AIS Grade Research Articles

Outcome in patients undergoing surgery for spinal injury in an Ethiopian hospital.

The objective of this study was to investigate epidemiology and outcome after surgical treatment for spinal injuries in Ethiopia. Medical records of patients who underwent surgery for spine injuries at Myungsung Christian Medical Center in Addis Ababa, Ethiopia, between January 2008 and September 2012 were reviewed retrospectively. Assessment of outcome and complications was determined from patient consultations and phone interviews. A total of 146 patients were included (129 males, 17 females). Their mean age was 31.7 years (range 15-81 years). The leading cause of injury was motor vehicle accidents (54.1%), and this was followed by falls (26.7%). The most common injury sites were lumbar (41.1%) and cervical (34.2%) regions of the spine. In 21.2% of patients, no neurological deficit was present before surgery, 46.6% had incomplete spinal cord injury (American Spinal Injury Association [ASIA] Impairment Scale [AIS] Grade B-D), and 32.2% had complete spinal cord injury (AIS Grade A). Follow-up was hampered by suboptimal infrastructure, but information regarding outcome was successfully obtained for 110 patients (75.3%). At follow-up (mean 22.9 months; range 2-57 months), 25 patients (17.1%) were confirmed dead and 85 patients (58.2%) were alive; 49 patients (33.6%) underwent physical examination. At least 8 of the 47 patients (17.0%) with a complete injury and 29 of the 68 patients (42.6%) with an incomplete injury showed neurological improvement. The reported incidences of pressure wounds, recurrent urinary tract infections, pneumonia, and thromboembolic events were 22.5%, 13.5%, 5.6%, and 1.1%, respectively. Patients showed surprisingly good recovery considering the limited resources. Surgical treatment for spine injuries in Ethiopia is considered beneficial.

Shoulder kinetics and ultrasonography changes after performing a high-intensity task in spinal cord injury subjects and healthy controls.

This is a prospective and comparative study between two groups. The objective of this study was to compare the changes in shoulder joint forces and their moments, as well as any possible ultrasound changes, when subjects with spinal cord injury (SCI) and healthy controls (CG) undertake a high-intensity manual wheelchair propulsion test. This study was conducted in an inpatient SCI rehabilitation center. A group of 22 subjects with SCI at level T2 or below who use a manual wheelchair (MWU), categorized as AIS grade A or B, were compared with a CG of 12 healthy subjects. Subjects in each group performed a high-intensity wheelchair propulsion test. The variables analyzed were shoulder joint forces and the moments at the beginning and at the end of the test. Ultrasound variables before and after the propulsion test were also analyzed. Correlations were also drawn between the ultrasonography and demographic variables. In both groups, peak shoulder forces and moments increased after the test in almost all directions. No differences in the ultrasound parameters were found. A greater long-axis biceps tendon thickness (LBTT) was associated with more shoulder pain according to WUSPI or VAS (r=0.428, P<0.05 and r=0.452, P<0.05, respectively). Shoulder joint forces and moments increase after an intense propulsion task. In subjects with SCI, these increases center on forces with less chance of producing subacromial damage. No changes are produced in ultrasonography variables, whereas a poorer clinical and functional evaluation of the shoulder of the MWUs appears to be related to a thicker long-axis biceps tendon.

What are the perspectives for ventilated tetraplegics? A French retrospective study of 108 patients with cervical spinal cord injury

ObjectiveTetraplegic 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 methodsThis 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. ResultsOne hundred and eight patients were included (49.0±21.1years). 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. ConclusionThe conclusion of this work is that the future of highly tetraplegic patients is compromised, especially for those who remain reliant on mechanical ventilation.

Activity-Based Therapy for Recovery of Walking in Chronic Spinal Cord Injury: Results From a Secondary Analysis to Determine Responsiveness to Therapy

ObjectiveTo gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial. DesignSecondary analysis of results from a randomized controlled trial with delayed treatment design. SettingOutpatient program in a private, nonprofit rehabilitation hospital. ParticipantsVolunteer sample of adults (N=38; 27 men; 11 women; age, 22–63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI). InterventionsA total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. Main Outcome MeasuresWalking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). ResultsThis secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program. ConclusionsABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Two-Wheelers Users' Injury Analysis Based on Cars to Two-Wheelers Accidents Data

China In-Depth Accident Study (CIDAS) group collects accident data by on-scene investigate way in Changchun, Beijing, Weihai, Ningbo and Foshan. Based on the CIDAS data, this study analyzed the group characteristics and body injury distributions of the casualties in motorcycles, electric bicycles and bicycles. As a result, the mixed driving is the major environmental factor for cars to two-wheelers accidents, and most of such accidents happened in crossroads. Moreover, 16 to 65 years old two-wheelers injury users accounted for 62.0% of the total two-wheelers casualties.Within the two-wheelers injury users over 46 years old, users with AIS4 injuries occupied 22.4%. Besides, AIS4 bicycle injuries over 46 years old accounted for 47.6% of the total injury users over 46 years old. A similar injury parts distribution and AIS grade distribution in the same injury part were found among the casualties of motorcycles, electric bicycles and bicycles users.

Transplantation of autologous bone marrow mesenchymal stem cells in the treatment of complete and chronic cervical spinal cord injury

Neuronal injuries have been a challenging problem for treatment, especially in the case of complete and chronic cervical spinal cord injury (SCI). Recently, particular attention is paid to the potential of stem cell in treating SCI, but there are only few clinical studies and insufficient data. This study explored the efficacy of autologous bone marrow mesenchymal stem cells (BMMSCs) transplantation in the treatment of SCI. Forty patients with complete and chronic cervical SCI were selected and randomly assigned to one of the two experimental groups, treatment group and control group. The treatment group received BMMSCs transplantation to the area surrounding injury, while the control group was not treated with any cell transplantation. Both the transplant recipients and the control group were followed up to 6 months, postoperatively. Preoperative and postoperative neurological functions were evaluated with AIS grading, ASIA score, residual urine volume and neurophysiological examination. Results showed that in the treatment group 10 patients had a significant clinical improvement in terms of motor, light touch, pin prick sensory and residual urine volume, while nine patients showed changes in AIS grade. Neurophysiological examination was consistent with clinical observations. No sign of tumor was evident until 6 months postoperatively. In the control group, no improvement was observed in any of the neurological functions specified above. BMMSCs transplantation improves neurological function in patients with complete and chronic cervical SCI, providing valuable information on applications of BMMSCs for the treatment of SCI.

Emergency Closed Reduction of a C4/5 Fracture Dislocation with Complete Paraplegia Resulting in Profound Neurologic Recovery

Introduction. Cervical spinal cord injuries due to traumatic fractures are associated with persistent neurological deficits. Although clinical evidence is weak, early decompression, defined as <24–72 h, has been frequently proposed. Animal studies show better outcomes after early decompression within one hour or less, which can hardly ever be achieved in clinical practice. Case Presentation. A 37-year-old patient was hospitalized after being hit by a shying horse. After diagnosis of C4/5 fracture dislocation and complete paraplegia, she was intubated and sedated with deep relaxation. Emergency reduction was performed at approximately 120 minutes after trauma. Subsequently, a standard anterior decompression, discectomy, and fusion were carried out. She was then transferred to a specialized rehabilitation hospital. Her neurologic function improved from AIS grade A on admission to grade B postoperatively and grade D after four months of rehabilitation. One year after the accident, she was ambulatory without walking aids and restarted horse riding. Discussion and Conclusion. Rarely in clinical practice, decompression of the spine canal can be performed as early as in this case. This case highlights the potential benefit of utmost early reduction in cervical fracture dislocations with compression of the spinal cord.

Medical complication in adults with spina bifida

SettingCohort study. IntroductionSpina bifida (SB) is a congenital malformation affecting the central nervous system (CNS) and is one of the most prevalent CNS disorders in children. Hydrocephalus (HC) is present in 80% of newborns with SB. The aim of the present study was to analyze the medical complications and to relate the complications to age at examination, the level of injury, AIS grade and presence of HC in adults with SB. Materials and methodsSB patients were recruited from the Spinalis out-patient clinic at the Karolinska University Hospital at their annual follow-up. The patients underwent a thorough general and neurological examination and background data including medical complications were retrieved from the medical files. Results127 of 157 (82%) SB patients (114 with MMC and 13 SB occulta) with a mean age of 34 years were included. Half of the patients had a complete SCI and a lumbar level was most common. Nearly 60% of the patients had HC. 88 patients (69%) suffered from at least one medical complication. Urinary tract infection (UTI), scoliosis and pain were the most common complications found in 46%, 30% and 28% of the patients, respectively. Less common complications were epilepsy, pressure ulcers (PU) and spasticity. DiscussionSB gives a disability including motor, sensory dysfunctions and the patients suffer from a high frequency of medical complications like UTI, scoliosis, pain, and epilepsy. Data gives basis for adequate routines for medical examination at the follow-up.

Predictive Value of Bronchoscopy in Assessing the Severity of Inhalation Injury

Inhalation injury is associated with severe pulmonary complications as inhaled products of combustion cause lung inflammation and loss of natural defenses. A bronchoscopic grading for inhalation injury has been proposed but has not yet been validated in burn patients. In this study, the authors evaluated whether bronchoscopic grading of injury clinically correlated with indices of gas exchange over the first 72 hours or predicted differences in hospitalization outcomes. They conducted a single-center retrospective review of all mechanically ventilated adults with suspected inhalation injury and thermal injury over an 18-month period. All recorded bronchoscopy examinations were reviewed and categorized injury according to the published abbreviated injury score (AIS 0: no injury, 1: mild, 2: moderate, 3: severe, and 4: massive injury). They also compared changes in oxygenation, airway pressures, chest radiograph findings, fluid administration, and early development of pneumonia and organ failure, by severity of inhalation injury according to the AIS. Thirty-two adult patients met inclusion criteria over the study period. This cohort was 69% male with a mean age of 44.5 ± 14 years and a mean % TBSA burn of 33.9 ± 17%. Of these 32 patients, 11 patients (34%) were classified as grade 0, 9 patients (28%) were classified as grade 1, 7 patients (22%) were classified as grade 2, and 5 patients (16%) were classified as grade 3. Measured carboxyhemoglobin levels increased significantly with higher AIS grade. Oxygenation indices were worse as grade worsened by 24, 48, and 72 hours. The incidence of acute respiratory distress syndrome increased by grade of injury: 0, 22, 57, and 80%, respectively, at 24 hours (P < .01), and remained statistically different at 48 and 72 hours. After adjustment for age, % TBSA burn, and full-thickness component, severe inhalation injury (grades 2 and 3) was associated with an increased risk of acute respiratory distress syndrome at 24 and 72 hours, as well as ventilator days >21 days, and a trend toward multiple organ dysfunction syndrome and mortality. Better understanding of the relationship between inhalation injury and lung physiologic sequelae is a burn research priority. The bronchoscopic grading of inhalation injury moderately correlates with early indices of impaired gas exchange in this cohort and may be a promising tool for staging lower airway injury. Prospective studies should definitively answer whether AIS bronchoscopy staging predicts hospitalization outcomes in inhalation injury.

Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients

IntroductionDespite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. MethodsWe analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. ResultsEight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p<0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS≤8) and multitrauma (ISS≥16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. ConclusionDespite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients.

The Impact of Sacral Sensory Sparing in Motor Complete Spinal Cord Injury

Kirshblum S, Botticello A, Lammertse DP, Marino RJ, Chiodo AE, Jha A. The impact of sacral sensory sparing in motor complete spinal cord injury. Objective To determine the effect of sensory sparing in motor complete persons with spinal cord injury (SCI) on completion of rehabilitation on neurologic, functional, and social outcomes reported at 1 year. Design Secondary analysis of longitudinal data collected by using prospective survey-based methods. Setting Data submitted to the National SCI Statistical Center Database. Participants Of persons (N=4106) enrolled in the model system with a motor complete injury (American Spinal Injury Association Impairment Scale [AIS] grade A or B) at the time of discharge between 1997 and 2007, a total of 2331 (56.8%) completed a 1-year follow-up interview (Form II) and 1284 (31.3%) had complete data for neurologic (eg, AIS grade, injury level) variables at 1 year. Interventions Not applicable. Main Outcome Measures AIS grade (A vs B) at 1 year, bladder management, hospitalizations, perceived health status, motor FIM items, Satisfaction With Life Scale, depressive symptoms, and social participation. Results Compared with persons with AIS grade A at discharge, persons with AIS grade B were less likely to require indwelling catheterization and be hospitalized and more likely to perceive better health, report greater functional independence (ie, self-care, sphincter control, mobility, locomotion), and report social participation in the first year postinjury. A greater portion of individuals with AIS grade B at discharge had improved neurologic recovery at 1 year postinjury than those with AIS grade A. Significant AIS group differences in 1-year outcomes related to physical health were maintained after excluding persons who improved to motor incomplete status for only bladder management and change in perceived health status. This recognition of differences between persons with motor complete injuries (AIS grade A vs B) has important ramifications for the field of SCI rehabilitation and research.

Cut Point Determination in the Measurement of Pain and Its Relationship to Psychosocial and Functional Measures After Traumatic Spinal Cord Injury: A Retrospective Model Spinal Cord Injury System Analysis

Forchheimer MB, Richards JS, Chiodo AE, Bryce TN, Dyson-Hudson TA. Cut point determination in the measurement of pain and its relationship to psychosocial and functional measures after traumatic spinal cord injury: a retrospective Model Spinal Cord Injury System analysis. Objective To evaluate potential pain cutoff scores reflecting mild, moderate, and severe pain in the spinal cord injury (SCI) population and determine the relationship between the derived cutoff scores and both psychosocial and functional outcome measures. Design Retrospective analysis. Setting SCI Model Systems. Participants Persons (N=6096; age >18y) with traumatic SCI (American Spinal Injury Association Impairment Scale [AIS] grades A–D; injured in 1973–2008). Interventions Not applicable. Main Outcome Measures Numeric rating scale (NRS) of pain severity (11 points), NRS of pain interference (5 points), Satisfaction With Life Scale, Patient Health Questionnaire-9, Craig Handicap Assessment and Reporting Technique Short-Form (CHART-SF), motor component of the FIM (M-FIM), and employment. Results The best set of pain severity cutoff points are 1 to 3, 4 to 6, and 7 to 10. This was validated by randomly assigning sample members to 2 groups and replicating. There were significant differences in all outcomes as a function of pain severity grouping, although they explained little of the variance in M-FIM and CHART-SF Physical Independence scale scores. Neurologic status differed significantly between pain groups, with incongruence between pain severity and interference in people in the AIS grade D group, who reported the greatest pain interference and least pain severity. Conclusion Pain severity can be categorized into groups that reflect pain interference. These groupings differentiate psychosocial well-being better than activity limitations. They do not provide a comprehensive pain assessment, for which pain type, location, and interference are likely to be necessary.

Diagnostic criteria of traumatic central cord syndrome. Part 3: Descriptive analyses of neurological and functional outcomes in a prospective cohort of traumatic motor incomplete tetraplegics

Prospective multicenter cohort study. To compare the neurological recovery and functional outcomes between traumatic central cord syndrome (TCCS) patients and motor incomplete tetraplegic patients. European Multicenter Study of human spinal cord injury. In 248 traumatic motor incomplete tetraplegics, initial phase (0-15 days) American Spinal Injury Association (ASIA) impairment grading, upper and lower extremity motor scores (UEMS and LEMS), upper and lower sensory scores and chronic phase (6 or 12 months) neurological outcomes were analyzed. In addition, chronic phase self-care and indoor mobility Spinal Cord Independence Measure (SCIM) items were studied. Tetraplegics were subdivided into three groups: (1) non-TCCS group (UEMSLEMS), (2) intermediate-TCCS group (UEMS=(1-9 points)<LEMS) and (3) TCCS group (UEMS=(10 points)<LEMS). Student's t-tests and χ(2)-tests were applied. A total of 89 non-TCCS subjects (AIS D, n=28), 62 int-TCCS (AIS D, n=43) and 97 TCCS (AIS D, n=80) subjects were analysed. Although minimal significant differences in chronic phase LEMS and UEMS outcomes were identified between TCCS and non-TCCS patients after stratification by the AIS grade, our data showed no significant differences in functional upper and lower extremity outcomes at 6 or 12 months post-injury. The AIS grading system, and not the diagnosis TCCS, continues to be the best available prognostic parameter for neurological and functional outcomes in motor incomplete tetraplegics. The authors recommend that for future outcome studies in motor incomplete tetraplegia, patients should not be selected based on, or stratified by, the diagnosis TCCS.

Standardization of data analysis and reporting of results from the International Spinal Cord Injury Core Data Set

The objective of this study was to provide guidelines for reporting results using the International Spinal Cord Injury (SCI) Core Data Set. International. A committee was created on request of the chair of the Executive Committee for the International SCI Data Set committees. The committee developed a draft consisting of set of recommendations, which were then reviewed and approved by the entire Executive Committee. Age at injury is recommended as reported by the mean, s.d., median and range. When grouped, 15-year increments are recommended as follows: 0-15, 16-30, 31-45, 46-60, 61-75 and 76+ years. For pediatric SCI, 0-5, 6-12, 13-15, 16-21 years are recommended. Time since injury should be reported by mean, s.d., median and range. The following intervals are recommended: <1 year, 1-5, 6-10, 11-15 years, and 5-year increments thereafter. Calendar time (years during which the study is conducted) is recommended grouped by either 5 or 10-year increments with years ending in 4 or 9. For 'length of stay', the mean and s.d., as well as the median is recommended for report. Severity of injury is under ordinary circumstances recommended, reported in five categories: C1-4 American Spinal Injury Association Impairment Scale grade (AIS) A, B or C; C5-8 AIS A, B or C; T1-S5 AIS A, B, or C; AIS D at any injury level; and ventilator dependent at any injury level or AIS grade. It is expected that these recommendations can facilitate a more uniform reporting of the very basic core data on SCI. This will facilitate comparison between different SCI studies.

Injury of the Posterior Ligamentous Complex of the Thoracolumbar Spine

Prospective diagnostic imaging study. To determine the accuracy of magnetic resonance imaging (MRI) in diagnosing injury of the posterior ligamentous complex (PLC) in patients with thoracolumbar trauma. Treatment decisions in thoracolumbar injury patients are currently based on the status of the PLC. It is, therefore, important to understand the accuracy of MRI in diagnosing varying degrees of PLC injury. Prior studies report that MRI is up to 100% sensitive for diagnosing PCL injury. Patients with an acute injury from T1 to L3 who required posterior surgery were prospectively studied. A musculoskeletal radiologist, based on the preoperative MRI findings, characterized each of the 6 components of the PLC as intact, incompletely disrupted, or disrupted. During the surgical procedure, the surgeon identified each component of the PLC as intact, incompletely disrupted, or disrupted. The radiologist's interpretation and surgical findings were compared. Forty-two patients with 62 levels of injury were studied. There were 33 males (78.6%) and 9 females (21.4%), and the average age was 35.7 years. According to the kappa score, there was a moderate level of agreement between the radiologist's interpretation and the intraoperative findings for all PLC components except the thoracolumbar fascia, for which there was slight agreement. The sensitivity for the various PLC components ranged from 79% (left facet capsule) to 90% (interspinous ligament). The specificity ranged from 53% (thoracolumbar fascia) to 65% (ligamentum flavum). There was less agreement between the radiologist and surgeon for the patients with less severe neurologic compromise, i.e., those patients with an AIS grade of either D or E. The sensitivity and specificity of MRI for diagnosing injury of the PLC are lower than previously reported in the literature. The integrity of the PLC as determined by MRI should not be used in isolation to determine treatment.

Total knee arthroplasty in a spinal cord-injured patient: A case report

Patients with spinal cord injuries are prone to knee hydrarthrosis (also known as “water on the knee”), which can cause pain, functional impairment and the restriction of social activities. Total knee arthroplasty is a potentially appropriate treatment. Here, we report on a patient presenting partial T12 AIS grade C paraplegia who was able to walk with two forearm crutches, an ankle-foot orthosis on the right leg and a knee-ankle-foot orthosis on the left leg. Thirteen years after the spinal cord injury, the patient presented with septic arthritis of the right knee, complicated by recurrent hydrarthrosis during standing and walking. Arthroscopy revealed advanced osteoarthritis. Total knee arthroplasty was performed, with very good functional and social outcomes two and half years after surgery.

Head Injury and Outcome—What Influence do Concomitant Injuries Have?

Severe head injury (HI) is known to be a major determinant of mortality in patients with multiple injuries but additional injuries also contribute to the clinical outcome. The Trauma Registry of the German Society for Trauma Surgery offers sufficient data for comparative outcome analysis in relation to the injury pattern. A total of 21,356 cases from Trauma Registry of the German Society for Trauma Surgery with complete data for pattern of injury (Abbreviated Injury Scale [AIS], Injury Severity Score), the incidence of hospital mortality, organ failure, sepsis, duration of hospital stay, and intubation-free days. Maximum AIS severity of HI, including brain, skull, face, and cervical spine, and injuries to the torso and/or extremities (TEI) were used for comparative subgroup analysis. Overall mortality rate was 13.7% (mean age, 41.3 years; 72.6% men; mean Injury Severity Score, 24.4). Patients with relevant HI (AISHI >/=3) were found to have a higher mortality rate (22.1%) than patients with relevant TEI (12.9%). In all HI severity subgroups mortality increased consistently by about 5% with TEI of grade 4, and by 15% with TEI of grade 5, but no increase is observed for lower severity grades. The incidence of organ failure (overall 31.4%), multiple organ failure (15.0%), and sepsis (9.9%) are mainly influenced by the severity of TEI. Intubation-free days are equally influenced by both types of injuries of grade 3 or higher. Mortality in patients with severe trauma is mainly determined by the severity of HI, while TEI contribute consistently only from AIS grade 4 or higher.

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

McKinley W, Meade MA, Kirshblum S, Barnard B. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil 2004;85:1818-25. Objective To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24h and 24–72h) and late (>72h) surgical spine intervention versus those treated nonsurgically. Design Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up. Setting Multicenter National Spinal Cord Injury Database. Participants Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable. Main outcome measures Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores). Results Subjects in the early surgery group were more likely ( P<.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P<.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P<.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P<.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency. Conclusions ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.

Injury scaling at autopsy: The comparison with premortem clinical data

The difference between injury scaling performed in the same patients on the basis of clinical information only and postmortem examination only is largely unknown. We compared scores in all 279 trauma patients who died in the Department of Critical Care Medicine at Auckland Hospital from 1982 through 1987 (93% blunt trauma, 4% penetrating trauma, 3% burns; median time until death—2 days) using both the 1980 and 1985 revisions of the Abbreviated Injury Scale (AIS-80, AIS-85) and derived Injury Severity Scores (ISS-80, ISS-85) where such scoring was based on clinical information only (CLAIS, CLISS) or postmortem findings only (PMAIS, PMISS). For the group as a whole, there was little difference in the distribution of scores between CLAIS and PMAIS or between CLISS and PMISS. However, CLISS-80 was different from PMISS-80 in 68% of individual patients. Most major differences between CLAIS and PMAIS (two AIS grades or more) occurred in the Head region, where injury scoring based on physiological features (e.g. coma) occurred without an anatomic injury of similar AIS grade, or in the Thorax region where therapy had either abolished the evidence of injury (e.g. pneumothorax) or injuries were discovered at postmortem examination which had not been appreciated clinically. Injury scaling data derived only from postmortem examination is not equivalent to that derived clinically. For maximum accuracy, postmortem data must be derived from an examination specifically guided by the needs of injury scaling and in full cognizance of injuries recognised and treated clinically.

A comparison of AIS-85 with AIS-80 for injury scaling in Blunt Trauma

As the effects on injury scaling of the differences between the 1980 and 1985 revisions of the AIS are unknown in blunt trauma, we compared them in all 1270 critically injured (median ISS, 26) blunt trauma patients (75% male, 74% road crash, overall mortality 17%) admitted to the Department of Critical Care Medicine at Auckland Hospital from 1983 through 1987. In 911 patients (72%) there were no differences between AIS-80 and AIS-85 in any body region or in derived ISS. Changes in AIS grades were most common in the abdomen (205 patients), thorax (100 patients), and head (61 patients) regions. Median ISS overall for the 1270 patients was unchanged at 26. One percent of patients had changes in ISS of 16–24 points. Direct comparison of groups of patients scored with these two revisions of the AIS is inappropriate, particularly in those with abdomen region injury.