Concomitant SCI and TBI


Am J Phys Med Rehabil. 2004 Jan;83(1):22-6.

Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries.

Macciocchi SN, Bowman B, Coker J, Apple D, Leslie D.

Neuropsychology Division, Shepherd Center, 2020 Peachtree Road, Northwest, Atlanta, GA 30309, USA.

            OBJECTIVE: This study was undertaken to determine if persons who sustain a spinal cord injury (SCI) and co-morbid brain injury (dual diagnosis [DDS]) evidence smaller functional gains and experience significantly longer rehabilitation lengths of stay than persons with only an SCI. DESIGN: This retrospective comparison study was performed at a 100-bed rehabilitation hospital specializing in acute SCI and traumatic brain injury rehabilitation. Summary scale outcome data of persons who sustained an SCI were compared with outcome data of a group of persons with a DDS. Comparisons were established by matching groups principally on level of SCI and admission Motor FIM trade mark score and secondarily on education, sex, and age. Outcome measures included admission Motor and Cognitive FIM score, discharge Motor and Cognitive FIM score, Motor and Cognitive FIM change, length of stay, and rehabilitation charges. RESULTS: Persons with a DDS evidenced a significantly more impaired Cognitive FIM score at admission and discharge from rehabilitation. Persons with a DDS also achieved a significantly lower Motor FIM change than persons with SCI. There were no significant differences between DDS and SCI groups regarding Cognitive FIM change, length of stay, or rehabilitation charges. Injury severity as defined by the Glasgow Coma Scale or intracranial lesions did not predict response to treatment in the DDS group. CONCLUSION: Persons with a DDS achieved smaller functional gains during rehabilitation than peers with SCI. Brain injuries seem to limit functional gains, although the relationship between brain injury severity and functional change is not linear. Prospective studies are needed to identify factors limiting functional gains in rehabilitation and assist in developing specific treatment programs for persons with SCI and brain injury.


Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions.

Cook N.

Intensive Crit Care Nurs. 2003 Jun;19(3):143-53.

Department of Nursing, University of Ulster, Magee Campus, Derry Co., Derry, Northern Ireland.

            Spinal cord injury (SCI) is a devastating and challenging condition. The events that lead to SCI, such as road traffic accidents, falls, sports and violence [Top. Spinal Cord Inj. Rehabil. 5 (1999) 83], are also the common aetiologies of traumatic brain injury (TBI). It's not surprising then, that 20-50% of those with cervical SCI have TBI [J. Trauma 46 (1999) 450]. The literature pertaining to the management of either injury in isolation is vast, but lacking where the two conditions are experienced together and require distinct adaptations to interventions. Consequently, a gap in the literature exists. This paper focuses on those patients with SCI of the cervical spine with associated head injury, and pay particular attention to respiratory difficulties, and presents interventions required to minimise and treat the effects of such pulmonary compromise.


SCI Nurs. 2003 Summer;20(2):86-92.

Dual diagnoses: the person with a spinal cord injury and a concomitant brain injury.

Arzaga D, Shaw V, Vasile AT.

            Spinal cord injury (SCI) alone is a devastating event that often results in physical disability. When the SCI is combined with a brain injury, the degree of disability can be magnified and the patient's rehabilitation becomes further complicated. It is not unusual for the head injury to be overlooked or undetected during the emergent and acute phases of treatment. The brain injury may first appear when the client demonstrates an inability or resistance to carry out functional activities appropriate to his/her level of injury. Cognitive deficits can limit or complicate the client's ability to adapt to his/her physical limitations, learn compensatory skills, and achieve the maximal level of independence. These patients require a wide base of physical, psychological, educational, and medical support. Because they are at a high risk for developing complications, they will require lifelong interventions and involvement from an interdisciplinary team to provide a safety net. The following article examines the patient with dual diagnoses of SCI and brain injury. A comprehensive review of commonly encountered problematic scenarios and interventions is presented.


Am Surg. 2003 Mar;69(3):261-5; discussion 265.

Severity of cervical spine ligamentous injury correlates with mechanism of injury, not with severity of blunt head trauma.

Albrecht RM, Malik S, Kingsley DD, Hart B.

Department of Surgery, University of Oklahoma, Oklahoma City, Oklahoma, USA.

            Clearance of the cervical spine (CS) in obtunded trauma patients in an intensive care unit is problematic. Patients with no osseous injuries have potential unstable extradural supportive soft tissue injury. Evaluation of the supporting structures involves dynamic fluoroscopy or MRI both of which have inherent risks and convenience issues. Defining which of these patients are at highest risk for severe supportive structure injury may improve resource utilization for CS clearance. The purpose of this study was to evaluate clinical factors that may predict the probability of CS supportive soft tissue injury in patients with traumatic brain injury. Patients who sustained traumatic brain injury with intracranial pathology, absence of CS osseous injury, and a limited cervical spine MRI within 72 hours of injury were included. Potential clinical predictors included the severity of the traumatic brain injury defined by the Abbreviated Injury Severity Score for the cerebrum and initial Glasgow Coma Scale, the Injury Severity Score (ISS), mechanism of injury, and high versus low-velocity mechanism. Severity of soft tissue/ligament injury was graded by MRI findings. One hundred twenty-five patients met the study criteria; 81 had negative MRI findings and in 44 the MRI study was positive for potentially unstable injuries. High-velocity mechanisms of injury and ISS--not the severity of the traumatic brain injury or initial Glasgow Coma Scale score--were statistically significant predictors of severe CS supportive soft tissue injuries. Obtunded blunt trauma patients who have been involved in high-velocity-mechanism incidents and have high ISS are at greatest risk for extradural supportive soft tissue CS injuries. These patients should either remain in CS immobilization until clinical evaluation can be completed or undergo further evaluation of their supportive soft tissue structures by MRI or fluoroscopic flexion/extension.


Spinal Cord. 2004 Feb;42(2):73-9.

Levels of brain wave activity (8-13 Hz) in persons with spinal cord injury.

Tran Y, Boord P, Middleton J, Craig A.

Department of Health Sciences, University of Technology, Sydney, NSW, Australia.

            STUDY DESIGN: Brain wave activity in people with spinal cord injury (SCI) was compared to brain wave activity in able-bodied controls. OBJECTIVES: To investigate whether a spinal injury results in changes in levels of brain wave activity in the 8-13 Hz spectrum of the electroencephalography (EEG). SETTING: Sydney, Australia. METHODS: Monopolar, multichannel EEG assessment was completed for 20 persons with SCI and 20 able-bodied, sex- and age-matched controls. A total of 14 channels of EEG were measured across the entire scalp for all participants. Comparisons between the able-bodied and SCI participants were made across the frontal, central, parietal, occipital and temporal regions. Comparisons were also made for impairment level, that is, between participants with tetraplegia and paraplegia. RESULTS: Compared to the able-bodied controls, consistently reduced brain wave activity (measured by magnitude and peak amplitude) in the 8-13 Hz component of the EEG occurred in persons with SCI across all regions and sites, and differences were larger in the central, parietal and occipital sites. The SCI group also had consistently lower frequencies than the able-bodied controls. Furthermore, the subgroup of SCI participants with tetraplegia generally had significantly reduced brain activity (magnitude and peak amplitude) compared with the paraplegic subgroup and able-bodied controls. CONCLUSIONS: The findings of this research enhance our understanding of changes in brain wave activity that could be associated with deafferentation that occurs following SCI, as well as provide essential data on the potential of SCI persons to use a 'hands free' environmental control system that is based upon 8-13 Hz brain activity.


Topics in Spinal Cord Injury Rehabilitation  

Volume 5, Number 2 / Fall 1999 - Dual Diagnosis: SCI-TBI, 1 - 20

Epidemiology of Spinal Cord Injury and Traumatic Brain Injury: The Scope of the Problem

Elie Elovic MD, Steven Kirschblum MD

            Traumatic injury to the central nervous system (CNS) is one of the most important issues concerning the health care system in the 1990s and will likely remain so into the next millenium. In the United States, there are 10,000 hospital admissions each year secondary to spinal cord injury (SCI), while there are more than 250,000 hospital admissions each year secondary to traumatic brain injury (TBI). The majority of SCIs occur in the young, and 55% of traumatic SCIs are sustained by people between 16 and 30 years old. A similar trend is noted in TBI with the highest incidence rate reported for those who are between 15 and 24 years old. Motor vehicle accidents (MVAs) and falls are the two most common causes of traumatic injuries to the CNS. Recent advances have lessened the incidence of MVAs related to the CNS, while there has been an increased rate of injury secondary to violence in both SCI and TBI. The issue of dual diagnosis of SCI and TBI is an important one. It is far more common for the patients with an SCI to also have a TBI diagnosed, with a rate between 24% and 50% reported. The converse of SCI diagnosed after a primary TBI is much less common with single digit rates between 1.2% and 6% reported.


Topics in Spinal Cord Injury Rehabilitation  

Volume 5, Number 2 / Fall 1999 - Dual Diagnosis: SCI-TBI, 83 - 90           

Traumatic Brain Injury Associated with Acute Spinal Cord Injury: Risk Factors, Evaluation, and Outcomes

Thomas K. Watanabe MD, Ross D. Zafonte DO, Edward J. Lairson MD

            Rehabilitation after spinal cord injury (SCI) involves learning new skills and adjusting to disability. The patient with SCI relies on intact cognitive processing to master these tasks. Therefore, even a mild traumatic brain injury (TBI) may hinder the rehabilitation effort. Because of the similarities in the mechanisms of SCI and TBI, it is not surprising that a large percentage of patients with SCI have a concomitant TBI, and it is important to identify this complication in these patients. To aid in this identification, we review literature examining the incidence and risk factors of SCI with TBI and also review evaluation tools and outcome studies for this challenging dual diagnosis.


Topics in Spinal Cord Injury Rehabilitation  

Volume 5, Number 2 / Fall 1999 - Dual Diagnosis: SCI-TBI, 76 - 82

Neuropsychological and Psychological Factors in Acute Rehabilitation of Individuals with Both Spinal Cord Injury and Traumatic Brain Injury

Joseph H. Ricker PhD, Theresa M. Regan PhD

            Traumatic brain injury (TBI) co-occurs with spinal cord injury (SCI) with sufficient frequency. Each form of injury has its own specific rehabilitation concerns; but when they occur together, there may be significant disruption of traditional rehabilitation treatment, goals, and outcome. Our article will review the cognitive and emotional features of concurrent SCI and TBI in the context of rehabilitation. Because of the psychological and neuropsychological features of these combined injuries, rehabilitation approaches and expectations will require modification. Implications for interdisciplinary rehabilitation will be discussed.


Defining assessment parameters in dual injuries: spinal cord injury and traumatic brain injury.

Lemke DM.

SCI Nurs. 1995 Jun;12(2):40-7.

            Assessment parameters for muscle testing in the individual with a spinal cord injury (SCI) have been clearly defined by the American Spinal Injury Association (ASIA). However, the ASIA standard requires the individual's participation in reporting sensory information and he/she must be able to perform specific tasks to complete the examination. In an individual with a dual injury, a SCI and a traumatic brain injury (TBI), neurological assessment can be impeded by the individual's inability to participate in the exam. Assessment needs to incorporate both cognitive and physical parameters that will appropriately assess both injuries. This article reviews the assessment parameters for both spinal cord injury and traumatic brain injury and provides assessment guidelines for bedside evaluation of functional ability. In addition, a review of the biomechanics of injury will provide a model for understanding dual injury.


The effectiveness of different methods of defining traumatic brain injury in predicting postdischarge adjustment in a spinal cord injury population.

Richards JS, Osuna FJ, Jaworski TM, Novack TA, Leli DA, Boll TJ.

Arch Phys Med Rehabil. 1991 Apr;72(5):275-9.

            Traumatic brain injury (TBI) can occur concomitantly with spinal cord injury (SCI). Much of the initial work in this area has focused on identifying coincidence rates and risk factors; less has focused on possible long-term implications of TBI when it occurs with SCI. In this study, SCI/TBI and neurologically matched SCI-only groups were formed on the basis of clinicians' ratings of neuropsychologic test scores. SCI/TBI and SCI-only groups were also formed using Halstead Category cutoff scores, presence/absence of loss of consciousness, and clinicians' ratings of severity of TBI. Dependent measures assessed an average of two years postinjury measured personal, social, and family adjustment of the individual with SCI and that of a significant other. Loss of consciousness and nonconsensus clinical ratings of presence/absence of TBI predicted postdischarge adjustment poorly. Severity ratings in the moderate to severe range, and Category cutoff scores did have some predictive value, with patients defined as impaired being more likely to report adjustment difficulties or being described as having adjustment difficulties by a significant other. The difficulty of making unequivocal diagnoses of TBI in this population is discussed and implications for future research delineated.