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SummaryA study of 9135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury (SCI) care systems was conducted. Follow-up ended December 31, 1985, by which time 50 persons had committed suicide (6'3% of deaths). Based on age-sex-race-specific rates for the general population, 10'2 suicides were expected to occur. Therefore, the standardized mortality ratio (SMR) for suicide was 4'9. The highestSMR occurred 1 to 5 years after injury. The SMR was also elevated for the first post-injury year, but was not significantly elevated after the fifth year. The SMR was significantly elevated for all neurological groups, but was highest for persons with complete paraplegia. The SMR was highest for persons aged 25 to 54 years, but was also elevated for persons aged less than 25 years. Suicide was the leading cause of death for persons with complete paraplegia and the second leading cause of death for persons with incomplete paraplegia. The most common means of committing suicide was by gunshot. These figures demonstrate the need for increased staff, patient and family awareness of this problem, and improved follow-up assessment and psychosocial support programmes.

Incidence and prevalenceThe incidence of spinal cord injury (SCI) varies according to source, however, reports considered to be most accurate indicate that the annual rate is between 30·0 and 32·1 new spinal cord injuries per million persons at risk in the U.S.A. (DeVivo et al., 1980; Kraus et al., 1975). DeVivo, et al. (1980), used the mathematical relationship between incidence and duration to re-estimate the prevalence of SCI, calculating the rate to be approximately 906 per million.This figure is nearly 50° () greater than that estimated by Kurtzke (1975) who based his calculations on the length of median post-injury survival; a less precise statistic in light of that which is known today. Age, sex and raceIn the U.S.A., SCIs occur most frequently in persons between 15 and 20 years of age. According to the National SCI Database maintained by the Department of Rehabilitation Medicine at the University of Alabama at Birmingham, the mean age at injury is 29·7 years, the median age is 25 years and the mode (i.e. the most frequent age at injury) is 19 years (Stover and Fine, 1986). Reported differences in age distribution are believed to reflect a myriad of non-comparable data collection strategies. The National SCI Database confirms that SCI occurs more frequently among males than among females (a 4: 1 ratio) and that the average, annual race-specific incidence rates for SCI are slightly higher for blacks than whites, a finding consistent with the higher accidental death rate observed among blacks (Accident Facts, 1983). EtiologyA review of the 10 000 + cases documented in the National SCI database con firms that in the U.S.A., as in virtually all other industrialised countries, most spinal cord injuries result from motor vehicle crashes (47·7%) followed by falls (20·8° 0)' acts of violence-gunshot wounds and stabbings (14·6%) and sporting-

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SummaryPatients admitted to the University of Alabama Hospital between 1973 and 1985 were studied to determine the benefits, if any, of early admission to an organised, multidisciplinary spinal cord injury (SCI) care system. Patients admitted within 1 day of injury who received all subsequent care within the system were compared with patients who received their acute care services elsewhere and who were admitted to the system solely for rehabilitation. Both patient groups were comparable with respect to age, neurologic level and extent of spinal cord lesion, pre-existing major medical conditions, associated injuries, ventilator dependency and acute surgical procedure experience. Findings included statistically significant reductions in acute care and total lengths of stay coupled with a highly significant reduction in the incidence of pressure ulcers for patients admitted within 1 day of injury. Moreover, for patients admitted within 1 day of injury, mortality rates were lower than reported previo":Sly for patients not admitted to an organised SCI care system. Key words: Spinal cord injury; Organised spinal cord injury care system; Length of stay; Hospital charges; Mortality; Medical complications.