Original Research

Prevalence and Predictors of Lower Limb Amputation in the Spinal Cord Injury Population

Fed Pract. 2022 April;39(4):168-174 | 10.12788/fp.0250

References

2. Theisen D, Vanlandewijck Y, Sturbois X, Francaux M. Central and peripheral haemodynamics in individuals with paraplegia during light and heavy exercise. J Rehabil Med. 2001;33(1):16-20. doi:10.1080/165019701300006489

3. Bell JW, Chen D, Bahls M, Newcomer SC. Evidence for greater burden of peripheral arterial disease in lower extremity arteries of spinal cord-injured individuals. Am J Physiol Heart Circ Physiol. 2011;301(3):H766-H772. doi:10.1152/ajpheart.00507.2011

4. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422-429. doi:10.1016/j.apmr.2007.11.005

5. Hennion DR, Siano KA. Diagnosis and treatment of peripheral arterial disease. Am Fam Physician. 2013;88(5):306-310.

6. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation. 2004;110(6):738-743. doi:10.1161/01.CIR.0000137913.26087.F0

7. Bauman WA, Spungen AM. Disorders of carbohydrate and lipid metabolism in veterans with paraplegia or quadriplegia: a model of premature aging. Metabolism. 1994;43(6):749-756. doi:10.1016/0026-0495(94)90126-0

8. Jörgensen S, Hill M, Lexell J. Cardiovascular risk factors among older adults with long-term spinal cord injury. PM R. 2019;11(1):8-16. doi:10.1016/j.pmrj.2018.06.008

9. Wu JC, Chen YC, Liu L, et al. Increased risk of stroke after spinal cord injury: a nationwide 4-year follow-up cohort study. Neurology. 2012;78(14):1051-1057. doi:10.1212/WNL.0b013e31824e8eaa

10. Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, Fowkes FG. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study. Eur Heart J. 1999;20(5):344-353. doi:10.1053/euhj.1998.1194

11. Bell JW, Chen D, Bahls M, Newcomer SC. Altered resting hemodynamics in lower-extremity arteries of individuals with spinal cord injury. J Spinal Cord Med. 2013;36(2):104-111. doi:10.1179/2045772312Y.0000000052

12. Miyatani M, Masani K, Oh PI, Miyachi M, Popovic MR, Craven BC. Pulse wave velocity for assessment of arterial stiffness among people with spinal cord injury: a pilot study. J Spinal Cord Med. 2009;32(1):72-78. doi:10.1080/10790268.2009.11760755

13. Oliver JJ, Webb DJ. Noninvasive assessment of arterial stiffness and risk of atherosclerotic events. Arterioscler Thromb Vasc Biol. 2003;23(4):554-566. doi:10.1161/01.ATV.0000060460.52916.D6

14. Ephraim PL, Dillifngham TR, Sector M, Pezzin LE, MacKenzie EJ. Epidemiology of limb loss and congenital limb deficiency: a review of the literature. Arch Phys Med Rehabil. 2003;84(5): 747-761. doi:10.1016/s0003-9993(02)04932-8.15. Levin ME. Preventing amputation in the patient with diabetes. Diabetes Care. 1995;18(10)1383-1394. doi:10.2337/diacare.18.10.1383

16. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95(8):875-883. doi:10.1097/00007611- 200208000-00018

17. Lo J, Chan L, Flynn S. A systematic review of the incidence, prevalence, costs, and activity and work limitations of amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury in the United States: a 2019 update. Arch Phys Med Rehabil. 2021;102:115-131. doi:10.1016/j.apmr.2020.04.001

18. Svircev, J, Tan D, Garrison A, Pennelly, B, Burns SP. Limb loss in individuals with chronic spinal cord injury. J Spinal Cord Med. doi:10.1080/10790268.2020.1800964

19. Brown DW. Smoking prevalence among US veterans. J Gen Intern Med. 2010;25(2):147-149. doi:10.1007/s11606-009-1160-0

20. Selim AJ, Berlowitz DR, Fincke G, et al. The health status of elderly veteran enrollees in the Veterans Health Administration. J Am Geriatr Soc. 2004;52(8):1271-1276. doi:10.1111/j.1532-5415.2004.52355.x

21. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116(9):1509-1526. doi:10.1161/CIRCRESAHA.116.303849

22. Yokoo KM, Kronon M, Lewis VL Jr, McCarthy WJ, McMillan WD, Meyer PR Jr. Peripheral vascular disease in spinal cord injury patients: a difficult diagnosis. Ann Plast Surg. 1996;37(5):495-499. doi:10.1097/00000637-199611000-00007

23. Taylor SM, Kalbaugh CA, Blackhurst DW, Cass, et al. Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions. J Vasc Surg. 2006;44(4):747–756. doi:10.1016/j.jvs.2006.06.015

24. Abdellaoui A, Al-Khaffaf H. C-reactive protein (CRP) as a marker in peripheral vascular disease. Eur J Vasc Endovasc Surg. 2007;34(1):18-22. doi:10.1016/j.ejvs.2006.10.040

25. Caro J, Migliaccio-Walle K, Ishak KJ, Proskorovsky I. The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC Cardiovasc Disord. 2005;5:14. doi:10.1186/1471-2261-5-14

Injury by Impairment Scale Level

Forty-nine (11.5%) of 426 patients with AIS level A SCI had undergone amputation. In order of prevalence, 23 (46.9%) were unilateral TFA, 17 (34.6%) were bilateral TFA, 10.2% were partial foot/toe, 4.1% were unilateral TTA, and 4.1% were a TTA/TFA combination. Both hip and knee disarticulations were classified in the TFA category.

Sixteen (13.0%) of 123 patients with AIS level B SCI had undergone amputation; 5 (31.3%) of those amputations were unilateral TFA, 6 (37.5%) were bilateral TFA, 3 (18.8%) were partial toe or foot, and 1 (6.3%) was for unilateral and bilateral TTA each.

Twelve (8.4%) of 143 patients with AIS level C SCI had undergone amputation: 6 (50.0%) were bilateral TFA; 3 (25.0%) were unilateral TFA; and 3 (25.0%) were unilateral TTA.

Fourteen (3.9%) of 356 patients with AIS level D SCI had undergone amputation. Of those 6 (42.9%) underwent a partial foot/toe amputation; 5 (35.7%) had undergone a unilateral TTA, and 1 (7.1%) underwent amputation in each of the following categories: bilateral TTA, unilateral TFA, and bilateral TFA each.

None of the 7 individuals with AIS E level SCI had undergone amputation.

Health Risk Factors

Of the 91 patients with amputation, the majority (81.3%) were either former or current smokers. Thirty-six percent of those who had undergone amputation had a diagnosis of DM, while only 21% of those who had not undergone amputation had a diagnosis of DM.

At the time of their annual examination 532 patients had a diagnosis of HTN while 523 patients did not. Among patients with amputations, 59 (64.8%) had HTN, while 32 (35.2%) did not. Of the 964 patients without amputation, the prevalence of HTN was 50.9%

.Of 1055 patients with SCI, only 103 (9.8%) had a PAD diagnosis, including 38 (41.9%) patients with amputation. Just 65 (6.7%) patients with SCI without amputation had PAD (P < .001). PAD is highly correlated with dysvascular causes of amputation. Among those with amputations due to dysvascular etiology, 50.0% (35/70) had PAD, but for the 21 amputations due to nondysvascular etiology, only 3 (14.3%) had PAD (P = .004).

References

1. Hopman MT, Nommensen E, van Asten WN, Oeseburg B, Binkhorst RA. Properties of the venous vascular system in the lower extremities of individuals with paraplegia. Paraplegia. 1994;32(12):810-816. doi:10.1038/sc.1994.128

2. Theisen D, Vanlandewijck Y, Sturbois X, Francaux M. Central and peripheral haemodynamics in individuals with paraplegia during light and heavy exercise. J Rehabil Med. 2001;33(1):16-20. doi:10.1080/165019701300006489

3. Bell JW, Chen D, Bahls M, Newcomer SC. Evidence for greater burden of peripheral arterial disease in lower extremity arteries of spinal cord-injured individuals. Am J Physiol Heart Circ Physiol. 2011;301(3):H766-H772. doi:10.1152/ajpheart.00507.2011

4. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422-429. doi:10.1016/j.apmr.2007.11.005

5. Hennion DR, Siano KA. Diagnosis and treatment of peripheral arterial disease. Am Fam Physician. 2013;88(5):306-310.

6. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation. 2004;110(6):738-743. doi:10.1161/01.CIR.0000137913.26087.F0

7. Bauman WA, Spungen AM. Disorders of carbohydrate and lipid metabolism in veterans with paraplegia or quadriplegia: a model of premature aging. Metabolism. 1994;43(6):749-756. doi:10.1016/0026-0495(94)90126-0

8. Jörgensen S, Hill M, Lexell J. Cardiovascular risk factors among older adults with long-term spinal cord injury. PM R. 2019;11(1):8-16. doi:10.1016/j.pmrj.2018.06.008

9. Wu JC, Chen YC, Liu L, et al. Increased risk of stroke after spinal cord injury: a nationwide 4-year follow-up cohort study. Neurology. 2012;78(14):1051-1057. doi:10.1212/WNL.0b013e31824e8eaa

10. Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, Fowkes FG. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh Artery Study. Eur Heart J. 1999;20(5):344-353. doi:10.1053/euhj.1998.1194

11. Bell JW, Chen D, Bahls M, Newcomer SC. Altered resting hemodynamics in lower-extremity arteries of individuals with spinal cord injury. J Spinal Cord Med. 2013;36(2):104-111. doi:10.1179/2045772312Y.0000000052

12. Miyatani M, Masani K, Oh PI, Miyachi M, Popovic MR, Craven BC. Pulse wave velocity for assessment of arterial stiffness among people with spinal cord injury: a pilot study. J Spinal Cord Med. 2009;32(1):72-78. doi:10.1080/10790268.2009.11760755

13. Oliver JJ, Webb DJ. Noninvasive assessment of arterial stiffness and risk of atherosclerotic events. Arterioscler Thromb Vasc Biol. 2003;23(4):554-566. doi:10.1161/01.ATV.0000060460.52916.D6

14. Ephraim PL, Dillifngham TR, Sector M, Pezzin LE, MacKenzie EJ. Epidemiology of limb loss and congenital limb deficiency: a review of the literature. Arch Phys Med Rehabil. 2003;84(5): 747-761. doi:10.1016/s0003-9993(02)04932-8.15. Levin ME. Preventing amputation in the patient with diabetes. Diabetes Care. 1995;18(10)1383-1394. doi:10.2337/diacare.18.10.1383

16. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95(8):875-883. doi:10.1097/00007611- 200208000-00018

17. Lo J, Chan L, Flynn S. A systematic review of the incidence, prevalence, costs, and activity and work limitations of amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury in the United States: a 2019 update. Arch Phys Med Rehabil. 2021;102:115-131. doi:10.1016/j.apmr.2020.04.001

18. Svircev, J, Tan D, Garrison A, Pennelly, B, Burns SP. Limb loss in individuals with chronic spinal cord injury. J Spinal Cord Med. doi:10.1080/10790268.2020.1800964

19. Brown DW. Smoking prevalence among US veterans. J Gen Intern Med. 2010;25(2):147-149. doi:10.1007/s11606-009-1160-0

20. Selim AJ, Berlowitz DR, Fincke G, et al. The health status of elderly veteran enrollees in the Veterans Health Administration. J Am Geriatr Soc. 2004;52(8):1271-1276. doi:10.1111/j.1532-5415.2004.52355.x

21. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116(9):1509-1526. doi:10.1161/CIRCRESAHA.116.303849

22. Yokoo KM, Kronon M, Lewis VL Jr, McCarthy WJ, McMillan WD, Meyer PR Jr. Peripheral vascular disease in spinal cord injury patients: a difficult diagnosis. Ann Plast Surg. 1996;37(5):495-499. doi:10.1097/00000637-199611000-00007

23. Taylor SM, Kalbaugh CA, Blackhurst DW, Cass, et al. Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions. J Vasc Surg. 2006;44(4):747–756. doi:10.1016/j.jvs.2006.06.015

24. Abdellaoui A, Al-Khaffaf H. C-reactive protein (CRP) as a marker in peripheral vascular disease. Eur J Vasc Endovasc Surg. 2007;34(1):18-22. doi:10.1016/j.ejvs.2006.10.040

25. Caro J, Migliaccio-Walle K, Ishak KJ, Proskorovsky I. The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC Cardiovasc Disord. 2005;5:14. doi:10.1186/1471-2261-5-14

Prevalence and Predictors of Lower Limb Amputation in the Spinal Cord Injury Population

References

Injury by Impairment Scale Level

Health Risk Factors

Pages

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