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European Journal of Physical and Rehabilitation Medicine logoLink to European Journal of Physical and Rehabilitation Medicine
. 2024 Dec 16;60(6):980–988. doi: 10.23736/S1973-9087.24.08554-X

Unveiling the mosaic: comparing demographics and outcomes in traumatic vs. non-traumatic spinal cord injuries

Emanuela LENA 1, Laura TIMELLI 2, Sergio DI FONZO 1, Angelo TONINI 1, Valerio PISANI 1, Caterina GARCOVICH 1, Emanuela COVELLA 1, Federica TAMBURELLA 3, Giorgio SCIVOLETTO 1,*
PMCID: PMC11729709  PMID: 39352291

Abstract

BACKGROUND

This study analyzed the percentage of patients with nontraumatic spinal cord injury (SCI) which is increasing with the increase of population age. However, little is known about the effect of the etiology of SCI on the outcome of these subjects.

AIM

The aim of this study was to investigate functional and neurological outcomes in patients with traumatic and nontraumatic spinal cord lesions, with a focus on factors influencing rehabilitation outcomes.

DESIGN

The design of this study was that of a retrospective analysis of prospectively recorded data.

SETTING

The setting of this analysis was a single Spinal Unit in Italy.

POPULATION

The population included 1080 subjects, of which 599 (55%) had injuries of traumatic origin and 481 (45%) had nontraumatic injuries.

METHODS

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI) were utilized as measurement tools. Multivariate (backwards selection, P=0.20) logistic regression was used to assess the associations of “complication during hospitalization,” “bowel management autonomy,” “spontaneous micturition,” “home destination” and “neurological improvement” with the following variables: etiology, age, sex, lesion level and severity and length of stay. Multivariate (backwards selection, P=0.20) negative binomial regression was used to assess the relative risks of higher SCIM and WISCI Scores at discharge after adjusting for the abovementioned variables.

RESULTS

Our work highlighted several significant differences between the traumatic and nontraumatic groups (including age, sex, lesion severity, and time from lesion onset to admission). Both groups exhibited comparable improvements in neurological and functional status, although some data were in favor of subjects with traumatic lesions. However, the regression analyses demonstrated that the main factors impacting the neurological and functional status at discharge were age, lesion level and severity, rather than the etiology of the lesion.

CONCLUSIONS

Our study provides valuable insights into the rehabilitation trajectories of traumatic and nontraumatic spinal cord injuries and demonstrates that the cause of SCI has no impact on rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An understanding of neurological and functional recovery after spinal cord lesions is essential for answering patients’ questions about their potential functional capabilities. It also assists in determining the necessary resources for inpatient rehabilitation and post discharge care. Moreover, the possession of a thorough grasp of the course and factors influencing the natural recovery of a spinal cord lesion is now a scientific necessity and is crucial for assessing the efficacy of new pharmacological and rehabilitative methods.

Key words: Spinal cord injuries, Rehabilitation, Treatment outcome

Nontraumatic spinal cord injuries (NTSCIs) represent an important and often overlooked category within the spectrum of spinal cord disorders. Although the exact incidence of NTSCIs is not known, it may vary from 7.7 to 26.9 new cases per million inhabitants per year.1-3 The prevalence of NTSCIs is reported to be approximately 360 cases per million inhabitants.4 In some cases, the number of admissions of patients with NTSCIs outnumbers that of patients with traumatic lesions.5 The etiology of NTSCIs encompasses a diverse range of medical conditions, such as tumors, vascular malformations, infections (such as transverse myelitis), and degenerative disorders (such as spinal stenosis). Additionally, congenital anomalies or autoimmune diseases may contribute to NTSCIs. Compared with their traumatic counterparts, NTSCIs present unique challenges in terms of prevention, management, and rehabilitation. Due to the fact that the onset is often insidious, and progression may be gradual, early detection and intervention of NTSCIs become paramount in optimizing outcomes for affected individuals. Research into NTSCIs is essential for identifying the underlying mechanisms, improving diagnostic tools, and developing targeted therapies. Additionally, an increase in awareness about these types of injuries is crucial to fostering a comprehensive understanding among health care providers, policymakers, and the public. Although there has been a substantial increase in the number of publications on NTSCIs over the last few decades, there are numerous challenges related to researching NTSCI rehabilitation, including case identification, study design, data collection, study funding, as well as a lack of preclinical and international research.6 In particular, despite the considerable incidence of nontraumatic lesions, limited research exists on the impact of different etiologies (specifically regarding traumatic vs. nontraumatic) on rehabilitation outcomes.7-14 This scarcity is likely attributed to the distinct characteristics of the two patient populations concerning age, lesion severity, and time from lesion onset to admission, which are well-established prognostic factors.9 Consequently, a comparison of the two patient groups remains challenging due to these differences. However, an understanding of the trajectory of neurological and functional recovery following spinal cord lesions (SCLs) is crucial for addressing patients’ inquiries about their potential functional abilities. It also helps gauge the required resources for inpatient rehabilitation and post discharge care. Additionally, a comprehensive understanding of the course and factors influencing the natural recovery of SCLs has become a scientific imperative for evaluating the effectiveness of novel pharmacological and rehabilitative approaches.15 Therefore, in this study, we aimed to assess the functional and neurological status at admission and discharge and to identify factors associated with functional outcomes in patients with traumatic injuries and NTSCIs.

Materials and methods

We conducted a retrospective analysis of the medical records of 1080 patients who experienced both traumatic and nontraumatic spinal cord injury (SCI) and who were admitted to our spinal unit in Rome, Italy, between 1996 and 2021 for rehabilitation treatment following the manifestation of a lesion. To ensure clinical stability, individuals showing disease progression were excluded from the study. In patients who were discharged or transferred for more than 3 weeks, any subsequent readmission was considered to be a second admission, thus leading to patient exclusion. Furthermore, patients who were admitted for less than 7 days were excluded. Neurorehabilitation was planned for each patient by a pool of neurologists and physiatrists and administered by therapists 6 days a week, with 3 sessions per day and each session lasting 1 hour. According to the needs of the patient, individual therapy could include physical therapy, cognitive therapy, occupational therapy, specific therapy for swallowing, and therapies for bowel and bladder dysfunctions. All the rehabilitation treatments began within 24 h of admission. The collected data included age, sex, lesion to admission time (LTA), and various injury variables, all of which were recorded in a dichotomous format (e.g., traumatic/nontraumatic for etiology, as well as present/absent for others). Associated injuries included traumatic brain injury, nonvertebral fractures necessitating surgery, severe facial injuries impacting sense organs, major chest injuries requiring chest tube or mechanical ventilation, severe hemorrhaging, or damage to any internal organ necessitating surgery. Neurological status assessment adhered to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI),16, 17 when considering motor scores, neurological level, and the ASIA Impairment Scale (AIS). Patients with motor and/or sensory function in the sacral segments were categorized as having an incomplete lesion (sacral sparing). Neurological recovery was defined based on improvements in the AIS impairment grade. Functional status at admission and discharge was evaluated through the Spinal Cord Independence Measure (SCIM) for activities of daily life independence18, 19 and the Walking Index for Spinal Cord Injury II (WISCI).20 Although not initially available in the original charts, WISCI Scores were retrospectively assessed from neurological clinical charts, categorizing patients into walking and not walking statuses based on home or community ambulation capacity. Bladder control and autonomy in bowel management were categorized according to established criteria. Patients were classified as having achieved normal bladder control or utilizing other emptying modalities. For bowel management, patients were categorized into those with autonomy and those without autonomy.9 Finally, we documented the incidence of complications during rehabilitation, inpatient length of stay (LOS), and the destination of patients at discharge (home vs. nursing home or other rehabilitation centers). We confirm that this research adhered to all relevant institutional and governmental regulations regarding the ethical involvement of human volunteers. Furthermore, our hospital is also a research institute, and all the patients signed an informed consent form for the utilization of their data in translational studies at admission (General Data Protection Regulation, article 6.1 letter e, article 9.2 letter j and article 89. Italian Legislative Decree 30 June 2003, N. 196, Privacy Code, Article 110 bis).

Statistical analysis

Patient demographics (such as sex and age), clinical characteristics (such as time between injury and hospitalization, associated injuries, surgical treatment, complications, AIS scale, lesion level, length of stay [LOS], pressure sores, spontaneous micturition, bowel management autonomy, destination after discharge, SCIM Score and WISCI Score), collected at admission and at discharge were summarized by using counts and percentages for categorical variables and medians and interquartile ranges or means and standard deviations for continuous variables. The data were also stratified by etiology (traumatic or nontraumatic), and differences between the two groups were assessed by using the Mann-Whitney Test for continuous measures after the nonnormal distribution of the variables was evaluated, and the χ2 test was used for categorical data. For the SCIM and WISCI Scores, the percentage changes at discharge compared to admission were also calculated. Moreover, we performed five multivariable (backwards selection, P=0.20) logistic regressions to assess the associations of: 1) “complication during hospitalization” (yes/no); 2) “bowel management autonomy” (yes/no); 3) “spontaneous micturition” (yes/no); 4) “home destination” (yes/no); and 5) “AIS improvement” (yes/no) with the following variables: etiology (traumatic/nontraumatic), age (<55/>55 years), sex, lesion level (cervical/lumbar/thoracic), AIS (A/B/C/D) and LOS (<75/75-120/120-175/>175 days). Finally, we performed a multivariable (backwards selection, P=0.20) negative binomial regression to assess the relative risks of higher SCIM and WISCI Scores at discharge, adjusting for the abovementioned variables. The data were analyzed by using Stata software, release 16.0. (Stata Corp, College Station, TX, USA). A significance level of 0.05 was used.

Results

The data of 1080 patients who met the inclusion criteria were available for analysis: 599 (55%) had traumatic injuries, and 481 (45%) had nontraumatic injuries. The traumatic group was more often male (83.6% vs. 59.3%), significantly younger (median age: 41 vs. 60 years), had a shorter time between injury and hospitalization (30 vs. 37 days), had many more associated injuries (44.3% vs. 0.3%), mostly underwent surgery (87.7% vs. 47.1%), had more complications at admission (37.4% vs. 20.7%) and during hospitalization (35.8% vs. 26.4%), had more cervical and fewer thoracic lesions (41.4% vs. 28.2% and 40.5% vs. 52.4%, respectively) and had the worst AIS (75% vs. 57% with grade A or B or C). Regarding the LOS, nontraumatic patients were discharged earlier (median: 98 days, IQR: 61-148) than were traumatic patients (median: 143 days, IQR: 93-205) (Table I).

Table I. —Characteristics of the patients at admission and during hospitalization.

Etiology Non traumatic (N.=599) Traumatic (N.=481) P value*
Gender, N. (%)
Female 244 (40.7) 79 (16.4)
Male 355 (59.3) 402 (83.6) <0.01
Age, years (median and IQR) 60 (48-70) 41 (28-57) <0.01
Time between injury and hospitalization, days – median (IQR) 37 (20-75) 30 (19-53) <0.01
Associated injuries, N. (%) 2 (0.3) 213 (44.3) <0.01
Surgical treatment, N. (%) 282 (47.1) 422 (87.7) <0.01
Complications at admission, N. (%) 124 (20.7) 180 (37.4) <0.01
Complications: details, N. (%)
Pressure sores 110 (88.7) 159 (88.3) 0.92
Paraostheoarthropathy 5 (4) 9 (5) 0.692
Respiratory 7 (5.7) 17 (9.4) 0.227
Deep vein thrombosis 1 (0.8) 5 (2.8) 0.225
Pulmonary embolism 0 (0) 3 (1.7) 0.149
Urological complications 3 (2.4) 2 (1.1) 0.378
AIS, N. (%)
Grade A 112 (18.7) 206 (42.8)
Grade B 43 (7.2) 54 (11.2)
Grade C 185 (30.9) 101 (21)
Grade D 259 (43.2) 120 (25) <0.01
Lesion level, N. (%)
Cervical 169 (28.2) 199 (41.4)
Thoracic 314 (52.4) 195 (40.5)
Lumbar 115 (19.2) 87 (18.1)
Other 3 (0.5) 3 (0.6) <0.01
Length of stay, days – median (IQR) 98.5 (61-147.5) 143 (93-205) <0.01
Complications during hospitalization, N. (%) 158 (26.4) 172 (35.8) 0.002
Pressure sores, N. (%) 22 (13.9) 35 (20.4) 0.123
Paraostheoarthropathy, N. (%) 1 (0.6) 8 (4.7) 0.025
Respiratory, N. (%) 18 (11.4) 23 (13.4) 0.586
Deep vein thrombosis, N. (%) 11 (7) 10 (5.8) 0.67
Pulmonary embolism, N. (%) 5 (3.2) 3 (1.7) 0.402
Urological complications, N. (%) 18 (11.4) 23 (13.4) 0.505
Other, N. (%) 108 (68.4) 103 (59.9) 0.109
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IQR: interquartile range; AIS: ASIA Impairment Scale. *Fisher’s Exact Test or Mann-Whitney Test, as appropriated.

At discharge, traumatic patients experienced significantly more pressure sores (20.4% vs. 12.9%) and a lower percentage of spontaneous micturition (32.4% vs. 43.6%), whereas there were no differences in fecal incontinence or bowel management autonomy. There were more traumatic patients sent to rehabilitation centers or nursing homes than nontraumatic patients (2.1% vs. 0.5% and 4.4% vs. 2.5%, respectively), and fewer patients who were sent home (86.5% vs. 90.2%) (Table II). At admission, the SCIM Score was significantly lower for patients with traumatic injuries (19.9±16.9 vs. 30.7±21.9), whereas there were no significant differences at discharge (60.7±26.3 vs. 63.2±26.5), therefore traumatic patients had a higher change in SCIM Score (Table III).

Table II. —Characteristics of the patients at discharge.

Etiology Non-traumatic (N.=599) Traumatic (N.=481) P value*
AIS impairment improvement 144 (24) 112 (23.3) 0.639
Pressure sores 77 (12.9) 98 (20.4) 0.003
Spontaneous micturition 261 (43.6) 156 (32.4) <0.01
Fecal incontinence 92 (15.4) 84 (17.5) 0.262
Bowel regularization
Yes, without drugs 193 (32.2) 108 (22.5)
Yes, with drugs 386 (64.4) 360 (74.8)
No 16 (2.7) 12 (2.5) 0.002
Bowel management autonomy 426 (71.1) 343 (71.3) 0.972
Destination after discharge
Home 540 (90.2) 416 (86.5)
Hospice 2 (0.3) 0 (0)
Rehabilitation center 3 (0.5 10 (2.1)
Nursing home 15 (2.5) 21 (4.4)
Moved to another hospital 39 (6.5) 34 (7.1) 0.034
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Values are expressed as N. (%). AIS: ASIA Impairment Scale. *The χ2 test was used to obtain these results.

Table III. —SCIM and WISCI Scores at admission and discharge.

Etiology Non-traumatic Traumatic P value*
SCIM
SCIM at admission, mean and SD 30.7 21.9 19.9 16.9 <0.01
SCIM at discharge, mean and SD 63.2 26.5 60.7 26.3 0.086
Change, discharge vs. admission in % 172.9 216.1 294.6 270.1 <0.01
WISCI
WISCI at admission, mean and SD 2.5 5.7 1.3 4.4 <0.01
WISCI at discharge, mean and SD 8.8 8.1 6.9 8.1 <0.01
Change, discharge vs. admission in % 81.9 190 73.1 100 0.495
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SCIM: Spinal Cord Independence Measure; WISCI: Walking Index for Spinal Cord Injury; SD: standard deviation. *Mann-Whitney Test.

Additionally, for the WISCI Score, traumatic patients were hospitalized with lower scores than were the nontraumatic counterparts (1.3±4.4 vs. 2.5±5.7, respectively); this difference still remained at discharge (6.9±8.1 vs. 8.8±8.1, respectively) (Table III). In the multivariate analysis, an association between having complications during hospitalization and having developed a traumatic lesion, being older, and having an AIS equal to C or D (compared to A) was found; moreover, bowel management autonomy was associated with age, lesion level (lumbar lesion and thoracic compared to cervical) and AIS C or D vs. A. Additionally, the odds of spontaneous micturition were greater for traumatic patients and for a higher level of AIS, and home destination was associated with lesion level (lumbar and thoracic compared to cervical), higher AIS (C or D vs. A), and longer LOS; in contrast, being older and male seemed to be associated with a lower likelihood of home destination, and AIS improvement was associated with an AIS at admission equal to B or C (Table IV).

Table IV. —Adjusted odds ratio from logistic regression.

Variables Odds ratio P value 95% CI
Having a complication during hospitalization
Etiology: traumatic vs. non traumatic 1.49 0.009 1.10 2.00
Age: ≥55 vs. <55 years 1.92 >0.001 1.42 2.59
Sex: male vs. female n.i.
Lesion level: lumbar vs. cervical n.i.
Lesion level: thoracic vs. cervical n.i.
AIS: B vs. A 0.84 0.477 0.52 1.35
AIS: C vs. A 0.52 >0.001 0.37 0.74
AIS: D vs. A 0.27 >0.001 0.19 0.39
LOS: 75-120 vs. ≤75 days n.i.
LOS: 120-175 vs. ≤75 days n.i.
LOS: >175 vs. ≤75 days n.i.
Bowel management autonomy
Etiology: traumatic vs. non traumatic 1.19 0.342 0.83 1.69
Age: ≥55 vs. <55 years 0.25 >0.001 0.18 0.36
Sex: male vs. female 1.37 0.071 0.97 1.94
Lesion level: lumbar vs. cervical 5.01 >0.001 3.00 8.36
Lesion level: thoracic vs. cervical 2.85 >0.001 1.99 4.08
AIS: B vs. A 1.10 0.711 0.66 1.86
AIS: C vs. A 2.42 >0.001 1.61 3.66
AIS: D vs. A 9.19 >0.001 5.62 15.01
LOS: 75-120 vs. ≤75 days 1.21 0.423 0.76 1.90
LOS: 120-175 vs. ≤75 days 0.97 0.887 0.61 1.54
LOS: >175 vs. ≤75 days 0.69 0.115 0.44 1.09
Spontaneous micturition
Etiology: traumatic vs. non traumatic 1.67 0.004 1.18 2.36
Age: ≥55 vs. <55 years n.i.
Sex: male vs. female 0.77 0.133 0.55 1.08
Lesion level: lumbar vs. cervical n.i.
Lesion level: thoracic vs. cervical n.i.
AIS: B vs. A 8.27 >0.001 3.58 19.13
AIS: C vs. A 22.51 >0.001 10.98 46.15
AIS: D vs. A 79.64 >0.001 38.47 164.89
LOS: 75-120 vs. ≤75 days 1.03 0.874 0.69 1.55
LOS: 120-175 vs. ≤75 days 0.76 0.229 0.48 1.19
LOS: >175 vs. ≤75 days 0.44 0.001 0.27 0.72
Home destination
Etiology: traumatic vs. non traumatic 0.65 0.067 0.41 1.03
Age: ≥55 vs. <55 years 0.58 0.013 0.37 0.89
Sex: male vs. female 0.43 0.002 0.25 0.73
Lesion level: lumbar vs. cervical 2.85 0.004 1.40 5.80
Lesion level: thoracic vs. cervical 1.31 0.254 0.83 2.07
AIS: B vs. A 0.88 0.713 0.45 1.72
AIS: C vs. A 1.12 0.661 0.67 1.90
AIS: D vs. A 5.67 >0.001 2.92 11.02
LOS: 75-120 vs. ≤75 days 4.09 >0.001 2.28 7.33
LOS: 120-175 vs. ≤75 days 5.56 >0.001 2.98 10.36
LOS: >175 vs. ≤75 days 4.83 >0.001 2.68 8.73
Having AIS improvement
Etiology: traumatic vs. non traumatic 1.00 0.991 0.68 1.47
Age: ≥55 vs. <55 years 0.69 0.063 0.47 1.02
Sex: male vs. female n.i.
Lesion level: lumbar vs. cervical n.i.
Lesion level: thoracic vs. cervical n.i.
AIS: B vs. A 11.55 >0.001 6.62 20.17
AIS: C vs. A 14.98 >0.001 9.34 24.02
AIS: D vs. A 0.11 >0.001 0.04 0.32
LOS: 75-120 vs. ≤75 days n.i.
LOS: 120-175 vs. ≤75 days n.i.
LOS: >175 vs. ≤75 days n.i.
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CI: confidence interval; n.i.: not investigated; LOS: length of stay; AIS: ASIA Impairment Scale.

Finally, we found that higher SCIM Scores at discharge were associated with a traumatic etiology, having a higher SCIM Scores at admission, male sex, presence of lumbar or thoracic lesions compared to cervical lesions, greater AIS scores, younger age, and a length of stay between 75 and 120 days versus <75 days (Table V). We obtained similar results for the WISCI Score, except that there were no associations with the etiology; furthermore, thoracic lesions appeared to be associated with lower WISCI values than cervical lesions, and a duration of stay >175 days was associated with a lower WISCI at discharge (Table VI).

Table V. —Incidence Rate Ratio from negative binomial regression: SCIM Score at discharge.

Variables IRR P value 95% CI
Etiology: traumatic vs. non traumatic 1.08 0.018 1.01 1.15
SCIM at admission (per unit increments) 1.01 >0.001 1.01 1.01
Age: ≥55 vs. <55 years 0.79 >0.001 0.75 0.84
Sex: male vs. female 1.08 0.012 1.02 1.15
Lesion level: lumbar vs. cervical 1.29 >0.001 1.19 1.40
Lesion level: thoracic vs. cervical 1.22 >0.001 1.14 1.31
AIS: B vs. A 1.11 0.050 1.00 1.23
AIS: C vs. A 1.29 >0.001 1.19 1.40
AIS: D vs. A 1.49 >0.001 1.36 1.63
LOS: 75-120 vs. ≤75 days 1.09 0.025 1.01 1.18
LOS: 120-175 vs. ≤75 days 1.08 0.059 1.00 1.18
LOS: >175 vs. ≤75 days 0.99 0.885 0.91 1.09
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IRR: Incidence Rate Ratio; CI: confidence interval; LOS: length of stay; AIS: ASIA Impairment Scale; SCIM: Spinal Cord Independence Measure.

Table VI. —Incidence Rate Ratio from negative binomial regression: WISCI Score at discharge.

Variables IRR P value 95% CI
Etiology: traumatic vs. non traumatic 0.97 0.764 0.79 1.19
WISCI at admission (per unit increments) 1.04 0.001 1.01 1.06
Age: ≥55 vs. <55 years 0.59 >0.001 0.48 0.73
Lesion level: lumbar vs. cervical 1.90 >0.001 1.45 2.50
Lesion level: thoracic vs. cervical 0.79 0.037 0.63 0.99
AIS: B vs. A 3.81 >0.001 2.62 5.53
AIS: C vs. A 9.50 >0.001 7.03 12.84
AIS: D vs. A 14.50 >0.001 10.64 19.75
LOS: 75-120 vs. ≤75 days 1.05 0.689 0.81 1.37
LOS: 120-175 vs. ≤75 days 1.26 0.126 0.94 1.71
LOS: >175 vs. ≤75 days 0.70 0.020 0.51 0.95
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IRR: Incidence Rate Ratio; CI: confidence interval; WISCI: Walking Index for Spinal Cord Injury; LOS: length of stay; AIS: ASIA Impairment Scale.

Discussion

The examined demographic characteristics of the two populations with spinal cord lesions (SCLs) aligned with the previously reported features of both general traumatic and nontraumatic populations with spinal cord pathology.9, 13, 14 Patients with traumatic and nontraumatic conditions exhibited significant group differences, which is consistent with previous reports.9, 13, 14 The traumatic patients were notably younger and predominantly male. Sex and age disparities may be attributed to various factors, including riskier behaviors and activities more commonly engaged in by males and younger subjects.21, 22 The shorter time between injury and hospitalization in the traumatic group underscores the urgent and critical need for prompt medical attention in the aftermath of traumatic events. However, this difference could also be attributed to the clinical workup for the diagnosis of NTSCIs or to other reasons (such as bed availability).9 Compared with those with NTSCIs, patients with traumatic SCIs more frequently had a complete lesion at the cervical level.9, 13, 14 Subjects with traumatic SCI also had a greater incidence of associated injuries and an increased likelihood of surgery.23 Both traumatic SCIs and NTSCIs are associated with elevated rates of complications at admission and during hospitalization, although the incidence of complications is greater in patients with traumatic injuries.24

In terms of neurological outcomes, both traumatic and nontraumatic patients demonstrated similar degrees of improvement, with approximately 25% of AIS B and C patients achieving at least an improvement of one ASIA impairment level between admission and discharge in both groups, whereas AIS A and D patients experienced little or no improvement because of floor or ceiling effects. This finding is comparable to the results reported in other studies13 and did not confirm previous data,25 that suggested better neurological recovery in nontraumatic patients. This effect is possibly attributed to methodological differences in the data analysis. The statistical approach that was used in the present study allowed the adjustment of confounding effects, such as age, sex, AIS impairment at admission, and lesion severity, which may have varied effects on the two populations.

According to previous findings,9, 13 at admission, traumatic patients exhibited significantly lower independence in daily life activities and walking, as indicated by lower SCIM and WISCI Scores, respectively. Differences in functional status at admission could be attributed to the severity of impairment in the acute phase of traumatic SCI but also to non-neurological trauma-related factors, such as major surgical sequelae, the need for orthotics,26 and the presence of associated lesions, which could impact independence at admission and slow the rehabilitation process.23

The functional status at discharge was comparable in both populations, with traumatic patients showing a greater increase in SCIM, which was likely influenced by their lower scores at admission and was consistent with previous publications.9, 13 However, improvements in walking function and bladder management improved less in the traumatic group. The two groups also showed differences in bowel management and discharge destination. However, these differences may be attributed to the different compositions of the two cohorts in terms of age and lesion features. To address this issue, we performed a multivariate analysis that allowed us to identify the factors impacting functional and neurological status at discharge. As shown in Tables IV-VI, the main factors for functional status are represented by the neurological characteristics of the lesion (level and severity) and age (with older age being associated with worse outcomes), whereas the etiology of the lesion rarely resulted as a determinant of outcomes.

With regard to bladder and bowel management, the multivariate analysis showed an association between reaching autonomy in bowel management and age, lesion level (lumbar lesion and thoracic) and having less severe lesions (AIS C or D), whereas the odds of achieving spontaneous micturition were greater for patients with higher levels of AIS; the findings on bladder function recovery reflect works in the literature reporting of a correlation between spontaneous bladder emptying and neurological status (specifically, the lower extremity motor score).27 However, the data on bowel management are slightly different. As reported by Pavese,27 we found an association between less severe lesions and bowel management independence; however, we also reported of an association between the level of the lesion and the age of the patients. This difference is likely due to the different outcomes that were chosen. Although Pavese examined the recovery of spontaneous evacuation, our outcome involved the independence of bowel management (whether regarding spontaneous emptying or artificial induction). It is clear that age and lesion level may have an impact on trunk control, manual dexterity and other factors that are essential for bowel management.28

The associations between home destination and lesion level, less severe lesions and longer LOS are consistent with the findings in the literature.29, 30 The association between lesion level and lesion severity may reflect increased independence in activities of daily living, which may facilitate discharge to home. In our study, we found a positive correlation between a longer LOS and a greater rate of home discharge, which is in contrast to the findings of a previous study.29 This association is likely due to the fact that as the Italian Health Service does not foresee funding restrictions/streams on the duration of inpatient rehabilitation for patients with SCI,8 patients continue their training for a long period of time to obtain a higher level of independence and to facilitate home discharge.

The associations between better functional and walking status at discharge (as reflected by higher SCIM and WISCI Scores) and lumbar or thoracic lesions, lower severity of the lesion and younger age are consistent with findings from previous studies. SCI rehabilitation outcomes are significantly influenced by both the level and severity of the lesion. The literature suggests that the anatomical location of the injury plays a crucial role in determining the functional recovery and quality of life of individuals with SCI.28 Compared with individuals with thoracic or lumbar injuries, individuals with cervical spine injuries often experience more challenges in rehabilitation. This is attributed to the greater impact on upper limb function and overall mobility in patients with cervical lesions.31 Moreover, the severity of the lesion, as assessed by factors such as the American Spinal Injury Association (ASIA) impairment scale, is correlated with the extent of functional impairment and the likelihood of achieving meaningful recovery.32 This emphasizes the importance of personalized rehabilitation approaches, when considering both lesion level and severity. The tailoring of interventions based on these factors can optimize outcomes, as the rehabilitation needs and potential for recovery differ significantly among patients with cervical, thoracic, and lumbar injuries. Research on the impact of age on SCI rehabilitation outcomes suggests that younger individuals often exhibit better recovery than their older counterparts.33 Younger patients tend to demonstrate greater neural plasticity and fewer comorbid diseases, thus facilitating more effective adaptation to injury.34 Additionally, they may have better overall health, thus enabling a more robust response to rehabilitation interventions. Conversely, older individuals with SCI may experience challenges due to age-related factors, such as diminished muscle mass, reduced bone density, and potential comorbidities. These factors can impede the rehabilitation process and limit functional recovery. Moreover, older adults may experience slower neurological regeneration, thus influencing the extent of improvement achievable through rehabilitation.33

Limitations of the study

Despite these discoveries, this study had certain limitations that necessitate additional scrutiny. The categorization of lesion levels into cervical, thoracic, and lumbar groups may be misleading when considering the divergent outcomes between high tetraplegia and high paraplegia versus low tetraplegia and low paraplegia. Although this study recognizes the necessity for a more nuanced stratification, the restricted number of subjects hindered a more granular analysis. To address the potential for poorer outcomes in nontraumatic patients due to concurrent pathologies or disease progression, adjustments were made in the statistical model, and patients who experienced disease progression during their stay were excluded. Nevertheless, a subsequent study could offer insights into the long-term consequences for patients with nontraumatic lesions. Additionally, the inclusion of nontraumatic patients with various etiologies introduces a potential bias, as cautioned by Ditunno.15 Finally, for some associations (particularly AIS impairment) with the outcomes, the 95% CI was very large, thus suggesting that there is a lack of precision and robustness of these findings. We should also consider that this is a study based on patients recruited from only one center, and it was not possible to provide an external validation confirming these results.

Conclusions

Considering the literature, the findings of this study reinforce the existing knowledge, while also providing nuanced insights into the specific characteristics and outcomes associated with traumatic and nontraumatic spinal cord injuries. The alignment of the results with established knowledge enhances the credibility and generalizability of the findings. These results not only contribute to the academic understanding of SCI but also have practical implications for health care professionals involved in the management and rehabilitation of individuals with spinal cord injuries. An understanding of these differences is crucial for tailoring rehabilitation strategies and improving the overall management of individuals with spinal cord injuries, thereby optimizing their long-term outcomes and quality of life.

Footnotes

Conflicts of interest: The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

Funding: This project was funded by the Italian National Ministry of Health (MoH) under the program Ricerca Finalizzata 2019 (grant N. RF-2019-12369396) after a peer-reviewed process and the programmed Ricerca Corrente. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the founder MoH, who had no role in the design of this study and who will not have any role during its execution, data analysis and interpretation and dissemination of decision results.

References

Articles from European Journal of Physical and Rehabilitation Medicine are provided here courtesy of Edizioni Minerva Medica S.p.A.

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