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and heterotrophic ossification, were prevalent during
acute care (8, 9).
Previous reports from Sweden did not provide a
comprehensive audit of secondary medical complica-
tions during different episodes of care, i.e. acute and
rehabilitation (8, 9). For example, previous interna-
tional literature has found direct associations between
outcomes, such as survival and recovery, and other
secondary medical complications, including pneumo-
nia, pulmonary embolism, and deep vein thrombosis
(10, 11). There is therefore a need to provide a more
comprehensive audit of the nature and prevalence
of secondary medical complications throughout the
chain-of-care, with the aim of informing prevention
strategies as well as further strengthening the specia-
lized approach followed in Sweden.
Given these knowledge gaps, the aims of this study
were: (i) to determine the prevalence of secondary
medical complications during acute care and rehabilita-
tion; (ii) to assess whether associations exist between
level, as well as completeness, of injury and the deve-
lopment of the most common complications; and (iii) to
determine the associations between having a secondary
medical complication, the number of complications
during acute care, rehabilitation and return-to-work
one year after injury.
METHODS
Design and participants
A prospective, population-based design was implemented
between May 2014 and October 2015 (18-month period) to
determine the incidence and aetiology of traumatic SCI (TSCI),
secondary medical complications, as well as outcomes fol-
lowing TSCI in Stockholm, Sweden. The Regional Board of
Ethics in Stockholm approved the project prior to the start of
data collection (dnr: 2014/137-31/1). All principles related to
research conducted on humans, as stipulated in the Declaration
of Helsinki, were adhered to throughout the study period. The
first part of the larger project, i.e. the epidemiology of TSCI in
Stockholm, Sweden, has been reported previously (12).
In the Greater Stockholm region, several level 1 trauma units
provide immediate and comprehensive intensive care, whereas
the only spinal injury unit provides post-acute/primary rehabi-
litation. Furthermore, 3 active inpatient rehabilitation units, as
well as one outpatient clinic delivering lifelong follow-up care,
are available. Newly-injured patients satisfying the following
criteria were eligible to participate in this study: (i) abnormal
imaging, such as with magnetic resonance imaging scan or
multi-slice computerized tomography scan, confirming an acute
TSCI or cauda equina lesion; (ii) the injury must have resulted in
persisting impairment (i.e. not just a concussion) after emergence
from neurogenic shock, which generally occurs within the first
24–72 h after injury; (iii) age 18 years or older; (iv) surviving at
least 7 days post-trauma; (v) admittance to the spinal injury unit;
and (vi) legitimately residing in Stockholm, Sweden. All parti-
cipants (n = 45) enrolled in the incidence cohort were followed
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throughout acute care, inpatient rehabilitation, and up until 1-year
follow up. Only 31 participants received inpatient rehabilitation,
while the rest received home/frail care (n = 2) or only outpatient
rehabilitation (n = 12) due to their mild injury severity grade
(American Spinal Injury Association Impairment Scale; AIS D).
Data collection variables and procedure
The SCI Basic Core Data Set, a questionnaire covering the most
essential data elements for the description of persons with TSCI,
was completed upon admission to the acute unit. The data-set
covers aspects of the injury event, extent of the injury including
neurological severity, and hospitalization (13). Assessment of
neurological severity was performed by 2 attending physicians
on both admission to and discharge from the spinal injury unit
(acute care) in accordance with the international standards
(1). The list of variables was extended by including secondary
medical complications, which included the following: pressure
injuries, pulmonary complications (atelectasis and pneumonia),
UTIs, deep vein thrombosis, autonomic dysreflexia, pulmonary
embolism, postural hypotension, spasticity, neuropathic/spinal
cord pain (i.e. pain at-level or below-level pain originating from
spinal cord ischaemia or trauma) and “other”. The selected
medical complications were screened weekly by the medical
team for the duration of acute care and inpatient rehabilitation.
Centralization of information on secondary medical complica-
tions was improved by developing a standardized list containing
operational definitions of complications, a box indicating the
presence of respective complications, and, where possible,
severity of complications. In addition, information on return-
to-work/study and mortality was collected one year after injury.
Statistical analysis
Concerning participants’ characteristics and the prevalence
of secondary medical complications, descriptive statistics
were used. Output was expressed as mean (SD) and median
(range), whereas the prevalence data were expressed as counts
(percentage). Concerning objective ii and iii, determining the
association between level and completeness of injury and the
3 main secondary medical complications, as well as between
secondary complications and return-to-work, inferential statis-
tics, i.e. Fisher’s exact test, was used.
The ASIA neurological classification system was simplified
by creating 2 categories for completeness of injury, i.e. complete
(AIS A) and incomplete (AIS B, C, and D), due to the lack of
statistical power for carrying out inferential statistics. A similar
approach was used for the number of complications, where zero
and 1 complication were grouped vs 2 or more complications.
The alpha level was set at 0.05 for measures of association.
RESULTS
Participants’ characteristics
Following an 18-month observation period, 49 newly-
injured persons with TSCI were registered in the Stock-
holm area, of whom 45 took part in the study. Of the
4 dropouts, 2 patients declined consent, 1 died after 7
days, and 1 was not part of the chain of care. Table I
illustrates the injury characteristics of those enrolled
in the study on admission to acute care.