Epidemiological and hematological profile of traumatic spinal cord injury: a retrospective study

doi:10.21203/rs.3.rs-1861154/v1

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Epidemiological and hematological profile of traumatic spinal cord injury: a retrospective study

https://doi.org/10.21203/rs.3.rs-1861154/v1

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Study design: A retrospective hospital-based study.

Objective: To describe the epidemiological features and identify hematological indicators with prognostic value for function of traumatic spinal cord injury (TSCI) in Beijing, China.

Setting: Xuanwu Hospital of Capital Medical University, Beijing.

Methods: Routine blood and clinical data of TSCI patients who admitted to Xuanwu Hospital of Capital Medical University from 2015 to 2021 were collected for detailed investigation.

Results: In all, 129 cases were identified. The most commonly affected age group was 46-60 years, and male-to-female ratio was 2.5:1. The leading cause was low fall (50.4%), followed by transport (25.6%). The most common injury site was the cervical spinal cord, especially C5, accounting for 86.0%. The proportion of TSCI patients receiving rehabilitation treatment after acute management was 27.2%. In addition, hemoglobin (Hb) concentrations in TSCI patients with increased Barthel index (BI) scores were significantly higher than those without increased BI scores (P＜0.05).

Conclusion: Prevention strategies for TSCI should mainly target 46-60 age group, males and low fall. The results of this study will serve as a basis for further studies on TSCI, at least in Beijing. The preventive programs should be designed according to the injury characteristics. Additionally, higher Hb concentration in peripheral blood is closely related to the improvement of activities of daily living (ADL) in TSCI patients, but further detailed research is urgently needed.

Traumatic spinal cord injury (TSCI) is catastrophic, which can lead to serious disability or even

death, and bring care and economic burden to families and society^[1]. Until now, there has been no breakthrough in the treatment of TSCI; therefore, prevention efforts are important. Gaining insight into the epidemiologic characteristics of TSCI is essential to help direct safety precautions and health care planning^[2]. At present, many developed countries have taken the lead in carrying out epidemiological investigations, and some of them have established the TSCI registration system regionally or nationally. However, there are hardly any proper epidemiological studies from developing countries^[3]. Given that epidemiological studies can provide a baseline for monitoring the effectiveness of interventions and help to prioritize resource allocation. Thus, they should be especially helpful for the resource-limited developing countries. Furthermore, the epidemiology of TSCI can vary drastically depending on geographical regions, which is linked to social, environmental, cultural and biological issues^{[3, 4]}. It is, therefore, imperative to implement epidemiological research on TSCI, especially in our country, a developing country with a large population, in order to formulate corresponding intervention strategies according to epidemiological characteristics.

Additionally, Current prognostication of patients after TSCI mostly relies on the neurological assessment of residual function attributed to lesion characteristics^[5]. However, it is often impractical to perform these tests soon after patient admission, which is too time-consuming and unreliable in emergency situations, especially if the patient is unresponsive or compromised. Therefore, it is urgent to select biomarkers that can be easily extractable from clinical data and routinely used across different healthcare institutions, which can indicate the neurologic outcome and prognosis of TSCI, and routine blood samples seem to meet this requirement. Due to blood samples are easily collected when patient admission and often also measured frequently during the first week after injury, at least for critically ill patients^[5]. Any changes of them may be practical and convenient for predicting SCI.

Beijing is the capital of China and also the economic, cultural and political center. Xuanwu Hospital of Capital Medical University is located in the core of the city. It is an internationally renowned tertiary class A general hospital characterized by neuroscience, and one of the founding bases and cradles of neuroscience in China. Its diagnosis and treatment of neurological related diseases ranks the leading position in China. Therefore, relevant studies of TSCI based on this hospital, such as epidemiology and hematology, is of great significance to implement corresponding preventive interventions and determining prognosis. This paper presents retrospective data on TSCI patients who were treated in Xuanwu Hospital of Capital Medical University from 1 January 2015 to 31 December 2021, in order to update the TSCI database and make efforts for the effective management of TSCI.

The medical records of all persons with TSCI admitted to Xuanwu Hospital of Capital Medical University from January 2015 to December 2021 were reviewed in 2022. Information was collected by the authors from 129 case sheets. The inclusion criteria for the study were: following the definition of TSCI: “A case of TSCI is defined as the impairment of the spinal cord or cauda equina function resulting from the application of an external force of any magnitude” ^[6]. The exclusion criteria were as follows: [1]SCI with non-traumatic causes; [2]incomplete medical records or medical records with uncertain diagnoses.

In this investigation, the detailed epidemiological information of patients with TSCI included age, gender, marital status, etiology, time of the injury, level of the injury, treatment, time to the hospital, activities of daily living (ADL) [evaluated by the Barthel index (BI) scale]. For the blood sample data, patients who had been admitted over 6 months post-injury were excluded, and the remaining 117 patients had their initial blood sample taken after admission for the further analysis. The hematological measures included white blood count (WBC) count, neutrophil count, neutrophil percentage, lymphocyte count, lymphocyte percentage, red blood cell (RBC) count, hemoglobin (Hb), platelets, albumin, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), glucose.

The data was gathered in a Microsoft Excel spreadsheet by two researchers and then cross-checked two times to assure information accuracy. Statistical analysis was performed using IBM SPSS Version 21.0. Continuous variables were analyzed in the form of the means with standard deviations (Mean ± SD). Categorical variables were expressed as the numbers of cases and percentages. We focused on the relationship between injury level, ADL, and hematological indexes, respectively. These patients were divided into the cervical and non-cervical SCI groups according to the injury level and divided into the increased and non-increased BI scores groups based on the difference in BI scores (discharge-admission). Further, we analyzed the difference in hematological indexes between the groups by independent sample t-test, in order to identify the significant predictors of hematological abnormalities for TSCI humans.

Age and gender

The patients were divided into 6 age groups: 0–15, 16–30, 31–45, 46–60, 61–75, ≥ 76. The most commonly affected age group was 46–60 years, accounting for 49.6% (n = 64) of the patients with TSCI in the study. The mean age of TSCI was 56.26 ± 13.3 years. For males the mean age was 55.91 ± 13.6 years and for females 57.11 ± 12.7 years. The age range was 10–93 years. Among 129 patients, 92 were males and 37 were females, and the ratio of male/female was 2.5:1. Furthermore, the high-risk age group was similar for male and female. (Fig. 1 & Table 1).

Marital status

The marital status consisted of married, unmarried, and other (divorced and widowed). Of the 129 patients, 94.6% were married, 3.1% were unmarried, and 2.3% were divorced or widowed (Table 1).

Cause of injury

The major causes of TSCI were low fall, transport and fall from height, in order of frequency. They constituted 89.2% of all cases. In addition, in this study, low fall was the most common cause for people aged 31 years and older (50.4%), especially in those older than 45 years of age (45.7%). The breakdown is shown in Table 1 and Fig. 2.

Level of injury

In this study, the most frequent lesions were concentrated in the cervical region (86.0%). The first high incidence level was C5 followed by C4. (Fig. 3 & Table 1).

Time and treatment conditions

The time from trauma to admission was depicted in Table 1. During the interval, some patients may be in an ambulance, and the others may be in other hospitals, which did not have advanced medical equipments. The length of hospital stay ranged between 1 and 34 days (median = 10). One hundred and eighteen individuals (91.5%) received surgical treatment, and the remaining 11 patients received conservative treatment.

Destination after acute management

Of the 129 patients, seventeen persons (13.2%) were transferred to the rehabilitation department of the same hospital, eighteen individuals (14.0%) went to rehabilitation hospitals, and sixty-three people (48.8%) went home without further treatment or rehabilitation. The destinations of the remaining 31 patients (24.0%) were unclear.

Table 1

General characteristics of the study population (N = 129)
Variable	No. of patients	Percentage (%)
Gender
Male	92	71.3%
Female	37	28.7%
Age
0–15	1	0.8%
16–30	1	0.8%
31–45	19	14.7%
46–60	64	49.6%
61–75	36	27.9%
≥76	8	6.2%
Marital status
Married	122	94.6%
Unmarried	4	3.1%
Others	3	2.3%
Cause of injury
Transport	33	25.6%
Low fall	65	50.4%
Fall from height	17	13.2%
Sports	5	3.9%
Others (violence, struck by object, etc)	9	7.0%
Level of injury
Cervical	111	86.0%
Cervico-thoracic	1	0.8%
Thoracic	11	8.5%
Thoraco-lumbar	3	2.3%
Lumbar	3	2.3%
Time to the hospital
<1 Day	6	4.7%
1–2 Days	42	32.6%
3–7 Days	15	11.6%
8–30 Days	32	24.8%
1–3 Months	15	11.6%
>3 Months	19	14.7%
Treatment
Conservation	11	8.5%
Surgery	118	91.5%

Correlation between BI, injury level and hematological parameters

For hematological components, we found that among all the selected hematological indicators, only Hb was related to the change of BI score, and Hb concentrations in TSCI patients with increased BI scores were significantly higher than those with non-increased BI scores (increased BI scores group: 135.7 ± 18.7g/l, non-increased BI score group: 126.7 ± 19.3g/l, P<0.05),that was, the improvement of ADL was relevant with higher Hb levels. In addition, no correlation was found between the level of injury and the hematological indicators we chose.

Xuanwu Hospital of Capital Medical University is a well-known tertiary class A general hospital characterized by neuroscience in China. It ranked 37th in the 2020 national hospital comprehensive ranking released by Hospital Management Institute of Fudan University, and 7th in the 2020 hospital comprehensive strength ranking in North China; Its neurosurgery ranked 4th in the national comprehensive ranking of specialties in 2020, and 2nd in the reputation list of hospitals in North China in 2020. A large number of patients with SCI (including traumatic and non-traumatic SCI) are treated by the neurosurgery sub-specialty "neurospine group" and orthopedics department of the hospital every year, which is particularly important for updating epidemiological data and searching for meaningful and easily accessible markers to identify patient conditions.

In the current study, the average age was 56.3 (13.3) years old, and most injuries occurred in the 46 to 60-year old age group, accounting for 49.6%, which was in accordance with the data from Shandong province of China previously published in 2021^[3]. However, one report from another hospital of Beijing showed that the mean age of people with TSCI was 39.1 years^[7]. Although the two studies were conducted in Beijing, the average age was different. This difference could be explained by the fact that the number of children with TSCI in our study was significantly lower than that in another study, since they have a well-known paediatric SCI department that attracted some paediatric SCI patients from other provinces and cities. In addition, the male/female ratio was 2.5:1, which was similar to other studies, and their gender distribution ranged from 2.4:1 to 4.7:1^{[2, 8–15]}. It could be explained by the fact that like most countries, men tend to engage in hazardous work, while few women were involved in dangerous occupations.

94.6% of the patients were married in our study, which was a higher percentage as compared with those in the studies from India (63.2%)^[4]. This may be due to the high incidence of TSCI in our paper among middle-aged and elderly people, who were relatively conservative and would not divorce easily in China. The higher marriage rate may result in more family support, fewer psychosocial issues and easier adaptation at home. However, few studies have commented on the marital status.

We observed that low fall was the main cause of TSCI. This finding was in accordance with some previous studies, for example, Chen J et al. found that falls were the leading cause of TSCI, accounting for 49.2%^[2]. Sabre L also made similar findings in Estonia^[16]. However, transport has been the most common accident mechanism for TSCI traditionally, especially in most developed countries. On the contrary, in the present study, low fall accounted for the largest proportion, which could be explained from the following aspects: Beijing was crowded with traffic, so many people may choose walking within a reasonable distance not only convenience but also benefit to physical exercise. Furthermore, Beijing was an aging city, as we knew, aging body became less flexible, they were more prone to injury, for example, when the road was uneven or they changed direction of shift. Meanwhile, we found that transport was the second most common cause of TSCI, this was similar to several former reports^{[17, 18]}. Given that low fall and transport were the main causes of TSCI, preventive measures should continue to be a focus, including fall prevention and traffic safety in anywhere.

Our data revealed that 86.0% of patients with TSCI suffered in a cervical injury, which was higher than other reports^{[8, 19]}. C5 was the commonest neurological level in our research, which has been proved by other studies^{[4, 20]}.The results may be not only related to the etiology but also correlated with the aging population of China. One study indicated that, of all the cause of TSCI, low fall was easy to cause patients (especially in the older population) suffer from cervical injury^[14]. Another research from Finland also found similar phenomenon^[21]. At present, the aging in Beijing is growing at an unprecedented rate, it is conceivable that, without preventive measures, fall-induced injuries of the cervical spine will steeply increase, which requires our attention.

Although most people with TSCI could go to the hospital in time after injury, due to the lack of comprehensive medical technology in primary hospitals, they need to be transported to a high-level hospital, preferably one with neurospinal specialties. Our data showed that almost half of patients with TSCI could visit our hospital within the first week for receiving a high level of treatment, such as spinal surgery. This implies that efforts need to be made in the future to expedite the referral of patients with TSCI to professional hospitals for treatment.

The percentage of patients receiving rehabilitation treatment was 27.2%, which was higher than in another study from Beijing in 2002^[22].This may be due to the fact that China's economy has grown rapidly, as well as the proportion of health insurance reimbursement has gradually increased in recent years, especially in Beijing, the capital city of China. Rehabilitation treatment can help TSCI patients reintegrate into society for making them reach their full potential as active participants in our society. We should appeal to all patients with TSCI after management for receiving rehabilitation treatment with the help of all sectors of society.

BI was a clinically commonly used scale to assess patients' activities of daily life (ADL), which included 10 items: stool control, urine control, grooming, toileting, eating, bed-to-chair shifting, walking, dressing, climbing and descending stairs, bathing, and for TSCI people, improvement in any item would be significant^[23]. Our study found that Hb levels in TSCI patients with increased BI scores were significantly higher than those without increased BI scores. This indicated that higher Hb concentration in peripheral blood is closely related to the improvement of ADL in TSCI patients. To the best of our knowledge, this is the first study to report the relationship between ADL and hematology after TSCI. However, studies on the relationship between Hb and neurological function have been reported in many literatures. For example, recent studies have shown that elevated Hb concentrations are associated with a higher likelihood of neurological remission, in other words, there is a link between the probability of neurological remission and the Hb concentration after TSCI^[24]. Another study suggested that the changes in blood Hb concentration was significantly associated with the severity of SCI and was not accounted for by effects of age^[25]. However, these findings were far from enough, and more studies were needed to establish whether or not the relationship between SCI recovery and Hb was causal. Ultimately, these findings need to be validated in a larger independent cohort before any clear clinical recommendations can be made.

This study first summarized the epidemiological characteristics of TSCI in Beijing municipality of China. The results demonstrated that a significant proportion of injuries were related to low fall, which was highlighted in the middle-aged patient group. At the same time, our data also showed that cervical segments were the most common locations of TSCI, which may be relevant to low fall. Besides, our data pointed out transport was the second leading cause of TSCI. Hence, with these results in mind, more appropriate prevention programs should be implemented, targeting both falls and transports. Furthermore, this research also found that meaningful changes to ADL for TSCI people may be associated with higher Hb concentration. But this was only a preliminary result, and further research is needed to explore the predictive value of Hb concentration on ADL in patients with TSCI.

Several limitations of the present study needed be acknowledged. First, the samples were smaller than what the authors liked to see. The reason was that our data did not include patients who went to the outpatient clinic and died soon after arriving at this hospital. Second, our study included very few patients under the age of 30. Finally, this study only proved that higher Hb concentration in peripheral blood was closely related to the improvement of ADL in TSCI patients. However, a detailed correlation between them was not given, and the specific reference range of Hb value, which was beneficial to the improvement of ADL for patients with TSCI, also needed to be determined.

This study outlines the urgent need for a prospective study to clarify the epidemiological characteristics of TSCI and to identify meaningful hematological indicators closely related to the functional improvement of patients with TSCI, at least in Beijing. Therefore, in the future, we need to record in detail all the information of patients with TSCI who come to Xuanwu Hospital of Capital Medical University, including general data, hematological indicators, and even imaging examination data. At the same time, based on this hospital, a standardized database of TSCI patients was established, and the relevant data were constantly increased and updated. In addition, when this project gradually matures, a multi-center TSCI database can be further established in Beijing, and related data can be collected and analyzed, so as to get a clear idea about the characteristics of TSCI patients and find meaningful functional indicators, which is easily accessible, to predict the prognosis of patients with TSCI, in order to better serve TSCI patients in Beijing.

Ethics approval and consent to participate Formal ethical approval was not required, as all the study data was collected as part of routine medical practice, and the data was analyzed retrospectively in a pseudonymized fashion.

Consent for publication Not applicable.

Availability of data and materials The datasets used and/or analysed during the current study are available from FL or WQS on reasonable request

Competing interests All authors declare that they have no conflicts of interest.

Funding This work was funded by the National Natural Science Foundation of China (Grant number 82102659) to FL.

Authors’ contributions WQS and FL conceived and designed the research. CKW and SH participated in analysing the data. FL, SH, and WQS wrote and revised the article. All authors read, revised, and approved the final manuscript.

Acknowledgements Not applicable.

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Epidemiological and hematological profile of traumatic spinal cord injury: a retrospective study

Status:

Version 1

Abstract

Figures

Introduction

Materials And Methods

Results

Age and gender

Marital status

Cause of injury

Level of injury

Time and treatment conditions

Destination after acute management

Correlation between BI, injury level and hematological parameters

Discussion

Summary

Limitations

Future Directions

Declarations

References

Status:

Version 1