ORIGINAL ARTICLE
EPIDEMIOLOGICAL INVESTIGATION OF TRAUMATIC SPINAL CORD INJURY CAUSED BY OBJECT STRIKE IN CHINA: STRATEGIES FOR WORKPLACE SAFETY IMPROVEMENT
Wenjie ZHANG1,2, Fangyong WANG1–3, Zezheng CHEN1,2, Yang YU1,2, Tao LIU1,2, Honghui LEI1, Haoran YIN1,2 and Meiling CHENG2,4
From the 1School of Rehabilitation Medicine, Capital Medical University, Beijing, 2China Rehabilitation Research Center, Beijing, 3University of Health and Rehabilitation Sciences, Qingdao, Shandong, and 4Wenzhou Medical University, Wenzhou, Zhejiang
Objective: Being struck by an object is a major cause of traumatic spinal cord injury in China. This study aims to investigate epidemiological characteristics of spinal cord injury caused by object strike.
Methods: This research analysed data from 435 cases of strike-induced spinal cord injury from 2013 to 2022. The collected information encompassed gender, age, level of neurological injury, surgical interventions, expense, occupation, and other relevant factors. χ2tests and Mann–Whitney U test were used with a statistical significance level of 0.05.
Results: The male-to-female ratio was 11.8:1. The 30–44 age group was more likely to suffer from complete spinal cord injuries (70.5%). The predominant occupations were workers (58.9%) and farmers (15.2%). Manual labourers are usually injured in the workplace (89.4%) with a high surgical rate (95.3%).
Conclusion: Young and middle-aged males engaged in manual work constitute the primary demographic for strike-induced spinal cord injury. Safety education in workplaces such as construction sites and mines should be emphasized to reduce the occurrence of spinal cord injuries caused by object strikes.
LAY ABSTRACT
This study aims to investigate epidemiological characteristics of spinal cord injury caused by object strike. This research analysed data from 435 cases of strike-induced spinal cord injury from 2013 to 2022 and collected information encompassing gender, age, level of neurological injury, surgical interventions, expense, occupation, and other relevant factors. The male-to-female ratio was 11.8:1. The 30–44 age group was more likely to suffer from complete spinal cord injuries (70.5%). Workers (58.9%) and farmers (15.2%) were the predominant occupations. Manual labourers are usually injured in the workplace (89.4%) with a high surgical rate (95.3%). Young and middle-aged males engaged in manual work constitute the primary demographic for strike-induced spinal cord injury. Safety education in workplaces such as construction sites and mines should be emphasized to reduce the occurrence of spinal cord injuries caused by object strikes.
Key words: complications; epidemiology; occupations; safety; spinal cord injury; workplace.
Citation: J Rehabil Med 2024; 56: jrm40880. DOI: https://doi.org/10.2340/jrm.v56.40880.
Copyright: © 2024 The Author(s). Published by MJS Publishing, on behalf of the Foundation for Rehabilitation Information. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).
Submitted: May 26, 2024; Accepted after revision: Oct 17, 2024; Published: Nov 12, 2024.
Correspondence address: Fangyong Wang, School of Rehabilitation Medicine, Capital Medical University, Beijing, China. Beijing Bo’ai Hospital, China Rehabilitation Research Center, No. 10, Jiaomen North Road, Fengtai District, Beijing 100068, China. University of Health and Rehabilitation Sciences, Qingdao, Shandong. E-mail: wfybeijing@163.com
Competing interests and funding: The authors have no conflicts of interest to declare.
Traumatic spinal cord injury (TSCI) constitutes a profoundly debilitating condition characterized by an abrupt, multi-system disorder that results in the irreversible disruption of homeostasis and neurological impairments beneath the injury site, culminating in substantial functional loss and potential permanent disability (1–3). Between 2000 and 2021, the global incidence of TSCI remained alarmingly high, ranging from 20 to 45 cases per million individuals (4). Asystematic review revealed that the pooled incidence of TSCI in China was estimated at 65.15 per million (5). The aetiological factors contributing to TSCI included falls from height (37.5%), traffic accidents (26.9%), being struck by an object (16.3%), and falls on the ground (8.3%) (6). Object strikes rank among the primary causes of TSCI in China.
The incidence of spinal cord injuries attributable to object strikes exhibited regional variability across China, yet it revealed distinct occupational trends. The proportion of spinal cord injuries resulting from such impacts was notably higher in Guangdong (19.5% from 2003 to 2011), Beijing (18.6% in 2002), and Chongqing (13.2% from 2009 to 2013) compared with other areas (7). A hospital-based investigation into the epidemiological characteristics of spinal cord injuries in northwestern China indicated that the occupations most vulnerable to these injuries were those of peasants and workers. Among a cohort of 3,487 patients with spinal cord injuries, peasants and workers constituted a significant 59.51% and 27.04%, respectively (8). Furthermore, a study focusing on the epidemiological profile of TSCI at Tianjin Medical University General Hospital corroborated these findings, revealing that peasants, workers, and unemployed individuals faced elevated risks of TSCI, with occupations of peasants and labourers representing 32.5% and 24.3%, respectively (9). The ongoing economic development has consequently led to an increase in the proportion of manual labourers, further intensifying these risks.
Although study of TSCI caused by falling or traffic accidents is easily available, investigation of epidemiological characteristics of spinal cord injury caused by object strike is rare. This study aims to investigate epidemiological characteristics of TSCI caused by object strike and to propose corresponding preventive measures.
METHODS
Study design
This retrospective study was conducted at the China Rehabilitation Research Center, the nation’s premier rehabilitation institution, which admits thousands of patients requiring rehabilitation from across China each year. The study focused on a cohort of 435 patients with TSCI caused by object strikes, admitted between 1 December 2012, and 30 November 2022. Their medical records were meticulously reviewed and independently evaluated by 2 researchers to ensure a comprehensive and unbiased analysis.
Processes
Two independent researchers examined the consultation records and imaging examinations to identify cases of TSCI caused by object strike. Patient details, including age, gender, occupation, neurological level, and severity of injury at admission, complications, and rehabilitation length of stay (LOS) were obtained from the medical record system.
There were 401 male cases and 34 female cases with a mean age of 39.2 years. They were categorized into 4 age groups: 15–29 years, 30–44 years, 45–59 years, and ≥60 years, to examine the characteristics of TSCI caused by object strike across different age demographics. The severity of the injuries was documented using the American Spinal Injury Association (ASIA) classification, categorizing them into complete injuries (Grade A) and incomplete injuries (Grades B, C, and D). Participants engaged in manual labour, including workers and farmers, were grouped into the manual work category, while those in professions such as civil service, education, and corporate employment were classified as non-manual workers to analyse occupational characteristics. Complications associated with TSCI encompassed urinary infections, neurogenic bladder, intestinal dysfunction, neuralgia, spasticity, osteoporosis, pressure ulcers, respiratory infections, and deep vein thrombosis. The epidemiological characteristics of TSCI caused by object strikes were evaluated by synthesizing data on age, gender, injury severity, neurological level, spinal surgery, complications, and overall costs.
Ethical permission was obtained at the authors’ institution. Informed consent was waived by the ethical review boards as this is a retrospective study.
Statistical analysis
Data analysis was performed using SPSS software (version 25.0; IBM Corp, Armonk, NY, USA) to assess relevant variables. Demographic factors, including gender, age, injury location, and payment method, as well as clinical variables such as injury severity, extent of injury, affected segments, and surgical treatment, were classified as categorical variables, while LOS was regarded as a continuous variable. Categorical variables were analysed using the χ test, whereas differences in LOS between the2 groups were evaluated using the Mann–Whitney U test, with a significance level set at 0.05. Descriptive statistics, including median and interquartile range (IQR), frequency, and percentage, were employed to describe the demographic and clinical characteristics of the study subjects who sustained injuries resulting from object strikes.
RESULTS
Characteristics of different age range groups
This study included 401 male and 34 female participants, yielding a mean age of 39.2 years (11.2). The male-to-female ratio was 11.8: 1. Table I illustrates the epidemiological characteristics across different age groups, with a peak age distribution observed in the 30–44 years bracket, accounting for 43.7%, followed by the 45–59 years group (29.4%). The incidence of paraplegia was higher than that of quadriplegia across all demographics. Notably, the youth group (15–29 years) exhibited the highest incidence of paraplegia (86.0%), while the elderly group demonstrated the lowest rate (58.8%). Individuals in the 15–29 years cohort were significantly more likely to experience ASIA A spinal cord injuries (75.0%), while the likelihood of ASIA D injuries was considerably lower (7.0%). The overall surgical rate was notably high at 91.5%, with both the 30–44 years group (94.7%) and the 15–29 years group (92.0%) exceeding 90%. Furthermore, the likelihood of choosing out-of-pocket payment for hospital expenses among those aged over 60 (41.2%) was significantly lower than that of the 30–44 years group (64.7%).
Distribution of neurological level of injury
As shown in Fig. 1, the distribution of neurological level of injury (NLI) in cases of TSCI predominantly centred on the thoracic region, with T10 (21.6%) and T11 (16.1%) being the most affected. The most common cervical spinal cord injury was observed at C4, accounting for 10.8% of all cases. Lumbar spinal cord injuries were the least frequent. In the manual labour group, the NLI was primarily concentrated in T10 (21.1%) and T11 (17.1%), with a smaller peak at C4 (14.3%). In contrast, in the non-labourer group, the most common NLI was T10 (26.5%), followed by C4 (14.1%).
Fig. 1. Number of cases with different neurological level of injury.
Occupations
Fig. 2 illustrates the distribution of cases across different occupations. The predominant professions were labourers (58.9%) and farmers (15.2%). Themanual labour group comprised 322 cases, while the non-manual labour group included 113 cases. Table II reveals statistically significant differences between manual and non-manual labourers in terms of age range, gender, complications, payment method, spinal surgery, and work-related injuries. The age distribution in the manual labour group (mean 39.44, SD 10.50) was concentrated in the 30–44 and 45–59 age brackets, accounting for 76.7%. Compared with manual labourers, the proportion of individuals aged over 60 was higher in the non-manual labour group. Both groups had a higher proportion of males. However, the gender ratio in the manual labour group (22.3) was significantly higher than in the non-manual labour group (4.7) (χ² = 20.694, p < 0.001).
| Characteristics | Manual-work group | Non-manual workgroup | p-value | ||
| Age | χ2 = 13.792, p = 0.003 | ||||
| 15–29 years | 68 (21.1) | 32 (28.3) | |||
| 30–44 years | 142 (44.1) | 49 (43.4) | |||
| 45–59 years | 105 (32.6) | 23 (20.4) | |||
| ≥ 60 years | 7 (2.2) | 9 (8.0) | |||
| Gender | χ2 = 20.694, p < 0.001 | ||||
| Male | 308 (95.7) | 93 (82.3) | |||
| Female | 14 (4.3) | 20 (17.7) | |||
| Neurological level ofinjury | χ2 = 0.555, p = 0.456 | ||||
| Tetraplegia | 77 (23.9) | 31 (27.4) | |||
| Paraplegia | 245 (76.1) | 82 (72.6) | |||
| ASIA | χ2 = 0.889, p = 0.374 | ||||
| A | 212 (65.8) | 80 (70.8) | |||
| B | 28 (8.7) | 9 (8.0) | |||
| C | 48 (14.9) | 12 (10.6) | |||
| D | 34 (10.6) | 12 (10.6) | |||
| Complications | χ2 = 2.389, p = 0.017 | ||||
| 0–1 | 92 (28.6) | 43 (38.1) | |||
| 2–3 | 121 (37.6) | 45 (39.8) | |||
| 4–5 | 83 (25.8) | 18 (15.9) | |||
| ≥ 6 | 26 (8.1) | 7 (6.2) | |||
| Spine surgery | χ2 = 23.577, p < 0.001 | ||||
| Yes | 307 (95.3) | 91 (80.5) | |||
| No | 15 (4.7) | 22 (19.5) | |||
| Payment method | χ2 = 6.534, p = 0.038 | ||||
| Own expense | 194 (60.2) | 64 (56.6) | |||
| Work injury insurance | 83 (25.8) | 22 (19.5) | |||
| Other | 45 (14.0) | 27 (23.9) | |||
| Workplace injury | χ2 = 118.054, p < 0.001 | ||||
| Yes | 288 (89.4) | 44 (38.9) | |||
| No | 34 (10.6) | 69 (61.1) | |||
| Total cost (RMB, million) | χ2 = 3.561, p = 0.059 | ||||
| 0–0.1 | 152 (47.2) | 65 (57.5) | |||
| ≥ 0.1 | 170 (52.8) | 48 (42.5) | |||
| Length of stay (days) | 88.0 (58.8, 115.3) | 71.0 (38.0,108.5) | p < 0.05* | ||
| *Mann–Whitney U test. | |||||
Fig. 2. Number of cases with different occupations.
Regarding payment methods, a greater proportion of manual labourers paid out-of-pocket (60.2%) compared with non-manual labourers (56.6%). Both groups demonstrated relatively low participation in work injury insurance, though the enrolment rate was marginally higher among manual labourers (25.8%) than their non-manual counterparts (19.5%) (χ² = 6.534, p < 0.05). Work-related injuries were notably more prevalent in the manual labour group, accounting for 89.4% of cases, whereas only 38.9% of non-manual labourers experienced work-related injuries. In terms of complications, a higher proportion of manual labourers experienced 4–7 complications (33.9%) compared with non-manual labourers (22.1%) (χ² = 2.389, p = 0.017). Furthermore, the incidence of spinal surgery was significantly greater among manual labourers (95.3%) relative to non-manual labourers (80.5%) (χ² = 23.577, p < 0.001). These findings collectively suggested that manual labourers tended to have longer hospital stays overall.
Complications
Table III presents the incidence of complications associated with TSCI in this study. Neurogenic bladder was the most common complication, with higher rates observed in the 30–44 age group (64.4%) and the 45–59 age group (56.6%). Urinary tract infections were more prevalent in the 15–29 age group (64.4%) and those aged over 60 (56.6%). Neuropathic pain, spasticity, and intestinal dysfunction were also frequent complications among patients with TSCI resulting from object strikes.
DISCUSSION
Being struck by object is one of the main causes of TSCI in China. Considering China’s huge population, the number of cases with TSCI caused by object strike cannot be ignored.
Research indicated that TSCI was more prevalent in men than in women; a systematic review revealed that the incidence of TSCI in males was 3.2 times that in females, corroborating the observed gender ratio of approximately 3:1 among TSCI patients (4). We found that in this survey the male-to-female ratio (11.8) was much higher than the ratio of TSCI caused by traffic accidents (2.7) and falls (4.6) (10, 11). This elevated sex ratio could be attributed to various factors. Menwere more likely to be employed in industries with heightened occupational hazards, such as construction, manufacturing, and transportation. These occupations exposed workers to an increased risk of falls, heavy machinery accidents, and other work-related incidents that may lead to spinal cord injuries (12). This pattern was further validated by the occupational characteristics of TSCI patients in our study, who predominantly worked as labourers and farmers (74%), with a male-to-female ratio reaching 22:1. Additionally, developing countries exhibited higher male-to-female ratios in TSCI cases (13). Based on global data, the age distribution of patients with traumatic SCI was bimodal; the first peak was between 15 and 29 years old, and the second smaller but growing peak was in those over 50 years old (14). With economic development and an ageing population, TSCI showed an ageing trend (15). Despite the ageing problem in China, the patients showed a tendency to be younger (39.2) in the investigation of TSCI caused by object strikes.
Globally, cervical spinal cord injuries accounted for more than 50% of TSCI, with their incidence significantly surpassing that of thoracic and lumbar injuries (16). Epidemiological research on TSCI in China reported that most injuries occurred in the cervical spine (61.3%), with incomplete quadriplegia being the most frequent presentation (44.2%) (17). However, in our survey, we observed that the thoracic spine was the most common site of injury, and younger patients were more likely to suffer from complete paraplegia. This finding aligned with an Australian study on workers with TSCI, which reported paraplegia in 68% of cases and tetraplegia in 32% (18). The level and severity of spinal cord injuries were crucial predictors of clinical outcomes. Previous studies have indicated that injuries at lower spinal levels tend to result in better prognoses (19). For instance, patients classified as Grade A on the American Spinal Injury Association (AIS) scale, which denotes complete injury, had only an 8.3% likelihood of walking independently 1 year post-injury. Conversely, those with Grade D injuries, indicating partial function, had a much higher probability (97.3%) of regaining independent mobility (20). These findings underscore the significant challenges faced by young patients with complete SCI, who are unlikely to regain independent ambulation.
Previous research has indicated that the proportion of patients with TSCI undergoing surgical intervention varied between 36.4% and 59.1% across different WHO regions (21). Surgical treatment appeared to be more prevalent among older patients (22). Our study revealed a surgery rate of 76.5% for those aged 60 and above, and an even higher rate of 94.7% among individuals aged 30–44. The primary factors guiding surgical intervention included spinal compression and neurological deficits (23). We speculated that the higher surgery rate may result from the CRRC accepting patients with severe spinal cord injuries nationwide, where significant spinal compression and neurological dysfunction were prevalent.
Surgery often led to extended hospitalization (24). In comparison with TSCI resulting from falls and traffic accidents, patients injured by object strikes exhibited longer LOS (10, 11). Workers who were labourers also experienced a longer LOS than those who were non-labourers. The severity of the SCI markedly influenced LOS, with more severe injuries correlating with prolonged hospitalization (25). Furthermore, LOS was significantly associated with complications such as neurogenic bladder, intestinal dysfunction, urinary tract infections, neuropathic pain, and respiratory infections, all of which were known to extend recovery time (26). The prevention, early diagnosis, and treatment of secondary complications in patients with TSCI were pivotal in mitigating the occurrence of these conditions, enhancing patient survival, reducing hospital stays, and improving health-related quality of life (27). In our survey, the most common complications of TSCI were neurogenic bladder and urinary tract infections. Urological issues were among the leading causes of re-hospitalization for individuals with TSCI, highlighting the critical importance of bladder management for these patients. Accurate diagnosis through urodynamic studies was essential for effective treatment and management (28, 29).
Given that labourers constituted over 70% of this study’s participants, and nearly 90% of these workers sustained injuries in the workplace, the implementation of targeted preventive measures for occupational spinal cord injuries was imperative. Ensuring occupational injury protection was essential to safeguard the fundamental rights of workers (30). The coverage rate of work-related injury insurance for labourers exposed to high occupational risks must be improved. Chinese migrant workers exhibited low awareness of health risks, with their work-related injury insurance coverage at just 23.6% (31). A survey conducted in the United States indicated that patients with traumatic spinal fractures were more likely to receive surgical treatment if they had insurance coverage (32). Based on this, we would advocate for the mandatory implementation of work-related injury insurance for migrant workers, along with encouraging individual farmers to purchase social insurance.
Primary prevention of work-related spinal cord injuries should be given substantially greater emphasis (33). A study on coalminers in Shanxi revealed that object strikes were the most common type of injury, comprising 53.63% of all incidents. Several risk factors for non-fatal occupational injuries included male gender, age, heavy manual labour, and working on underground front lines (34). Given these risks, targeted safety education was essential, particularly for labourers, with a specific focus on young and middle-aged men. Young workers (aged 15–24 years) experienced higher rates of work-related injuries compared with those aged 25–44. This increased risk may be attributed to limited or non-existent prior work experience or safety training. Therefore, providing adequate safety training and education for younger workers is crucial in reducing occupational injury rates and ensuring safer work environments (35).
The restoration of impaired neurological function and structural integrity following SCI remains an enduring challenge (36). Given that the majority of patients in this study sustained complete SCI, effective rehabilitation during the later stages is of paramount importance. Manella et al. have documented a case report that highlights significant improvements in ground walking ability after intensive physical therapy and robotic-assisted gait training (37). Additionally, another study found that exoskeleton-assisted walking activates the pelvic floor muscles, underscoring the therapeutic potential of such technologies (38). While over 95% of SCI patients at CRRC have undergone physical therapy, further advancement and integration of programs like robotic movement training are essential to optimize rehabilitation outcomes.
In terms of limitations in this study, first, the sample is concentrated in 1 hospital and cannot represent all patients with spinal cord injury. Also, some patients’ information was lost and screened out. Second, patient information such as occupation and place of injury was recorded manually by researchers and may be inaccurate. Third, misclassification of AIS at the time of the initial examination or follow-up may lead to change from neurologically complete to incomplete status. Lastly, as to the method’s limitation, confounders are likely to be part of our results considering the choice of methods itself.
In summary, the incidence of spinal cord injury resulting from object strikes predominantly affects young and middle-aged men engaged in physically demanding labour. Among all affected populations, complete paraplegia is the primary outcome, with high rates of complications, surgical interventions, and extended hospital stays. Thus, it is crucial to expand the coverage of work-related injury insurance and to enhance safety education in high-risk environments such as construction sites and mines. Moreover, improvements in rehabilitation treatment measures are vital to optimize recovery outcomes for these individuals.
ACKNOWLEDGEMENTS
The authors disclose receipt of the following financial support for the research, authorship, and publication of this article. This work was supported by the National Key R&D Program of China (Project No. 2021YFF0501600 and Subject No. 2021YFF0501604). Ethical permission was obtained at the authors’ institution (No. CRRC-IEC-RF-SQ-004-01). Informed consent was waived by the ethical review boards as this is a retrospective study. The authors would like to thank the members of the Spine Surgery Department of Beijing Bo’ai Hospital and the staff of Medical Record Room of China Rehabilitation Research Center for their help.
REFERENCES
- Guest JD, Kelly-Hedrick M, Williamson T, Park C, Ali DM, Sivaganesan A, et al. Development of a systems medicine approach to spinal cord injury. J Neurotrauma 2023; 40: 1849–1877. https://doi.org/10.1089/neu.2023.0024
- Sterner RC, Sterner RM. Immune response following traumatic spinal cord injury: pathophysiology and therapies. Front Immunol 2023; 13: 1084101. https://doi.org/10.3389/fimmu.2022.1084101
- Haoru Dong, Donglei Shi, Yifeng Bao, Xingyu Chen, Longnian Zhou, Haiyue Lin, et al. Transcriptome alterations and therapeutic drugs in different organs after spinal cord injury based on integrated bioinformatic analysis. J Neurorestoratol 2023; 11: 100056. https://doi.org/10.1016/j.jnrt.2023.100056
- Lu Y, Shang Z, Zhang W, Pang M, Hu X, Dai Y, et al. Global incidence and characteristics of spinal cord injury since 2000–2021: a systematic review and meta-analysis. BMC Med 2024; 22: 285. https://doi.org/10.1186/s12916-024-03514-9
- Hu Y, Li L, Hong B, Xie Y, Li T, Feng C, et al. Epidemiological features of traumatic spinal cord injury in China: a systematic review and meta-analysis. J Front Neurol 2023; 14: 1131791. https://doi.org/10.3389/fneur.2023.1131791
- Li J, Liu G, Zheng Y, Hao C, Zhang Y, Wei B, et al. The epidemiological survey of acute traumatic spinal cord injury (ATSCI) of 2002 in Beijing municipality. Spinal Cord 2011; 49: 777–782. https://doi.org/10.1038/sc.2011.8
- Yuan S, Shi Z, Cao F, Li J, Feng S. Epidemiological features of spinal cord injury in China: a systematic review. Front Neurol 2018; 9: 683. https://doi.org/10.3389/fneur.2018.00683
- Wang ZM, Zou P, Yang JS, Liu TT, Song LL, Lu Y, et al. Epidemiological characteristics of spinal cord injury in Northwest China: a single hospital-based study. J Orthop Surg Res 2020; 15: 214. https://doi.org/10.1186/s13018-020-01729-z
- Zhou Y, Wang XB, Kan SL, Ning GZ, Li YL, Yang B, et al. Traumatic spinal cord injury in Tianjin, China: a single-center report of 354 cases. Spinal Cord 2016; 54: 670–674. https://doi.org/10.1038/sc.2015.173
- Zhang ZR, Wu Y, Wang FY, Wang WJ. Traumatic spinal cord injury caused by low falls and high falls: a comparative study. J Orthop Surg Res 2021; 16: 222. https://doi.org/10.1186/s13018-021-02379-5
- Wu Y, Zhang Z, Wang F, Wang W. Current status of traumatic spinal cord injury caused by traffic accident in Northern China. Sci Rep 2022; 12: 13892. https://doi.org/10.1038/s41598-022-16930-9
- Jiang SH, Nico E, Bhaskara M, Patil S, Edgar MC, Sadeh M, et al. Characteristics of work-related spine injury in the USA: a National Trauma Data Bank analysis. Acta Neurochir (Wien) 2023; 165: 3097–3106. https://doi.org/10.1007/s00701-023-05731-2
- Bellucci CH, Castro Filho JE, Gomes CM, Bessa Junior Jr, Battistella LR, Souza DR, et al. Contemporary trends in the epidemiology of traumatic spinal cord injury: changes in age and etiology. Neuroepidemiology 2015; 44: 85–90. https://doi.org/10.1159/000371519
- Ahuja CS, Wilson JR, Nori S, Kotter MRN, Druschel C, Curt A, et al. Traumatic spinal cord injury. Nat Rev Dis Primers 2017; 3: 17018. https://doi.org/10.1038/nrdp.2017.18
- Guan B, Anderson DB, Chen L, Feng S, Zhou H. Global, regional and national burden of traumatic brain injury and spinal cord injury, 1990–2019: a systematic analysis for the Global Burden of Disease Study. BMJ Open 2023; 13: e075049. https://doi.org/10.1136/bmjopen-2023-075049
- Ding W, Hu S, Wang P, Kang H, Peng R, Dong Y, et al. Spinal cord injury: the global incidence, prevalence, and disability from the Global Burden of Disease Study 2019. Spine 2022; 47: 1532–1540. https://doi.org/10.1097/BRS.0000000000004417
- Zhou H, Lou Y, Chen L, Kang Y, Liu L, Cai Z, et al. Epidemiological and clinical features, treatment status, and economic burden of traumatic spinal cord injury in China: a hospital-based retrospective study. Neural Regen Res 2024; 19: 1126–1133. https://doi.org/10.4103/1673-5374.382257
- Bae SW, Shin HI, Bang MS, Lee MY. Epidemiology of work-related traumatic spinal cord injury: an analysis of workers’ compensation claims in Korea, 2011–2019. J Occup Environ Med 2023; 65: e453–e457. https://doi.org/10.1097/JOM.0000000000002852
- Yekaninejad MS, Derakhshanrad N, Kazemi E, Derakhshanrad A, Saberi H. Influential factors for final neurorehabilitation outcome scores in patients with spinal cord injury: a longitudinal cohort study. J Neurorestoratol 2024; 12: 100117. https://doi.org/10.1016/j.jnrt.2024.100117
- van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and prognosis of traumatic spinal cord injury. Global Spine J 2011; 1: 1–8. https://doi.org/10.1055/s-0031-1296049
- Kumar R, Lim J, Mekary RA, Rattani A, Dewan MC, Sharif SY, et al. Traumatic spinal injury: global epidemiology and worldwide volume. World Neurosurg 2018; 113: e345–e363. https://doi.org/10.1016/j.wneu.2018.02.033
- Ge L, Arul K, Ikpeze T, Baldwin A, Nickels JL, Mesfin A. Traumatic and nontraumatic spinal cord injuries. World Neurosurg 2018; 111: e142–e148. https://doi.org/10.1016/j.wneu.2017.12.008
- Dalbayrak S, Yaman O, Yılmaz T. Current and future surgery strategies for spinal cord injuries. World J Orthop 2015; 6: 34–41. https://doi.org/10.5312/wjo.v6.i1.34
- Wu Q, Ning GZ, Li YL, Feng HY, Feng SQ. Factors affecting the length of stay of patients with traumatic spinal cord injury in Tianjin, China. J Spinal Cord Med 2013; 36: 237–242. https://doi.org/10.1179/2045772313Y.0000000090
- Keusen P, Vuilliomenet T, Friedli M, Widmer M. Age at onset of spinal cord injury is associated with increased inpatient care needs, reduced independence at discharge and a higher risk of institutionalization after primary inpatient rehabilitation. J Rehabil Med 2023; 55: jrm00353. https://doi.org/10.2340/jrm.v54.4468
- Gross-Hemmi MH, Pacheco D. People with spinal cord injury in Switzerland. Am J Phys Med Rehabil 2017; 96: S116–S119. https://doi.org/10.1097/PHM.0000000000000571
- Sezer N, Akkuş S, Uğurlu FG. Chronic complications of spinal cord injury. World J Orthop 2015; 6: 24–33. https://doi.org/10.5312/wjo.v6.i1.24
- Franceschini M, Cecconi L, Bonavita J, Pournajaf S, Ferro S, Pagliacci MC, et al. Causes and length of stay of readmission among individuals with traumatic spinal cord injury: a prospective observational cohort study. Spinal Cord 2023; 61: 383–390. https://doi.org/10.1038/s41393-023-00874-6
- Sweis R, Biller J. Systemic complications of spinal cord injury. Curr Neurol Neurosci Rep 2017; 17: 8. https://doi.org/10.1007/s11910-017-0715-4
- Ran X, Zhao Y. Behind the flexibility: insufficient occupational injury protection of gig workers in China. Front Public Health 2023; 11: 1117180. https://doi.org/10.3389/fpubh.2023.1117180
- Hu R, Hu N, Liu R, Shi L, Shi J, Ling L. Association between occupational health and safety knowledge and behaviours among migrant workers: results from a cross-sectional study in China. BMJ Open 2020; 10: e040143. https://doi.org/10.1136/bmjopen-2020-040143
- Daly MC, Patel MS, Bhatia NN, Bederman SS. The influence of insurance status on the surgical treatment of acute spinal fractures. Spine 2016; 41: E37–45. https://doi.org/10.1097/BRS.0000000000001177
- O’Connor P. Work related spinal cord injury, Australia 1986–97. Inj Prev 2001; 7: 29–34. https://doi.org/10.1136/ip.7.1.29
- Cui Y, Tian SS, Qiao N, Wang C, Wang T, Huang JJ. Associations of individual-related and job-related risk factors with nonfatal occupational injury in the coal workers of Shanxi Province: a cross-sectional study. PLoS One 2015; 10: e0134367. https://doi.org/10.1371/journal.pone.0134367
- Evoy R, Syron L, Case S, Lucas D. Traumatic injuries among Alaska’s young workers: linking cases from four data systems. BMC Public Health 2023; 23: 57. https://doi.org/10.1186/s12889-022-14676-7
- Huang H, Chen L, Moviglia G, Sharma A, Al Zoubi ZM, He X, et al. Advances and prospects of cell therapy for spinal cord injury patients. J Neurorestoratol 2022; 10: 13–30. https://doi.org/10.26599/JNR.2022.9040007
- Manella KJ, Torres J, Field-Fote EC. Restoration of walking function in an individual with chronic complete (AIS A) spinal cord injury. J Rehabil Med 2010; 42: 795–798. https://doi.org/10.2340/16501977-0593
- Williams AMM, Deegan E, Walter M, Stothers L, Lam T. Exoskeleton gait training to improve lower urinary tract function in people with motor-complete spinal cord injury: a randomized pilot trial. J Rehabil Med 2021; 53: jrm00222. https://doi.org/10.2340/16501977-2864