The Epidemiology of Childhood and Adolescent Traumatic Spinal Cord Injury in the United States: 2007

Abstract

The burden of acute traumatic spinal cord injury (TSCI) among U. S. children and adolescents was last described over a decade ago using inpatient data. We describe cumulative incidence, mortality, discharge disposition, and inflation-adjusted charges of childhood and adolescent TSCI in the U.S. using emergency department (ED) data from the Nationwide Emergency Department Sample (2007–2010). Patients ages 17 years and younger with a diagnosis of acute TSCI were identified using the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes 806.* and 952.* (N=6132). The cumulative incidence of childhood and adolescent TSCI averaged 17.5 per million population per year. The median age at presentation was 15 years (interquartile range [IQR]=12-16) and the majority of patients were male (72.5%). The overall median new injury severity score (NISS) was 16 (IQR=9-27), remaining unchanged during the study duration (p=0.703). Children 5 years and younger were more likely to be injured from a road traffic accident (RTA; 50.9%), sustain C1-C4 injuries (47.4%), have more severe injury (median NISS=22; IQR=13-29), and concurrent brain injury (24%) compared to older children and adolescents, p<0.001. Firearms were implicated in 8.3% of injuries, of which 94.7% were among adolescents ages 13–17 years. Of the 35 TSCI-related ED deaths, 40% occurred among children ages 5 years and younger. 62.4% of patients required inpatient admission. Despite stable cumulative incidence and overall injury severity, ED treatment charge per visit increased on average $1394 from $3495 in 2007 to $4889 in 2010 (p=0.008). RTA-related TSCI disproportionately affects young children, while firearm-related TSCI is most common among adolescents. These findings inform TSCI prevention strategies. Prevention may be key in mitigating rising healthcare cost.

Introduction

In the United States, injuries are the leading cause of death and disability among children ages 18 and younger and account for an estimated 40% of all deaths in children older than 1 year.¹ Injuries are therefore a significant public health threat and a leading cause of high disability-adjusted life years.² We recently estimated that 12,939 new adult traumatic spinal cord injuries (TSCI) occur in the U.S. each year—a cumulative incidence of 56.4 per million population per year.³ This estimate is 41% higher than previous estimates of 40.0 per million population projected by the National Spinal Cord Injury Statistical Center that were derived primarily from inpatient discharge data of patients of all ages from facility- or regional-based analyses in the 1990s.⁴ Similarly, there is limited current data focusing on the incidence and burden of childhood and adolescent TSCI in the U.S. Although childhood and adolescent TSCI comprise less than 10% of all new TSCI, it presents an enormous burden to the healthcare system due to improved life expectancy and possible lifelong need for rehabilitation and health care services.^5

–8 The estimated lifetime cost for treatment of TSCI at the point of injury for a 25-year-old with tetraplegia is $4.6 million, approximately 1.8-fold higher than a 50-year-old. The lifetime cost would be significantly higher among children and adolescents with TSCI, compared with adults given greater expected average life expectancy.^8,9

The most recent national estimate of childhood and adolescent TSCI (19.9 per million population) utilizes inpatient discharge data from 1997 to 2000 and may include patients with late effects of TSCI as part of incidence calculations.¹⁰ This approach potentially misclassifies cases and may provide an inaccurate estimate of the true burden of acute TSCI among children and adolescents in the U.S.

While the examination of inpatient discharge data assumes that all acute TSCI receive inpatient care, the use of ED records to assess acute TSCI regardless of trauma center level designation provides more informative estimates of the actual burden of acute TSCI. ED records include all patients with TSCI regardless of injury severity, a factor that may influence provider practice and patient preferences, including whether a patient is admitted into inpatient care. We utilized nationally representative ED visit data from the U.S. Government Healthcare Cost and Utilization Project (HCUP) to update the epidemiology and burden of childhood and adolescent TSCI at the level of the U.S. national population. As such, this is the first nationwide estimate of the burden of acute TSCI among U.S. children and adolescents at the point of initial care—the ED—following a traumatic incident.

Methods

Study design and setting

We utilized the Nationwide Emergency Department Sample (NEDS).¹¹ The NEDS, an administrative database, is the largest all-payer ED database from approximately 960 hospital-based EDs comprising 20% of all hospital-based EDs in the U.S. each year. A total of 28,584,301 ED visits, corresponding to a weighted total of 128,970,364 ED visits in the U.S. were captured in 2010, of which 25,511,069 (19.8%) were ages 17 years or younger. According to the NEDS study design, the 20% sample of U.S. hospital-based EDs are selected from strata defined by the four U.S. census regions, trauma center designation, urban/rural location, hospital teaching status, and ownership. States contributing data to the NEDS and population distribution by U.S geographic region are presented in Appendix A.¹² The NEDS design utilizes the complete list of American Hospital Association (AHA) community, non-rehabilitation hospital-based EDs as the target universe to calculate post-stratification hospital- and discharge-level weights that are assigned to each ED visit. The application of post-stratification discharge level weights in the current study provides estimates of ED visits that are representative of all U.S. ED visits, even from facilities that were not sampled from the target universe within each stratum. For each ED visit, up to 15 diagnoses can be reported using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. The principal diagnosis is defined as the main reason that brings a patient to the ED.^11,12 The Institutional Review Board of the Johns Hopkins Hospital approved the study.

Study population

ED visits among patients ages 17 years and younger with non–birth-related TSCI from 2007 through 2010 were identified using ICD-9-CM diagnosis codes recorded in any of the 15 diagnosis fields (Appendix B). We included all children and adolescents with a principal diagnosis (main reason for ED visit) of TSCI. When TSCI was identified in diagnosis fields 2 to 15, only children and adolescents with an accompanying principal diagnosis of traumatic injury (ICD-9-CM codes 800.0-959.9) were retained in these analyses. Because patients with polytrauma carrying a principal diagnosis of other traumatic injury may have a secondary diagnosis of TSCI, our approach in selecting TSCI cases reduces the possibility of incomplete ascertainment. Likewise, patients with a principal diagnosis of viral pneumonia who carry a secondary diagnosis of TSCI are far less likely to have presented to the ED for acute TSCI but rather for viral pneumonia. Children and adolescents with diagnosis codes for birth trauma to the spine and spinal cord were excluded (ICD-9-CM 767.4).

Characterization of TSCI

We described level and severity of TSCI, spinal cord injury without radiologic abnormality (SCIWORA), paralysis, concurrent traumatic brain injury (TBI), overall injury severity using New Injury Severity Scores (NISS), and mechanism of injury. Level of TSCI was categorized as high cervical (C1-C4), low cervical (C5-C7), thoracic, lumbosacral, and multi-site/other/unspecified. We identified SCIWORA (952.0-952.9), incomplete versus complete TSCI (Appendix C), paraplegia versus quadriplegia (344.1 and 344.00-344.09), and concurrent TBI (800.0-804.9 and 850.0-854.1) using ICD-9-CM codes. We used the International Classification of Diseases Programs for Injury Categorization to generate the NISS, a composite score ranging from 1 to 75, and derived from the three most severe injuries in any region of the body. NISS has been extensively used for prediction of mortality following trauma. A higher score represents more severe injuries, hence higher risk of mortality.^13
–15 NISS has been shown to be a better predictor of mortality following trauma than the original Injury Severity Score (ISS).¹⁶

Definitions for intent and mechanisms of injury provided by the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System were utilized to evaluate ICD-9-CM external causes of injury codes.^13,17 Mechanisms of injury were grouped into falls, road traffic accidents (RTAs), firearm injuries, struck by other persons/objects, sports, and other mechanisms. Other mechanisms include injuries related to machinery, fire/burns, poisoning, overexertion, and adverse effects from medical/surgical care. Because of the small number of individuals for some mechanisms within specified age groups, we collated them to create a single category: “Sports/others” for patients age 0–5 years and “Firearm/others” for patients age 6–12 years, to adhere to HCUP reporting guidelines. Injury intent was classified as unintentional, deliberate self-harm (e.g., suicide, attempted suicide and other self-inflicted injuries), other intentional injuries (e.g., assault and injuries sustained during law enforcement arrests), and injuries of undetermined intent.

Patient demographics, hospital characteristics and outcome measures

Demographic variables included age, sex, median household income by patients' residential zip code, insurance status at the time of discharge, and the specific payer for treatment received. Age was categorized into four groups (≤5, 6–12, 13–15, and 16–17 years), as described in prior literature.^10,18 In this report, patients ages 13–17 years are referred to as adolescents. NEDS does not report information on race. Hospital characteristics include geographic region and urban-rural designation where the ED was located, trauma center level designation, and teaching hospital status. Three outcome measures were assessed: mortality in the ED, ED disposition, and total ED charges.

Statistical analysis

Discharge-level sampling weights were applied to begin the analysis.¹² Patient and hospital characteristics were described across all age groups. Counts and proportions are presented for categorical data and median and interquartile ranges (IQR) for continuous data. Statistical significance was evaluated at p<0.05 using chi-square and Fischer's Exact Test for categorical data, and analysis of variance for continuous data. We performed subgroup analyses describing selected demographic and injury characteristics for TSCI-related ED visits that resulted in death. The financial burden incurred to treat childhood and adolescent TSCI in the ED was described using mean charge per ED visit for fatal and non-fatal TSCI, from which we computed cumulative ED charges over the study duration in 2010 U.S. dollars adjusted for inflation.¹⁹ We calculated annual cumulative incidence of childhood and adolescent TSCI as the total number of TSCI ED visits in each year, (excluding patients who were discharged to another acute care hospital to avoid the potential of double-counting patients who may have been transferred to another ED within the NEDS sampling frame, n=902), as a proportion of the total population of U.S. children and adolescents ages 17 years or younger for the same years.²⁰ Additionally, we estimated sex-stratified annual cumulative incidence and four-year cumulative incidence of childhood and adolescent TSCI. Sensitivity analyses were conducted comparing demographic factors, injury characteristics, and outcomes of children and adolescents with a principal versus secondary TSCI diagnosis. We examined the sub-population of patients who were discharged directly to home from the ED for their demographic and injury characteristics, as well as concurrent secondary diagnosis that accompanied their visit to the ED, where available. All analyses were conducted using STATA 12.0 (College Station, TX).

Results

Demographic and hospital characteristics

Of 6132 TSCI ED visits identified in these analyses, 72.5% were males and the median age was 15 years (interquartile range, IQR=12-16; Table 1). The male:female ratio was lower (1.2:1) in children ages 5 years and younger, compared to 3.7:1 among adolescents ages 16–17 years (Fig. 1). The majority of TSCI ED visits were at teaching hospitals (65.2%), at hospitals located in urban areas (87.0%), and in the southern (32.5%) and midwest (30.1%) U.S. regions. A total of 26.3% of childhood and adolescent TSCI were treated at non-trauma centers (Table 1).

FIG 1.

Age-specific gender distribution of childhood and adolescent traumatic spinal cord injuries, Nationwide Emergency Department Sample (2007–2010).

Table 1.

Patient and Hospital-Level Characteristics of All Children and Adolescents Presenting with Acute Traumatic Spinal Cord Injury to U.S. Emergency Departments between 2007 and 2010

Demographic and hospital characteristics	Count ^a	Proportion (%)
Total weighted count	6132	-
Patient demographics
Age (years)^b	15	12–16
Age groups
≤5 years	529	8.6
6–12 years	1174	19.2
13–15 years	1860	30.3
16–17 years	2569	41.9
Sex
Male	4447	72.5
Female	1685	27.5
Income quartile by residential zip code
0–25%	1680	28.1
25.1–50.0%	1685	28.2
50.1–75.0%	1418	23.8
75.1–100.0%	1186	19.9
Insurance status
Insured	5837	95.7
Uninsured	263	4.3
Primary payer
Government	1725	28.3
Private insurance	3788	62.1
Other third party^c	324	5.3
Uninsured	263	4.3
Hospital characteristics
Geographic region
Northeast	851	13.9
Midwest	1847	30.1
South	1994	32.5
West	1441	23.5
Urbanicity
Rural	800	13.0
Urban	5333	87.0
Hospital teaching status
Teaching hospital	4000	65.2
Non-teaching hospital	2132	34.8
Trauma center level
Not a trauma center	1613	26.3
Level I	2221	36.2
Level II	814	13.3
Level III	260	4.2
Level I or II	360	5.9
Level I,II, or III	864	14.1

Counts may not add up to the total because of missing data.

Median and interquartile range.

Includes Worker's compensation, Civilian Health and Medical Program of the Uniformed Services, Civilian Health and Medical Program of Veteran Affairs, Title V, and other government programs.

Cumulative incidence of childhood and adolescent TSCI in the U.S

Between 2007 and 2010, an average 17.5 per million population per year ages 17 years and younger sought emergency treatment for acute TSCI in the U.S., representing 1308 new injuries per year. The annual cumulative incidence of TSCI was 20.0 per million population in 2007, compared with 15.2 per million population in 2010 (p=0.119; Fig. 2). The cumulative incidence of TSCI in males was approximately 2.4 times greater than females in 2007, and 2.8 times greater in 2010.

FIG 2.

Annual incidence rates of childhood and adolescent traumatic spinal cord injuries stratified by gender, Nationwide Emergency Department Sample (2007–2010).

Age-specific visit and injury characteristics

Overall, cervical injuries were most common (19.8% high cervical and 20.7% lower cervical; Table 2). A total of 22.0% ED visits had no clearly defined level of injury recorded. SCIWORA and complete TSCI were identified in 54.8% and 9.7% of the study population, respectively. The overall median NISS was 16 (IQR=9-27) and 14.3% of TSCI-related ED visits had concurrent TBI. Median NISS remained unchanged between 2007 (16, IQR=10-27) and 2010 (17, IQR=9-27; p=0.703). The most common mechanism of injury was RTA (37.0%) followed by falls (20.4%). TSCI attributed to sports and firearm use occurred in 6.9% and 8.7% of ED visits respectively, while mechanism of injury was not specified in 7.0% of the study population (Fig. 3).

FIG 3.

Mechanism of childhood and adolescent traumatic spinal cord injuries, Nationwide Emergency Department Sample (2007–2010).

Table 2.

Visit and Injury Characteristics among Children and Adolescents Presenting to U.S. Emergency Departments with Acute Traumatic Spinal Cord Injury between 2007 and 2010

	Total	≤5 years	6–12 years	13–15 years	16–17 years
Visit and injury characteristics	n(%)^a	n(%)^a	n(%)^a	n(%)^a	n(%)^a	p
	6132	529	1174	1860	2569
ED visit timing						0.436
Weekday	3908 (63.7)	370 (70.0)	770 (65.5)	1167 (62.8)	1601 (62.3)
Weekend	2224 (36.3)	159 (30.0)	405 (34.5)	692 (37.2)	968 (37.7)
Level of injury						<0.001
C1-C4	1213 (19.8)	251 (47.4)	248 (21.1)	311 (16.8)	403 (15.7)
C5-C7	1270 (20.7)	79 (15.0)	146 (12.4)	419 (22.5)	626 (24.4)
Thoracic	1294 (21.1)	59 (11.2)	253 (21.5)	297 (16.0)	684 (26.6)
Lumbosacral	1009 (16.5)	42 (7.9)	121 (10.3)	328 (17.6)	518 (20.2)
Multi-site/other/unspecified	1347 (22.0)	98 (18.6)	407 (34.7)	504 (27.1)	338 (13.2)
SCIWORA						<0.001
Yes	3361 (54.8)	351 (66.4)	880 (75.0)	1145 (61.5)	985 (38.3)
No	2771 (45.2)	178 (33.6)	294 (25.0)	715 (38.5)	1585 (61.7)
Injury severity						0.206
No paraplegia/ quadriplegia	5830 (95.1)	488 (92.2)	1134 (96.5)	1798 (96.7)	2410 (93.8)
Paraplegia	135 (2.2)	18 (3.4)	22 (1.8)	34 (1.8)	61 (2.4)
Quadriplegia	168 (2.7)	23 (4.4)	19 (1.6)	27 (1.5)	98 (3.8)
Injury type						0.004
Complete	592 (9.7)	55 (10.3)	64 (5.4)	142 (7.6)	333 (13.0)
Incomplete	5540 (90.3)	474 (89.7)	1111 (94.6)	1718 (92.4)	2237 (87.1)
Concurrent TBI						0.024
Yes	879 (14.3)	127 (24.0)	142 (12.1)	251 (13.5)	359 (14.0)
No	5254 (85.7)	402 (76.1)	1032 (87.9)	1609 (86.5)	2210 (56.0)
NISS	16 (9–27)	22 (13–29)	10 (9–22)	13 (9–21)	18 (10–29)	<0.001
NISS categories						<0.001
9 to 15	3048 (49.7)	151 (28.5)	756 (64.4)	1136 (61.1)	1005 (39.1)
16 to 25	1397 (22.8)	168 (31.8)	174 (14.9)	377 (20.3)	677 (26.4)
Above 25	1687 (27.5)	210 (39.7)	244 (20.8)	347 (18.6)	886 (34.5)
Injury intent						<0.001
Unintentional	4976 (81.1)	458 (95.3)	984 (96.8)	1511 (89.1)	1976 (80.5)
Deliberate self-harm	35 (0.6)	≤10^c	≤10^c	≤10^c	30 (1.2)
Other intentional causes^b	483 (7.9)	14 (2.6)	14 (1.2)	142 (7.6)	313 (12.2)
Undetermined intent	639 (10.4)	58 (10.9)	167 (14.2)	186 (10.0)	228 (8.9)
Mechanism of injury						<0.001
RTA	2111 (34.4)	269 (50.9)	354 (30.2)	482 (25.9)	1006 (39.2)
Falls	1164 (19.0)	95 (18.0)	347 (29.5)	316 (17.0)	406 (15.8)
Firearm	509 (8.3)	27 (5.0)	-	129 (6.9)	353 (14.0)
Struck by others/objects	928 (15.1)	19 (3.5)	163 (13.9)	399 (21.5)	347 (13.5)
Sports	391 (6.4)	-	96 (8.2)	179 (9.6)	116 (4.5)
Others	443 (7.2)	-	-	208 (11.2)	235 (9.2)
Firearm/others	85 (1.4)	-	85 (7.3)	-	-
Sports/others	70 (1.1)	70 (13.2)	-	-	-
Not reported	432 (7.0)	49 (9.3)	129 (11.0)	147 (7.9)	107 (4.2)

Counts may not add up to the total because of missing data.

Includes assault and injuries sustained during law enforcement arrests.

A cell count of ≤10 is presented to adhere to reporting guidelines set by the Healthcare Cost and Utilization Project (HCUP) as privacy precaution.

ED, emergency department; SCIWORA, spinal cord injury without radiologic abnormality; TBI, traumatic brain injury; NISS, new injury severity score; RTA, road traffic accidents.

Children ages 5 years and younger had more severe injuries and were more likely to be injured from a RTA, sustain high cervical injuries, and experience concurrent TBI, compared to older children and adolescents ages 6–12, 13–15, and 16–17 years (all, p<0.001; Table 2). Complete injury was identified in 10.3% of children ages 5 years and younger.

RTA (30.2%) and falls (29.5%) were the two most common mechanism of TSCI in children age 6–12 years, with majority sustaining high cervical (21.1%) and thoracic level (21.5%) injuries. Complete injury was present in 5.4% of children age 6–12 years.

The prevalence of intentional injuries, both self-inflicted and inflicted by others, was lowest in children 12 years and younger. As age increased, the proportion of intentional injuries increased concomitantly, with self-inflicted injuries occurring mostly among adolescents age 16–17 years (Table 2). Of the total of 8.3% of firearm-induced TSCI, 70.2% were intentional injuries and 94.7% occurred among adolescents between ages 13 and 17 years.

Fatal injuries

Thirty-five children and adolescents (0.6%) with TSCI died in the ED; most were male (62.5%), were injured from RTA (88.6%), and succumbed to cervical injury (74.3%). Forty percent of ED deaths were among children ages 5 years and younger. The median NISS for fatal injuries was 27 (IQR=9-42), 11 points higher than the median NISS in non-fatal injuries (16, IQR=9-27) though not statistically significant (p=0.239).

Discharge disposition and total ED charges

In total, 62.4% of children and adolescents presenting to U.S. EDs with acute TSCI were admitted directly for inpatient care, 20.1% were discharged home, and 1.8% were discharged directly to a chronic care or rehabilitation facility (Fig. 4).

FIG 4.

Emergency department discharge disposition among traumatic spinal cord injured children and adolescents, Nationwide Emergency Department Sample (2007–2010).

Compared with patients who were not discharged home, patients who were discharged home directly from the ED were more likely to present to the ED on a weekday, to an ED located in a rural area, a non-teaching hospital-based ED, and a non-trauma center (all, p<0.001; Table 3). Patients discharged home were less likely than patients who were not discharged home to have been injured from an intentional cause, sustained an RTA or firearm injury, and have lower injury severity (all, p<0.001). Frequent accompanying secondary diagnoses among patients who were discharged home were sprains and strains, disturbance of skin sensation, concussion, SCIWORA, and injury to face, head, and neck.

Table 3.

Comparison of Demographic Features and Hospital and Injury Characteristics Between TSCI-Related ED Visits That Were Discharged Home with Those Not Discharged Home

	Discharged home		Not discharged home
Variable	Count^a	Proportion (%)	Count^a	Proportion (%)	p value
Weighted count (row %)	1224	20.1	4873	79.9	-
Age groups					0.308
≤5 years	74	6.0	441	9.0
6–12 years	391	31.9	783	16.1
13–15 years	405	33.1	1434	29.4
16–17 years	354	29.0	2215	45.5
Sex					0.383
Male	861	70.4	3564	73.1
Female	363	29.6	1310	26.9
Timing of visit					0.015
Monday-Friday	862	70.4	3029	62.2
Saturday/Sunday	362	29.6	1845	37.9
Geographic region					0.770
Northeast	190	15.5	661	13.5
Midwest	379	31.0	1455	29.9
South	368	30.1	1608	33.0
West	287	23.4	1149	23.6
Urbanicity					<0.001
Rural	264	21.6	513	10.5
Urban	959	78.4	4360	89.5
Hospital teaching status					<0.001
Teaching hospital	605	49.4	3388	69.5
Non-teaching hospital	619	50.6	1486	30.5
Trauma center level					<0.001
Not a trauma center	617	50.4	982	20.2
Level I	313	25.5	1900	39.0
Level II	118	9.7	687	14.1
Level III	89	7.3	167	3.4
Level I or II	16	1.3	344	7.0
Level I,II or III	71	5.8	793	16.3
Income quartile					0.248
0–25%	303	25.1	1365	28.9
25.1–50.0%	308	25.5	1368	28.9
50.1–75.0%	328	27.2	1090	23.1
75.1–100.0%	268	22.2	905	19.1
Insurance status					0.070
Insured	1135	93.8	4675	96.3
Uninsured	75	6.2	179	3.7
Injury intent					<0.001
Unintentional	1105	90.3	3840	78.8
Deliberate self-harm	≤10^c	-	35	0.7
Other intentional causes^b	28	2.3	450	9.2
Undetermined intent	91	7.4	548	11.2
External causes of injury					<0.001
Falls	323	26.4	841	17.3
RTA	255	20.8	1825	37.5
Firearm injuries	12	1.0	502	10.3
Struck by others/objects	317	25.9	610	12.5
Sports-related	92	7.5	304	6.2
Others	155	12.7	429	8.8
Not reported	69	5.7	362	7.4
Level of injury					<0.001
C1-C4	186	15.2	1017	20.9
C5-C7	161	13.2	1092	22.4
Thoracic	226	18.5	1067	21.9
Lumbosacral	187	15.3	822	16.9
Multi-site/other/unspecified	464	37.9	874	17.9
SCIWORA					<0.001
Yes	931	76.1	2426	49.8
No	293	23.9	2448	50.2
Type of spinal cord injury					<0.001
Complete	23	1.9	561	11.5
Incomplete	1200	98.1	4313	88.5
Concurrent TBI					<0.001
Yes	39	3.2	835	17.1
No	1185	96.8	4039	82.9
NISS categories					<0.001
9 to 15	1094	89.4	1941	39.8
16 to 25	105	8.6	1288	26.4
Above 25	24	2.0	1645	33.8

Counts may not add up to the total because of missing data.

Includes assault and injuries sustained during law enforcement arrests.

A cell count of ≤10 is presented to adhere to reporting guidelines set by the Healthcare Cost and Utilization Project as a privacy precaution.

TSCI, traumatic spinal cord injury; ED, emergency department; RTA, road traffic accidents; SCIWORA, spinal cord injury without radiologic abnormality; TBI, traumatic brain injury; NISS, new injury severity score.

The average ED-related charge incurred per visit between 2007 and 2010 was $4133 (95% CI: $3765-$4504) for non-fatal injuries and $12,903 (95% CI: $6059-$19,746) for fatal injuries (p<0.001; Table 4). The average charge for non-fatal injuries increased from $3495 (95% CI: $2952-$4039) in 2007 to $4889 (95% CI: $4023-$5756) in 2010 (p=0.008). Overall cumulative ED charge incurred to manage acute TSCI (fatal and non-fatal) in U.S. EDs amounted to $25.7 million over the study duration. In 2010, the average inflation-adjusted total ED-related charge incurred per visit was significantly greater than that in 2007 by $1394.

Table 4.

Financial Burden Incurred for Treatment of Acute Traumatic Spinal Cord Injuries among Children and Adolescents Presenting at U.S. Emergency Departments (EDs), 2007–2010

Total charges	Alive at discharge (95% CI) N=6,097	Died in the ED (95% CI) N=35
Average charge per visit (2007–2010)	$4133 ($3765-$4504)^a	$12,903 ($6059-$19,746)^b
2007	$3495 ($2952-$4039)	-
2008	$4029 ($3255-$4802)	-
2009	$4128 ($3424-$4832)	-
2010	$4889 ($4023-$5756)^c	-
Annual cumulative charges	$6,299,725 ($5,738,801-$6,865,222)	$112,901 ($53,016-$172,778)
4-year cumulative charges	$25,198,901 ($22,955,205-$27,460,888)	$451,605 ($212,065-$691,110)

Annual cumulative charge=(a ^* N)/4

p<0.001 comparing average charge per visit among patients who died in the ED versus those who were discharged alive.

p=0.008 comparing average charge per visit for the treatment of children with acute traumatic spinal cord injuries who were alive at discharge in 2010 versus 2007.

Average charge per visit for individual years among patients that died in the ED were not calculated because of small sample sizes in individual years.

Sensitivity analyses

Child and adolescent ED visits with a secondary diagnosis of TSCI totaled 1499 (24.4%) cases. There was no difference in the distribution of age, gender, income quartile, insurance status, ED visit timing, and hospital characteristics comparing patients with principal versus secondary diagnosis of TSCI (Table 5). However, patients with a secondary diagnosis of TSCI had higher median NISS (22, IQR=13-29 vs. 13, IQR=9-24), were more likely to present with high cervical TSCI (22.1% vs. 19.0%) have intentional injuries (16.2% vs. 6.4%), and to be injured in a RTA (41.1% vs. 32.3%) or from firearm use (17.2% vs. 5.6%), compared with patients with a principal diagnosis of TSCI (all, p<0.01). Fewer patients with a secondary diagnosis of TSCI had complete spinal cord injuries. While there was no difference in mortality, compared with patients carrying a principal diagnosis of TSCI, patients with a secondary diagnosis of TSCI were more likely to be treated at a trauma center (77.7% vs. 72.4%; p=0.044) and to be admitted for inpatient care (71.4% vs. 59.5%; p<0.001), further suggesting that a secondary diagnosis of TSCI sufficiently captured acute traumatic injuries.

Table 5.

Sensitivity Analysis: Comparison of Demographic Features, Hospital and Injury Characteristics, and Outcomes Comparing TSCI-Related ED Visits with Principal and Secondary Diagnosis of TSCI

	Principal TSCI		Secondary TSCI
Variable	Count^a	Proportion (%)	Count^a	Proportion (%)	p value
Weighted count (row %)	4633	75.6	1499	24.4	-
Age (years)^b	15	12–16	15	11–16	0.084
Age groups					0.308
≤5 years	372	8.0	157	10.5
6–12 years	853	18.4	321	21.4
13–15 years	1436	31.0	423	28.2
16–17 years	1972	42.6	598	39.9
Sex					0.699
Male	3347	72.2	1100	73.4
Female	1286	27.8	399	26.6
Timing of visit					0.546
Monday-Friday	2931	63.2	977	65.2
Saturday/Sunday	1703	36.8	522	34.8
Geographic region					0.152
Northeast	670	14.5	181	12.1
Midwest	1451	31.3	396	26.4
South	1478	31.9	516	34.4
West	1035	22.3	406	27.1
Urbanicity					0.422
Rural	626	13.5	173	11.6
Urban	4007	86.5	1326	88.4
Hospital teaching status					0.020
Teaching hospital	2936	63.4	1065	71.0
Non-teaching hospital	1697	36.6	434	29.0
Trauma center level					0.030
Not a trauma center	1279	27.6	334	22.3
Level I	1670	36.1	551	36.8
Level II	634	13.7	180	12.0
Level III	219	4.7	41	2.7
Level I or II	264	5.7	96	6.4
Level I,II or III	567	12.2	297	19.8
Income quartile					0.562
0–25%	1255	27.8	426	29.4
25.1–50.0%	1242	27.5	442	30.6
50.1–75.0%	1106	24.5	312	21.5
75.1–100.0%	918	20.2	268	18.5
Insurance status					0.229
Insured	4390	95.3	1446	96.9
Uninsured	216	4.7	47	3.1
Primary payer					<0.001
Government	1159	25.2	567	38.0
Private insurance	2994	65.0	794	53.2
Other third party^c	238	5.1	85	5.7
Uninsured	216	4.7	47	3.1
Injury intent					<0.001
Unintentional	3887	83.9	1089	72.6
Deliberate self-harm	29	0.6	≤10^e	-
Other intentional causes^d	253	5.5	230	15.3
Undetermined intent	465	10.0	174	11.6
External causes of injury					<0.001
Falls	992	21.4	171	11.4
RTA	1495	32.3	616	41.1
Firearm injuries	261	5.6	259	17.2
Struck by others/objects	798	17.2	129	8.6
Sports-related	318	6.9	77	5.2
Others	448	9.7	137	9.1
Not reported	321	6.9	111	7.4
Level of injury					0.002
C1-C4	881	19.0	332	22.1
C5-C7	1081	23.3	189	12.6
Thoracic	919	19.8	375	25.0
Lumbosacral	730	15.8	279	18.6
Multi-site/other/unspecified	1023	22.1	324	21.7
SCIWORA					<0.001
Yes	2380	51.4	981	65.5
No	2253	48.6	518	34.5
Completeness of spinal cord injury					<0.001
Complete	524	11.3	68	4.6
Incomplete	4109	88.7	1431	95.4
Concurrent TBI					0.092
Yes	708	15.3	171	11.4
No	3925	84.7	1328	88.6
NISS	13	9–24	22	13–29	<0.001
NISS categories					<0.001
9 to 15	2575	55.6	473	31.5
16 to 25	1048	22.6	350	23.3
Above 25	1010	21.8	677	45.2
Disposition if discharged alive					<0.001
Home	921	20.0	303	20.4
Inpatient	2749	59.5	1057	71.4
To another acute care hospital	799	17.3	103	6.9
To a chronic care facility/program^f	95	2.1	13	0.9
Miscellaneous^g	52	1.1	5	0.3
Died in the ED	17	0.4	18	1.2	0.120

Counts may not add up to the total because of missing data.

Median and interquartile range.

Includes Worker's compensation, Civilian Health and Medical Program of the Uniformed Services, Civilian Health and Medical Program of Veteran Affairs, Title V, and other government programs.

Includes assault and injuries sustained during law enforcement arrests.

A cell count of ≤10 is presented to adhere to reporting guidelines set by the Healthcare Cost and Utilization Project as a privacy precaution.

Includes skilled nursing facilities, intermediate care facilities, and home health care programs.

Includes “AMA, Against medical advice,” “transferred to court/ law enforcement,” as well as “discharged alive, but destination unknown.”

TSCI, traumatic spinal cord injury; ED, emergency department; RTA, road traffic accident; SCIWORA, spinal cord injury without radiologic abnormality; NISS, new injury severity score.

Discussion

Between years 2007 and 2010, for every one million children and adolescents in the U.S., an average 17.5 children and adolescents presented to the ED with acute TSCI. This represents 1308 child and adolescent ED visits per year for acute TSCI, with annual ED charges totaling $6.4 million. Throughout the study period, a total of 3806 child and adolescent patients (62.4%) with acute TSCI were admitted to inpatient care from the ED, with 35 (0.6%) ED deaths.

Our findings of TSCI cumulative incidence of 17.5 per million population per year is lower than the 19.9 per million population per year previously reported by Vitale and colleagues from an analysis of the 1997–2000 Kids' Inpatient Database.¹⁰ Our estimates are however higher than the incidence of childhood and adolescent TSCI, 4.6 per million population reported in Sweden between 1985 and 1996, and 11.0 to 14.0 per million population reported in Coimbra, Portugal between 1989 and 1992.^21,22

In our study, on average, 952 children and adolescents (62.4%) per year were admitted for inpatient care from the ED.¹⁰ Our epidemiological approach presents a better estimate of the burden of acute childhood and adolescent TSCI. First, TSCI cumulative incidence calculations were derived from ED utilization and have the advantage of including patients who are not admitted to inpatient care. Although persons discharged from the ED were less likely to have sustained a complete spinal cord injury, concurrent TBI, or SCI with radiologic abnormality, proportionately more patients presented to a non-trauma center, and without insurance which could have influenced the decision for discharge. Patients also may have been discharged against medical advice, a category that could not be analyzed as a line item in adhering to HCUP reporting guidelines of very rare events. It is also possible that during the acute phase of injury, some persons with TSCI may be discharged because they experience improvement in neurological deficits, such as with a neurapraxia. In the future, it will be worth examining the outcomes of persons who were discharged from the ER following admission for TSCI.

Second, our inclusion criteria limited TSCI to only acute injuries based on ICD-9-CM codes 806.* and 952.*. This is in contrast to findings from Vitale and colleagues, which included ICD-9-CM code 907.2, representing late effects of spinal cord injury (SCI).¹⁰ By excluding a diagnosis of late effects of TSCI, we limit the possibility of including patients with remote TSCI in incidence calculations. Additionally, we performed a sensitivity analysis to ensure that we did not include remote TSCI in incidence calculations. Third, we avoided double-counting patients who had been transferred from the ED to another acute care hospital because of the potential that they were subsequently admitted to another ED in the NEDS sampling frame. These, and the absence of data in the NEDS pertaining to pre-hospital deaths, may suggest that our current findings are a conservative estimate of the true burden of childhood and adolescent TSCI in the U.S.

The annual cumulative incidence of childhood and adolescent TSCI in the U.S. remained fairly stable over the study duration. This is in contrast to non-age-specific reports suggesting a rise in overall TSCI incidence in the U.S.^4,23

–26 We recently reported increasing annual cumulative incidence of adult TSCI among person's ages 65 years and older.³

Despite fairly stable annual cumulative incidence, the average treatment charge per ED visit increased steadily between 2007 and 2010, even after accounting for the cost of inflation. Assuming a constant child and adolescent TSCI incidence rate through to 2017, we estimate that approximately $12 million in ED charges would be incurred to treat acute TSCI in 2017.

Concurring with previous studies, the male-to-female distribution of TSCI is fairly balanced in younger children; however, with increasing age, male predominance becomes more apparent.^10,18,26,27 At age 16 to 17 years, for every female, there were four males injured with TSCI (Fig. 2). Similar to prior reports^{5,6,10,18,27,28} RTAs remain the most common cause of TSCI and are more commonly implicated in children 5 years and younger (50.9%) but less so in children 6–17 years (25.9%–39.2%). Older children (13–17 years) are more likely to have intentional injuries from assaults and firearms. Assault and firearm-induced TSCI, especially among adolescents, has been on the increase since the mid-1990s.^5,29
–31 In this study, 25% of all TSCI was a result of firearm use or being struck by others/objects.

Significantly more children age 5 years and younger sustained high cervical injuries, complete TSCI, concurrent TBI and greater median NISS scores, compared with older children. Prior studies report similar injury patterns and trends.^{5,8,10,18,31
–33} Several hypothesis have been reported for this observation. Back seat failure and improper head/body restraint in car seats are common causes of whiplash injuries, particularly in rear end collisions.^34,35 The cervical spine above C4 in children younger than 8 years has been shown to be anatomically and biomechanically different than the mature adult spine. Hyperlaxity of ligamentous attachments and musculoskeletal constituents, incomplete ossification, a larger head-to-torso ratio are among factors that predispose young children to high cervical injuries even after low impact rear-end collisions.^5,7,31,32,36

Among adolescents ages 16–17 years, the median NISS was 18, representing severe injuries, with 40.0% involved in a RTA. Although TBI rates were not as high as that seen in children 5 years and younger, reports suggest that the use of lap-shoulder belts in older children predisposes them to thoracic level injuries and consequent intra-thoracic and intra-abdominal injuries, which may be driving the composite NISS score and represents multiple severe injuries.^33
–35 More research is necessary to understand how to maximize the safety potential of car seats, seatbelts, airbags and road safety laws so that these injuries can be avoided among road users of all ages.

Children ages 6–12 years were least affected by intentional injuries. In addition to RTA, falls, being struck by others/objects, and sports were common causes of TSCI in this age group. Targeted research in this age group is necessary to understand how, why, and when these injuries occur. Educating parents, teachers and peers on prevention strategies and how to handle potential TSCI-injured children may minimize avoidable neurological sequelae.

Besides optimizing injury prevention strategies, it is vital to ensure that, once injured, patients are getting to the appropriate level of care immediately. Characterized as major trauma, TSCI treatment protocols recommend that all patients with potential TSCI be treated at a Level I trauma center.³⁷ We determined that up to 25.0% of injuries were managed at a non-trauma center and 14.7% required transfers to another acute care hospital. An acutely injured spinal cord runs the risk of further neurologic deterioration resulting from secondary injuries to the spinal cord.³⁸ A common cause of secondary injury is inadvertent movement of the spinal cord, which could arise during transport from one center to another. Besides potentially exposing the patient to additional movement, hospital transfers cause a delay in administering definitive care and may predispose patients to worse outcomes.^37
–39 Further research is necessary to understand the reasons why as many as 25.0% of acute TSCIs in children and adolescents are managed in non-trauma centers and how this affects patient outcomes.

Limitations associated with these analyses are associated primarily with use of administrative databases in research. Detailed clinical and social histories necessary to provide a more comprehensive assessment of TSCI characteristics, such as drug history or exact mechanisms by which a fall or RTA took place, are not available in administrative databases. Further, comprehensiveness and quality of information present in the database relies on accuracy of physician reporting and data entry.⁴⁰ Complete versus incomplete TSCI was determined by ICD-9-CM codes. Although American Spinal Injury Association Impairment Scale (AIS) scores⁴¹ are necessary to describe the degree of functional impairment following SCI, NEDS does not collect this information nor is the procedure of assessment of complete versus incomplete TSCI made by each ED physician reported. Because of the progressive nature of neurologic injury at onset, the challenges associated with AIS evaluations in young children,⁴² and the availability of physicians trained to evaluate SCI in the ED, ICD-9-CM code determination of injury severity in the ED may be misclassified. To enhance the true ascertainment of SCI severity, we encourage NEDS to implement the ascertainment and collection of AIS classification for persons presenting to EDs with SCI. This information will provide a more accurate burden of injury severity and help make appropriate worldwide comparisons.

The main strength of this analysis is the utilization of a representative sample of all U.S. ED visits regardless of trauma center level designation to estimate the incidence of childhood and adolescent TSCI. Findings from this study provide updated objective national estimates of the burden of acute childhood and adolescent TSCI and may serve as a benchmark for future studies.

In conclusion, an average of 1308 children and adolescents in the U.S sustained TSCI each year over the study duration. Although cumulative incidence rates and overall injury severity held fairly steady during the study period, average ED charge per visit increased. RTAs remain the leading cause of non-fatal and fatal TSCI, disproportionately affecting children 5 years and younger, while intentional assaults including firearm-related TSCI are most common among adolescents. TSCI prevention is of paramount importance. Findings from this study may help policymakers and stakeholders understand the current burden and characteristics of acute TSCI among children and adolescents, which is necessary to ensure optimal resource planning for health care prevention, treatment and rehabilitation.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix

Appendix C.

Description of ICD-9 Codes for Complete Traumatic Spinal Cord Injury

ICD-9 Code	ICD-9 code description ^a
806.01	C1-C4 closed fracture with complete lesion of cord
806.06	C5-C7 closed fracture with complete lesion of cord
806.11	C1-C4 open fracture with complete lesion of cord
806.16	C5-C7 open fracture with complete lesion of cord
806.21	T1-T6 closed fracture with complete lesion of cord
806.26	T7-T12 closed fracture with complete lesion of cord
806.31	T1-T6 open fracture with complete lesion of cord
806.36	T7-T12 open fracture with complete lesion of cord
806.61	Closed fracture of sacrum and coccyx with complete cauda equina lesion
806.71	Open fracture of sacrum and coccyx with complete cauda equina lesion
952.01	C1-C4 level complete spinal cord injury without evidence of spinal bone injury
952.06	C5-C7 level complete spinal cord injury without evidence of spinal bone injury
952.11	T1-T6 level complete spinal cord injury without evidence of spinal bone injury
952.16	T7-T12 level complete spinal cord injury without evidence of spinal bone injury
952.4	Cauda equina syndrome without evidence of spinal bone injury

ICD-9 code descriptions are standard descriptions based on the World Health Organization's International Classification of Diseases, Ninth Revision.¹

1. Classifications of Diseases, Functioning, and Disability [Internet]. Hyattsville (MD): National Center for Health Statistics; [updated 2010 Jan 04; reviewed 2009 Sep 1]. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Available at: www.cdc.gov/nchs/icd/icd9cm.htm. Accessed November 21, 2012.

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The Epidemiology of Childhood and Adolescent Traumatic Spinal Cord Injury in the United States: 2007–2010

Abstract

Introduction

Methods

Study design and setting

Study population

Characterization of TSCI

Patient demographics, hospital characteristics and outcome measures

Statistical analysis

Results

Demographic and hospital characteristics

Cumulative incidence of childhood and adolescent TSCI in the U.S

Age-specific visit and injury characteristics

Fatal injuries

Discharge disposition and total ED charges

Sensitivity analyses

Discussion

Footnotes

Author Disclosure Statement

Appendix

References