Keywords
epidemiology - spinal cord injuries
Introduction
Traumatic spinal cord injuries (SCIs) comprise spinal injuries in any part of the
spinal column that contains the spinal cord.[1] They may result in motor, sensory, sphincter and autonomic dysfunction below the
level of the lesion. The evaluation of neurological lesions is established by the
Frankel scale, and they are graded as complete lesion, incomplete lesion and normal
function.[2] The severity of the lesion is classified as complete or incomplete according to
the norms established by the American Spinal Cord Injury Association (ASIA), the complete
lesion corresponding to the total absence of motor and sensory functions below the
level of the lesion.[3]
The complications of SCIs include pulmonary complications, spasms, pain and urinary
tract infections (UTIs), among others. The most common cause of death in these patients
is pneumonia.[4]
[5] Several studies indicate that UTI is the most common complication, followed by pain
and spasms.[3] The prevalence of pain after a SCI varies considerably, and is seen in about one-half
to two-thirds of the patients.[5]
There is no official notification of SCI cases. However, it is estimated that the
annual incidence is 21 patients per million inhabitants.[6] In developing countries, the incidence is 25.5 cases per million every year.[7] Men are most affected,[7]
[8] corresponding to 82.8% of all cases. The average age is 32.4 years in developing
countries.[7] Since SCIs affect mostly young and economically active people, they end up interrupting
the individual's professional activity at the peak of the potential for economic gain,
generating a high cost to society.[7]
[9]
The two main causes of SCIs pointed out in international studies are automobile accidents
and falls (41.4% and 34.9% respectively), followed by violence and sports accidents.[7]
[10] National studies diverge from classic statistics, having gunshot wounds in second
place among the causes of SCIs, followed by falls and cold steel wounds.[9]
The adequate time for surgical intervention after a SCI remains controversial. Several
studies did not show a clear improvement in the neurological prognosis; however, there
is evidence of clinical safety in early surgical intervention.[11]
[12]
[13]
[14]
Brazil's currently available epidemiological data are relatively scarce and conflicting
with the literature.[9]
[15] Therefore, we have proposed to evaluate the epidemiological profile of patients
with SCIs submitted to a surgical procedure in the state of Espírito Santo.
Materials and Methods
A cross-sectional, descriptive study was performed based on the analysis of 70 records
of patients submitted to a surgical procedure due to SCIs in the state of Espírito
Santo from February 2011 to February 2015.
The selected patients were admitted to several private and public hospitals in the
state of Espírito Santo, and were referred by the central regulation of beds or by
spontaneous demand. The following variables were analyzed: age, gender, patient origin,
fracture level, neurological level, trauma mechanism and complications in the first
60 days after surgery.
Data were collected and distributed in projections using the Microsoft Excel (Microsoft
Corporation, Redmond, WA, US) software to evaluate the distribution of each analyzed
piece of data. The percentiles and absolute numbers of affection of each analyzed
event were considered.
Results
A total of 70 records were analyzed, and 79% of them corresponded to male patients
(n = 55). The mean age was 44 years, ranging from 14 to 75 years. Young people (20–24
years old) constituted 32% of the cases, followed by adults (31–59 years old; 28%);
young adults (25–30 years old; 20%); adolescents (10–19 years old; 12%); and the elderly
(over 60 years old; 8%) ([Table 1]).
Table 1
|
Age (years)
|
Classification (Brazilian Ministry of Health)
|
%
|
|
10–19*
|
Adolescent
|
12
|
|
20–24*
|
Young
|
32
|
|
25–30*
|
Young adult
|
20
|
|
31–59*
|
Adult
|
28
|
|
≥ 60*
|
Elder
|
08
|
Among the trauma mechanisms, automobile accidents represented 44% of the total, followed
by gunshot wounds (GSWs), which corresponded to 27% of the cases. Falls and dives
occupied the third and fourth places respectively ([Table 2]). Half of the patients in the sample presented lesions in the cervical region, and
26%, in the thoracolumbar region. The thoracic segment was the third most affected
site, and the lumbar segment was affected in only 4% of the cases ([Table 3]).
Table 2
|
Injury mechanism
|
Total of patients (70)
|
%
|
|
Gunshot wound
|
19
|
27
|
|
Automobile accident
|
31
|
44
|
|
Fall
|
15
|
22
|
|
Diving
|
5
|
7
|
Table 3
|
Injury level
|
Total of patients (70)
|
%
|
|
Cervical
|
35
|
50
|
|
Thoracic
|
14
|
20
|
|
Thoracolumbar*
|
19
|
26
|
|
Lumbar
|
2
|
4
|
According to the Frankel scale, 46% of the patients were classified as Frankel A.
Frankel C was the second most frequent classification, with 19 cases, followed by
Frankel E, B and D, with 9, 8 and 2 cases respectively ([Table 4]).
Table 4
|
Frankel
|
Total of patients (70)
|
%
|
|
A
|
32
|
46
|
|
B
|
8
|
11
|
|
C
|
19
|
27
|
|
D
|
2
|
3
|
|
E
|
9
|
13
|
During the first 60 days after surgery, the patients were checked for the presence
of complications. Out of the 70 patients, 36 had complications during this period.
The most frequent was UTI, with 18 cases, followed by the presence of pressure ulcer,
which occurred in 10 cases. A total of 4 patients developed pneumonia, and 1 had cardiac
complications. During the first 2 months after surgery, 3 patients had an association
of UTI and eschar ([Table 5]).
Table 5
|
Clinical complications until 60 days postsurgery
|
Total of patients (70)
|
|
UTI
|
18
|
|
Pressure ulcer
|
10
|
|
Pneumonia
|
4
|
|
Cardiac
|
1
|
|
UTI and eschar
|
3
|
As to the origin, 35 patients came from the metropolitan region of the state capital
of Vitória. The others came from the central region (18 patients), the southern region
(4 patients) and the northern region (7 patients) of the State of Espírito Santo.
A total of 6 patients came from other states ([Table 6]).
Table 6
|
Patient origin
|
Total of patients (70)
|
%
|
|
Metropolitan area of the capital city of Vitória
|
35
|
50
|
|
Central region of the State of Espírito Santo
|
18
|
25
|
|
Southern region of the State of Espírito Santo
|
4
|
5
|
|
Northern region of the State of Espírito Santo
|
7
|
11
|
|
Other states
|
6
|
9
|
Discussion
Spinal cord injury is a disease that presents a devastating potential not only for
patients and families, but also for the economy, since it involves a huge financial
health cost.[15]
An adequate analysis of the distribution and prevalence of SCIs is of paramount importance
for the planning and development of strategies to approach polytrauma and for the
implementation of measures to increase population awareness.
In the present study, there was a predominance of male patients (79%), which in line
with the data from the literature.[7]
[8]
[9]
[15]
[16] The mean age of the most affected patients in developing countries is 32.4 years
old, according to a study by Rahimi-Movaghar et al.[7] The average age found in the present study, was higher: 44 years old. However, considering
the classification of the Brazilian Ministry of Health, both averages place these
patients within the age group of adults (31–59 years old).
Fractures occurred mostly at the cervical level (50%), which similar to in the findings
of national and international studies.[8]
[9]
[17] About 4.5% of the patients in one study had more than one fracture at different
medullar levels.[18] Therefore, due to the high frequency of cervical fractures and their great impact
on the neurological status and the quality of life of the patients, protection of
the cervical spine in the initial care becomes essential.
Regarding the severity of the neurological deficit, the majority of patients (46%)
were classified as Frankel A, due to the absence of any motor or sensory function
below the lesion. This neurological picture was also observed in national studies.[15]
The two main causes of SCIs in the present study (automobile accidents and gunshot
wounds) are similar to those found in the epidemiological analysis of national data.[9] However, this result differs from the international figures, in which falls appear
as the second main cause of SCIs.[7]
[10] In developed countries, the proportion of trauma by automobile accident is stable,
with a tendency to decrease, which is justified in part by the better infrastructure
and greater safety provided by their automotive vehicles.[19]
Among the complications, UTI was the most frequent, present in 26% of the cases with
complications, a result similar to those reported in several international studies.[3] Pagliacci et al[20] suggest that 53.7% of SCI patients presented urologic complications in the first
6 months posttrauma.
The origin of the patients was evaluated according to the macro-regional division
of the state of Espírito Santo,[21] with the majority of patients submitted to surgery for traumatic SCI (75%) coming
from the metropolitan region of the capital city of Vitória and the central region
of the state of Espírito Santo ([Table 6]). The southern region of the state had less referrals, probably due to the proximity
to the city of Rio de Janeiro. A total of 9% of the patients came from another state
(southern region of the state of Bahia), since the closest reference center for these
patients is located in Vitória.
Conclusion
The patients submitted to a surgical procedure for SCI in the state of Espírito Santo
are predominantly men, with a mean age of 44 years, cervical spine injury due to automobile
accidents, classified as Frankel A, and originally from the metropolitan regionof
the city of Vitória. The main complication presented was UTI.
