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Thread: Life Expectancy after Spinal Cord Injury

  1. #1

    Life Expectancy after Spinal Cord Injury

    Life Expectancy after Spinal Cord Injury
    Wise Young PhD MD
    1 June 2012

    A friend with spinal cord injury asked me recently what his life expectancy is. I told him that there have been many studies and the results should be readily available through the published literature. He asked if I could summarize that literature. So, here it is.

    Early studies of life expectancy in spinal cord injury showed that people with spinal cord injury lived short lives before World War II. During World War II, life expectancy after spinal cord injury could be measured in weeks [1]. Life expectancy increased significantly for people injured in the 1960’s and the 1970’s, compared to those injured in the 1950’s. Le and Price [2] estimated a mean survival of 110.5 months (9 years and 2.5 months) for spinal cord-injured persons who were injured between 1963 and 1976. This was much longer than the figure of 52.8 months (4 years and 4.8 months) calculated in 1955 by Dietrick and Russi. The leading causes of death were due to cardiovascular condition, respiratory infections, suicide, and urinary tract damage. Deaths due to renal disease declined but death due to suicide, liver disease, and alcohol abuse increased markedly [3].

    By 1980’s, however, a 30.2 year mean life expectancy was an agreed upon value for people with spinal cord injury. DeVivo, et al. [4] used this figure to estimate spinal cord injury prevalence of 906 cases per million persons in the United States. Minaire, et al. [5] pointed out that most deaths occurred early after spinal cord injury but for people who survived a year or more after injury, life expectancy approached values observed in the general population in France. The leading causes of death in 9135 persons injured between 1973 and 1984 were pneumonia, non-ischemic heart disease, septicemia, pulmonary emboli, and ischemic heart disease [6]. Amongst veterans with traumatic spinal cord injury, compared to non-disabled veterans, survival was comparable for approximately 20 years after onset but survival of those with spinal cord injury fell off beyond this point [7]. Old age at the time of injury was a strong predictor of poor survival but, amongst patients who survived the acute phase of injury, long-term survival approached normal lifespans.

    Life expectancy of people with high cervical injuries was low. In 1995, DeVivo, et al. [8] studied 435 ventilator-dependent spinal-injured persons admitted to the Model Systems between 1973 and 1992. The one-year survival rate was 25.4% and 15-year survival rate was 16.8%. However, those who survived the first year, the cumulative survival over 14 years was 61.4%. Moreover, mortality rates of ventilator dependent people injured after 1986 fell by more than 91% compared to 1973. In 2011, Watt, et al. [9] did a retrospective review of spinal cord injury who had assisted ventilation on or after admission in 1981-2005. Mean survival of weaned patients in the age group of 31-45 was 19.3 years compared to 10.5 years for ventilated patients. Survival was only better during the first few years [10].

    The trend for decreased mortality rate after spinal cord injury occurred around the world. In 1997, Hartkopp, et al. [11] reported a remarkable decline in mortality rates of complete tetraplegics in Denmark between 1953-1972 versus 1972-1992. In Canada, McColl, et al. [12] studied patients injured at ages 25-34 between 1945 and 1990. The study predicted a median survival time of 38 years post-injury, with 43% surviving at least 40 years. In England, a 50-year study revealed that the leading cause of death was from respiratory infections, followed by urinary infections and heart disease. In Australia, the projected mean life expectancy approached 70% of normal for individuals with complete tetraplegia and 84% of normal for complete paraplegics [13]. Norway has similar results [14]. In Africa, improved survival can result from small advances in technology. For example, a study from Nigeria [15] showed that patients treated with suprapubic cystotomy (SPC) had significantly less mortality than urethral catheterization (9% vs. 36%).

    Spinal injured children have a slightly lower life expectancy compared to people who were injured as adults. The risk of mortality depended on the amount of remaining function [16]. Mortality risk in children with spinal cord injury was highest during the first 10 years, higher than children with traumatic brain injury. However, after 10 years, the statistics began to converge. For high-functioning persons, life expectancies were only 3-5 years shorter than the general population. However, for those without mobility 6 months after injury, the life expectancy was only 15 years. However, according to Shavelle, et al. [17], for children who survived more than 2 years after injury, their life expectancy were only slightly less than an otherwise comparably injured person who was injured as an adult. A person with minimal deficits had approximately 83% of normal life expectancy compared to 50% in a person injured in childhood at a high cervical level but without ventilation.

    While life expectancy is increasing, the rate of depression has increased as well. For example, according to Kemp and Krause in 1999 [18] the average age of people with spinal cord injury in the United States was in the late 40’s. A higher percentage of people with spinal cord injury, i.e. 41%, have significant depressive symptoms compared to only 22% and 15% of people with polio and non-disable people. While expectations of quality of life remain relatively high, independence declined in the fifth decade post-injury [19].

    Most of the improvement of life-expectancy in spinal cord injury is due to reduced mortality during the first two years. The life expectancy of people who survive more than 2 years tend to be similar to the normal population [20]. The improved early survival may be due to better acute spinal cord injury care, critical care, and rehabilitation. Chronic care has not changed as dramatically and may even have declined. In 1999, DeVivo, et al. [21] showed that the odds of dying fell by 67% in 1993-1998, compared to 1973-1977. However, mortality rates after the first anniversary of injury, which had been declining steadily from 1973 to 1998, actually increased 33% for persons injured between 1993-1998, compared to those injured between 1988-1992. This suggests the need for renewed efforts to prevent and treat complications of spinal cord injury.

    Strauss, et al. [22] in 2008, published an article entitled “Economic factors and longevity in spinal cord injury: a reappraisal” in the Archives of Physical Medicine and Medical Rehabilitation. Using the Model Systems database, which documents 7331 persons injured since 1873 and evaluated between November 1995 and 2005, they found that life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. The positive effects of favorable economics, however, were substantially less than previously reported, largely because health care insurance through worker’s compensation was no longer as powerful a predictor of survival.

    In 2010, Krause & Saunders surveyed 1361 adults for an average of 9.7 years after traumatic spinal cord injury. Mortality was determined in 2007. Risk factors that were predictive of mortality include smoking, binge alcohol consumption, and psychotropic medications. In 2011, Krause & Saunders [23] assessed the same group of patients and found that a history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized in the past year were predictive of mortality. Using 3 age points as examples, the greatest estimated lost life expectancy was associated with chronic pressures ulcers (50.3%), following by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and a diagnosis of probable major depression (18%). There was a 6.7% reduction in life expectancy for each standard deviation of increase in urinary tract infections. Finally, Krause, et al. [24] found that the odds of mortality were significantly higher for those with income between $25,000 and $75,000, compared to those with incomes of >$75,000.

    Complications of spinal cord injury increase with age. In 2012, DeVivo [25] pointed out that the rise of complications associated with older people with spinal cord injury will ensure that the percentage of older persons with spinal cord injury will not increase until better care of these older patients becomes available. Groah, et al. [26] pointed out that life expectancy increases in older patients with spinal cord injury have not kept pace with life expectancy increases in non-injured people and that the causes are likely to be multifactorial, including injury occurring in older individuals, susceptibility of people with spinal cord injury to numerous conditions that impose a health risk, and some people with spinal cord injury engaging risky behavior.

    Krause & Saunders [27] examined risk factors in spinal cord injury and control populations. They found that age, disability, smoking and income significantly increase mortality in people with spinal cord injury and that the effects of these risky factors are magnified in people with spinal cord injury compared to the general population. They [28] also examined the model systems data and confirmed that household income and education have very significant effects on life expectancy. Risk of mortality is substantially increased with poor socioeconomic characteristics. Although the authors of this study did not say so, I suspect that this may well be due to increasing disparity in the quality of medical care delivered to wealthy and poor in the United States. One of the highest correlates with survival and better quality of life is education level achieved, suggesting that knowledgeable care of oneself is conducive to longer and better quality of life.

    Finally, Middleton, et al. [29] in Australia did a 50 year analysis of mortality in 2013 persons injured between January 1955 and June 2006. Within the first year after injury, 88 people with tetraplegia (8.2%) and 38 persons with paraplegia (4.1%) died. Among first year survivors, overall 40-year survival rates were 47% and 62% for persons with tetraplegia and paraplegia, respectively. This statistic is probably representative life expectancy of spinal cord injury around the world. If you had severe spinal cord injury in the past 50 years, you have about 6% chance of dying the first year, a bit less if you were paraplegic (4.1%) and a bit more (8.1%) if you were tetraplegic. If you have a severe high cervical (C1-4) injury at age 25, you have a 64-69% chance of surviving to 65 years old, 65-74% for a severe cervical injury (C5-8), 88-91% for severe lower thoracic and lumbosacral injury (T1-S5), 96-97% for mild spinal cord injuries (ASIA D).

    In summary, life expectancy for people with spinal cord injury was very low only 50 years ago. The average survival of people after spinal cord injury was about 52.8 months in the 1950’s. By the 1960’s, this number had more than doubled to 110.5 months. By the 1980’s, most epidemiologists agreed that average survival was over 30 years. Life expectancy continued to increase over the 1990’s, such that more than half of people survive over 40 years after spinal cord injury. Mortality of course varied depending on treatment severity, level, and age of injury. Those with the most severe and highest levels of injury, including ventilator dependency have the lowest survival rates. People who were injured at an older age had lower survival rates. However, a large majority of people now injured at age 25 can look forward to surviving to 65 years or older. Over 90% of people with thoracic/lumbar spinal cords injuries or incomplete spinal cord injuries survive to age 65. Paradoxically, after many decades of steadily increasing life expectancy, mortality rates for older people with spinal cord injury have increased in the past decade, possibly because the decline in health care coverage for older people with severe disabilities. Recent reports suggest that people with lower household incomes have significantly lower life expectancy than people who earn more than $75,000 per year. Thus, many factors influence life expectancy after spinal cord injury, including the extent of neurological impairment and socioeconomic factors. But, if people can and do take care of themselves and do not engage in risky behaviors (such as smoking), they should have life expectancies that are close to the general population.

    Reference
    1. Schneider RC, Webster JE, Lofstrom JE. A follow-up report of spinal cord injuries in a group of World War II patients. J Neurosurg. 1949;6(2):118-26.
    2. Le CT, Price M. Survival from spinal cord injury. J Chronic Dis. 1982;35(6):487-92.
    3. Geisler WO, Jousse AT, Wynne-Jones M, Breithaupt D. Survival in traumatic spinal cord injury. Paraplegia. 1983;21(6):364-73.
    4. DeVivo MJ, Fine PR, Maetz HM, Stover SL. Prevalence of spinal cord injury: a reestimation employing life table techniques. Arch Neurol. 1980;37(11):707-8.
    5. Minaire P, Demolin P, Bourret J, Girard R, Berard E, Deidier C, et al. Life expectancy following spinal cord injury: a ten-years survey in the Rhone-Alpes Region, France, 1969-1980. Paraplegia. 1983;21(1):11-5.
    6. DeVivo MJ, Black KJ, Stover SL. Causes of death during the first 12 years after spinal cord injury. Arch Phys Med Rehabil. 1993;74(3):248-54.
    7. Samsa GP, Patrick CH, Feussner JR. Long-term survival of veterans with traumatic spinal cord injury. Arch Neurol. 1993;50(9):909-14.
    8. DeVivo MJ, Ivie CS, 3rd. Life expectancy of ventilator-dependent persons with spinal cord injuries. Chest. 1995;108(1):226-32.
    9. Watt JW, Wiredu E, Silva P, Meehan S. Survival after short- or long-term ventilation after acute spinal cord injury: a single-centre 25-year retrospective study. Spinal Cord. 2011;49(3):404-10.
    10. Shavelle RM, DeVivo MJ, Strauss DJ, Paculdo DR, Lammertse DP, Day SM. Long-term survival of persons ventilator dependent after spinal cord injury. J Spinal Cord Med. 2006;29(5):511-9.
    11. Hartkopp A, Bronnum-Hansen H, Seidenschnur AM, Biering-Sorensen F. Survival and cause of death after traumatic spinal cord injury. A long-term epidemiological survey from Denmark. Spinal Cord. 1997;35(2):76-85.
    12. McColl MA, Walker J, Stirling P, Wilkins R, Corey P. Expectations of life and health among spinal cord injured adults. Spinal Cord. 1997;35(12):818-28.
    13. Yeo JD, Walsh J, Rutkowski S, Soden R, Craven M, Middleton J. Mortality following spinal cord injury. Spinal Cord. 1998;36(5):329-36.
    14. Lidal IB, Snekkevik H, Aamodt G, Hjeltnes N, Biering-Sorensen F, Stanghelle JK. Mortality after spinal cord injury in Norway. J Rehabil Med. 2007;39(2):145-51.
    15. Nwadiaro HC, Nnamonu MI, Ramyil VM, Igun GO. Comparative analysis of urethral catheterization versus suprapubic cystostomy in management of neurogenic bladder in spinal injured patients. Niger J Med. 2007;16(4):318-21.
    16. Strauss DJ, Shavelle RM, Anderson TW. Long-term survival of children and adolescents after traumatic brain injury. Arch Phys Med Rehabil. 1998;79(9):1095-100.
    17. Shavelle RM, Devivo MJ, Paculdo DR, Vogel LC, Strauss DJ. Long-term survival after childhood spinal cord injury. J Spinal Cord Med. 2007;30 Suppl 1:S48-54.
    18. Kemp BJ, Krause JS. Depression and life satisfaction among people ageing with post-polio and spinal cord injury. Disabil Rehabil. 1999;21(5-6):241-9.
    19. McColl MA. Expectations of health, independence, and quality of life among aging spinal cord-injured adults. Assist Technol. 1999;11(2):130-6.
    20. Strauss DJ, Devivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil. 2006;87(8):1079-85.
    21. DeVivo MJ, Krause JS, Lammertse DP. Recent trends in mortality and causes of death among persons with spinal cord injury. Arch Phys Med Rehabil. 1999;80(11):1411-9.
    22. Strauss D, DeVivo M, Shavelle R, Brooks J, Paculdo D. Economic factors and longevity in spinal cord injury: a reappraisal. Arch Phys Med Rehabil. 2008;89(3):572-4.
    23. Krause JS, Saunders LL. Health, secondary conditions, and life expectancy after spinal cord injury. Archives of physical medicine and rehabilitation. 2011;92(11):1770-5.
    24. Krause JS, Saunders LL, DeVivo MJ. Income and risk of mortality after spinal cord injury. Archives of physical medicine and rehabilitation. 2011;92(3):339-45. PMCID: 3181072.
    25. Devivo MJ. Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord. 2012;50(5):365-72.
    26. Groah SL, Charlifue S, Tate D, Jensen MP, Molton IR, Forchheimer M, et al. Spinal cord injury and aging: challenges and recommendations for future research. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2012;91(1):80-93.
    27. Krause JS, Saunders LL. Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population? Spinal Cord. 2012.
    28. Krause JS, Saunders LL, Acuna J. Gainful employment and risk of mortality after spinal cord injury: effects beyond that of demographic, injury and socioeconomic factors. Spinal Cord. 2012.
    29. Middleton JW, Dayton A, Walsh J, Rutkowski SB, Leong G, Duong S. Life expectancy after spinal cord injury: a 50-year study. Spinal Cord. 2012.
    Last edited by Wise Young; 06-09-2012 at 08:56 AM.

  2. #2
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  3. #3
    Thanks for the review.
    I guess I'm doing okay at 45 years post, from this.

    Quote Originally Posted by Wise Young View Post
    Le and Price [2] estimated a mean survival of 110.5 months (89 years and 2.5 months) for spinal cord-injured persons who were injured between 1963 and 1976.
    I think this is a typo - "89 years" should read "9 years".


    Quote Originally Posted by Wise Young View Post
    If you had severe spinal cord injury in the past 50 years, you have about 5% chance of surviving the first year, a bit less if you were paraplegic (4.1%) and a bit more (8.1%) if you were tetraplegic.
    I think this is a typo - "surviving" should read "dieing in".
    Last edited by ThomasB; 06-02-2012 at 08:33 AM. Reason: Nitpicking sorry lol

  4. #4
    Dr.Wise, thanks for sharing us this valuable and entertaining observation, just what is it doing here, in the Cure-thread? Or it's a crisis of the genre?

  5. #5
    Good info, but I don´t see the point in surviving for so long. Quad for 30-40 years? No thanks, is already a nightmare ending the first 10.
    -Ramps in buildings are necessary, but it would be usefull to have another ones for people (mind/heart).....

    -Hoc non pereo habebo fortior me

  6. #6
    I'll take what I can get. Too many things to do to worry about if I'm gonna die soon or if there's a cure. Who cares, it's life I'm livin'; maximizing my potential with what I have left.

  7. #7
    Patrick. That's probably the best thing I've read all day :-) Isildur...your attitude on life kind of sucks. But I bet you already know that....

  8. #8
    Surely, I think it all depends on what you have in your life. I was injured 30 years ago, not long after celebrating a 13th anniversary with my dear wife, with whom I have just celebrated a 43rd anniversary of our marriage. I won't give up one day with the love of my life without a fight. Yes, life isn't what I would have wanted for either one of us...but it is our life and we are making it happen, life is good, and our life is sweet. I am totally blessed.

    All the best,
    GJ

  9. #9
    Quote Originally Posted by Colin83 View Post
    Patrick. That's probably the best thing I've read all day :-) Isildur...your attitude on life kind of sucks. But I bet you already know that....
    Is not my attitude, is the real life what sucks.
    Are you a quad with high injury? If you are happy, and want to get older alone and full of health issues good for you, but don´t trample my opinion
    -Ramps in buildings are necessary, but it would be usefull to have another ones for people (mind/heart).....

    -Hoc non pereo habebo fortior me

  10. #10
    Senior Member GinoL's Avatar
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    Quote Originally Posted by Patrick Madsen View Post
    I'll take what I can get. Too many things to do to worry about if I'm gonna die soon or if there's a cure. Who cares, it's life I'm livin'; maximizing my potential with what I have left.
    I agree 100% Patrick! June 10 will 38 years for me and no regrets. Like most of us with SCI I have my good days and bad but the good days out number the bad by far. Live one day at a time and be the best at what you can do! A positive attitude will carry you a long way!

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