Clinical Geriatrics

This article is the second in a continuing series on trauma care and the older adult. The first article of the series, “Trauma in the Elderly: Causes and Prevention,” was published in the January 2010 issue. This series will discuss the growing problem of trauma in the elderly, including its causes and possible ways to prevent it, care in the acute stages, and manifestations and treatment strategies when trauma involves the torso, spine, brain, and hip. Authors include skilled experts in the trauma field representing various specialties at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and the University of Maryland School of Medicine.

Introduction

Traumatic injuries to the spinal column and/or spinal cord can cause significant disability, morbidity, and mortality. Recent literature suggests that there is a misconception in the understanding of these injuries. Most think that these injuries occur in isolation and to adolescents or young adults. Jabbour et al1 report that recent epidemiological studies on patients with spinal cord injury (SCI) depict a bimodal distribution. The first peak occurs in adolescents and young adults as expected; the second peak, however, occurs in the elderly population (age > 65 yr). It is estimated that in the United States, the population of individuals older than age 65 years will double over the next 30 years. Traumatic injuries, and their complications, are the leading cause of unexpected death in this age group. Spinal cord and/or column injury account for a significant number of these traumatic injuries.

Epidemiology

It is estimated that the annual incidence of SCI in the United States is approximately 40 per million, or nearly 12,000 new cases per year. In the past, statistics have shown that SCI primarily affected young adults. The average age of injury was 28.7 years in the 1970s, with most injuries occurring between the ages of 16 and 30. As the population ages, however, we have seen an increase in the average age of injury as well. More recently, the National Spinal Cord Injury Statistical Center is reporting 40.2 years to be the average age at injury.2

Nearly 81% of SCIs occur in males. Most frequently affected are Caucasians (66.1%) and African Americans (27.1%). Two percent are of Asian descent, and the percentage of Hispanic patients affected has increased to over 8% since 2005.2 Motor vehicle crashes account for 42.1% of SCIs. Falls are the next most common cause, followed by acts of violence and recreational sporting events.

The expense of SCIs to both individuals affected and to society is astronomical. SCIs cost the nation an estimated $9.7 billion each year. The cost of living for a patient with a SCI varies according to the level and severity of injury. Patients with high tetraplegia (C1-C4) have a mean expenditure of $801,161 in the first year following injury and $143,507 each subsequent year.2 Lower levels of injury and incomplete injuries are associated with lower overall costs.

Although life expectancy has improved for patients with SCI over the past 20 years or so, it is still not at the level of life expectancy for those people without SCI. For a patient age 60+ with a SCI, the mean life expectancy is just under 18 years, as opposed to over 22 years for the general population. For low tetraplegics (C5-C8) over age 60 years, the mean life expectancy is only 10 years, and for high tetraplegics and ventilator-dependent patients with SCI, life expectancy is only 7.6 and 1.8 years, respectively.2 The first year of injury holds a higher mortality rate than subsequent years. In the past, renal failure was the leading cause of death among patients with SCI. With the improvements in urologic care, this is no longer the case.