Dual Diagnosis: Spinal Cord Injury and Traumatic Brain Injury. Hollis Bell, MD ABPMR

Transcription

1 Dual Diagnosis: Spinal Cord Injury and Traumatic Brain Injury Hollis Bell, MD ABPMR

2 Outline n SCI Traumatic vs Not n Dual Diagnosis Incidence n Cognitive Deficits n Brain Injury Traumatic vs Not Making the diagnosis n Dual Diagnosis Rehab Outcomes Program Design Research Basis

3 Spinal Cord Injury n Traumatic MVC/Falls/Violence/Sports n Non-Traumatic Vascular Cancer n Metastatic/Primary Degenerative

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7 Cognitive Deficits n Premorbid Developmental/Dementia Prior TBI/CVA Drug/ETOH Psychiatric n Medications Pain, Anxiolytic, Spasticity, GI n Psychologic Distress Anxiety/Depression/PTSD

8 Concomitant Brain Injury n Secondary Brain Injury Vertebral artery damage Cerebral artery damage Hypoxia Hypoperfusion n Traumatic Brain Injury DAI/contusion/IPH/SDH/EDH

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10 Dual Diagnosis n Incidence n How to Diagnose n Predictors n Outcomes n Rehabilitation planning

11 Dual Diagnosis: Incidence n Broad range reported % n Variability explained by How TBI is diagnosed Retrospective vs prospective Trauma vs Inpatient Rehab Sample size

12 Brain Injury Dx: Methods n History n Mechanism of Injury n Amnesia posttraumatic n Loss of consciousness n Glasgow Coma Score n CT vs MRI n NeuroPsych Tests

13 NeuroPsych Testing n Premorbid IQ n Verbal Fluency n Memory n Attention/Concentration n Speed of Processing

14 n Broad range reported % n Associated Findings

15 Analysis of Patients with Spinal Cord Trauma Associated with Traumatic Brain Injury Joao Simao de MeloNeto Columna 13(4) 2014

16 Brazil SCI Tertiary care n 52/321 had TBI with SCI = 16.2% n TBI =clinical + radiologic abnl n 58% car accident, 13% motorcycle n 11% fall, 10% diving n 74% Cervical 1-7 (RR3.48)

17 demeloneto et al n Mild TBI GCS = 65% n Moderate TBI GCS 9-12 = 8% n Severe TBI GCS 3-8 = 27% n Facial Trauma 24% n Pneumonia 33% n SCI+TBI 20 days longer hospital p=0.011 n SCI+TBI 2.48 higher death risk p<0.01

18 Longitudinal Incidence and Concurrence Rates for Traumatic Brain Injury and Spine Injury - A Twenty Year Analysis George Ghobrial, et al Clin Neurol Neurosurg

19 n National Inpatient Sample (Healthcare Cost and Utilization Project) n

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22 National Inpatient Sample n C spine fractures increased 4x n Age increased over the years n Authors note concern of underdiagnosis

23 Missed Diagnosis of Traumatic Brain Injury in Patients with Traumatic Spinal Cord Injury Bhanu Sharma, et al J Rehabil Med

24 Toronto SCI tertiary Retro and Prospective n Clinical GCS, PTA, LOC Only 3.3% of sample lacked data n Neuroimaging CT n Neuroimaging - MRI n Neuropsychological Testing Wechsler Test of Adult Reading Attention and Speed Processing Memory Executive Function

25 TBI defined n Two or more + findings on clinical scales w GCS <=13 n CT report w hemorrhage n + MRI custom protocol for microbleeds n Neuropsych test disparity between current and est premorbid IQ

26 Dual Diagnosis = 44.6% n 33% classified by CT n 33% classified by clinical n 24% classified by MRI

27 Missed DD n 58.5% were NOT classified with TBI by acute hospital n Non MVC missed 1.5 times more p<0.05 n Cervical SCI missed 60% n Sub Cervical SCI missed 53%

28 Traumatic Spinal Cord Injury and Concomitant Brain Injury: A Cohort Study EM Hagen, et al Acta Neurol Scand

29 n no information regarding LOC time = Mild TBI Norwegian Counties n No TBI = GCS 15, no LOC n Mild TBI = GCS 14-15, <5min LOC/amnesia n Mod TBI = GCS 9-13, LOC >=5min, focal neuro n Severe TBI = GCS 3-8

30 Dual Diagnosis = 46.8% n 30.1% mild/11.0% mod /5.7% severe TBI n ETOH 70.3% DD p<0.001 n Incomplete SCI less likely TBI p<0.001 n Severe TBI greatest among pedestrian, motorcycle, car accidents p<0.001 n Cervical SCI = DD OR 2.26

31 Hagen et al n our results are most likely underestimates of the true incidence of TSCI with concomitant TBI n Increasing incidence over the years

32 Traumatic Brain Injury in Spinal Cord Injury: Frequency and Risk Factors Bojana Budisin, et al J Head Trauma Rehabil 2015

33 n Tertiary spinal cord rehabilitation program n n 91 final sample n Indicators of TBI CT, MRI GCS <=14, PTA, LOC

34 TBI Diagnosis n definitively positive- 2 or more positive indices n definitively negative 3 or more negative indices n Ambiguous 1 positive clinical neurological indicator with all other variables negative 1 or 2 negative clinical or imaging

35 Conservative Rate n 36 TBI POS / (36 POS + 26 NEG + 29 AMB) = 39.6% n MVC 3.8 times more likely 31.6% of SCI falls had associated TBI n Cervical 36% had TBI n SubCervical 43.9% had TBI n All multilevel spine injury had TBI

36 Aggressive n 36 TBI POS / (36 POS + 26 NEG) = 58.1% n MVC 8.99 times more likely TBI 57.1% of SCI falls sustained TBI n Cervical % had TBI n SubCervical 58.1% had TBI n All multilevel SCI had TBI

37 n % incidence n Ambiguity usually due to lack of clinical indices GCS, PTA, LOC at scene and ED

38 Spinal Cord Injury and Co- Occurring Traumatic Brain Injury: Assessment and Incidence Macciocchi, Stephen et al Arch Phys Med Rehabil

39 Shepherd Jan n 198 with SCI eligible for inclusion n Medical record review (no self report) n PTA /GCS/CT or MRI n None/mild/mild complicated/ moderate/severe

40 n Mild PTA <24 h; GCS 13-15; neg imaging n Mild comp PTA<24h; GCS13-15; + imaging n Moderate PTA 1-6 d; GCS 9-12; +/- imaging n Severe PTA>=7days; GCS 3-8; +/- imaging n LOC 54% n Some duration of PTA 58% 34% unable to estimate duration of PTA from records

41 60% SCI+TBI n 34% mild n 10% mild complicated n 6% mod n 10% severe n 74% of each MVC and falls had TBI p<0.001 n MVC and falls more severe TBI p<0.01 n Cervical SCI accounted for 50% of TBI cases 81% of C1-4 TBI had Mod/Severe

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43 Traumatic Brain Injury is Under-Diagnosed in Patients with Spinal Cord Injury Tolonen, Anu et al J Rehabil Med

44 31 pts Finland prospective n TBI = Any period of LOC Any period of PTA Any alteration in mental state Any focal neurological finding transient or permanent due to TBI (cranial n, hemi deficits) 17wks post injury Neuropsych testing 19wks post injury Neuroradiological findings 20wks

45 74.2% had SCI + TBI n 22.6% GCS <15 n 61.3% PTA n 12.9% neurological sx n 67.7% abnl Npsych testing n 32.3% abnl MRI

46 Military TBI + SCI n Iraq personnel closed or penetrating head injury 9.8% SCI or spinal column injury n VA SCI population- 409 traumatic SCI patients n Chart searched for LOC/TBI/brain injury/head trauma n 24.2% concurrent TBI

47 Self Report TBI with SCI n 105 SCI admissions 2 Rehab Hospitals n Self Report exceeded actual by 66% TBI Chart Review Self Report No Mild Comp Mild 1 Mod 2 16 Severe 0 4

48 SCI and BI Outcomes n Acute Hospital n LTACH n IRF n SNF n Community Integration

49 Traumatic SCI with Concomitant Brain Injury: Inhospital Complication Rates and Resource Utilization n Mansfield, Kevin etal. Univ of Louisville n JSM Neurosurg Spine 2(2) n 2014

50 n National Trauma Databank 900+ US trauma centers n 16, 577 SCI - 5,968 with TBI n SCI + TBI compared to SCI alone n Matched cohorts race, gender, ISS, insurance, trauma level, mechanism of injury, ETOH presence