CDE Detailed Report

1 – Most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more adjacent and contiguous motion segments.
2 – If there are two or more discrete spinal column injuries, this is the second most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more adjacent and
contiguous motion segments separated by at least one intact vertebral level to the above or below spinal column injury.
3, 4, etc. If there are three or more discrete spinal column injuries, this is the third, fourth, etc. most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more
adjacent and contiguous motion segments separated by at least one intact vertebral level to the above or below spinal column injury.
99 - Unknown

Choose one. If a preexisting or concomitant sexual problem is present it is not possible to determine the exact impact of the spinal cord lesion on sexual function and the data should be appropriately identified. Unknown refers to individuals who were not sexually active prior to their lesion, thus it would be unknown if sexual dysfunction was present.

This element requires the assessor to directly ask the individual with spinal cord lesion the following question "Does any of the musculoskeletal challenges above interfere with your activities of daily living (transfers, walking, dressing, showers, etc.)?"

Regular use of one or more collecting appliances is to be recorded. For each collecting appliance type indicate if it is used. Individuals with spinal cord lesions that use such appliances less than once a month, "for the sake of safety", and who have no more than exceptional episodes of leakage during a year should be excluded (adapted from Levi and Ertzgaard 1998). For other possible collecting appliances it is recommended to write them in a textfield, from which it will be possible to retrieve more detailed data when necessary.

within the last four weeks

Choose one - This is to be filled in for each level of injury, starting with the most cephalic injury. Acute injury to the posterior ligamentous complex should be diagnosed clinically or radiographically. Clinical evidence relies on the presence of marked local bruising and/or a palpable interspinous gap possibly with local tenderness. Radiologic diagnosis is dependent on the existence of a widened interspinous space on AP or lateral x-ray or reformatted CT of the spine, or by appropriate MRI. It may also appear as avulsion of a bone from the spinous processes or lamina. When a traumatic injury to the disc and annulus occurs in association with posterior element distraction, subluxation, or dislocation, this will be recorded as a disc and posterior ligamentous complex injury. In the case of multiple spinal column injuries, a separate entry will be filled out for each level of spinal column injury.
Posterior ligamentous complex injury will be defined as the presence of acute disruption or injury to the posterior ligamentous complex through the spinal column from the occiput to the level of the sacrum. Acute injury to the posterior ligamentous complex will
be diagnosed clinically or radiographically. Clinical evidence relies on the presence of marked local bruising and/or a palpable interspinous gap possibly with local tenderness. Radiologic diagnosis is dependent on the existence of a widened interspinous
space on AP or lateral x-ray or reformatted CT of the spine, or by appropriate MRI. It may also appear as avulsion of a bone from the spinous processes or lamina. Disc Injury will be defined as a traumatic disruption of the annulus of the disc through either distraction, translation, or rotation. It will also include a traumatic disc protrusion causing a spinal cord injury. Isolated traumatic disc injuries commonly occur with hyperextension mechanisms in the cervical spine. When a traumatic injury to the disc and annulus occurs in association with posterior element distraction, subluxation, or dislocation, this will be recorded as a disc and posterior ligamentous complex injury. In the case of multiple spinal column injuries, a separate entry will be filled out for each level of spinal column injury.

With respect to UTI, individuals with spinal cord lesions may have many signs and symptoms due to their spinal cord lesion or other problems. Therefore, it is important to determine that an individual's signs and symptoms are of a new onset or have increased and are not chronic in nature from a preexisting or intercurrent problem. A UTI is characterized by the new onset of sign(s)/symptom(s) accompanied by laboratory findings of a UTI, (bacteriuria, leukocyturia and positive urine culture) (National Institute on Disability and Rehabilitation Research (NIDDR) criteria for UTI, 1992). The individual would be expected to have an onset of symptoms within 2 weeks. However, it is possible that a person's UTI could develop into a chronic condition such as chronic testicular pain from epididymitis. It is important to note that individuals with a spinal cord lesion may have many other signs and symptoms (see below) in addition to traditional signs and symptoms of a UTI in able-bodied individuals. Because of alterations in sensation, some symptoms may be absent in individuals with spinal cord lesions. Other problems, such as autonomic dysreflexia, may develop or worsen due to a UTI.

Record the time duration in minutes based on each individual?s own assessment of average time consumption. The code "Not applicable" can be used by some individuals with stomas.

For each pulmonary complication or condition indicate if occurred within the last year.

Choose one

Regular use of one or more collecting appliances is to be recorded. For each collecting appliance type indicate if it is used. Individuals with spinal cord lesions that use such appliances less than once a month, "for the sake of safety", and who have no more than exceptional episodes of leakage during a year should be excluded (adapted from Levi and Ertzgaard 1998). For other possible collecting appliances it is recommended to write them in a textfield, from which it will be possible to retrieve more detailed data when necessary.

Record in time duration in minutes based on each individual's own assessment of time consumption. This element begins at the end of the previous element (Bowel care initiation to stool comes out past three months average duration).

Choose one.
This element does not distinguish between spontaneous or assisted defecation. Not applicable can be used i.e. in subjects with ileo- or colostomy.
The frequency of defecation is very variable. However, in the general population more than 94% defecate between three times per day and three times per week (Drossman et al. 1982). Among individuals with SCI approximately 3% defecate less than once every week. Extremely few individuals will not have defecated within the last four weeks. However, in order to be able to compute the Cleveland Constipation Score this option is included. Infrequent defecation is an indicator of insufficient bowel management and associated with impact on quality of life (Krogh et al. 2006).

Choose one. When querying individuals about psychogenic arousal it is recommended that the interviewer focus on the woman's awareness of vaginal lubrication as opposed to clitoral engorgement.

Choose one. Respiratory symptoms entirely due to higher level SCI should not be included in this element.

Identifies whether the anatomic site and laterality type describes the fracture, heterotopic ossification, contracture, or degenerative change/overuse

Bladder stone or upper urinary tract stone removal includes any type of removal, including via endoscopy, extracorporal shock wave lithotripsy (ESWL), or open lithotomy.
The ileoureterostomy is corresponding to the formely ileal loop or ureteroileocutaneostomy (Bricker conduit). The continent catheterizable valves, include Monteand Mitrofanoff procedures.
For other possible surgical procedures it is recommended to write them in a textfield, from which it will be possible to retrieve more detailed data when necessary. If there is more than one "other" surgical procedure, this field may be duplicated or triplicated, with the latest date given when the particular procedure has been performed. If the information has been documented once and noadditional surgical procedures on the urinary tract have been performed it is not necessary fill in this item again, to avoid redundant data.

Record in time duration in minutes based on each individual's own assessment of time consumption. This element begins at the end of the previous element (Stool intermittent or continuous defecation with or without assistance past three months average duration).

Code each of the new diagnoses made using SNOMED CT.

Choose one. Most individuals with complete SCI are unable to feel perianal pain during defecation. In such cases the code "Never" and not the code "Unknown" should be used. Indirect indicators of perianal pain during defecation such as perspiration, spasms or headache are not registered here. The code "Not applicable" is mainly for individuals with stomas.