Prognosis in Spinal Cord Injury

1. Prognosis and care in SCI
Henry Prakash

2. ASIA
 Evolution for the Frankels
 Ease of assessment
 Tetra versus Para
 Prognostication
 Research

3. Recovery
 All teraplegics will recover one level!
 Stauffer’s et all 1976
Dittuno 92’ – 70-80% Motor complete tetra will
have some improvement at the level in 3- 6mo
Dittuno 2005
 Motor complete - 1-2 levels
 Motor Incomplete- Multiple levels

4. Paraplegia
 Waters’ 92 – N-108
Complete Para
 73%(T2-L2) No change 1 yr
 18% improved to next Nu level
 7% - 2 Nu levels
Incomplete (T11-L3)
78% - Had significant improvement
70% Able to ambulate 1-2 yrs
27% Did not need Aids

5.  T11 – Below , Potential for ambulation with
brace
 L3 or Lower – Community ambulation

6. Hazard Ratio
 Outcome measure used inTime to Event
analysis
 Looks from enrolment to event occurrence
 Hazard – instantaneous event rate
 HR= Hazard inTreatment Arm/ Hz in
Comparator

7. Interpretation
 HR = 1, Event rates same in both arms.
 HR = 2, At any time twice the no. Pt in the
treatment group are having the event
proportional to the comparator group.
 HR = 0.5, , At any time half as many Pts Pt in
the treatment group are having the event
proportional to the comparator group.

10. Spinal Cord Injury
 One of the most complex neurological impairments
 sensory
 motor
 bladder-bowel
 sexual functions
• US: 12000 new cases a year (NSCISC 2013)
• >700 known SCI within 100km of CMCVellore!!!

11. Spinal Cord Injury- Survival
trends
↓ ↓ ↓ 1970s-1980s* ↑ ↑ ↑
 Causes: uremia, septicemia, pneumonia
*D.J. Strauss, M.J. Devivo, D.R. Paculdo, R.M. Shavelle. Trends in life expectancy after
spinal cord injury Arch Phys Med Rehabil, 87 (2006), pp. 1079–1085

12. Deaths Vs Survival
Death
    → 
------------------------------------------------------------------
-
Survival
    →
   →
  →


13. • Traumatic SCI n=490
• Within follow-up 1981 to 2011
• Approx 100km radius of CMC
 Outcomes: Survival rates, mortality risk factors
 Methods: Kaplan-Meier and Cox model.
SCI Survival- PMR, CMC Vellore
1981-2011

14. Survival Analysis
    →
   →
  →


15. Spinal Cord Injury- Survival

16. SCI Survival- PMR, CMC Vellore
1981-2011
5 years → 86%
15 years → 71%
20 years → 63%
25 years → 58%

17. Factors predicting Survival rates
• Level of Injury
 High cervical: Hazard Ratio 3.9 (compared to Lumbosacral)
• Extent of lesion (Frenkel/ASIA)
 Complete: Hazard Ratio 23 (compared to motor incomplete)
SCI Survival- PMR, CMC Vellore
1981-2011

18. CMC
5 years → 86%
15 years → 71%
20 years → 63%
25 years → 58%
* Razzak A, Helal SU, Nuri RP. Life expectancy after spinal cord injury in a developing country-a retrospective study at CRP,
Bangladesh.Disability,CBR & Inclusive Development 2011;22:114-23
Bangla Desh*
43.6%*
SCI Survival- PMR, CMC Vellore
1981-2011

19. CMC
5 years → 86%
15 years → 71%
20 years → 63%
25 years → 58%
* Denmark, Canada, Australia, Israel, USA,UK, Norway, Finland
Developed countries*
69% to 86%*
SCI Survival- PMR, CMC Vellore
1981-2011

20. Promising survival trend – contributing factors
• Comprehensive medical rehabilitation under one roof
 Neurogenic bladder
 Pressure ulcer
• Goal oriented therapy : independence in daily living
• Rehab Mela + Follow-up in the community
• Vocational resettlement
SCI Survival- PMR, CMC Vellore
1981-2011

21. Limitations
• No denominator (population data)
• No medical data/ mortality analysis
• Post-rehabilitation only (hospital events unaccounted for)
• Small subset of all rehabilitated SCIs (~5000 persons)
SCI Survival- PMR, CMC Vellore
1981-2011

22. Conclusions
• structured follow-up → positive impact on survival
• Complete, higher SCI → lower survival
SCI Survival- PMR, CMC Vellore
1981-2011