Spinal Cord Injuries Following Suicide Attempts

Spinal Cord Injuries Following Suicide Attempts

Suicide has become an increasing concern as there are an estimated one million completed suicides per year worldwide. Suicide rates have increased by 60% over the last 50 years, particularly in developing countries. Suicide attempts are up to 20 times more. In 1996 more than 150,000 people committed suicide in 38 countries of the World Health Organization European Region. Suicide is currently one of the most important causes of death in Europe among young and middle-aged people, especially men. In some European Countries, in the age group 15-34, suicide ranks second among the most common causes of death. Nine of the ten countries with the highest suicide rates in the world are in the European Region.

In the EUROSAVE (European Review of Suicide and Violence Epidemiology) study, Finland had the highest suicide rate, while Greece had the lowest for the latest available year (1997). Greece also had the lowest undetermined deaths in 1984 and 1997. Botsis suggests that in Greece formal statistics by the National Statistics Office are not representative of reality when they refer to reported suicides. Families avoid reporting suicide as the cause of death for religious reasons. Natural causes are reported instead.

Several possible theories have been proposed to explain the increased risk conferred by multiple attempts. One possibility is that multiple attempts reflect persistent risk factors (e.g., a chronic or recurring psychiatric disorder or adverse psychosocial conditions). Esposito et al studied 74 single attempters (SAs) and 47 multiple attempters (MAs; ages 12-18) seen in an emergency department after a suicide attempt and found higher rates of mood disorder diagnosis among MAs. Joiner , suggests that multiple suicide attempts increase the risk for subsequent attempts because practice allows MAs to acquire the ability to engage in more serious suicidal behavior.

Initial clinical data of the 32 patients included in this study are shown in Table 1. At admission, ATLS guidelines were used for all patients. Associated injuries of the abdomen were present in five patients (patients 1, 4, 10 and 22). In these patients, a laparotomy was necessary for intraperitoneal bleeding, spleen and kidney injury, and mesenteric tear prior to the surgical operation for the spine fracture. Head injuries were revealed with CT scan in six patients (patients 3, 7, 8, 14, 26 and 30). In these cases craniotomy and decompression were performed first, before stabilization of the spinal fractures. Thoracic injuries (ribs fractures or sternum fracture) were present in three patients (patients 3, 5 and 28). Conservative treatment with assisted ventilation was necessary in these cases. Long bone fractures (femoral, tibial, bimalleolar, calcaneal, radial and humeral), including pelvic fractures, were treated by external fixation or closed reduction and immobilization in plaster or temporary splint. Subsequently, reduction and internal fixation, if required, were performed from 8 hours to 5 days later.

Regarding the treatment of the spinal fractures – dislocations, instrumentation devices including titanium rods, transpedicular screws, sacral bars and bone grafting were used on all patients. Patients were evaluated by a consulting psychiatrist as soon as their condition and cooperation permitted. Assessment included an interview and a complete mental status examination.

The only complications encountered were two cases of aspiration pneumonia, one of which resulted in prolonged stay on the intensive therapy unit due to difficulty weaning the patient off the ventilator. All patients were discharged from hospital approximately 6–8 weeks after the operation with a custom-made thermoplastic thoracolumbar or lumbosacral orthosis for another 8 weeks and instructions for physical therapy and rehabilitation programs. After discharge 13 patients returned to their homes and 19 to another hospital or entered residential care.

Patient
Age/gender
Mechanism of injury
Neurological deficits at admission
Associated Lesion
Surgical treatment
Follow-up
Recovery and outcome
1
23/F
Fall from building
Bowel and bladderdysfunction;saddle anesthesia;incomplete L5-S1 paraplegia
L4 fracture, humeral shaft fracture
Laminectomy; titanium rods and transpedicular screws, humeral external fixation
6 years
Recovery
2
18/M
Fall from building
Incomplete paraplegia
L2 fracture
Laminectomy; titanium rods and transpedicular screws
8 years
Recovery
3
34/F
Fall from building
Completeparaplegia
T9 fracture
Laminectomy; titanium rods and transpedicular screws
2 years
None
4
42/F
Fall from window
Incomplete paraplegia
L3 fracture
Laminectomy; titanium rods and transpedicular screws
18 months
Recovery
5
20/F
Fall from building
Completeparaplegia
T5 – T6 fracture, dislocation
Laminectomies; titanium rods and transpedicular screws
1 year
None
6
48/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
5 years
Recovery
7
65/F
Fall from building
Incompletetetraplegia
C2 – C3 fracture, dislocation
Anterior plating
17 months
Death, second suicide attempt at 2 years
8
56/M
Fall from building
Central cord syndrome
C2 – C3 fracture, dislocation
Anterior plating
2 years
Death (renal failure)
9
41/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
22 months
Recovery
10
27/F
Fall from building
Completeparaplegia
L1 fracture
Laminectomy; titanium rods and transpedicular screws
10 years
None
11
31/F
Fall from building
Bowel and bladderdysfunction;saddle anesthesia;complete L4–S1paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
9 years
None
12
39/M
Fall from building
Complete tetraplegia
C2 – C3 fracture, dislocation
AnteriorC2 – C3 plating
30 months
None
13
46/F
Fall from building
Complete tetraplegia
C2 – C3 fracture, dislocation
Anterior plating
25 months
None
14
51/F
Fall from building
Complete tetraplegia
C2 – C3 fracture
Anterior plating
3 years
Death (renal failure)
15
36/M
Fall from building
Incomplete tetraplegia
C7 fracture
Anterior plating
1 year
Recovery
16
19/F
Fall from building
Complete tetraplegia
C2 – C3 fracture, dislocation
Anterior plating
14 months
None
17
39/M
Fall from building
Incomplete paraplegia
Sacral fracture, Dennis III
Transiliac sacral bars
34 months
Recovery
18
41/F
Fall from bridge
Complete tetraplegia
C2 – C3 fracture, dislocation
Anterior plating
8 years
None
19
47/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
3 years
Recovery
20
34/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
1 year
Recovery
21
53/M
Fall from building
Complete paraplegia
Transverse fracture of the sacrum with anterior displacement
laminectomies; titanium rods and transpedicular screws; bone grafting
32 months
Death (pneumonia)
22
38/F
Fall from building
Incomplete paraplegia
L1 – L2 fracture, distal radius fracture
Laminectomies; titanium rods and transpedicular screws, cast for the distal radius fracture
23 months
Recovery
23
47/F
Fall from building
Brown – Sequard syndrome
T8 fracture
Laminectomy; titanium rods and transpedicular screws
2 years
Recovery
24
41/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
4 years
Recovery
25
35/M
Fall inside the house
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
15 months
Recovery
26
36/F
Fall from building
Incomplete tetraplegia
C6 – C7 fracture
Anterior plating
19 months
Recovery
27
27/F
Fall from building
Incomplete paraplegia
L5 fracture
Laminectomy; titanium rods and transpedicular screws
7 years
Recovery
28
33/F
Fall from building
Complete paraplegia
T9 – T10 fracture, dislocation
Laminectomies; titanium rods and transpedicular screws
2 years
None
29
55/F
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
31 months
Recovery
30
50/F
Fall from building
Complete paraplegia
T8 – T9 fracture, dislocation
Laminectomies; titanium rods and transpedicular screws
13 months
Death (renal failure)
31
44/F
Fall from building
Incomplete paraplegia
L3 fracture, distal radius fracture
Laminectomy; titanium rods and transpedicular screws, cast for the distal radius fracture
4 years
Recovery
32
23/M
Fall from building
Incomplete paraplegia
L4 fracture
Laminectomy; titanium rods and transpedicular screws
8 years
Recovery
TABLE 1.
Clinical data of the patients

The mean follow-up was 6 years (range: 12 months – 10 years). At follow-up, only 27 of the patients were available for evaluation due to the death of 5 patients 1-3 years post injury. Of the five patients one had committed suicide (patient 7) and the other four had presented medical complications [renal failure in 3 patients (patients 8, 14 and 30) and pneumonia in one (patient 21)]. Of the remaining patients, two were involved in further unsuccessful suicide attempts due to psychiatric problems, 1 to 3 years post first injury (patients 10 and 24) (Table 1). All survivors received psychiatric follow-up.

Adolescent suicide and attempted suicide have been recognized as a growing health problem in both Europe and the rest of the world. The highest average person-based ratio of male: female suicide attempt rate was found in the age group 15-24 years (1: 1.9), the next highest in the age group 45-54 years (1: 1.7). This ratio decreases in the age group up to 55 to 1: 1.4 (range: 1:3.4 to 1:0.6) .

In the two Greek studies referring to attempted suicide hospitalized in internal medicine wards due to drug intoxication and self poisoning there is a definite precedence of females with the first showing a percentage of male 34.2% and female 65.8% , and the second a ratio of male to female of 1:1.97 in an age group of 20-30 years . Other studies also report parasuicide as more common in females and younger ages . Contrarily, in the nationwide study of 1980-1995 of suicides a mean age-standardized rate of 5.86/100,000 males to 1.89/100,000 females was demonstrated. In addition, an increase in suicide rates was reported with age for males, with rising trends in the ages of 45-54yrs and decreasing rates for females in the 15-24yrs and 75-84yrs age group. Mostly violent methods are used among men . This male to female trend is confirmed in the Epirus study where a mean age-standardized suicide rate per year 4/100,000 males was reported to 1.29 females/100,000. Once again a significant rising trend was shown for male suicides in the ages 35-44yrs and 65-74yrs, while low female rates were found in the under 35yrs age group.

In the current study, the ratio between males to females was 1:3. Females were more likely to make a more dangerous jump that increased their mortality. Others suggest that young males tended to use more lethal methods in attempts and to repeat more often than females. A previous suicide attempt is in itself the strongest predictor of future suicide and local rates of attempted suicide and regional and national suicide rates in young people, especially males, are strongly correlated. There is an association between repeated suicide attempts and completed suicide, particularly in males and when a violent method has been used.

The underlying psychology of suicide is complex and unique to each individual. However, certain themes emerge from studying individuals who have attempted or completed suicides. In all age groups, depression, alcohol and drug dependence, as well as history of mental illness are known to be risk factors for suicide. Twenty percent of people who attempt suicide will make another attempt within the year, and 10% ultimately succeed. Injuries resulting from direct impact are mostly fractures. The area over which the impact force is applied influences the severity of the fractures. The smaller the area over which the patients land, the greater the load/ unit area. Patients who land on their legs tend to sustain more serious injuries than those who land on their sides.

There were two main combinations of fractures in this series. The patients with spinal fracture combined with pelvic and extremity fractures. Only three of them sustained upper extremity fractures (patients 1, 22 and 31). Twelve patients presented with pelvic or lower extremity fractures associated with upper extremity fractures. The difference between the two groups shows that fractures in the upper extremities usually exclude fractures of the spine. Upon impact, the falling body has a kinetic energy which is converted, in its major part, into fracture energy. In the first group most of the kinetic energy is dissipated to the lower extremities, pelvis and spine, causing fractures at these sites. In the second group, patients use their upper extremities in an attempt to protect themselves, possibly via more flexion at the hip level. This increased flexion converts the remaining energy into forward rotational energy of the trunk exposing the extended upper extremities to fractures. It is probable that this form of energy dissipation protects the spine from fracture.

The initial treatment should be limited to life-saving procedures and short spine and limb stabilization procedures. Fractures should be treated by methods that will allow early mobilization and transfer to the psychiatric ward. Treatment by traction or spica cast is not well tolerated by these patients and interferes with their nursing care. Rigid internal fixation, whenever possible for unstable fractures, is recommended.

The results of our study and others show that most of the patients who attempt suicide by jumping suffer from serious psychiatric disorders. These patients suffer from a broad spectrum of psychiatric symptoms: schizophrenia, depression, drugs or alcohol abuse, personality disorder and manic depression. The proportion of patients with schizophrenia is far higher than found in general suicide attempts where it is estimated to range from 5% to 10%. Sometimes they have active suicidal ideation or even a detailed suicidal plan. Thus, the treatment approach for such patients must take into account their psychiatric state. The psychiatric manifestations create subjective distress for the patient and may hinder or even prevent the medical and surgical care of the patient in some instances.

In this sample of patients the fact that most individuals appeared to have responded to treatment, indicated that all admissions following self-harm should have access to appropriate psychiatric treatment. The finding that three of the patients within this study, attempted suicide following SCI, suggests that a small number of the people who have attempted suicide will re-attempt. We believe that routine screening for suicide and risk assessments might highlight those who are most at risk of re-attempting suicide, thus allowing healthcare professionals to be aware of these individuals and adopt appropriate strategies to address suicidal ideation and behavior.

The prevalence of psychiatric and mental health problems illustrated in this series highlights the importance of educating staff in the care of patients with mental health problems. In view of the special needs of these individuals, services should ensure regular follow-up to prevent deterioration and monitor progress. Moreover, future clinical research should also evaluate the specific problems of people who have both SCI and a psychiatric diagnosis.

Until now it has been difficult to obtain comparable international data on suicide attempts, owing to disparities in definitions, survey designs and study methods. It has been our experience that psychiatric conditions, and especially suicide risk, should be evaluated and treated as early as possible during the orthopaedic or surgical hospitalization. Management requires both psychopharmacological therapy and psychotherapy. It has to be directed towards the achievement of symptomatic relief and, if possible, towards the remission of the primary psychiatric disorder. The management of these patients in the orthopaedic or surgical ward is difficult, because of restlessness, noncooperation of the patient and the problem of staff inexperienced in handling the psychiatric patient. When prolonged orthopaedic and rehabilitation management is necessary, it is suggested that the patient be transferred to the psychiatric hospital while continuing the necessary orthopaedic treatment.