Statistical analysis

A descriptive analysis of each variable was carried out, providing the absolute and relative distributions for the qualitative variables, together with position measures such as the mean or median, and, in the case of quantitative variables, dispersion measures such as standard deviation.

The relationships between qualitative variables were assessed with Pearson's Chi Square test or Fisher's test, depending on whether or not the expected frequency hypothesis was verified. The differences of quantitative variables between two groups were evaluated through the Student's t test for independent samples, with Welch's correction for non-equality of variances. For groups of 3 or more, the Anova test or the Kruskal-Wallis test was used in function of the fulfillment or otherwise of the hypothesis of normality and homoscedasticity.

The level of significance used was 0.05.

Statistical analysis was performed using R (R Development Core Team program), version 3.4.4.

Variables related to support after the spinal cord injury: use of support products, use of aids for personal mobility, and associationism related to the injury.

Legal and ethical aspects

Authorization to carry out the study was granted by both the Research Ethics Committee of the Principality of Asturias, and the Area IV (Oviedo) Management and the Nursing Directorate.

The list of patients was kept by the main researcher on an electronic device without connection to the internet, and the EMRs were encrypted and anonymized.

The confidentiality and anonymity of the data used were guaranteed following the provisions of Organic Law 15/1999 for the Protection of Personal Data, which was the law in force at the time of the study.

Results related to the injury

The most frequent causes of injury were: traffic accidents, 30.3% (n = 27), which break down into 19.1% (n = 17) car accidents, 10.1% (n = 9) motorcycle accidents, and 1.1% (n = 1) other types of traffic; workplace accidents, 25.8% (n = 23), and fortuitous accidents, 20.2% (n = 18). Spinal cord injuries produced after an autolytic attempt correspond to 11.2% (n = 10) of all injuries. Sports accidents account for 5.6% (n = 5), and 3.4% (n = 3) are from accidents diving into shallow water. 1.1% (n = 1) is due to direct trauma to the spine, 1.1% (n = 1) to assault, and 1.1% (n = 1) to unknown causes.

25.8% (n = 23) had a history prior to injury of mental health disorders: 6.7% (n = 6) had an anxiety-depressive disorder, 6.7% (n = 6) a personality disorder, 5.6% (n = 5) drug addiction, 3.4% (n = 3) schizophrenia, 1.1% (n = 1) bipolar disorder, 1.1% (n = 1) chronic alcoholism, and 1.1% (n = 1) other mental illnesses. Relating the cause of the spinal injury to the presence of a history of mental health disorders reveals that these are not present in people who suffered a sports accident or in those who suffered an occupational accident, but do appear with a p <0.001 in 24% of those who suffered a traffic accident, in 26.3% of what was labelled a fortuitous accident, and in 100% of those whose injury was secondary to an autolytic attempt.

The mean age at injury was 40.2 years, with a standard deviation of 12.1 and a median of 41 years. The median time from injury to study was 109 months, with a standard deviation of 160 and a median of 76 months.

33.7% (n = 31) of the injuries occurred in summer, 23.9% (n = 22) in winter, 21.7% (n = 20) in autumn, and 17.4% (n = 16) in spring. There are no statistically significant differences that relate the cause of the injury to the season.

The most frequent type of injury is paraplegia with 38.5% (n = 30), followed by paraparesis with 28.2% (n = 22). 20.5% (n = 16) have tetraparesis and 12.8% (n = 10) have quadriplegia. If the injuries are grouped according to their extension, it is observed that 52.6% (n = 41) have incomplete injuries and 47.4% (n = 37) have complete injuries.

According to neurological level, dorsal injury is the most frequent with 45.4% (n = 39), followed by cervical injury with 30.2% (n = 26), and lumbar injury with 24.4% (n = 21). There is a gender difference: in men the most frequent injury is dorsal injury with 45.6% (n = 31), followed by cervical injury with 35.3% (n = 24) and lumbar injury with 19, 1% (n = 13). In women, the most frequent injuries are dorsal and lumbar with 44.4% (n = 8), followed by cervical with 11.1% (n = 2). There is a statistically significant relationship between sex and level of lesion, with a p value = 0.045.

The distribution of lesions according to bone level is reflected in Table 1:

TABLE 1:  DISTRIBUTION OF SPINAL CORD INJURY ACCORDING TO BONE LEVEL 

81.6% (n = 71) have undergone some sort of surgical intervention to stabilize their SCI.

According to ASIA at discharge, 50.7% (n = 35) have an ASIA A injury, 27.5% (n = 19) an ASIA D injury, 14.5% (n = 10) an ASIA C injury, 4.3% (n = 3) an ASIA B injury, and 2.9% (n = 2) an ASIA E injury.

Among the incomplete clinical lesions that produce recognizable clinical syndromes, 10.3% (n = 8) have Brown-Séquard syndrome, 7.7% (n = 6) have central cord or Scheneider syndrome, 5.1% (n = 4) conus medullaris syndrome, and 2.6% (n = 2) cauda equina syndrome. Table 2 shows the most important relationships between the presence of syndromes and the associated secondary complications.

TABLE 2:  PRESENCE OF SYNDROMES AND ASSOCIATED SECONDARY COMPLICATIONS 

Results related to hospitalization

In the first admission after the injury occurred, 41.4% (n = 36) were referred from other hospitals in the region to the HUCA, as this is the center of reference for the treatment of people with spinal cord injury at the regional level.

38.7% (n = 33) were referred from the HUCA to other national reference hospitals to complete treatment: 23.3% (n = 20) were referred to the National Hospital for Paraplegics in Toledo, which is the national reference hospital; 2.3% (n = 2) were referred to the Institut Guttman de Barcelona; 12.8% (n = 11) to other hospitals.

62.5% (n = 57) required admission to the ICU. The average length of stay in the ICU was 12.1 days, with a standard deviation of 21.9 and a median of 3; the time of hospitalization unit was 93.8 days, with a standard deviation of 81.8 and a median of 75; the total hospitalization time was 106 days, with a standard deviation of 83.4 and a median of 88. Table 3 shows the most important relationships between hospitalization times and types of injury.

TABLE 3:  RELATIONSHIPS BETWEEN THE TIME OF HOSPITALIZATION IN THE ICU IN DAYS, TIME IN UNIT OF HOSPITALIZATION, TOTAL TIME OF HOSPITALIZATION, AND THE TYPES OF INJURY 

^*Statistically significant with p<0,05.

Results about secondary complications related to spinal cord injury

46.5% (n = 39) had PU, of which 26.2% (n = 22) had PU in multiple areas of the body, 7.1% (n = 6) had sacral ulcers, 4.8% (n = 4) occipital ulcers, 3.6% (n = 3) on the toes, 2.4% (n = 2) on the heels, 1.2% (n = 1) in the ischium and 1.2% (n = 1) in the trochanter. There is a relationship between the presence of a history of mental health disorders and PU complications with a p value = 0.01.

Among urological complications, 68.7% (n = 57) have neurogenic bladder, of which 31.3% (n = 26) have this condition added to repeated urinary tract infections (UTIs). 2.4% (n = 2) presented repeat UTIs without neurogenic bladder. Other complications are urinary urgency, 4.8% (n = 4) and incontinence, 2.4% (n = 2). 21.7% (n = 18) did not present urological complications.

With regard to gastrointestinal complications, 60.2% (n = 50) presented neurogenic bowel, 8.4% (n = 7) constipation, 1.2% (n = 1) incontinence, and 1.2% (n = 1) gas incontinence. 28.9% (n = 24) did not present any gastrointestinal alteration.

30.1% (n = 25) of people with spinal cord injury have neuropathic pain, compared to 19.3% (n = 16) who have mechanical pain. 13.3% (n = 11) presented both neuropathic and mechanical pain. 37.3% (n = 31) have no pain.

46.4% (n = 39) presented muscle spasticity.

3,6% (n=3) of patients presented an autonomic dysreflexia crisis.

With regard to respiratory complications, 10.7% (n = 9) presented or present respiratory complications.

Tables 4,5 and 6 show the most important relationships between complications secondary to traumatic SCI and the type of lesion according to involvement, extent, and neurological level, respectively.

TABLE 4:  SECONDARY COMPLICATIONS AND TYPE OF INJURY ACCORDING TO AFFECTION 

TABLE 5:  SECONDARY COMPLICATIONS AND TYPE OF INJURY ACCORDING TO EXTENSION 

TABLE 6:  SECONDARY COMPLICATIONS AND INJURY ACCORDING TO NEUROLOGICAL LEVEL 

Regarding post-injury complications in mental health, 30.1% (n = 25) suffered from anxiety-depressive syndrome, 3.6% (n = 3) from an autolytic attempt, 1.2% (n = 1) from insomnia, 16.9% (n = 14) have mental illnesses that they had prior to injury, and 2.4% (n = 2) have other illnesses of the mental sphere. 45.8% (n = 38) did not present complications in mental health.

There is a statistically significant relationship between marital status and mental complications derived from the injury with a p value = 0.045, such complications being more frequent in married people and less in unmarried people. There is also a relationship between having a previous mental health history and having post-injury mental complications, with a p value <0.001.

Regarding gait disturbances, 58% (n = 47) were unable to walk, 7.4% (n = 6) were able to walk short distances with support, 7.4% (n = 6 ) presented pareto-spastic gait, and 1.2% (n = 1) steppage gait. 25.9% (n = 21) presented other undefined gait disturbances.

Results on supports related to spinal injury

87.3% (n = 69) use support products in their daily lives. If we focus on aids for personal mobility, 59.3% (n = 48) move in a wheelchair, 28.4% (n = 23) with crutches or an English cane, 3.7% ( n = 3) with some other aid, and 8.6% (n = 7) without aid for travel.

Table 7 shows the relationships between the type of injury, gait disturbances, and the use of support products.

TABLE 7:  RELATIONSHIP BETWEEN THE TYPE OF INJURY, GAIT ALTERATIONS, AND THE USE OF SUPPORT PRODUCTS 

In 16.3% (n = 15) of the EMR, membership or not of an association is reflected. Within this percentage, 73.3% (n = 11) belongs to the Asociación de Parapléjicos y Grandes Minusválidos Físicos (Association of Paraplegics and the Seriously Physically Handicapped), 6,7%(n=1) to the Confederación Española de Personas con Discapacidad Física y Orgánica (Spanish Confederation of People with Physical and Organic Disabilities), while 20%(n=3) do not belong to any association.