CDE Detailed Report

Choose one
This variable documents whether any of the following spinal surgical procedures were performed during the inpatient hospitalization following a traumatic SCI: laminectomy, neural canal restoration, reduction, spinal fusion, or internal fixation of the spine.

Because it is possible that an injury event may be classifiable into more than one of these categories, the following prioritization has been established for assigning codes: First coding priority is given to sports. If the injury event involved sports it should be coded as a 1 (Sports) regardless of whether it involved assault, transport or a fall. Code 1 would be appropriate whenever the ICECI Injury Activity Axis would be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4) regardless of coding on other ICECI Axes. Second priority is given to Assault. If the event did not involve sports but it did involve an assault, then the event should be coded as a 2 (Assault) regardless of whether it involved transport or a fall. Code 2 would be appropriate whenever the ICECI Intent of Injury Axis would be coded as "assault" (ICECI Intent of Injury code 3) and the ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4) regardless of other ICECI Axes. Third priority is given to Transport. If the event was neither sports nor assault related but it involved transport, then the event should be coded as 3 (Transport) regardless of whether it involved a fall. Code 3 would be appropriate whenever the ICECI External Cause of Injury Axis would be coded as "transport injury event" (ICECI External Cause of Injury code 1.1) and ICECI Intent of Injury Axis would not be coded as "assault" (ICECI Intent of Injury code 3) and ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4). Fourth priority is given to Fall. If the event was neither sports, assault nor transport related and it involved a fall then it should be coded as 4 (Fall). Code 4 would be appropriate whenever the ICECI External Cause of Injury Axis would be coded as "falling, stumbling, or jumping" (ICECI External Cause of Injury code 1.5) and ICECI Intent of Injury Axis would not be coded as "assault" (ICECI Intent of Injury code 3) and ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4). Use code 5 (other traumatic cause) for all other known (specified) traumatic causes whenever codes 1 through 4 of this etiology variable do not apply. Paralysis secondary to surgical procedures when the patient does not have a neurological deficit prior to surgery would be coded in this category. Use code 6 (non-traumatic cause) if there is impairment of the spinal cord or cauda equina function that is not caused either directly or indirectly by an external event.
For traumatic spinal cord injuries, this variable has been adapted from the International Classification of External Causes of Injuries (ICECI). In its entirety, the ICECI provides a multi-axial description of the event that resulted in SCI. Four axes have been developed, including the External Cause of Injury Axis, the Intent of Injury Axis, the Place of Injury Axis, and the Injury Activity Axis. Use of the complete version of the ICECI (including all four axes and subcategories not included in the core data set) is recommended for injury surveillance activities or other research studies the goal of which would be to provide information useful for the development of interventions targeted at primary prevention of spinal cord injuries.

Place of residence at time of discharge should indicate the intended final disposition. If the patient is discharged to a hospital or nursing home temporarily for custodial care only pending home renovations or for other reasons, then the intended final destination should be coded, rather than coding a temporary destination, such as a "hospital," "rehabilitation facility," or "nursing home." For cross-sectional post-discharge studies, this variable documents current place of residence. When the person is currently hospitalized on a temporary basis, the usual place of residence should be coded rather than "hospital."

The participant or subject identifiers or IDs should be assigned by the study.

If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.
If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the examination was not done due to age, condition, or other reason, or there was no corresponding admission or discharge.

The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the sensory level should be recorded as X99.

For cross-sectional post-discharge studies, this variable documents the sensory level from the most recent neurologic examination.

Choose one. Response is obtained by report of the participant/subject or caretaker.
Record the gender to which the patient identifies. In recognition of some people identifying as transgender, transsexual, intersex or other similar gender affiliation, this can be specified by 'Transgender or other related category' (New and Currie 2016; Reisner et al. 2016).

Record the year, month, and day of death. If the month or day is unknown, it should be coded "99"; if the year is unknown, it should be coded "9999".

Record the year, month, and day for the inpatient rehabilitation facility admission. If the month or day is unknown, it should be coded "99"; if the year is unknown, it should be coded "9999."
In centers where there is comprehensive management, i.e. acute and rehabilitation in the same department, there will often be a distinction between the acute care program and the rehabilitation program, and the date registered when the patient is considered to be transferred from the acute to the rehabilitation program. This variable will make it possible to calculate the length of stay for inpatient acute management and rehabilitation respectively.

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
For non-traumatic cases, the date of injury should be coded as the approximate date of first physician visit related to symptoms of spinal cord dysfunction.

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).