Epidemiology of traumatic spinal cord injury (TSCI) differs with respect to country, region, and time period. The mean age of TSCI occurrence in the developing countries is 32.4 years, and injury most common occurs in 20–30 year olds [6]. In recent years, the average age of patients with TSCI has been increasing, particularly in the developed countries [7]. A statistical study conducted in Norway in 2012–2016 showed that the 60–74 year-old age group was the most vulnerable to TSCI [8], while another study showed that the average age at the occurrence of TSCI was 55.5 years in the United States [9]. The aging of a national population is a serious problem worldwide. With continuous economic development and increasing life expectancy in China’s population, the average age of TSCI is also increasing. The average age of TSCI patients in Beijing was 38.1 years old in 2002 and 40.2 years old in 2013–2019 [10]. Suzhou city has a large aging population that is increasing. In 2017, the average life expectancy of Suzhou residents reached 83.04 years. By the end of 2018, elderly persons over 60 years accounted for 26.0% of population in Suzhou, and even exceeded 30% in several districts and counties. The average age of TSCI patients evaluated in our present study was 50.7 years old, and 50–59 year-olds were the most vulnerable age group. In the Suzhou region, patients with TSCI showed an increasing trend in average age. Low fall was the second leading cause of TSCI among people aged 70 to 79 years, and were the leading cause of TSCI in patients over 80 years.
The following actions should be taken to address these trends. (1) First, we must increase our focus on these age groups, improve public education on TSCI, and advocate appropriate levels of calcium supplementation and exercise among the elderly. Research has shown that therapeutic exercise programs can reduce the fall rate and number of falls in the elderly [11]. Elderly patients having osteoporosis, or cervical and lumbar spine diseases, may need to avoid uneven or slippery roads during rain, snow, or other hazardous weather. (2) Government should improve medical insurance options, especially for the elderly, and rationally allocate medical resources. (3) Because many elderly persons fall at home, safety should be considered in implementing home design for the elderly [3]. (4) Improved planning should be implemented for urban-road construction, and barrier-free road and green-transportation systems should also be improved. (5) Renovation of old and new village elevators should be promoted and emphasized, especially for patients who fall during the climbing of stairs. (6) In hospitals, specific intraoperative or rehabilitation plans should be made available to elderly patients with spinal cord injury, and corresponding manuals should be developed.
In recent years, low fall was recorded as the leading cause of TSCI in developed countries such as Japan [3], Italy [12], and New Zealand [13]. Globally, automobile accidents remain the leading cause of TSCI, especially in the developing countries [14]. The results obtained in our present study show that traffic accident was the main cause of TSCI, which was consistent with another study showing that traffic accident was the main cause of TSCI in Beijing in 2013–2019 [10]. Presently, vehicle ownership in Suzhou ranks as the fourth in China. It is necessary to increase penalties for traffic violations, such as those for driving while under the influence and running red lights. Additionally, it is vital that all drivers and passengers wear seat belts. It is also necessary to strengthen community education on safety, improve safety assessment and training in driving school, and emphasize safety awareness and observation of traffic rules for the public. Our study shows that 35.88% of automobile accidents involved electric bikes. Running red lights by non-motorized vehicles is also an important cause of traffic accidents. Illegal modification and assembly of electric bikes should be prohibited and strictly penalized, and registration of electric bikes should be required. The maximum speed of electric bikes should be restricted. Operators of non-motorized vehicles should not operate their vehicles while under the influence, and should be subject to the anti-drunk-driving laws applied to operators of motorized vehicles. All cyclists and passengers should be required to wear helmets.
The results obtained in this study show that after traffic accident, the second leading cause of TSCI was fall from height, especially in the 10–49 year-old group. This was determined as the most important cause of TSCI because urban construction, and the construction industry, in Suzhou are developing rapidly. The young and middle-aged populations are the main workers at numerous construction sites. It is, therefore, necessary to improve safety education for construction site managers and workers, including distribution of safety manuals and enforcing the wearing of safety helmets and ropes. Medical insurance options for these persons should also be improved, and safe construction should always be prioritized. Our study also shows that the thoracolumbar segment was the site most likely fractured in fall from height, which agrees with findings by Wang et al [15]. The chest and waist regions, which are usually in the lowest positions during falls from heights, receive the greatest impact force during these falls, thereby causing injuries with increased severity [15]. In addition, this segment of the population often constitutes the main labor force for families and societies; therefore, TSCI in these persons poses a heavy burden on families and societies.
A systematic review published in 2014 showed that the proportion of men with spinal-cord injury is higher than that of women [16]. A survey by Fanuel et al. showed that the ratio of male:female with cervical spinal cord trauma on Mount Kilimanjaro in Tanzania, Africa, is 6.5:1 [17], while that in Japan has remained 3:1 over the past 30 years [3]. A study by Chen et al. in China showed that the ratio of male:female with TSCI is 3.4:1 in the Guangdong Province [19]. Liu et al. reported that the ratio of male:female with TSCI is 4.73:1 in Beijing, China [19]. Our results indicate that the ratio of male:female with TSCI in Suzhou city was 3.1:1, indicating that more men than women accounted for all the causes of injury examined in this study. The difference in the proportion of men to women was the greatest for fall from height and smallest for low fall. This is mainly because men engage in more social activities, and in heavy-duty and high-risk jobs, than do women [20]. Thus, the difference between the sexes was the greatest for fall from height. While women are more prone to osteoporosis than are men, the difference in proportion of males to females was lowest for low fall.
A survey by Mitchell et al. showed that the cervical segment was the one injured most in New Zealand, accounting for 54% of the patient cohort examined that study [13]. In Beijing, the segment injured most in 2013–2019 was also the cervical segment, accounting for 44.1% of the total patient population, and showing an increase of 4.9%, compared with the percentage obtained in 2002 [10]. These results were also consistent with our findings. Due to the degeneration of cervical spine, rigidity of the vertebral joints, and ossification of the posterior longitudinal ligament, small external forces can easily cause considerable damage [21]. Moreover, the cervical spine has a large range of motion relative to that of the thoracolumbar spine, and when there are no protective measures for this anatomical region, cervical spinal cord injury is likely to occur in traffic accident [15]. Our study also shows that cervical spine was the segment most vulnerable to fracture in traffic accidents. Therefore, it is also important to wear a helmet during cycling. We should also focus on developing strategies to protect the cervical spine and performance of rehabilitation exercises.
Hao et al. reported that the proportion of patients with complete spinal cord injury (ASIA Grade A ) was as high as 56.7% between April 1992 and August 2006 [4], while in this study, the proportion of patients with complete spinal cord injury was 13.7%; this discrepancy may be related to improvements in emergency first aid techniques used for individuals with spinal-cord injury, and advancements in early treatment by professional medical institutions, both of which reduce the disability caused by TSCI.
The data on complications of TSCI were often missing from the patient records reviewed in our present study. Evaluation of the complete statistical data available indicated that urinary tract infection was the most common complication, followed by lung infection and deep vein thrombosis of the lower limbs. Among patients with only one complication, the longest hospital stay was 105 days, observed in patients with bedsores. Patients with complications had longer hospital stays than those without complications. Patients with multiple complications had longer hospital stays that those with only one complication. Complications at late stages of spinal-cord injury are the main factors affecting the quality of life and life expectancy of patients with TSCI. Thus, treating complications and implementing early professional rehabilitation are critical in reducing the mortality and improving the survival of these patients [21]. In developed countries, patients with spinal cord injury can receive continuous treatment for complications and individualized early rehabilitation, which reduces mortality, and improves self-sufficiency and quality of life, in this patient population [22]. The concept of early rehabilitation has been increasingly emphasized in China. Early postoperative rehabilitation, such as bladder-function training, joint mobility training, and cardiopulmonary training, will reduce the incidence of urinary tract infection, deep vein thrombosis in the lower limbs, and lung infections, respectively.
The results obtained in our present study indicate that average hospital stay was 51.1 days, and length of hospital stays was related to numerous factors. The ratio of surgical:conservative treatment in patients with TSCI was 4.7:1. Patients who received surgical treatment had longer hospital stays than those who received conservative treatment. Increased severity of ASIA-graded injury was related to increased length of hospitalization. In addition, patients with injuries in the thoracolumbar segment showed the longest hospital stays. The severity of spinal cord injury mainly depends on the degree of spinal cord compression at the moment of fracture generation, followed by factors such as location of the fracture and secondary spinal stenosis. Thus, the degree of spinal cord injury cannot be inferred based solely on fracture imaging data [23]. Thoracolumbar fractures result in high rates of disability. Short-term observations indicate that surgical treatment can reduce the total disability rate; however, the results obtained in patients with severe spinal cord injuries (including ASIA Grade A and ASIA Grade B cases) did not reach statistical significance [23]. Therefore, the degree and location of injury, and choice of surgical treatment, are likely closely related to the duration of hospitalization, and to the economic burden placed on families and societies.
Current options for the treatment of spinal cord injury are limited, which, in turn, limits the cure rate and highlights the importance of prevention [20]. Epidemiological analysis of TSCI can increase the public’s awareness of TSCI-associated damage [24]. Previous epidemiologic studies of TSCI focused mainly on TSCI incidence and etiology, age and sex of the patients, and degree of injury to the spine [15]. In recent years, studies have identified high-risk groups, predicted TSCI-related trends, and focused on prevention of high-risk behaviors that can result in TSCI. Studies have also examined pre-hospital first aid and early postoperative rehabilitation in order to develop effective intervention measures for the prevention and treatment of TSCI, and for reasonable allocation of medical resources [22].