Difficulties capturing co-occurring traumatic brain injury among people with traumatic spinal cord injury: a population-based study

In this study we sought to identify co-occurring TBI among persons with TSCI admitted to a spinal rehabilitation centre in NZ. Our aim was to evaluate the feasibility of a published algorithm for capturing co-occurring TBI. We were unable to consistently apply the algorithm because of variable documentation of TBI indicators. However by careful notes review we were able to identify co-occurring TBI in 39% of TSCI cases with a small number of additional suspected TBI cases where TBI could not be confidently ruled in or out based on the information available. Including all cases of TBI, suspected or otherwise resulted in up to 55% of the sample having sustained co-occurring TBI. This seems consistent with the small number of international studies reporting co-occurring TBI rates [1, 8]. In addition, it has been reported that among persons with TSCI, 30–34% also sustain a mild TBI, 11–16% sustain a moderate TBI and 6–10% sustain severe TBI [1]. While broadly echoing the patterns in our sample, some variability associated with the way we incorporated neuroimaging findings may have resulted in a higher proportion of mild TBI and lower proportion of moderate TBI relative to other published studies. Acute neuroimaging such as CT is not routinely recommended after mild head trauma with exceptions according to widely used head CT rules [6]. While the role of magnetic resonance imaging for evaluating the injured spine following TSCI is reasonably well established [17], this is less established and lacks sensitivity for acute management of TBI, especially for cases in the mild range of severity [18]. In our sample, neuroradiology findings, positive or negative, were available for only a small number of cases, perhaps reflecting these issues.

Applying the algorithm published by Macchiocchi et al [2]. was not feasible because of the inconsistent recording of references to PTA in particular, as well as other TBI signs and indicators. When references were made to PTA or amnesia it was difficult to confidently estimate duration. The GCS score was not able to be found in a third of cases and references to loss of or altered consciousness were patchy at best. This is not unique to the study context and reinforces issues with inconsistent screening for TBI noted by others [19]. These are issues that will impact clinical uptake of such an algorithm by clinicians.

Turning to the mild TBI literature and diagnostic guidelines may be helpful and especially relevant given most issues with consistency of identifying co-occurring TBI are associated with injuries in the mild range [1, 5]. TBI in the moderate and severe range may be more obvious. In a synthesis of mild TBI practice guidelines [6], a three-step approach to TBI diagnosis was suggested. First and critically, clinicians should establish a plausible mechanism, where sufficient biomechanical energy is evident to disrupt brain function. While commonly reported but not always consistently found across studies [8], cervical level injuries should flag a co-occurring TBI diagnosis. Other mechanistic risk factors for co-occurring TBI such as transport injuries and falls have been identified reasonably consistently in other studies [5]. These are potentially useful starting points for routine screening for TBI among persons with TSCI, and especially those with cervical spinal cord injury.

The second step is to query signs and symptoms of altered mental status and the third step underscores the importance of considering confounding factors, such as substance intoxication, acute psychological stress, and treatments administered early after injury. At steps two and three, TBI indicators such as the GCS score, PTA if available, other evidence of altered mental status as available should be considered in the context of confounds. Such a three step approach underscores the importance of looking for multiple converging sources of information to capture TBI co-occurring with TSCI, notwithstanding documentation problems as described.

One other issue our study highlighted was the inconsistency with which TBI indicators travelled with the individual as they progressed from the injury site to the first hospital and then the rehabilitation centre. This has been noted as a significant area of concern by others and emphasises the need for more standardised screening processes to ensure co-occurring TBI is consistently communicated across the continuum of care [19].

Our study underscores the need for a consistent approach to capturing co-occurring TBI. The three step approach outlined above incorporating multiple sources of information to reliably capture and then consistently communicate co-occurring TBI may have promise [19]. The larger issue however is how such approaches can be incorporated into clinical practice. There is a body of evidence describing barriers and difficulties with uptake of evidence-based guidelines in clinical practice [20], and this is a focus of our ongoing work.

Limitations

This is a small sample from a single centre albeit with a wide nationally representative catchment area. Further, while the number of suspected TBI cases was relatively small, including these in total figures for TBI can inflate estimates because of possible false positives [8]. The figures we report should be considered with this caveat in mind.

Inability to access paramedic records resulted in missing information because a large proportion of cases sustained injuries in other regions and paramedic records did not travel with the individual to the rehabilitation facility. This is not likely to be a significant issue if initial GCS information and references to altered mental state are captured reliably elsewhere.

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