1.42 (95% confidence interval=
0.81–2.5) times more chance to be divorced or separated in comparison with males adjusted for age, education and occupation (P=0.11).
The most common cause of injury was MVA (61.8%) followed by falls
(24.5%), heavy drop (5.2%), violence (3.8%), sports (2.8%) and others
(1.9%). Different mechanisms for MVA included car (46.5%), bike
(11.3%) and pedestrian (4.0%) accidents. Surprisingly, walnut trees
were a common cause for falling and included 72% of all falls from
trees (9.0% of all falls). Different etiologies for sport injuries included
diving (2%), gymnastics (0.2%), wrestling (0.1%) and others (0.5%).
The occupational status of our patients has been tabulated in
Table 2. About 35.1% of cases did have an independent income source
to live (employed, retired and housekeeper), whereas 64.9% were
dependent either on their family support or social welfare and
insurance organizations for their care costs. The more severe and
rostral the TSCI, the higher was the prevalence of unemployment
(Po0.001). Accordingly, the highest prevalence of unemployment was
found in patients with complete tetraplegia (78.9%).
Overall, most participants had thoracic cord injuries (57.9%)
followed by cervical lesions (31.5%). Figure 3 shows distribution of
neurological levels in our patients. As shown, a bimodal distribution
with two peaks at C5 (11.8 %) and T12 (17.0 %) levels is observed.
The most common morphology for the spinal injury was facet
dislocation for cervical and translation rotation for thoracolumbar
injuries (Table 3). Spinal Cord Injury Without Radiological
Abnormality (SCIWORA) was found in 6.15% of all participants
(51.4% cervical and 48.6% thoracic). Childhood TSCIs (⩽15 years)
were 74 cases (6.7%). In children, the etiologies were MVA (68.5%),
child abuse (12.3%), fall (11.0%), sport (5.5%) and heavy drop
(2.7%). Also, SCIWORA was the most common mechanism for all
childhood TSCI (46.4%). Childhood SCIWORA was mostly due to
Table 1 Demographic and background data of the studied cases
Patient characteristics Frequency (%)
Age at the time of injury (in years)
Mean ±s.d. (min–max) 29.1±11.2 (0.8–70.5)
Age groups (in years)
0–15 76 (6.7)
16–30 646 (56.8)
31–45 316 (27.8)
46–60 86 (7.6)
61–75 13 (1.1)
Sex
Male 901 (79.2)
Female 236 (20.8)
Education
Illiterate 80 (7.0)
Elementary 225 (19.8)
High school 326 (28.7)
GED 285 (25.1)
University degree 221 (19.4)
Adult marital status
Single 397 (34.9)
Married 646 (56.8)
Divorced/emotional separation 79 (7.0)
Widowed 15 (1.3)
Level of Injury
Cervical 358 (31.5)
Thoracic 658 (57.9)
Lumbar 121 (10.6)
AIS
A 608 (53.5)
B 213 (18.7)
C 200 (17.6)
D 109 (9.6)
E 7 (0.6)
Etiology
MVA 703 (61.8)
Falling 279 (24.5)
Heavy drop 59 (5.2)
Violence 43 (3.8)
Sport 32 (2.8)
others 21 (1.9)
Abbreviations: AIS, ASIA Impairment Scale; GED, General Education Development diploma;
MVA, Motor Vehicle Accidents.
Epidemiological study of traumatic spinal cord injuries
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MVA (73.2%), followed by falling (16.9%). Regarding the severity of
TSCI in children, ~ 56.7% were AIS A. All child abuses had a
penetrative etiology in our cases—five cases due to bullet and four
cases due to stab wound.
According to Wyndaele categorization (Table 4), as expected, most
participants (61.7%) belonged to the third group (that is, injury level
T1-S5 with AIS A, B or C). In the same way, according to Burns
classification (Table 5), the most common category in our participants
was complete paraplegia (43.6%).
Falling and sports as the etiology for TSCI were much more
common in men compared with women (28.0% vs 13.6% and 3.5%
vs 0.4%, respectively; Po0.001). There was a significant association
between age and etiology (Po0.001). Falling was more common
(48.4 vs 11.0%) in older participants (⩾46 years) in comparison with
children (⩽15 years). With increasing years of education, sport-related
injuries became more common, whereas violence and heavy drop
became less common (P=0.022). In illiterate subjects, there was no
case of sport-related injuries, whereas 5.5% of TSCI in patients with
university education was athletics. In contrast to all other causes,
incomplete tetraplegia was the most common category in sport-related
injuries (75.0%), and thoracic lesions were very rare in these patients
(6.3%, Po0.001).
Frequencies of various complications after TSCI in our patients
have been tabulated in Table 6. The most common complications after
TSCI were PUs (37.5%, grade III or IV), followed by autonomic
dysreflexia (37%) for lesions above T6. Smoking was observed in
16.0% of all subjects; the mean (pack/year) for smokers was 5.03
(s.d.=5.59). Illicit drug abuse following TSCI was observed in 8.8%
(mostly opium 8.7%, and stimulants 0.1%), whereas alcohol abuse
was found in 3.2% of cases."