April 2011 Archives

In the United States:The National Spinal Cord Injury Database was established in 1973 and collects all the spinal cord injuries in United States through 26 federally funded Model SCI Care Systems. Estimated prevalence of SCI patients in the United States in 2010, who are alive, is approximately 265,000. It is estimated that the annual incidence of spinal cord injury (SCI), is approximately 40 cases/ 1,000,000 population or approximately 12,000 new cases/ year, excluding those who expired at the scene of the accident.
In Minnesota, 192 cases of occupation related spinal cord injuries were registered in Minnesota Statewide Trauma System at the Department of Public Health in the last 10 year period (2000- 2010).The number of cases registered per year varied from 31 per year in 2000 to 8 per year in 2009. There has been a gradual downward trend in spine related injuries in Minnesota along with overall incidence in the United States. 

                    Frequency trends of work related SCI's in Minnesota from 1999 - 2009

1.Age at Injury: SCI primarily affects young adults. From 1973 to 2005 there was a gradual increase in the average age at injury to the spinal cord. The average age has increased from 28.7 years to 40.2. Few reasons for the increase in the average age at SCI are increase in median age of the general population of the United States by 8 years during this period, survival rates of older persons at the scene of the injury event or age-specific incidence rates.
2.Gender: In United States incidence of SCI is higher in males than females. Since 1980 till today, there is a small decrease in the percentage of male's involved in SCI's from 81.8% to 80.9 %.
3.Race: Secondary to changes in the demographics in the United States, there was an observed significant change in race-specific incidence rates that is, the racial/ethnic distributions of people who had SCI's.

4.Etiology: In United States, motor vehicle crashes are the leading cause for SCI's and account for 42.1% of all reported SCI cases. Other common causes are falls, violence (primarily gunshot wounds), and recreational sporting activities. .                                                                                    

Depending on the level of the SCI, the disease severity changes from complete paralysis of all extremities (quadriplegia) to incomplete paralysis of lower extremities (paraplegia). Cervical level injuries lead to quadriplegia and thoracic and lumbar level injury leads to paraplegia. Data showed that the most common disease diagnosis, at the time of discharge, are incomplete quadriplegia (30.1%); followed by complete paraplegia (25.6%), complete quadriplegia (20.4%), and incomplete paraplegia (18.5%). Trends show that the percentage of persons with incomplete quadriplegia has slightly increased, while complete paraplegia has slightly decreased.
Employment Status:Post injury occupational status: 57.5% of people sustaining an SCI were employed at the time of their injury and the data are unclear, regarding work relatedness of the injury; however, only 11.5% of persons were able to return to work, after 1 year of the injury and 35.4% were able to return to a similar level of employment, after 20 years of the injury.

1) Age: Age group between 16 and 20 years - prone to spinal cord injuries,
Under 65 Years - Motor vehicle crashes,
Over 65 years - Falls .
2) Sex: Being a male is a risk factor,
80% of the cases - Males
3) Type of occupation: Work related injuries account for 28% of SCI's in the past 5 years. Most victims are unemployed, at the time of injury, followed by the production, craft and construction workers(1).
4) Driving safety measures: Usage of safety measures such as seat belts helped in reducing the severity of the spinal cord injuries, however, the reliability on the responses given by the victims, at the time of treatment, is debatable, regarding whether they were or were not wearing a seat belt.
5) Health Conditions: Medical conditions such as osteoporosis, arthritis or cancer increased the severity of the spinal cord injury(5).

Average yearly health care and living expenses, not including indirect costs such as losses in wages, fringe benefits and productivity, varied not only depending on the severity of the disease, but also on the age of the victim.

Average estimated indirect costs such as losses in wages, fringe benefits and productivity are estimated to be $66,626 per year, depending on the level of the spinal cord injuries and severity of injury. Finally, total annual costs attributed to SCI were $40.5 billion in 2008, which is estimated to be a 317% increase from 1998, accounting to be a total of $9.7 billion.

1) Education: Victims of SCI at a younger age are either unemployed or people, who had an education level just above the eighth grade(1). It seems that the level of education has an impact on the incidence or prevalence of SCI. The perspective of a person changes with regards to risk-taking behaviors, by educating them regarding the risks and personal benefits of the behavior as per the trans-theoretical model. However, educating the younger generation to change their risk-taking behaviors is a difficult task and requires much effort and resources. This may limit the progress of injury prevention strategies. Driving under the influence (DUI) or alcohol intoxication while driving is also one of the reasons for motor vehicle crashes and this risk behavior can be modified by education regarding the risks of such behavior.
Educating the elderly to prevent falls may be another important factor. The elderly usually have dementia and denial regarding their health status, which may limit our progress. They try to get up from the bed or sitting posture, without assistance, which may lead to a fall. Prevention of falls decreases not only the risk of SCI's but also of bone fractures and brain injuries.
2) Limited budget for these safety measures: Safety measures are the next best way to prevent SCI. We have made progress in decreasing the number of motor vehicle crashes, in the last century, by increasing the safety measures in the transportation vehicles, roads and other technology. However, this progress took more than 50 -60 years and required the appropriate allocation of budget not only for installation of the safety measures, but also for conducting research. Lack of resources for safety measures, installation on the roads, and improved motor transportation is a limiting factor.
3) Technology for safety of the transportation vehicles is another limiting factor in decreasing the incidence of the SCI's. We made good progress in decreasing the number of motor vehicle injuries by increasing safety measures in the transportation vehicles; however, again this progress took 50 -60 years for their invention. We need more research and technology to increase the safety of transportation vehicles to decrease the force of impact to the passenger.

1) Pre-event:
a) Human :Education and training on safety measures: According to the data from the CDC, 25% of the motor vehicles crashes are associated with alcohol intoxication. Educating the drivers and passnegers regarding alcohol and driving and also enforcing stringent laws for those, who drink and drive, may decrease the incidence of the motor vehicle crahses (7).
b) Vehicle: Decreasing the force of impact on the spinal cord by inventing new safety measures in transportation vehicles, may be another good approach. The invention of front air bags and side air bags to prevent the injuries to the neck, face and chest has decreased the incidence of injuriesto these sites. Recently Ford and Lexus came up with a new reconfigured curve-shaped tether system, which is supposed to decrease the incidence of whiplash injuries (8).
c) Environment :Increasing the safety of the roads by decreasing sharp objects and turns,and increasing the visibility of the roads would decrease the number of crashes and SCI's.

2) Event:
a) Human: Spinal cord is protected by a stracture of verterbral bones, which needs much higher impact of energy to get fractured or injured. So increasing the strength of the bones in the elderly by treating or preventing osteoporosis decreases the incidence of the SCI's.
b) Vehicle: Decreasing the force of impact to the spinal cord by interposing material such as Thorax Abdomen Pelvis (TAP) side airbags for drivers and front passengers and Whiplash Injury Lessening (WIL) front seats and headrests will decrease the risk of SCI's.
c) Environment: Road safety measures such as collapasible side walls, avoiding sharp turns, sharp objects, flammable buidings, ditches and valleys, poorly designed guard rails can be used to decrease the degree of energy transfer from the environment to the victim at the time of impact.

3) Post Event:
a) Human: Improvement in medical emergency services and paramedic teams helps in delivering first aid, at the scene and helps to decrease the complications of an unstable vertebral column such as spinal cord injury. As stablization of the vertebral column is the best preventive measure for SCI's and early transportation to the hospital limitscomplications such as bleeding and swelling of the spinal cord.
b) Vehicle: Non collapsible vehicles and accessibility to easily evacuvate the driver and the passenger after the incident saves time and helps in early transfer of the victim to the hospital for early and appropriate treatment.
c) Environment: Improvement and accessiblity of evacuation services and hospital transport, helps in decreasing the impact and complications from the incident and reducing the number of secondary accidents occurring after the primary one.

1. Do not create a hazard: Preventing creation of recreational vehicles and banning certain recreational sports, helps in decresing the incidence of SCI's. This is, however, an impractical method, which can rise aligations against the policies.
2. Reduce the amount of hazard: Decreasing the maximum speed limits, using mechanised fork lifts, increasing safety standards of recreational and other motor vehicles, helps to reduce the amount of hazard.
3. Prevent release of the agent: Extensive education for all drivers and passengers regarding crashes, driving under the influence and other safety mesasures prevents the occurence of the event.
4.Modify release of the agent: Safety measures such as Whiplash Injury Lessening (WIL) front seats and headrests, decreases the risk of SCI's. .
5.Separate in time or space: Use of non collapsible cars, collapsable side rails such that source of the energy, can be maintained at a proper distance from the body.
6. Separate with a physical barrier: Thorax Abdomen Pelvis (TAP) side airbags, and driver and front passenger airbags, helps to decrease the transfer of energy to the drivers.
7. Modify surfaces and basic structures. Self-adjustable lumbar region of the seats, elimination sharp objects in the car, use of breakaway designs for utility poles and light poles along roadsides can all be modifiable structures.
8. Increase the resistance of the vertebral coulmn of a person: Implementing strength training, smoking cessation,and ideal weight maintenance programs, in order to, decrease the risk of osteoporosis and other individual factors contributing to SCI's will help.
9. First aid and emergency response. Training paramedics and first responders in proper first aid procedures and maintaining written response protocols will aid in the prevention or exacerbation of SCI. Ensuring immediate access to medical care and efficient reporting systems is a step in the right direction.
10. Acute care and rehabilitation. Assisting with access to medical services and provision of rehabilitation and return to work planning would be appropriate. Retraining in other areas for workers, whose injuries preclude return to previous job tasks, will assist to encourage SCI victims to return to work in a appropriate capacity

The most appropriate way to decrease the incidence of SCI's will be incorporation of all the possiable components identified in the strategies of Dr. Haddon, as outlined above. This comprehensive approach allows us to integrate the road and vehicle safety measures, workers safety measures,elimination of biomechanical hazards, adoption of administrative practices specifically aimed at injury reduction, on-going training for all workers and paramedics regarding best practice techniques, implementation of a surveillance program to identify high-risk places and jobs, and encouragement of general road safety education.

Spinal cord injuries.pdf

1. Annual Report for the Spinal Cord Injury Model Systems 2009: Spinal Cord Injury Information Network at the University of Alabama at Birmingham
2. Minnesota Statewide Trauma Registry: Department of Helath, St.Paul Minneosota.
3. PopBites: Volume 01-21: June 2001 Minnesota's State Government Workforce is Aging
4. Spinal cord injury: Hope through research. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/sci/detail_sci.htm. Accessed July 2, 2009.
5. Spinal trauma. The Merck Manuals: The Merck Manual for Healthcare Professionals. http://www.merck.com/mmpe/print/sec21/ch311/ch311a.html. Accessed June 17, 2009.
6. Drug Benefit Trends. Vol. 21 No. 6
7. Injury Epidemiology : Research and Control Measures: Third Edition: Leon S. Robertson.
8. New Airbag Design Could Cut Whiplash Injuries: http://www.dlaka.com/new-airbag-design-could-cut-whiplash-injuries/
9. http://www.bls.gov/
10.The Journal Topics in Spinal Cord Injury Rehabilitation Volume 16 Number 4 in 2011