Epidemiology of Traumatic Spinal Cord Injury in the Netherlands: Emergency Medical Service, Hospital, and Functional Outcomes

Abstract

Background:

Evaluating treatment of traumatic spinal cord injuries (TSCIs) from the prehospital phase until postrehabilitation is crucial to improve outcomes of future TSCI patients.

Objective:

To describe the flow of patients with TSCI through the prehospital, hospital, and rehabilitation settings and to relate treatment outcomes to emergency medical services (EMS) transport locations and surgery timing.

Method:

Consecutive TSCI admissions to a level I trauma center (L1TC) in the Netherlands between 2015 and 2018 were retrospectively identified. Corresponding EMS, hospital, and rehabilitation records were assessed.

Results:

A total of 151 patients were included. Their median age was 58 (IQR 37–72) years, with the majority being male (68%) and suffering from cervical spine injuries (75%). In total, 66.2% of the patients with TSCI symptoms were transported directly to an L1TC, and 30.5% were secondarily transferred in from a lower level trauma center. Most injuries were due to falls (63.0%) and traffic accidents (31.1%), mainly bicycle-related. Most patients showed stable vital signs in the ambulance and the emergency department. After hospital discharge, 71 (47.0%) patients were admitted to a rehabilitation hospital, and 34 (22.5%) patients went home. The 30-day mortality rate was 13%. Patients receiving acute surgery (<12 hours) compared to subacute surgery (>12h, <2 weeks) showed no significance in functional independence scores after rehabilitation treatment.

Conclusion:

A surge in age and bicycle-injuries in TSCI patients was observed. A substantial number of patients with TSCI were undertriaged. Acute surgery (<12 hours) showed comparable outcomes results in subacute surgery (>12h, <2 weeks) patients.

Introduction

Traumatic spinal cord injury (TSCI) is a relatively rare but devastating condition, resulting in high morbidity and mortality rates. Reported global incidence rates vary between 10 to 83 cases per million.^1,2 The Dutch incidence rate is low compared to these global rates, with 14.0 cases per million in 2010.³ Dutch TSCI-related mortality rates are 3.4 per million, which is also low compared to the European average of 6.7 per million.⁴ Global TSCI studies have shown a bimodal distribution in age with trends between 15 and 30, and over 65 years of age.¹ In Europe, the main TSCI mechanism varies per country. Falls followed by traffic accidents are the predominant causes of TSCI in the Netherlands.^3,5

The central region of the Netherlands is a relatively small, but densely populated urban area of 1500 km² with approximately 1.3 million inhabitants.⁶ One level I trauma center (L1TC) and multiple level II/III trauma centers serve the trauma patients in this region. These patients are generally transported to the trauma centers by an ambulance provided by the central Dutch region’s emergency medical service unit (EMS; in Dutch, Regionale Ambulancevoorziening Utrecht [RAVU]). The trauma care in the Netherlands is aided by the helicopter emergency medical service (HEMS), with specialized helicopter crews mainly used for on-scene stabilization. The Dutch HEMS preferably only transports patients if the site is inaccessible by ambulance.

In the Netherlands, it is consensually considered as optimal that patients with TSCI receive specialized care, which is designated in the 11 Dutch L1TCs, to prevent potential mortality and disability.⁷ Therefore, the direct transport of TSCI patients to designated centers, whilst going past closer nonspecialized centers, is preferred over stabilization in a lower level trauma center.^8,9 After L1TC admission, Dutch spinal surgeons generally prefer direct surgical stabilization in the first hours of admission to prevent further neurological deterioration.⁷ Whether to perform the surgery in the acute or the subacute phase, however, remains a topic of debate.⁷

Reliable data on the outcomes of TSCI management are essential to improve acute care strategies, leading to improvements in patient care outcomes. In this study, the main objective was to provide an epidemiologic description of TSCI patients in the prehospital, trauma center, and rehabilitation hospital settings. The second objective was to evaluate treatment outcomes related to EMS transport and surgery timing.

Method

Study design and population

All trauma patients who were admitted to the University Medical Center Utrecht, the L1TC in the region, with at least one injury to the spine between January 1, 2015, and December 31, 2018, were identified retrospectively. All patient records were evaluated independently by an orthopedic surgeon and a rehabilitation specialist for correctness. All patients diagnosed with TSCI were eligible for inclusion. Patients with confirmed absence of myelopathy or patients with an inconclusive TSCI diagnosis were excluded.

Data sources

Patients were identified in the regional trauma registry (Traumazorgnetwerk Midden-Nederland), a well-established trauma database with information on injury and acute care parameters. These data were supplemented with corresponding medical records from the L1TC. Prehospital data were extracted from the EMS registry supplied by the central Dutch region’s EMS (RAVU). Rehabilitation data were provided by De Hoogstraat Revalidatie, an affiliated rehabilitation hospital with a specialized SCI unit.

The anonymized L1TC and trauma registry records were matched by deterministic linkage with the prehospital and rehabilitation hospital records by age, gender, injury date, and admission length.

A waiver of consent was provided by our hospital’s Medical Ethics Committee (METC, WAG/mb/19/041369).

Assessments and variable definitions

Outcome measures for evaluating treatment were the length of stay in the intensive care unit (ICU), hospital, and rehabilitation hospital; use of the ventilator; assessment of neurological impairment; functional recovery; mortality; surgery revisions; and rehospitalizations to the L1TC. Neurological assessment was done at L1TC discharge, rehabilitation hospital admission, and rehabilitation hospital discharge. It was performed according to the American Spinal Injury Association Impairment Scale (AIS), a clinician-administered 5-point scale ranging from complete paralysis (AIS-A) to full recovery (AIS-E).¹¹ Functional recovery was assessed using the Utrecht Scale for Evaluating of clinical Rehabilitation (USER), a validated clinician-administered tool measuring the independence in self-care and mobility. The sum of both examinations ranges from 0 (entirely dependent) to 70 (entirely independent).¹²

Prehospital variables included patient demographics (age and gender), injury mechanism, worst prehospital vital signs: Glasgow Coma Scale (GCS), heart rate (HR), systolic blood pressure (SBP), and peripheral oxygenation (SpO2); HEMS use; prehospital times; and the Revised Trauma Score (RTS), based on the GCS, SBP, and the respiratory rate. This 13-point scale is widely used for determining urgency in prehospital triage.¹³ A lower score relates to higher injury severity.

Available variables from the L1TC were vital signs, use of cranial and spine decompression surgery, and discharge location. The Abbreviated Injury Scale of body regions version 2008 and the Injury Severity Score (ISS) were used as measures of injury severity.¹⁴ Moderate to severe injury was defined as the Abbreviated Injury Scale ≥3. Spine injuries were assessed according to the AOSpine Injury Classification Systems.¹⁵

Statistical analysis

Data were presented as per STROBE guidelines.¹⁶ Data were analyzed using IBM SPSS Statistics, version 25.0.0 (Armonk, NY, USA). Bivariate analyses in the subset of direct admissions and secondary emergency department (ED) transfers and the subset of acute and subacute surgeries were performed using the nonparametric Mann-Whitney U test (ordinal/continuous variables) and the Pearson’s chi-square test (dichotomous variables). The Fisher’s exact test was used in comparisons with an expected cell count <5. The Wilcoxon signed-rank test was used in comparing matched variables (vital parameters, USER admission and discharge scores). Statistical significance was specified as p < .05. Continuous variables are presented in medians [q1–q3]. Categorical data are shown as absolute numbers (%).

Results

Sample

Between January 1, 2015, and December 31, 2018, a total of 151 patients were admitted to the L1TC and treated for TSCI. In total, 100 (66%) TSCI patients were admitted directly to the L1TC and 46 (31%) patients were transferred secondarily from a lower level trauma center. Forty-eight (48%) patients of the 100 directly admitted patients were transported by the L1TC region’s EMS (RAVU). Seventy-one (47%) patients were admitted to inpatient rehabilitation, of whom 65 (92%) were treated in the affiliated rehabilitation hospital. Twenty-one (14%) patients died over hospital stay, and 18 (12%) patients were referred to a nursing home. The sample details are supplied in Figure 1.

Figure 1.

Hospital admission and discharge flowchart. ED = emergency department; EMS = emergency medical service; TSCI = traumatic spinal cord injury.

Patient and injury characteristics

Patients were mostly male with blunt injuries caused by falls and traffic accidents, resulting in 92% of the patients with moderate to severe spine injury and 19% with moderate to severe TBI. Figure 2 shows a trimodal age distribution with a median of 58 years [37–72]. Traffic accidents were mainly bicycle-related (43%) and car-related (28%). Most spinal injuries were type-B distraction injuries (54%) and occurred in the subaxial cervical regions (75%; Table 1).

Figure 2.

Age distribution.

Table 1.

Patient and injury characteristics (N = 151)

Characteristics	n (%) or median [q1,q3]
Age, years	58 [37–72]
Gender, male	103 (68)
Blunt injuries	149 (99)
Revised Trauma Score (N = 100)	7.84 [5.03–7.84]
Injury Severity Score	18 [13–26]
Abbreviated Injury Scale (N = score ≥3)a
1. Head	29 (19)
2. Face	2 (1)
3. Neck	7 (5)
4. Thorax	25 (17)
5. Abdomen	9 (6)
6. Spine	139 (92)
7. Upper extremity	1 (1)
8. Lower extremity	13 (9)
9. External and other	0 (0)
Use of HEMS	25 (17)
Injury mechanism
Assault	2 (1)
Falls from height	35 (23)
Falls no height	60 (40)
Traffic	47 (31)
Pedestrian	5 (3)
Car	13 (5)
Motorcycle/Moped	8 (17)
Bicycle	20 (13)
Other	1 (1)
Unknown	7 (5)
Spine fracture typeb
Compression (type A)	23 (15)
Distraction (type B)	82 (54)
Translation (type C)	39 (26)
Facet (type F)	1 (1)
Upper cervicalc	6 (4)
Spine fracture locationd
Cervical	114 (75)
Thoracic	25 (17)
Lumbosacral	12 (8)

Note: HEMS = helicopter emergency medical service.

^aShown in frequencies of the maximum Abbreviated Injury Scale ≥3 score per body region in a patient. One patient can have multiple injures ≥3.

^bThe injury type corresponding with the spinal cord lesion is displayed according to the AOSpine classifications system.

^cThe AOSpine classifications system identifies upper cervical fractures separately, therefore atlanto-occipital fractures are displayed in total.

^dThe highest fracture associated with the spinal cord lesion is displayed.

Prehospital variables

Twenty-five (17%) patients received on-scene assistance from HEMS, but only one was transported to the L1TC per helicopter (Table 2).

Table 2.

Prehospital, hospital, and rehabilitation clinical characteristics and outcomes

Clinical characteristics and outcomes	n (%) or median [q1, q3]
Prehospital (EMS registry) (n = 48)
On-scene vital parametersa
GCS	15 [14–15]
Respiratory rate, rpm	16 [13–18]
Heart rate, bpm	76 [65–87]
Saturation (%)	97 [96–99]
Systolic blood pressure, mm Hg	127 [115–158]
Transport times, minutes
Time from call to arrival on scene	8:30 [6:00–12:00]
On-scene time	24:30 [21:00–34:00]
Time from scene to ED	12:00 [9:00–17:45]
Total prehospital time	50:00 [42:00–63:45]
Hospital (hospital records) (n = 151)
Spine conservative treatment	37 (25)
Spine surgery treatment	114 (75)
Acute (<12 hours)	70 (61)
Subacute (>12 hours, <2 weeks)	39 (34)
Postacute (>2 weeks)	6 (5)
Neurocranial surgery	8 (5)
ICU admissions	65 (43)
Days in ICU	3 [1–13]
Ventilator use	62 (41)
Days on ventilator	2 [1–5]
Days in hospital	12 [6–20]
Day 30 mortality	19 (13)
Mortality over hospital stay	21 (14)
AIS grades on hospital discharge
AIS-A	21 (14)
AIS-B	13 (9)
AIS-C	21 (14)
AIS-D	49 (33)
AIS-E	26 (17)
Missing	21 (14)
Rehabilitation hospital (SCI unit registry) (n = 65)
Days in rehabilitation	85 [44–129]
USER score on admission	13 [8–22]
USER score on discharge	35 [14–55]
USER score median difference	14 [0–28]
AIS conversions	30 (46)
Conversion from complete to incomplete (n = 16)	8 (50)
Fully recovered	3 (3)
AIS deterioration	3 (5)

Note: AIS = ASIA Impairment Scale: A = complete lesion, B–D = incomplete lesion, E = full recovery; ED = emergency department; EMS = emergency medical service; HEMS = helicopter emergency medical service; L1TC = level I trauma center; RTS = Revised Trauma Score; TBI = traumatic brain injury; USER = Utrecht Scale for Evaluation of Clinical Rehabilitation.

^aThe worst measurements in the prehospital phase are displayed.

The 48 patients transferred by the L1TC’s region EMS (RAVU) provided data for further analysis. These patients were relatively stable with a median RTS of 7.84 [5.03–7.84], with generally adequate vital signs measured in the prehospital setting (Table 2). There were no significant differences between vital signs measured prehospitally and in the ED.

The prehospital time (from ambulance dispatch to ED arrival) within the 48 transported patients was mainly under the hour mark, with a median of 50:00 [42:00–63:45] minutes. Further details on prehospital timeframes are shown in Table 2.

Hospital variables and outcomes

Table 3 shows patient characteristics and outcomes in the hospital setting. Most admitted patients received spinal surgery (75%) as opposed to conservative (25%) treatment (e.g., a Philadelphia collar). A total of 65 (43%) patients were admitted to ICU with a median stay of 3 [1–13] days, of which 62 (41%) patients were mechanically ventilated with a median length of 2 [1–5] days. The median hospital stay was 12 [6–20] days. The most common category of neurological impairment at discharge was AIS-D (33%). Nineteen (13%) patients died within 30 days after the injury date, and 21 (14%) patients died over hospital stay, of which most (90%) of the deceased patients also suffered moderate to severe traumatic brain injury (TBI). Thirty-four (23%) patients were discharged home after hospital treatment, all classified as either AIS-D or AIS-E.

Table 3.

Comparison of outcomes in the triage and surgery-timing subsets

	Triage subseta			Surgery timing subsetb
	Direct L1TC admissions	Secondary ED transfers		Acute (<12 h)	Subacute (>12 h, <2 wk)
	n (%) or median [q1,q3]		p	n (%) or median [q1,q3]		p
	Trauma center
No. of cases	100 (100)	46 (100)		70 (100)	39 (100)
ICU admissions	59 (59)	10 (22)	<.001*	34 (49)	18 (46)	.64
Days in ICU	4 [1–12]	4 [1–12]	.63	4 [2–13]	6 [1–19]	.63
Ventilator use	53 (53)	8 (17)	<.001*	31 (44)	17 (44)	.64
Days on ventilator	2 [1–5]	3 [1–5]	.69	2 [1–5]	4 [1–7]	.76
Days in hospital	12 [6–24]	11 [6–18]	.47	14 [9–20]	13 [9–29]	.13
Day 30 mortality	15 (15)	4 (9)	.29	7 (10)	2 (5)c	.62
Mortality over hospital stay	18 (18)	3 (7)	.07	7 (10)	2 (5)c	.62
Rehospitalizationsc	29 (29)	9 (20)	.23	20 (29)	10 (26)	.74
	Rehabilitation hospital
No. of casesd	49 (49)	14 (30)		39 (56)	15 (39)
Days in rehabilitation	92 [49–140]	81 [36–86]	.21	85 [40–132]	103 [79–140]	.24
USER score on admission	11 [6–20]	17 [12–36]	.14	13 [10–20]	9 [0–14]	.06
USER score on discharge	27 [12–51]	35 [15–64]	.45	35 [21–53]	12 [0–52]	.12
USER score median difference	14 [0–28]	12 [−3–37]	.76	16 [8–35]	9 [0–32]	.23
AIS conversions	20 (41)	5 (36)	.73	19 (49)	8 (53)	.76
Full recovery	2 (10)	0 (0)	n/a	1 (5)	0 (0)	n/a
AIS deterioration	0 (0)	1 (20)	n/a	0 (0)	3 (20)	n/a

Note: AIS = ASIA Impairment Scale; L1TC = level I trauma center; USER = Utrecht Scale for Evaluation of clinical Rehabilitation.

^aPatients transferred from other ICUs or from foreign hospitals were excluded.

^bPostacute patients (n = 2) were excluded from analysis due to low sample size.

^cRehospitalizations were registered as readmissions to the L1TC within the first year post discharge.

^dFurther observation and analysis concern only the patients admitted to the rehabilitation hospital.

^*Statistically significant.

Readmissions to the L1TC were required in 38 (29%) out of the 130 surviving patients, within the first year postdischarge. Eighteen (14%) patients were readmitted for revision of surgery, 16 (12%) for urinary tract complications, and 10 (13%) for respiratory complications. Nine additional patients died within the first year.

Rehabilitation outcomes

Patients were in the rehabilitation hospital for a median of 85 [44–129] days. There was a significant increase in the combined self-care and mobility scores of the USER when comparing the median assessment of 13 [8–22] at admission and the median assessment of 35 [14–55] at discharge from the rehabilitation hospital (p < .001). Remarkably, 8 (13%) of 16 (25%) patients with complete TSCI showed improvement in impairment from complete lesions to incomplete lesions. Further rehabilitation outcomes are displayed in Table 2.

Triage and surgery timing subsets analyses

Table 3 shows bivariate comparisons of outcomes within the triage subset and the surgery timing subset. In the triage subset, treatment results were compared in the 100 directly admitted patients and 46 patients secondarily transferred from a lower lever trauma center. Secondarily transferred patients were significantly less injured compared to patients directly admitted to the L1TC regarding the median ISS (21 [16–33] vs 16 [10–18], p < .001) and the amount of TBI (n = 29 [100%] vs n = 0 [0%]). Additionally, all patients with TBI in the entire sample were directly admitted to the L1TC. The direct admissions had more ICU admissions (n = 59 [59%] vs n = 10 [22%], p < .001) and subsequently received more ventilator support (n = 53 [53%] vs n = 8 [17%], p < .01) with comparable median days on the ventilator. The secondarily transferred patients received more spine surgeries (n = 70 [70%] vs n = 41 [89%], p < .001). Patients admitted to the rehabilitation hospital within this subset showed no significant differences regarding rehabilitation stay, functional scores, and the median difference in functional scores between both groups.

In the surgery timing subset, outcomes were compared between the 39 (69.6%) patients operated in the acute phase (<12 hours) and the 15 (26.8%) in the subacute phase (>12 hours, <2 weeks). Postacute operated patients were excluded from further subanalysis due to a low sample size (n = 2). Acutely operated patients were significantly more injured regarding the median ISS (20 [16–26] vs 16 [10–25], p = .049), while measuring comparable mortality rates, number of rehospitalizations to the L1TC, functional recovery, and AIS conversions after rehabilitation. Patients operated in the subacute phase showed AIS deterioration in three (20%) patients admitted to the rehabilitation hospital.

Discussion

This retrospective cohort study in the central region of the Netherlands adds to recent epidemiologic data on TSCI in the Netherlands.^3,5 Results from this study show an aging and predominantly male (68%) population with incomplete SCI (55%) in the subaxial cervical region. Falls (63%) were most prevalent, followed by traffic incidents (31%), of which cycling accidents (42%) were the largest group. Mortality during hospital stay was 14%, where the deceased mostly suffered from TBI. Nearly a third of the patients were undertriaged before L1TC admission, by being transferred in from a lower level trauma center. Patients operated in the acute phase (<12 hours) showed comparable recovery rates after rehabilitation with patients operated in the subacute phase (>12 hours, <2 weeks).

Several studies on the incidence of TSCI in the Netherlands have been published in the last decades.^3,5 In comparison to the other Dutch TSCI studies, there is a noticeable trend in the age distribution. Van Asbeck et al.⁵ illustrated a peak in young adults between 21 and 30 years of age, while Nijendijk et al.³ showed more elderly than diagnosed in 1994, with a peak between 61 and 70 years. In comparison, our study shows a trimodal age pattern with the towering peak between 70 and 80 years. This may also explain the high incidence of falls in this study, as can also be observed in the aging Dutch trauma population in general.¹⁷ Not only are the elderly more prone to falling, but they are also subsequently more affected by TSCI. Due to decreasing bone density and flexibility of the spine, the elderly become more vulnerable to TSCI, even with seemingly minor trauma.¹⁸

Dutch cycling-related accidents were substantially more prevalent, with 13% compared to 5% in 1994 and 4% in 2010 in the previous Dutch studies.^3,5 This may be explained by the increasing bicycle use among the elderly, as the elderly (age >65) accounted for more than half of the growth of total cycling use in the Netherlands in 2017.¹⁹ This increase also corresponds with trends in cycling-related mortality in the Netherlands in recent years and might be explained by the rising pressure on Dutch traffic systems and the increasing popularity of electronic bicycles (e-bikes).^20,21

The time interval from the ambulance dispatch call up until the patient arrives in ED (total prehospital time) generally stayed under the hour mark in the patients transported by the participating EMS unit (RAVU). These short total prehospital times might partly be the result of the high population density and relatively short distances in the central region of the Netherlands. It is naturally expected that TSCI patients would benefit from swift and adequate prehospital triage. However, due to the low sample size of the EMS records and the prehospital times primarily being adequate, we could not relate these prehospital times to treatment outcomes.

In this study, a third of the (32%) patients were referred from a lower level trauma center. According to the Dutch guidelines, they should have been transported directly to an L1TC for specialized care.²² A survey by Fransen et al.⁷ revealed that the majority of Dutch EMS personnel favor short transport times; when operating far from an L1TC, they opt for a closer lower level trauma center when transporting unstable patients, regardless of suspected TSCI.⁷ Compared to the secondarily transferred patients in our study, the directly admitted patients measured comparable outcomes. Although more severely injured, we could not find outcome differences between these groups.

The new TSCI management guidelines were published in the Netherlands in 2019, standardizing immediate over delayed TSCI surgery.²² This was much needed, as the survey by Fransen et al.⁷ revealed that many Dutch L1TCs differ in whether the trauma surgeon, orthopedic surgeon, or the neurosurgeon is in charge of TSCI patients. They also showed a wide variety in TSCI assessment and management among the EMS and L1TCs. Patients in this study mostly received surgery in the acute phase and showed mortality rates and functional outcomes similar to the patients receiving surgery in the subacute phase. Therefore it was not clear if swift TSCI surgery yielded superior outcomes. Numerous variables (e.g., surgery approach, preexisting cervical spinal canal stenosis) not included in this study could have significantly influenced the effect of surgery in the acute phase.

Almost half of the patients were admitted to the affiliated SCI-rehabilitation unit after hospital treatment. Overall, AIS grades have improved considerably over rehabilitation stay as well as the USER functional mobility and self-care scores. This study AIS conversion rate from complete to incomplete (50%) after the rehabilitation hospital treatment was much higher than in comparative literature.²³ This might be regarded as a success in rehabilitation treatment.²² However, the clinical AIS examination is known for its high interobserver variability, even when performed by trained clinicians. It seems probable that this percentage is overestimated, as some patients with complete TSCI might have retained some sensory function missed during the initial AIS evaluation.²⁴

Mortality in this study was strongly related to brain injury severity, as 90% of the deceased patients had moderate to severe TBI. In Dutch ICU, TBI is the most prevalent death cause in polytrauma patients, exceeding exsanguination, multi-organ failure, and acute respiratory distress syndrome.²⁵ This relative shift might be due to the advancements in critical care in general, and of in-house attending polytrauma teams, effectively treating these conditions.²⁶ A similar formation has been established in our center for TSCI patients as well, with an in-house attending team of spinal surgeons. Further research is required to evaluate its effect on the TSCI outcome.

There are certain limitations to this study. First, the presented data originate from one regional L1TC that serves an urban population. Therefore, conclusions might not be generalizable to other (i.e., suburban or rural) regions. However, to gather corresponding hospital records with EMS records and rehabilitation records on a larger, multicenter scale would have been unfeasible. Besides, the index L1TC examined in this research is established as one of the largest in the Netherlands, and the urban service area is comparable to other L1TCs. Second, due to the retrospective data collection and multiple assessed sources, data completion proved to be challenging. For example, cases with missing endpoints had to be reassessed by a corresponding expert based on patient history. EMS data were only available from the central region’s EMS (RAVU). Therefore, data from the neighboring region’s EMS units were missing. The data originate from a nationwide prehospital registry still in progress, and further research on variables associated with TSCI outcome could benefit significantly from this registry. Third, the analysis of outcomes in surgery times in this study was not corrected for numerous potential confounders; as this topic is widely disputed, further investigation on risk factors would be of great benefit to acute TSCI management.

In conclusion, this project aims to provide an update on epidemiologic trends in TSCI in the Netherlands. This study articulates an aging cohort of male patients with incomplete cervical lesions. Injuries were predominantly due to falls and traffic accidents with a rising trend in bicycle-related injuries, typical to the Dutch bike travel tradition. With short transport times there were also a high number of undertriaged patients, possibly leading to treatment delays. Subject to extensive debate in acute TSCI management, no clear superiority in outcomes was observed in patients who received acute over subacute surgery. Extensive research is needed to relate treatment outcomes to surgery timing further.