Abstract
Objective
Tetraplegic patients are often difficult to manage in intensive care units (ICU). The aim of our study was to calculate the incidence of patients in ICU with cervical spinal cord injury with special focus on tetraplegic patients on ventilation support and their future perspectives.
Materials and methods
This retrospective study included patients with cervical spinal cord injury in Upper Normandy, between 2002 and 2012. Data analyzed included age, sex, past medical history, date of onset of quadriplegia, level of neurological involvement, AIS grade, and ventilatory status.
Results
One hundred and eight patients were included (49.0 ± 21.1 years). The most common etiology was fall (50 patients [46.3%]). Incidence was calculated at 12.7 per one million inhabitants. Tracheotomy was performed in 40.7% of patients. Long-term mechanical ventilation was required for 6.5%. At the end of the study, 9 patients (9.6%) were permanently hospitalized, 61 patients (64.9%) had returned home but none of the four ventilated patients had been discharged.
Conclusion
The conclusion of this work is that the future of highly tetraplegic patients is compromised, especially for those who remain reliant on mechanical ventilation.
1
Introduction
Incidence of cervical spinal cord injury has been estimated at 23 cases per one million inhabitants a year . According to different studies, its prevalence ranges from 223 to approximately 700 cases per one million inhabitants . Among these patients, slightly more than half present with cervical spinal cord injury, which caused the tetraplegia . In France, overall incidence of spinal cord injury was estimated in 1978 at 12.7 cases per million inhabitants a year . More recently, it was found to consist in 19.4 cases per million inhabitants a year . Among these patients, 43.3% are tetraplegic. It would consequently seem that the incidence and prevalence of spinal cord injury have been steadily increasing and that the proportion of tetraplegic patients has grown correspondingly higher and higher.
Patients presenting with high spinal cord injury can also present with severe ventilatory disorders; in this population, the latter constitutes the second most frequent cause of mortality during the first year following the trauma (28% of deaths) , and the first cause of mortality subsequent to the first year (31% of deaths) . Respiratory failure is connected with damage to motor control of the diaphragm , of which the innervation by the phrenic nerve essentially comes from C4, with variable contributions from C3 and C5 . The proportion of tetraplegic patients relying on a ventilator is correspondingly higher and higher. In the United States alone, it is estimated to have risen from 1.5% in the 1970s to 4.6% during the 2005–2008 period , and it is associated with a 90% decrease in mortality as well as increasing life expectancy, even though the latter has remained lower than that of tetraplegics not relying on ventilation .
While this trend has been observed in virtually all developed countries, as of now there exists no data on the outcomes of ventilated tetraplegic patients. The goal of our study was to calculate incidence level from 2002 to 2012 of the adult population with spinal cord injury in the Haute-Normandie region (France). We were particularly interested in ventilated tetraplegic patients and their clinical outcomes; given their ventilatory handicap accompanying tetraplegia, were they able to leave hospital?
2
Material and Methods
2.1
Patients
This retrospective, descriptive study concerns patients over 18 years of age having suffered spinal cord injury in Haute Normandie (France) between 1 January 2002 and 31 December 2012.
The persons to be studied were identified through the medical information system of the Rouen CHU among the patients hospitalized in the neurosurgery and the surgical intensive care units whose medical records included as main or associated diagnosis the following PMSI (Programme de Médicalisation des Systèmes d’Information [CIM 10]) codings: tetraplegia (G82.5), flaccid tetraplegia (G82.3), spastic tetraplegia (G82.4). The above units are the only ones to treat acute tetraplegic patients. Non-traumatic (tumoral, vascular, inflammatory and degenerative) spinal cord injuries, traumatic thoracic or lumbar spinal injuries, traumatic spinal and brain injuries having occurred before 2002 and forms of tetraplegia with no relation to spinal cord injury were excluded from the analysis. An expert physician (AQ) made the selections from within the existing medical records.
2.2
Data collection
The hospitalization reports of the patients included in the study were consulted to carry out data collection. When the information contained in the reports was insufficient, the complete medical records were consulted.
The collected data included date of birth, sex, past medical history, tetraplegia onset date, level of neurological damage at the end of hospitalization in acute care (defined as the last non-injured metamere) and the severity of the lesion in terms of AIS grade (ASIA Impairment Scale) . The circumstances in which the spinal cord injury occurred were likewise noted.
Downstream hospital units were questioned in view of determining patient outcome. Dates of admission and discharge were given so as to calculate the length of hospital stays in each unit. Ventilatory status on discharge was also mentioned, as was performance of tracheotomy or decannulation during the stay. The dates of tracheotomy or decannulation were recorded when the relevant information was available.
2.3
Statistical analysis
Statistical analysis was carried out with StatView 5.0 (SAS Institute Inc. ® ) software. The calculated values were presented as mean ± standard deviation. Existence of differences between the sub-groups was analyzed by means of non-parametric Mann & Whitney tests. A difference was considered significant when the probability P of first-order error was lower than 0.05. Existence of correlations between the different parameters was analyzed by means of non-parametric Spearman tests. A correlation was considered as significant when the probability P of first-order error was lower than 0.05.
2
Material and Methods
2.1
Patients
This retrospective, descriptive study concerns patients over 18 years of age having suffered spinal cord injury in Haute Normandie (France) between 1 January 2002 and 31 December 2012.
The persons to be studied were identified through the medical information system of the Rouen CHU among the patients hospitalized in the neurosurgery and the surgical intensive care units whose medical records included as main or associated diagnosis the following PMSI (Programme de Médicalisation des Systèmes d’Information [CIM 10]) codings: tetraplegia (G82.5), flaccid tetraplegia (G82.3), spastic tetraplegia (G82.4). The above units are the only ones to treat acute tetraplegic patients. Non-traumatic (tumoral, vascular, inflammatory and degenerative) spinal cord injuries, traumatic thoracic or lumbar spinal injuries, traumatic spinal and brain injuries having occurred before 2002 and forms of tetraplegia with no relation to spinal cord injury were excluded from the analysis. An expert physician (AQ) made the selections from within the existing medical records.
2.2
Data collection
The hospitalization reports of the patients included in the study were consulted to carry out data collection. When the information contained in the reports was insufficient, the complete medical records were consulted.
The collected data included date of birth, sex, past medical history, tetraplegia onset date, level of neurological damage at the end of hospitalization in acute care (defined as the last non-injured metamere) and the severity of the lesion in terms of AIS grade (ASIA Impairment Scale) . The circumstances in which the spinal cord injury occurred were likewise noted.
Downstream hospital units were questioned in view of determining patient outcome. Dates of admission and discharge were given so as to calculate the length of hospital stays in each unit. Ventilatory status on discharge was also mentioned, as was performance of tracheotomy or decannulation during the stay. The dates of tracheotomy or decannulation were recorded when the relevant information was available.
2.3
Statistical analysis
Statistical analysis was carried out with StatView 5.0 (SAS Institute Inc. ® ) software. The calculated values were presented as mean ± standard deviation. Existence of differences between the sub-groups was analyzed by means of non-parametric Mann & Whitney tests. A difference was considered significant when the probability P of first-order error was lower than 0.05. Existence of correlations between the different parameters was analyzed by means of non-parametric Spearman tests. A correlation was considered as significant when the probability P of first-order error was lower than 0.05.
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