The epidemiology of pre-hospital potential spinal cord injuries in Victoria, Australia: a six year retrospective cohort study

© 2016, The Author(s). Background: Traumatic Spinal Cord Injury (TSCI) is relatively uncommon, yet a devastating and costly condition. Despite the human and social impacts, studies describing patients with potential TSCI in the pre-hospital setting are scarce. This paper aims to describe the epidemiology of patients potentially at risk of or suspected to have a TSCI by paramedics, with a view to providing a better understanding of factors associated with potential TSCI. Methods: This is a retrospective cohort study of all adult patients managed and transported by Ambulance Victoria (AV) between 01 January 2007 and 31 December 2012 who, based on meeting pre-hospital triage protocols and criteria for spinal clearance, paramedic suspicion or spinal immobilisation, were classified to be at risk of or suspected to have a TSCI. Data was extracted from the AV data warehouse, including demographic details, trauma aetiology, paramedic assessment, management and other event characteristics. Results: A total of 106,059cases were included in the study, representing 2.3 % of all emergency transports by AV. Subjects had a median age of 51 years (interquartile range; 29–78) and 52.4 % were males (95 % CI 52–52.7). Males were significantly younger than females (M: 43 years [26–65] vs. F: 64 years [36–84], p =0.001). Falls and traffic accidents were the leading causes of injuries, comprising 46.9 and 39.4 % of cases, respectively. Other causes included accidents due to sport, animals, industrial work and diving, as well as violence and hanging. 29.9 % of patients were transported to a Major Trauma Service (MTS). A proportion of 48.8 % of the study population met the Pre-hospital Major Trauma criteria. Conclusion: This is the first study to describe the epidemiology of potential TSCI in Australia and is based on a large, state-wide sample. It provides background knowledge and a baseline for future research, as well as a reference point for future in policy. Falling and traffic related injuries were the leading causes of potential SCI. Future research is required to identify the proportion of confirmed TSCI among the potentials and factors associated with TSCI in prehospital settings

The Pre-Hospital Management of Suspected Spinal Cord Injury and its Association with Patient Outcomes

Traumatic spinal cord injury (TSCI) is relatively uncommon, but devastating and often leads to long-term disabilities. It affects the patient’s functioning, health and quality of life. Pre-hospital care may play a significant role in the reduction of secondary damage and further neurological deterioration, recovery and outcomes of patients following TSCI. <br>    <br>   Review of the literature identified a paucity of high-level evidence regarding the association between pre-hospital spinal immobilisation and patient neurological and functional outcomes. Therefore, the main aims of the thesis were to explore patient profiles of those who are at-risk of sustaining TSCI, identify the differences between at-risk and confirmed with TSCI and examine the differences between patients with TSCI who received pre-hospital spinal immobilisation and those who did not. All studies included adult trauma patients who were attended, managed and transported by Ambulance Victoria (AV) paramedics over a six-year period (2007 - 2012). <br>    <br>   The study of those at-risk to have sustained TSCI (potential TSCI) included 106,059 patients, with patient demographics and event characteristics of this cohort described. Falls and traffic-related incidents were the most common causes, with slightly more males (52.4%). The study also provided a clear definition of potential TSCI and baseline knowledge for future research. <br>    <br>   The potential TSCI dataset was then linked with the Victoria State Trauma Registry to identify patients with confirmed TSCI. This linkage identified 257 patients with confirmed TSCI (0.2%), mainly due to falls and traffic incidents. Patients had a median age of 49 years with males comprising 84.1% of the cohort. In addition, there were several independent indicators of confirmed TSCI including AV Pre-hospital Potential Major Trauma (PMT) criteria, male gender, the presence of neurological deficits, the presence of an altered conscious state, sustain a high fall (> 3 meters), diving accident and motorcycle and bicycle collisions. <br>    <br>   The non-immobilised TSCI patients were more likely to have sustained a low fall, be attended and managed by ALS paramedics and transported by road ambulances to a hospital other than a major trauma service or spinal care unit. The non-immobilised TSCI group also had worst long-term functional outcome scores compared to the immobilised TSCI group. The characteristics of TSCI patients who were not immobilised led to speculating that the non-immobilised group were not recognised or misdiagnosed by the pre-hospital care provider, which may have led to a different pathway of care compared to those immobilised. Outcome measurement at earlier stages of care should be validated and considered to examine the clinical effect of pre-hospital spinal immobilisation. <br>    <br>   This body of work provides empirical studies contributing to the knowledge gaps relating to describing TSCI from the pre-hospital perspectives, as well as the association between pre-hospital spinal immobilisation and patient outcomes following TSCI.  However, large prospective studies in this field are unlikely to be feasible and therefore we need to maximise the knowledge we can derive from observational studies such as those undertaken in this thesis. Meanwhile, hopefully, the findings in this thesis can improve pre-hospital spinal care leading to improved patient outcomes and decreased the burden of TSCI