Spinal injuries centres (SICs) for acute traumatic spinal cord injury
The majority of complications in traumatic spinal cord injury (SCI) can occur in the first 24 hours and it has been suggested that spinal injury centres (SICs) may influence the pre-transfer care of people with SCI. The specialist SIC concept has been adopted in a number of high-income countries. However, even in such countries, a potentially significant number of people with SCI do not have the opportunity to access this system and are managed in a non-specialist environment.
To answer the question: does immediate referral to an SIC result in a better outcome than delayed referral?
The following databases were searched: AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED, and PsycLIT. Searches were updated in May 2003 and included the Cochrane Injuries Group Specialist Register. The reference lists of retrieved articles were checked.
Randomised controlled trials and controlled trials that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI.
Data collection and analysis
Two reviewers independently selected studies. One reviewer was to have assessed the quality of the studies and extracted data.
No randomised controlled trials or controlled trials were identified that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI. All of the studies identified were retrospective observational studies and of poor quality.
The current evidence does not enable conclusions to be drawn about the benefits or disadvantages of immediate referral versus late referral to SICs. Well-designed, prospective experimental studies with appropriately matched controls are needed.
搜尋以下的資料庫：AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED, and PsycLIT. 資料找尋到2003年5月，包括Cochrane Injuries Group Specialist Register，審閱參考文獻所提的相關文章。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
Plain language summary
Still not clear whether people with a spinal cord injury should go straight to a specialist centre
Spinal cord injury is a serious condition and the effects are usually permanent. In several countries, specialist centres have been set up, where patients can be taken within a few hours of their injury, but even in these countries many patients are dealt with in non-specialist hospitals. This review tried to answer the question: does immediate referral to an SIC result in a better outcome than delayed referral? However, a comprehensive search failed to find any controlled studies and so it is not yet possible to answer the question. The reviewers call for appropriate research to be done.
The annual incidence of spinal cord injury (SCI) throughout the world is 15−40 cases per million (Sekhon 2001). In the USA alone, there are approximately 10,000 new cases of SCI per year (McDonald 2002).
SCI can occur at any age, the effects are usually permanent and currently there is no cure (Harrison 2000). The modal age of an SCI is 19 years and, consequently, the lifetime cost of care may be high. The average lifetime cost of treating a person with SCI has been estimated at between US$500,000 and US$2 million, depending upon the location and extent of the injury (McDonald 2002). The most common mechanism of injury is a sudden unexpected impact or deceleration (e.g. road accidents, domestic falls). Further neurological deterioration, resulting from lesion extension after the initial injury, can occur naturally in about 5% of cases (Harrison 2000), and complications associated with the systemic effects of SCI can lead to respiratory compromise. Significant delays and complications, sometimes leading to admission to an intensive therapy unit (ITU), can also arise as a result of inappropriate or poorly informed management.
The first 24 hours following injury constitute 'immediate care'. It is during this time that the majority of complications can occur (Harrison 2000). Decisions made at the scene of the injury can have a profound impact on the outcome for and ongoing management of individual patients, so care pathways are crucial. It has been suggested that spinal injury units (SICs) may influence the pre-transfer care of people with SCI by liaising closely with, and by providing advice and information to, colleagues in general hospitals (Talbot 1979).
Spinal injury centres
The concept of the specialist SIC was first conceived in the 1930s and 1940s by Sir Ludwig Guttman in the UK and by Donald Munro in the USA (Smith 1999). In the UK, the National Spinal Injuries Centre (NSIC), based at Stoke Mandeville Hospital, was opened in 1944.
There are currently 12 spinal injury centres (SICs) in the UK and Ireland, which provide comprehensive acute, rehabilitation and continuing care facilities and services. In the USA, the Model Regional Spinal Cord Injury Care System program was established in the early 1970s. At present 16 centres are funded by the National Institute on Disability and Rehabilitation Research. The goal of these centres is to provide care within 24−48 hours for victims of SCI within a defined system (Donovan 1994). The specialist SIC concept has also been adopted in other high-income countries, including Canada and Australia.
The following minimum standards of SCI care were agreed by all senior medical and paramedical staff at the NSIC in July 2001 (personal communication, Brian Gardner):
admission of all newly injured SCI persons in the SCI centre with 24 hours of injury, provided they are fit to make the journey by ambulance
readmission of all SCI persons requiring inpatient hospital treatment into an SCI centre, provided they are fit to make the journey by ambulance
review of SCI persons annually by outreach visits or by a visit to the SIC
all treatments of accepted value to SCI persons to be available in the SCI centre.
The UK Spinal Injuries Association (SIA) and the British Association of Spinal Cord Injury Specialists (BASCIS) both recommend that transfer to a specialist SIC should be made as soon as possible after diagnosis of the spinal cord injury (Aung 1997; Carvell 1989; Carvell 1994; SIA 1997).
In the majority of cases, referral of SCI patients to a local SIC takes place within a few weeks or months of injury. Accepted delays in transfer can be due to availability of spinal or ITU beds or physiological status; transfer may also be delayed due to distance or mode of transport, or where patients present with significant accompanying trauma or respiratory compromise. However, even in high-income countries, a potentially significant number of people with SCI do not have the opportunity to access this system and are managed in a non-specialist environment (commonly orthopaedic, neurosurgical or general rehabilitation areas) (Smith 1999). In low-income countries, very few SCI patients would ever be transferred to an SIC.
Why it is important to do this review
A systematic review was commissioned by the UK Health Technology Assessment Programme (Bagnall 2003) on the effectiveness and cost-effectiveness of acute hospital-based services for spinal cord injuries. The HTA review aimed to answer four research questions. One of those questions, 'Does immediate referral to an SIC result in a better outcome than delayed referral?', is addressed in this review.
To answer the question: 'Does immediate referral to a spinal injuries centre (SIC) result in a better outcome than delayed referral?'
Criteria for considering studies for this review
Types of studies
Published and unpublished randomised controlled trials and controlled trials.
Types of participants
People of any age with a complete or partial interruption of spinal cord function resulting from trauma.
Types of interventions
Immediate (as defined by relevant studies) versus delayed referral to an SIC. The question covers referral rather than transfer to an SIC since patients may need to remain in the receiving hospital. The key factor was the advice and influence of the SIC in the management of care.
Types of outcome measures
The following outcomes were included in the review:
time spent on intensive therapy units (ITUs)
time to start of rehabilitation
time from injury to completion of rehabilitation
psychological and social outcomes (including employment)
incidence of secondary complications (including pressure sores, chest infections, urinary infections, septicaemia, upper urinary tract dilation, urinary calculi, renal failure, bladder cancer, contractures of muscle, limitation of range of movement in the paralysed joints, constipation, haemorrhoids, anal fissures, deep vein thrombosis, pulmonary emboli, autonomic dysreflexia, ingrowing toenails, osteoporosis, and fractures of long bones)
other adverse events
Search methods for identification of studies
A search strategy was devised to find studies about referral, transfer and discharge of spinal cord injured patients. The strategy combined 'SCI' search terms with search terms for 'referral, transfer and discharge'. The terms used in the search strategy were identified through discussion with the research team involved in the HTA review, by scanning background literature, and by browsing through the MEDLINE thesaurus (MeSH).
Full details of the search strategies are available from the authors.
Searches were conducted for the HTA review in October 2001. The searches were updated for this Cochrane review in May 2003.
The following databases were searched:
Allied and Complementary Medicine (AMED)
Cochrane Controlled Trials Register (CCTR)
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Database of Abstracts of Reviews of Effectiveness (DARE)
Health Economic Evaluations Databases (HEED)
Health Management Information Consortium (HMIC)
National Research Register (NRR)
NHS Economic Evaluation Database (NHS EED)
Cochrane Injuries Group Specialist Register
In addition the following indexes were searched:
Conference Papers Index
Science Citation Index
Searching other resources
Searches were also carried out on the Internet using medical search engines such as OMNI (http://omni.ac.uk/), meta-search engines such as Copernic (http://www.copernic.com/), and general search engines such as Alta Vista (http://www.altavista.com/) and Google (http://www.google.com/). The following web-based trial sites were also searched: Clinicaltrials.gov (http://clinicaltrials.gov) and Current Controlled Trials (http://www.controlled-trials.com). Specialist spinal cord injury and spinal injury related web sites searched included the Spinal Injuries Association (http://www.spinal.co.uk/), the British Association of Spinal Cord Injury Specialists (http://www.bascis.pwp.blueyonder.co.uk/) and the National Spinal Cord Injury Association (http://www.spinalcord.org/).
The reference lists of all retrieved studies were also scanned for additional studies.
Data collection and analysis
Two reviewers independently screened study citations for inclusion. It was intended to extract data from included studies onto forms developed for different study designs on a Microsoft Access database. One reviewer was to have extracted data and a second reviewer check the forms for accuracy. Disagreements were to be resolved by discussion or, when necessary, with reference to a third reviewer.
The quality of the studies that were included were to be assessed according to the following criteria set out in NHSCRD's report 4 (CRD 2001): method of randomisation; adequacy of concealment of allocation; baseline comparability of groups; blinding of participants and/or investigators, and; handling of drop-outs and missing data (intention to treat analysis). Quality assessment was to be carried out by one reviewer, onto forms in an Microsoft Access database, and checked by the second reviewer for accuracy. Disagreements were to be resolved by discussion or, when necessary, with reference to a third reviewer. Quality scores were not assigned to studies, but the results of quality assessment were to be discussed in the report.
As no RCTs or controlled studies were identified, meta-analysis was not possible.
Description of studies
See: Characteristics of excluded studies.
In the HTA review (Bagnall 2003), 22 studies were identified that addressed the question of referral to SICs. All studies included a control group, in that early referral to an SIC was compared with late referral and/or no referral. However, all studies were retrospective observational studies and of poor quality. There was some doubt over the comparability of groups at baseline and/or on confounding factors in many of the studies. In all studies it was not possible to separate the time of referral and the time of transfer. True late referrals may be a different group of patients with a medical reason why they could not be referred at an earlier stage. A full discussion of these studies, including full data extraction and quality assessment tables, is available in the HTA review.
Update searches, conducted for the review in May 2003, located 514 records. Of these, seven articles were retrieved for full inspection. No relevant published RCTs or controlled trials were identified. The majority of the identified studies were retrospective case series and did not directly investigate whether early referral to an SIC resulted in better outcomes. One study (Geisler 2001) was a post-hoc secondary analysis of data from a multicentre study of acute spinal cord injury. Another study (Smith 2002) was a journal publication of a retrospective observational study identified for the HTA review.
Risk of bias in included studies
No studies were included.
Effects of interventions
No studies were included.
No RCTs or controlled trials were identified that answered the question of whether immediate referral to a spinal injuries centre (SIC) resulted in a better outcome than delayed referral. All of the studies identified in the original and update searches were retrospective and of poor quality. The limitations of this type of study design meant that all of the identified studies suffered from a number of methodological flaws. The validity of the studies may be affected by confounding and other biases. Well-designed, prospective experimental studies with appropriately matched controls are needed.
Implications for practice
The current evidence is insufficient to enable the reviewer to comment on the benefits of early referral to SICs in patients with traumatic SCI.
Implications for research
Well-designed, prospective experimental studies with appropriately matched controls are required to assess the benefits that may be associated with early referral to SICs. All future research should be planned in association with people with SCI and their carers to ensure that appropriate and relevant research is carried out. It had been suggested than an interesting comparison would be within an early referral group, comparing those who were transferred early with those who were transferred late (Bagnall 2003).
We wish to thank Steven Duffy for conducting the update searches for the review.
Data and analyses
Download statistical data
This review has no analyses.
|11 July 2008||Amended||Converted to new review format.|
Protocol first published: Issue 4, 2003
Review first published: Issue 4, 2004
Contributions of authors
L Jones - Involved in protocol writing, study selection and report writing.
AM Bagnall - Involved in protocol writing, study selection and report writing.
Declarations of interest
Characteristics of studies
Characteristics of excluded studies [ordered by study ID]
|Ash 2002||Retrospective case series.|
|Catz 2002a||Restrospective case series.|
|Catz 2002b||Restrospective case series.|
|Geisler 2001||Post-hoc secondary analysis of data from a multicentre study.|
|Smith 2002||Journal publication of data identified for the HTA review.|
|Tobimatsu 2001||Restrospective case series.|
|Wang 2001||Restrospective case series.|