Epidemiology of Traumatic SCI

Motor Vehicle Crashes

There were 84 studies reporting on SCI as a result of motor vehicle crashes (MVC) (Table 7). These studies presented statistics from 30 different countries; all continental regions were covered by at least one study. A variety of data sources were used including national and regional registries and national, regional or local hospital admission/discharge records or surveys. The studies used a variety of methods to collect and aggregate data. North America had the most studies (N=26), primarily from the United States (N=17 studies), followed by Europe (N=23 studies).

The proportion of SCI related to MVCs ranged from 6.9% in Nepal (Shresta et al. 2007) to 89% in Nigeria (Olasode et al. 2006). The most frequent proportion fell within the 40-49.9% range (N=22 studies) followed by the 30-39.9% range (N=19 studies). Differences in inclusion criteria may be one of the primary reasons for the wide variation of reported estimates as some studies included all causes of SCI while others excluded non-traumatic causes or other subgroups such as patients with neurodegenerative diseases, or individuals with or without neurological deficits.

In the United States and Canada, MVCs are the most common cause of SCI. Most recent estimates indicate MVCs account for 41% to 45% of SCIs in the United States (National Spinal Cord Injury Statistical Center February 2010; DeVivo and Chen 2011). In British Columbia, Alberta, and Manitoba Canada, MVCs are the primary cause of SCI (Lenehan et al 2012; Dryden et al. 2003; McCammon and Ethans 2011). Data from Manitoba indicated that the relative proportion of SCIs resulting from MVCs declined over time as indicated by decreasing frequencies among three different cohorts (47.4,%, 39.3%, 34.9%) sampled at three different time points between 1981 and 2007 (McCammon and Ethans 2011). Over this time, an increase in the frequency of females incurring a SCI due to MVCs was also observed (McCammon and Ethans 2011). Contrary to this, Pirouzmand (2010) reports an increase in relative frequencies of SCI due to MVCs from 1986 to 2006, in Toronto, Ontario, Canada, and Couris et al. (2010) report consistent frequencies from 2003 to 2006 in all of Ontario, Canada, with more women (28.5%) than men (23.0%) sustaining SCI.

Most recent estimates from Europe indicate MVCs to be the leading cause of SCIs in regions of Spain, Iceland and Turkey, and the second most common in regions of Norway. In Aragon, Spain, MVCs were the most common cause of SCI (57.0%) between 1972 and 2008, with higher incidence in males than females for all ages (Van Den Berg et al. 2011). Similarly, Cosar et al. (2010) report MVCs have accounted for 55.1% of SCIs among 127 individuals taking part in an in-patient rehabilitation program in Turkey between 1996 and 2008. In two counties in Norway, MVCs were found to be the second leading cause (34.2%) of SCI between 1952 and 2001. During this observation period MVCs resulting in a SCI increased overall and specifically among younger (<30 years) males (Hagen et al. 2012).

In Asia, MVCs are the primary cause of SCI in Taiwan (58.8%) (Wu et al. 2011), Iran (52.0%) (Chabok et al. 2009), Saudi Arabia (85%) (Alshahri et al. 2012), India (45%) (Chhabra and Arora 2012) and in one study from China (Hua et al. 2013). Other studies from the region found that MVCs were the second leading cause of SCI, including in Beijing (22.3%) and other areas of China (Tianjin (34.1%; 36.4%) (Ning et al. 2011; Li et al. 2011; Wu et al. 2012) as well as Pakistan (32.0%) (Qureshi et al. 2010). Similar to other studies, MVCs leading to SCI were most common among young, males, with MVCs occurring due to fatigue with highway driving without the use of seatbelts (Ning et al. 2011).

Two papers with a specific focus on SCIs resulting from MVCs were found in the most recent update. One paper reporting on MVCs in the United States used both the Crash Injury Research Engineering Network (CIREN), and the National Automotive Sampling System’s Crashworthiness Data System (NASS-CDS) databases (Stein et al. 2011). The CIREN database includes only newer fleet of vehicles and thus newer safety features, in addition to the reporting of significant injuries, whereas the NASS-CDS database represents a national probability sample of vehicles that are involved in any police-reported MVCs. The authors found that among the more serious MVCs as those included in the CIREN database, 11.5% of case occupants (n=3,524) had cervical spine injuries, whereas 0.35% of all occupants (N=48,660,000) in the NASS-CDS database sustained a cervical spine injury. Rollover and other severe crashes led to much higher risk of cervical spine injury. Older individuals (>65 years) were at an increase risk of cervical spine injury. Seat belt use was effective at preventing cervical spine injuries whereas airbag deployment may increase the risk of sustaining a cervical spine injury when in a serious MVC.

Lieutaud et al. (2010) reported on data from an epidemiological database of every MVC requiring medical attention in health facilities in the Rhone area of France since 1995. From 1997 to 2006, 144 (0.15%) individuals suffered a SCI out of the 97,341 patients included in the database. Cervical SCIs were the most frequent type of injury. More motorcyclists sustained a SCI compared to other types of major spinal trauma. Being younger, male, a motorcyclist, and not wearing a seatbelt were identified as risk factors for SCI.

Table 7. Motor Vehicle Crashes

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: % (n of cases)
Hua et al. 2013 N=561	China	Retrospective review of individuals who were treated at The General Hospital of Chinese People’s Armed Police Forces	Males = 79.9% Mean Age =31.85 years	MVC Specific: Incomplete: 47.7% Cervical (55.7%) Cervical-Thor (4.5%) Thoracic (32.8%) Thor-Lumbar (4.5%) Lumbo-sacral (2.4%)	51.2%
Ibrahim et al. 2013 N=292 (traumatic and non)`	Kuala Lumpur, Malaysia	2006-2009 Admitted to the Department of Rehabilitation Medicine, Hospital Kuala Lumpur	Males = 77% Mean age = 39 years	Tetraplegia: 37% (108) Paraplegia: 63% (180)	Traumatic: MVC: 66%
Wang et al. 2013 N=761	Anhui Province, China	All patients admitted to two hospitals within Anhui Province, China between January 2007 and December 2010	Males = 77.3% Mean age = 45 years	Cervical (46.3%) Thoracic (20.4%) Lumbrosacral (33.3%)	21.2%
Alshahri et al. 2012 N=307	Riyadh, Saudi Arabia	2003 to 2008 Traumatic SCI, admitted to Riyadh Military Hospital in Saudi Arabia	Males = 88% Mean age=29.5 years	Complete tetra = 21% Incomplete tetra = 31% Complete para = 29% Incomplete para = 18%	MVC: 85% (n=262)
Chhabra and Arora 2012 N=1138	India	All patients admitted to an Indian Spinal Injuries Centre 2002 to 2010.	85.5% males Mean age: 34.4 years	AIS A: 71.1% AIS B: 14.7% AIS C:8.2% AIS D: 6.0%	Road traffic accident: 45%
Knutsdottir 2012 N=207	Iceland	1975-2009 Patients admitted to Landspitali University Hospital	Males: 72% Mean Age: 38 years	Males: 72% Mean Age: 38 years	Road traffic Accidents: 42.5%
Lenehan et al. 2012 N=930	British Columbia, Canada	1995-2004 Hospital admissions to level 1 trauma center were prospectively collected using a locally designed spine database	Males = 80% Median: 35 years	Cervical: 45.1% Thoracic: 24.5% L/S: 20.9% Unspecified: 9.5%	Motor vehicle accident: 51.4%
Middleton et al. 2012 N=324	New South Wales, Australia	January 2004 to June 2008, Data from Ambulance Service of New South Wales	Males = 85% Mean age = 42 years	Not Specified	MVC (on-road): 31.2% MVC (off-road): 9.3%
Sabre et al. 2012 N=595	Estonia	1997-2007 SCI patients admitted to any Estonia hospitals	Male:Female = 5.5:1 Average age of injury = 39.0 years	C1-C4, AIS, A, B, C = 9.9% C5-C8, AIS, A, B, C = 28.9% T1-S5, AIS , A, B, C = 26.7% All AIS D = 23.9% Unknown = 10.6%	MVC = 29.4%
Wu et al. 2012 N=143	Tianjin, China	Patients admitted to Tianjin Medical University General hospital with diagnosis of tSCI	Mean age 54.6 years Male:Female = 5:1	ASIA A = 5.6% ASIA B = 16.8% ASIA C = 18.9% ASIA D = 58.7%	MVC = 36.4%
Devivo et al 2011 N=45,442	USA	1935-2008 Persons who were treated at either a SCI Model System or a Shriners Hospital SCI unit	Males= 79.2% Mean age at injury= 32.5 years	19.8% C1-4 32.6% C 5-8 45.4% Paraplegic 2.2% Normal	MVC 45.4% (n=20,631)
Li et al. 2011 # of patients: N=1079 data collected: N=264	Beijing, China	Patients with acute TSCI admitted to civilian or military hospitals during Jan 1- Dec 31 2002	200 male (76%) Mean age: 41.7 years Range: 6-80 years	Cervical (n=13, 4.9%) Thoracic (n=74, 28%) Thoracolumbar, lumbar and lumbosacral (n=176, 66%)	MVC: 22.3% n=59
McCammon and Ethans 2011 N=553	Manitoba, Canada	1981-1985, 1998-2002, 2003-2007 Inclusion criteria: survival to hospital admission with TSCI, or outpatient referral to an SCI rehabilitation specialist. Exclusion criteria: congenital causes of paralysis such as spina bifida or cerebral palsy as well as acquired paralysis from multiple sclerosis or GuillanBarre syndrome.	75.8% male Mean Age: 1981-1985: 29.0 years 1998-2002: 35.3 years 2003-2007: 39.8 years	1981-1985: Cervical: 46.2% Thoracic:33.0% Lumbar: 20.9% Sacral:0.0% 1998-2002: Cervical:45.0% Thoracic:33.3% Lumbar: 21.6% Sacral:0.0% 2003-2007: Cervical:51.3% Thoracic:34.9% Lumbar:12.5% Sacral:1.3%	Motor vehicle accident: 81-85: 44.5% 98-02:31.1 03-07: 28.8
Ning et al. 2011 N=869	Tianjin, China	All patients with TSCI aged 15 or older admitted to tertiary hospitals in Tianjin from Jan 1, 2004- Dec 31, 2008	738 male (84.9%) Mean age (sd) 46.0 (14.2)	Cervical (71.5%) Thoracic (13.3%) Lumbar (15.1%) Sacral (0.1%)	MVC: (34.1%) n=296
Stein et al. 2011 N=3524	USA	Case occupants older than 14 years old and in a vehicle accident between 1996 – Nov 2009 with cervical spine injuries.	1691 male (49.3%)	Automobile: 2,457, 71.5% Light truck: 305, 8.9% Utility vehicle: 460, 13.4% Van-based truck: 213, 6.2%	MVC: Frontal crash: 2,096, 61.4% Lateral: 1,094, 31% Rollover: 142. 4.0% Other: 80, 2.3%
Van Den Berg et al. 2011 N=540	Aragon, Spain	Hospitalized from January 1972 to December 2008 for traumatic SCI and received medical care in Aragon following the acute stabilization period, regardless of place of injury and acute care.	79% male, mean age 39.6±17.7 yrs.	36.9% (n=199) cervical 37.4% (n=202) thoracic 19.3% (n=104) lumbar 4.3% (n=23) sacral	Traffic accidents (57%)
Wu et al. 2011 N=41,586	Taiwan	All SCI patients older than 20 years of age and admitted to medical services from 1998-2008 that were identified using the National Health Insurance Research Database of Taiwan.	62% male (n=25857) 61.2% had traumatic SCI (n=25,439)	Cervical: 51.8% N=21,557 Thoracic: 12.3% N=5,098 Lumbar: 22.9% N=9,533 Other SCI: 13.0% N=5,398	MVC: (58.8%) n=14,955 calculated using N traumatic SCI= 25,439)
Cosar et al. 2010 N TSCI=127	Turkey	Patients with traumatic SCI who participated in an inpatient rehabilitation program at a tertiary research hospital from 1996-2008.	67.7% (n=86) male mean age 37.81±13.65 years	36 (28.3%)-tetraplegic (C4-T1) 76 (59.8%)-paraplegic (T2–T12) 15 (11.8%) had conus– cauda equina (L1–S4) injury	MVC; (55.1%) n=70
Couris et al. 2010 N=936	Ontario, Canada	The study included all patients aged 18 years or older living in Ontario during the fiscal years 2003– 2004 (through 2006–2007) who experienced TSCI.	74.1% (n=694) male mean age: 51.3±20.1 years	65.5% (n=610) cervical 21.3% (n=198) thoracic 10.0% (n=93) lumbar 3.2% (n=30) other	MVC: (24.5%) n=229
Hagen et al. 2010 N=336	Norway (2 counties: Hordaland and Sogn og Fjordane)	Patients who suffered a TSCI from 1952- 2001 and lived in Hordaland or Sognog Fjordane	Male to female ratio was 4:7:1 % of women varied from 6.9- 24.4%	Complete (41.4%) Incomplete (58.6%) Cervical (52.4%) Thoracic (29.5%) Lumbar/sacral (18.2%)	MVC: 34.2% n=104 Car accident 19.9% Motorcycle accident 6.8% Bicycle accident 4.2% Pedestrian3.0%
Lieutaud et al. 2010 N=1523 (MST) N=144 (SCI)	France	1997-2006 Major spinal trauma (MST, AIS score 2 or more) and SCI (AIS score 4 or more)	Males= 63% Female= 37%	MST: 40% cervical 33% thoracic 36% lumbar SCI: 58% cervical 37% thoracic 6% lumbar	MST: Car occupant (n=804) 2-Wheel motorized riders (n=329) Pedestrians (n=165) Cyclists (n=124) Others (n=101) SCI: Car occupant (n=73)2-Wheel motorized riders (n=47) Pedestrians (n=13) Cyclists (n= 7) Others (n=4)
NSCISC 2010 N=26,852	USA	1973-2009 26 federally funded Model SCI Care Systems and National SCI Database	Male= 80.8% (1973-2009) Mean age at injury = 40.2 years (2005- 2009)	2005-2009 Tetraplegia = 55.2% Paraplegia = 44.4 % Complete Tetraplegia = 16.9% Incomplete tetraplegia = 38.3% Complete Paraplegia = 22.9% Incomplete Paraplegia = 21.5%	MVC: 41.3%
Pirouzmand 2010 N=12,192	Toronto, Canada	1986-2006 SCI and SI in Sunnybrook Trauma Registry Database	[SI Male=66% Median age=36 years] SCI Male= 76% Median age=33 years CSCI Median age= 30 years	[Spinal Injury= 23.2% -Cervical= 29% – Thoracic= 21% – Lumbosacral= 50%] SCI= 5.4% – Cervical=29% – Thoracic=21% – Lumbo-sacral = 50% – Multiple Levels= 20% CSCI=3%	MVC: 57%
Qureshi et al. 2010 N=521	Rawalpindi, Pakistan	All patients who suffered a spinal injury and were admitted to the Spine Unit of a tertiary care hospital in Pakistan from 2001-2008.	402 male (77%) Mean age (sd) 39.1 (16.17)	Level of injury: Thoraco-lumbar spine (n=369, 71%), lower cervical spine (n=93, 18%), upper cervical spine (n=42, 8%) and sacrum (n=9, 2%). Injuries at multiple levels in 8 (2%) Complete SCI-(43%) Incomplete SCI- (33%)	Road traffic accident: (32%) n=166
Chabok et al. 2009 N=245	Guilan, Iran	Patients admitted to Poursina Hospital, with TSCI	71.8% male	Neurological status: 15 complete 29 incomplete 201 no neurological damage cervical- n=17 thoracic- n=6 thoracolumbar- n=48 Lumbar= 12	MVC: (52%) n=127
Obalum et al. 2009 N=468	Lagos, Nigeria	1992-2006 Registrars at the emergency room and wards from the Lagos University Teaching Hospital (receives the majority of SCI patients in Lagos)	Male=70.1% 66.2% were ages 40 years and below. Peak age incidence = 21-30 years.	ASIA A n=230 ASIA B n=45 ASIA C n=36 ASIA D n=41 ASIA E n= 34 Death n=82 Lumbar n=278 Cervical n=142 Thoracic n=48	MVC: 77.4% (n=362)
Ahoniemi et al. 2008 N=1647	Finland	1976-2005 Register survey; Medical records from registers of Käpylä Rehabilitation Centre	Male= 83% Mean age of injury (M/F): 1976-1985: 34.7/35.8 1986-1995: 36.7/38.3 1996-2005: 42.4/40.4	50.6% tetraplegia 49.4% paraplegia	MVC: 39.5% (n=650)
Macciocchi et al. 2008 N= 298	Southeastern, USA	2004-2005 All patients admitted for traumatic SCI between the ages 16-59. Excluded if unable to speak English.	Male=79% Mean age =28.7±10.1 years. 74% of all eligible patients	C1-4 ASIA A-C, n=9 C1-4 ASIA D, n=5 C5-8 ASIA A-C, n=30 C5-8 ASIA D, n=6 T1-8 ASIA A-C, n=26 T1-8 ASIA D, n=2 T9-12 ASIA A-C, n=15 T9-12ASIA D, n=3 L1-S3 ASIA A-C, n=5	MVC: 63% (n=188)
National Spinal Cord Injury Statistical Center 2008 N=25,415	USA	1973-2008 Residents of the US who have sustained traumatic SCI. Data from Model SCI Care Systems captures approx 13% of all new SCI cases in the U.S	Male=77.8% (2000-2008) Average age = 39.5 years (2005- 2008)	2000-2008 Incomplete tetraplegia: 34.1% Complete paraplegia: 23.0% Complete tetraplegia:18.3% Incomplete paraplegia: 18.5%	MVC: 42% (n=10,674)
Fassett et al. 2007 N=412	Philadelphia, Pennsylvania, USA	1978-2005 Geriatric patients treated in Delaware Valley Regional Spinal Cord Injury Center at Thomas Jefferson University Hospital	≥70 years old. No further demographics given	High quadriplegic (C4 and above)=42% Paraplegic=22% ASIA A ~ 45% ASIA B ~ 13% ASIA C ~ 15% ASIA D ~ 24%	MVC: 13% (n=54) Pedes-trian: 2% (n=8
Shrestha et al. 2007 N=149	Eastern region, Nepal	2001-2004 Admission to hospital in Dharan with cervical spinal injury.	Males=80% Mean age=40 (6- 88) years Mortality=6 (4%)	Frankel levels: A=54 (36%) B=20 (13%) C=22 (15%) D=19 (13%) E=34 (23%)	MVC: 21.5% (n=32)
Olasode et al. 2006 N=71	Ile-Ife, Nigeria, Africa	All traumatic SCI within an 18 month period were included. Only patients with significant craniocerebral injuries were excluded.	Males=66.7% Age range=12-80 years	tetraplegic n=39 paraplegic n=13 recovered with no residual disability n=14 died n=5	MVC: 89% (n=63)
Pickett et al. 2006 N=151	London, Ontario, Canada	1997-2006 Admissions to hospital in London, Ontario with SCI	Men=74.2% Mean age = 42.2 ± 20.9 (9-96) years Mortality=12 (8%)	Cervical=75% Thoracic= 10% Lumbar=9% Junctional=6% Complete=35% Incomplete=65%	MVC: 35.1% (n=53) Other type of vehicle 11.9% (n=18)
Calancie et al. 2005 N=229	Dade County, Florida, USA	Acute traumatic spine and/or spinal cord injury admitted to Jackson Memorial Hospital	Male = 74.6% Average age at injury=40.0±17.5 years 15 were children	ASIA A = 32.8% (75) ASIA B = 4.8% (11) ASIA C = 24.0% (55) ASIA D = 31.5% (72) ASIA E = 7.0% (7.4) Fractures: Cervical = 62% T1-T10 = 15% (35) T11-L4 = 19% (44) Non-fractures: Cervical = 3% (7) Complete = 32.8%	MVC: 43.2% (n=99), Pedestrians hit by car=3.9% (n=9), Motorcycle=1.7% (n=4)
Dahlberg et al. 2005 N=152	Helsinki, Finland	January 1, 1999 cross-section date Adult citizens (18 years or more) of Helsinki who had permanent sensory or motor deficits because of traumatic SCI (ASIA A–D). ASIA-E cases were excluded.	Males = 76% Average age of injury=47.9 years	Data only for 121 subjects: 46% (n=56) tetraplegia 54% (n=65) paraplegia 57% (n=69) incomplete 43% (n=52) complete	MVC: 35% (n=53)
Gur et al. 2005 N=539	Southeastern Anatolia, Turkey	1990-1999 4 hospitals that were major referral centers for trauma	Male= 77.2% Average age of injury=30.62 (1-70) years	Incomplete paraplegia 29.3% (n=158) Complete paraplegia 45.1% (n=243) Incomplete tetraplegia 13.7% (n=74) Complete tetraplegia 13.9% (n=75) Cervical: 25.4% (n=137) Thoracic: 36.7% (n=198) Lumbar: 34.0% (n=183)	MVC: 37.1% (n=200)
Lakhey et al. 2005 N=233	Dharan, Nepal	May 1997- April 2001 Orthopaedic ward of BP Koirala Institute of Health Sciences	Male=72.5% <20years old=26 individuals (11.1%), 20-30yrs=59 (25.3%), 31-40yrs=49 (21.0%), 41-50yrs=37 (15.9%), >50yrs=62 (26.6%)	cervical = 88 (37.8%) dorsal = 70 (30.0%) lumbar = 72 (30.9%) none bony = 3 (1.3%) complete = 46.8%	MVC: 6.9% (n = 16)
Umaru and Ahidjo 2005 N=36	Maiduguri, Nigeria	1998-2002 Admissions to hospital in Maiduguri with SCI. Exclusion Criteria: Cases with inadequate information	Males=83% Mean age=34.3±3 (13- 55) years Mortality=3 (8%)	Cervical=14 (39%) Thoracic=10 (28%) Thoracolumbar=10 (28%) Lumbar=2 (6%) Complete=20 (56%) Incomplete=16 (44%)	MVC: 61.1% (n=22)
Dryden et al. 2003 N=450	Alberta, Canada	1997-2000 Data from the Alberta Ministry of Health and Wellness, records from the Alberta Trauma Registry, and death certificates from the Office of the Medical Examiner	71.6% male Median age of injury=35.0 years	61.5% (n=277) cervical 17.3% (n=78) thoracic 17.1% (n=77) lumbar/sacral/ cauda equina 4.0% (n=18) unspecified	MVC: 56.4% (n=254)
Krassioukov et al. 2003 N=58	Toronto, Canada	1998-2000 Admissions to hospital in Toronto with traumatic SCI. Exclusion Criteria: Patients admitted with ASIA E.	Males=87% Ages 17-59 years: Mean age=38.7 (17-56) years	ASIA A and B=30% ASIA C and D=70%	MVC: 31% (n=18)
Kuptniratsaikul 2003 N=83	Thailand	1997-2000 All SCI patients admitted to Spinal Unit, Siriraj Hospital, Nagkok.	Males=79.5% Average age =32.3 ±11.7 years.	Tetraplegic n=19 Paraplegic n=18 ASIA D=25	MVC: 75.7% (n=63)
Pagliacci et al. 2003 N=684	Italy	1997-1999 Rehabilitation admissions to 32 institutions in Italy with traumatic SCI.	Males = 80% Mean age=38.5 (11-94) years.	ASIA Scores: A=346 (50%) B=72 (10%) C=149 (22%) D=94 (14%) E=12 (2%)	MVC: 53.8% (n=684)
Pickett et al. 2003 N=2385	Ontario, Canada	1994-1999 SCI in Ontario Trauma Registry	Males=69% <20 years =17% 20-39 years= 44% 40-59 years=23% ≥60 years=16	Not given.	MVC: 42.8% (n=1021) Automobile =75% Motorcycle =7% Bicycle=3% Pedestrian =6% Other=10%
Singh et al. 2003 N=483	Haryana, India	2000-2001 Accident and emergency services and department of Orthopaedic Surgery and Rehabilitation of Pt. B.D. Sharma PGIMS, Rohtak.	Male=74.7% male Mean age at injury=35.4 years	164 tetraplegia 283 paraplegia	MVC: 34.8% (n=168)
Catz et al. 2002 N=250	Israel	1959-1992 Traumatic SCI, admitted to the Loewenstein Rehabilitation Center, the major referral center for rehabilitation medicine in Israel.	Males=75.6% Mean age = 34.5 years (range 6-83 years).	High cervical 7.6% low cervical 28.8% thoracic 32.4% lumbar 31.2%	MVC: 32.8% (n=82)
O’Connor 2002 N=265	O’Connor 2002 N=265	1998-1999 Australian Spinal Cord Injury Register (ASCIR) for persons 15 years and older. All adult SCI cases are reported to the ASCIR Transient neural deficits were excluded.	Male= 76 % No other demographics given	C4 n=47 C5 n=45 C6 n=22 L1 n=30 T12 n=17 Incomplete tetraplegia n=101 Incomplete paraplegia n=64 Complete tetraplegia n=51 Complete paraplegia n=48	MVC: 43% (n=114)
Burke et al. 2001 N=161	Kentucky and Indiana counties, USA	1993-1998 University of Louisville Hospital SCI Trauma Registry and patient medical records	Male=75% male Mean age of injury=34.0 years 59.5% single 29.4% married 85.5% White 14.5% African American	56.5% cervical 28% complete (all cases) 58% Frankel A 17% Frankel B 7% Frankel C 15% Frankel D	MVC: 54.7% (n=88)
Karacan et al. 2000 N=581	Turkey	1992 Nation-wide survey of SCI admissions to medical institutions. Exclusion Criteria: Patients who died before hospitalization.	Males=71% Mean age=35.5±15.1 years. Females=166 (29%)	Cervical=31.7% Thoracic=26.6% Lumbar=25.1% Tetraplegia=87 (32%) Paraplegia=394 (68%)	MVC: 48.8% (n=283)
National Spinal Cord Injury Statistical Center (NSCISC) 2000 N=19648	USA	1973 -1990’s 24 federally funded Model SCI Care Systems and National SCI Database	Male= 81.7% Mean age at injury=31.8 years; 55% within 16-30 years old	Tetraplegia = 51.7% Paraplegia = 46.7 % Complete Tetraplegia = 18.5% Incomplete tetraplegia = 29.5% Complete Paraplegia = 27.9% Incomplete Paraplegia = 21.3%	MVC: 37.4% (n= 7348)

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: % (n of cases)
Ravaud et al. 2000 N=1668	France	1995-1996 Self-administered questionnaire survey at 35 specialized Rehabilitation Centres	Males (73%) Mean age of injury=30.5 years	7.4% C1-C2 16.4% C3 26.3% C4 28.5% C5 18.6% C6 2.5% C7-C8 54% complete	MVC: 57.9% (n=959)
van Asbeck et al. 2000 N=126 (specific data for 113)	Netherlands	1994 Patients with SCI in National Registration system. Further analysis occurred only for cases in which medical records were obtained Exclusion Criteria: Spinal contusions with no or temporary neurological symptoms.	Males=77% <20 years=15 (13%) 21-30 years=28 (25%) 31-60 years=36 (32%) >61=34 (30%) Mortality=18 (16%)	Complete tetraplegia=26 (23%) Incomplete tetraplegia=39 (34%) Complete paraplegia=29 (26%) Incomplete paraplegia=19 (17%)	MVC: 31.0% (n=35)
Igun et al. 1999 N=68	Plateau State, Nigeria	1984-1997 Radiologically confirmed diagnosis of spinal cord injury.	Males=91.2% Mean age = 30 years.	Cervico-thoracic n=32 Cervico-thoracic n=36 Deaths n=18	MVC: 51.5% (n=35)
Caldana and Lucca 1998 N=127	Veneto, Italy	1994-1995 New cases of traumatic spinal cord injury and nontraumatic spinal cord disease treated in regional hospitals (small hospitals excluded)	Male = 83.5%; average age of 39.8 years Female = 16.5%; average age of36 years	Cervical=62 (21 were complete) Thoracic=29(25) Thoracolumbar (T12- L1)=18(11) Caudal=14(3) Unidentified=1	MVC: 53% (n=306) Other road accidents=19% (n=110) (Motorbike=7, Moped=7, Bicycle=3, Pedestrian=2)
Farmer et al. 1998 N=1817	USA	1979-1993 Regional Spinal Cord Injury Center of Delaware Valley (RSCICDV)	Male=78.7% Mean age=37.6 years 72.2% White, 23.5% African American, 2.5% Hispanic 35.9% married 16% unemployed	62.4% cervical 26.8% thoracic 10.8% lumbosacral 40.9% complete 59.1% incomplete 25.1 % quadriplegia complete 36.7% quadriplegia incomplete 15.8% paraplegia complete 21.5% paraplegia incomplete	MVC: 29.9% (n=543)
Levy et al. 1998 N=136	Zimbabwe	1988-1994 Admissions to National Rehabilitation Centre with traumatic SCI.	Males=89% Majority were between 20 and 49 years of age	Cervical=69 (51%) Below Cervical=67 (49%)	MVC: 50% (n=68)
Martins et al. 1998 N= 398	Portugal	1989-1992 2 hospitals that treat all SCI in the central region of Portugal. Including deaths due to SCI and paediatric cases. Cases without neurological lesion, rehospitalization and vertebral lesions were excluded.	Male=77% Average age = 50.53±21.85 years	Complete n=220 Incomplete n=176 Deaths = 223	MVC: 57.3% (n=228)
Aung and Masry 1997 N=219	Great Britain	1985-1988 New traumatic admissions to the Midlands Centre for SCI	Male=79%; Average age of 35.5 years. Female=21%; Average age of 44.2 years.	Cervical n=116 Thoracic n=73 Lumbar n=30	MVC: 50% (n=110)
Exner and Meinecke 1997 N= 22,212	Germany	1976-1996 All traumatic and non-traumatic SCI	72% male	62% paraplegic 38% tetraplegic	MVC: 35% (n=7774)
Maharaj 1996 N=75	Fiji	1985-1994 Medical records of spinal cord paralysis patients admitted to the Medical Rehabilitation Unit at Tamavua Hospital	Male=87% Mean age=38.3 (6-76) years Fijian=60% Indian=35% Employed =47% Unemployed =41%	40 (53%) tetraplegia 35 (47%) paraplegia 46 (61%) complete 29 (39%) incomplete	MVC: 25.3% (n=19)
Karamehmetaglu et al. 1995 N=152	Istanbul, Turkey	1992 New patients with traumatic SCI, including pediatrics.	Males=75.6% Mean age = 33 years. 72% of patients were under 40.	Tetraplegic n=50 Paraplegic n=102	MVC: 41% (n=62)
Levi et al. 1995 N=353	Stockholm, Sweden	1991-1994 Survey of the regional Stockholm SCI population	Males=81% Average age of injury=31 (3-77) years	Cervical 41.6% (n=147) Thoracic 36.0% (n=127) Lumbar 14.7% (n=52) Sacral 1.4% (n=5) Complete 39.4% (n=139) Incomplete 59.5% (n=210	MVC: 45.6% (n=161)
Shingu et al. 1995 N=9752	Japan	1990-1992 Survey of nationwide institutions assumed to accept SCI patients. Exclusion criteria: Patients only receiving outpatient services in this period	Males=80.4% Mean age=48.6±19.1 (0.92-96) years.	Frankel levels: A=2518 (25.8%) B=1208 (12.4%) C=1984 (20.3%) D=1761 (18.1%) E=2242 (23.0%) Unknown=39 (0.4%) Cervical=7317 (75.0%) Below cervical=2408 (24.7%) Unknown=27 (0.3%) Complete=61.1%	MVC: 43.7% (n=4261)
Silberstein and Rabinovich 1995 N=196	Novosibirsk, Russia	1989-1993 All in patients with SCI admitted to the Department of SCI. Nerve root or plexus injury was excluded.	Males=93.4% Mean age =34.7 years.	Cervical spine C1-2 n=15 C3-7 n=81 Thoracic T1-12 n=54 Lumbar L1-5 n=46	MVC: 25.1% (n=49)
Thurman et al. 1995 N=223	Utah, USA	1989-1991 Utah residents with SCI in Statewide reporting system of the Utah Department of Health, Bureau of Epidemiology.	Male= 76% Median age=29 years	128 (57%) tetraplegia 95 (43%) paraplegia 41 (18%) fatal 21 (9%) died before hospital admission 110 (49%) Frankel A/B/C 46 (21%) Frankel D 25 (11%) returned to full neurological function	MVC= 49.3% (n=110)
Hart et al. 1994 N=616	South Africa	1988-1993 All records of SCI from the Natalspruit Spinal Rehabilitation Unit	Males=80% Males between 15-40 made up the majority of patients	Complete n=404 Incomplete n=212 Cervical spine n=155 Upper thoracic n=135 Lower thoracic n=249 Lumbar spine n=74	MVC: 25% (n=154)
Price et al. 1994 N=376	Oklahoma, USA	1988-1990 SCI cases in Oklahoma statewide multilevel surveillance system Exclusion Criteria: Non Oklahoma residents; patients who died at scene; injuries to nerve roots or spinal plexus.	Male= 80% <15 years=12 (3%) 15-19 years=66 (18%) 20-29 years=110 (29%) 30-59 years=145 (39%) ≥60 years =43 (11%) Mortality=30 (8%)	Complete tetraplegia=55 (15%), Incomplete tetraplegia=157 (42%) Complete paraplegia=59 (16%), Incomplete paraplegia=105 (28%)	MVC: 47.9% (n=180)
Shingu et al. 1994 N=3465	Japan	1990 Survey of nationwide institutions assumed to accept SCI patients; Exclusion criteria: Traumatic cervical syndrome cases and extradural nerve root; Patients only receiving outpatient services in this year or who obtained injury abroad	Male=81.2% Mean age=44.1 years	Cervical=1218 (79%) Below cervical=328 (21%) Unknown=1	MVC: 44.6% (n=1545)
Soopramanie 1994 N=412 (SCI=270)	Bucharest, Romania	1992-1993 SCI patients admitted to Dr. Gh. Marinescu Hospital	Males=77% 37.6% labourer 8.7% farmer 18.2% retired	158 cervical 81 thoracic 36 lumbar 47% incomplete Frankel grade A n=134 Frankel grade B n=24 Frankel grade C n=25 Frankel grade D n=73 Frankel grade E n=150	MVC: 13% (n=54)
Stavrev et al. 1994 N=980	Plovdiv and Plovdiv region, Bulgaria	1983-1992 Treatment for SCI at 2 clinics in Plovdiv region	Males=72% ≤20 years=82 (8%) 21-40 years=387 (40%) 41-60 years=298 (30%) 61-70 years=137 (14%) >70 years=76 (8%) Mortality=72 (7%)	Cervical=206 (21%) Thoracic (>T7) =275 (28%) Lumbar=399, (41%) Other=100 (10%) Neurological deficit=409 (42%) No neurological deficit=572 (58%)	MVC: 37.4% (n=367)
Woodruff and Baron 1994 N=150	West Virginia, USA	1985-1988 Data collected during the West Virginia Spinal Cord Injury Registry, includes only injured patients surviving until hospitalization	Male= 82% Majority of individuals were between 15-24.	57% tetraplegia 43% paraplegia	MVC: 57% (n=86)
Acton et al. 1993 N=644	Arkansas, USA	1980-1989 Arkansas residents in Arkansas State Spinal Cord Commission registry. Exclusion Criteria: Lesions caused by degenerative disease; people who died at scene.	Males=80% Mean age males=32.4 years Mean age females=35.4 years	Tetraplegia=124 Paraplegia=181	MVC: 80% (n=515) Motorcycle= 11% (n=71) Off road vehicles= 4% (n=26) Bicycles= 3% (n=19) Pedestrian = 2% (n=13)
Dixon et al. 1993 N=164	New Zealand	1988 SCI cases in Health Services Statistics files.	Males=73.2% Males aged 15- 29 years=46%	C1-C4=49 (30%) C5-C7=30 (18%) T1-T6=19 (12%) T7-T12-19 (12%)	MVC: 54% (n=89)
Lan et al. 1993 N=99	Hualien county, Taiwan	1986-1990 Treatment of traumatic SCI in 4 hospitals in Hualien county. Exclusion Criteria: People who died before hospitalization; nontraumatic SCI; patients with transient paralysis; non residents of Hualien.	Males=80% Mean age (males)=44 years Mean age (females)=46 years Mortality=10 (10%)	Complete tetraplegia =5 Incomplete tetraplegia = 5 Complete paraplegia =6 Incomplete paraplegia = 7	MVC: 61.6% (n= 61)
Tator et al. 1993 N=201	Toronto, Canada	1974-1981 First 220 admissions to Acute Spinal Cord Injury Unit in Toronto. Exclusion Criteria: Admissions >30 days after injury; spinal injuries without cord involvement; nerve root involvement only; penetrating injuries; injuries below L2; Patients who died on scene or upon arrival.	Males=79.6% Mean age=34.5 years Median age=27.0 years	Cervical=63.2%, Thoracic=16.9%, Thoracolumbar=19.9% Complete=46.2%, Incomplete=53.8%	MVC: 40.8% (n=82)
da Paz et al. 1992 N=1255 (SCI=108)	Brazil	1988 36 public hospitals from 7 Brazilian capitals (represents 6.2% of all hospitals and 9.2% of the total hospital bed capacity.	Male=80.6% Mean age= 30.3 (range 6-56) years 5.6% high education	94 (87.0%) complete 61 (64.9%) paraplegia 33 (35.1%) quadriplegia	MVC: 41.7% (n=45)
DeVivo et al. 1992 N=6563	USA	Admissions to Spinal Cord Injury Care Systems within 1 year of injury from: 1973-1977	N=1955 Males=81.9% Mean age=28.0 years	Frankel grade at discharge: Complete=56.4% Sensory=9.7% Motor nonfunctional=9.0% Motor functional=24.1% Recovered=0.8%	MVC: 42.5%
		1978-1980	N=1784 Males=82.4% Mean age=28.4 years	Frankel grade at discharge: Complete=51.8% Sensory=13.7% Motor nonfunctional=7.2% Motor functional=25.9% Recovered=1.4%	MVC: 48.0%
		1981-1983	N=1391 Males=82.7% Mean age=30.5 years	Frankel grade at discharge: Complete=57.2% Sensory=11.7% Motor nonfunctional=7.8% Motor functional=22.5% Recovered=0.8%	MVC: 48.8%
		1984-1986	N=1433 Males=84.5% Mean age=31.2 years	Frankel grade at discharge: Complete=48.6% Sensory=16.2% Motor nonfunctional=11.0% Motor functional=23.5% Recovered=0.6%	MVC: 44.9%
Dincer et al. 1992 N=1,694	Turkey	1974-1985 SCI patients admitted to Ankara Rehabilitation Centre	Males = 75.7% Average age of injury=26.8 (1-70) years Agricultural workers= 19.8% (n=336) Housewives= 19.9% (n=338) Private industry workers = 19.5% (n=330)	Complete paraplegia 85.1% (n=1442) Incomplete paraplegia 6.9% (n=116) Complete tetraplegia 4.8% (n=82) Incomplete tetraplegia 3.2% (n=54)	MVC: 35.4% (n=600)
GarciaReneses et al. 1991 N=1010	Spain	1984-1985 Every traumatic and non traumatic SCI patient in specialized Spanish hospitals	Male=72.4%. Mean age = 41.8 ± 1.2 years.	Sensory-motor incomplete SCI = 49% Complete SCI= 38%	MVC: 52.2% (n=527)
Goebert et al. 1991 N=59	Hawaii, USA	1987-1989 Traumatic injury Patient at the Rehabilitation Hospital of the Pacific	Male=84.7% Mean age=20.2 years 0-15years=5.2% 16-30 years=44.8% 31-45 years=25.9% 46-60 years= 12.1% 61-90 years=12.1%	High Quad (C1-4)=16.2% Low Quad (C5-8)=45.9% High Thoracic (T1- 6)=18.9% Low Thoracic (T7- 12)=10.8% Lumbar (L1-5)=8.1% Frankel Grades: Complete (A)=50.8% Motor functional (D)=35.6%	MVC: 37.9% (n=22) automobile =81.1% of motorcycle =13.6%, bicycle =4.5%
BieringSorensen et al. 1990 N=268	Kingdom of Denmark (Denmark, Greenland, Faroe Islands)	January 1975- December 1984 Admission to national specialized rehabilitation hospitals	Male=76.9% 40% within 15-24 years old	268 traumatic lesions Cervical = 136 Thoracic = 76 Lumbar = 56 Complete tetraplegia = 22% Incomplete tetraplegia = 29% Complete paraplegia = 26% Incomplete paraplegia = 23%	MVC: 47% (n=125)
Ring et al. 1986 N=202	New South Wales, Australia	1977-1978 Admissions to New South Wales hospitals with spinal injury; death certificates that involved spinal injury. 99% of cases had neurological involvement.	Males= 81% ≤1 years=2 (1%) 2-14 years=13 (6%) 15-24 years=84 (42%) 25-44 years=58 (29%) 45-64 years=30 (15%) ≥65 years=15 (7%) Mortality=69 (39%)	Glasgow Outcome Scale: Severe disability=98(49%) Moderate disability=19 (9%) Good recovery=13 (6%) Not recorded=3 (1%)	MVC: 65.3% (n=132)
Chen et al. 1985 N=560	Taipei, Taiwan	1978-1981 All record from general hospitals in Taipei. Included all spinal cord lesions with or without vertebral injury.	Males=86% Mean age = 35.9 (range 20-49) years.	Incomplete Paraplegia n=118 Complete paraplegia n=180 Incomplete Tetraplegia n=117 Complete Tetraplegia n=145 Death n=31	MVC: 44.5% (n=249)
Griffin and Opitz 1985 N=154	Olmsted County, Minnesota, USA	1935-1981 Medical recordslinkage system of the Rochester Project at the Mayo Clinic, periodic multi-centre surveys	Male= 72% 153 White, 1 Black	56.5% (n=87) cervical 31.8% (n=49) thoracic 9.1% (n=14) lumbar 2.6% (n=4) sacral	MVC: 69.8% (n=106)
Gee and Sinha 1982 N=36	Papua New Guinea	1978-1981 Traumatic injury Patients that stayed in Port Moresby, Lae and Manding hospitals	Male = 88% Mean age = 26years (range 16-41 years)	Cervical = 22% Upper thoracic = 11% Thoraco-lumbar = 28% Lumbar = 39%	MVC: 34 % (n=12)