CDE Detailed Report

Disease: Spinal Cord Injury
Sub-Domain: The International SCI Data Sets
CRF: International SCI Core Data Set v2.0

Displaying 1 - 23 of 23
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C06004 Ventilatory assistance utilization frequency indicator VentltryAsstncUtilztnFreqInd Documents any use of any type of ventilatory assistance used to sustain respiration on the date of final inpatient discharge (the date of discharge from the last inpatient rehabilitation hospital or discharge from the last acute care hospital if the patient is not admitted to a rehabilitation hospital). Documents any use of any type of ventilatory assistance used to sustain respiration on the date of final inpatient discharge. Ventilatory Assistance 0;1;2;3;9 0=No;1=Yes, less than 24 hours per day;2=Yes, 24 hours per day;3=Yes, unknown number of hours per day;9=Unknown Numeric values

Choose one - Ventilatory assistance includes but is not limited to mechanical ventilators, phrenic nerve stimulators, external negative pressure devices, and BiPAP. Do not include routine administration of oxygen; periodic IPPB administration; or CPAP.

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C19160 Discharge facility type DischargeFacilityTyp The type of facility to which the participant was discharged The type of facility to which the participant was discharged Place upon discharge/current residence: Assisted living residence;Correctional institution;Deceased;Group living situation;Homeless;Hospital;Hotel or motel;Nursing home;Other unclassified;Private residence;Unknown Assisted living residence;Correctional institution;Deceased;Group living situation;Homeless;Hospital;Hotel or motel;Nursing home;Other unclassified;Private residence;Unknown Alphanumeric

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."

Adult;Pediatric Supplemental 1.00 2014-05-29 12:12:43.0 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C06005 Data collected date and time DataCollDateTime Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date of Examination Date or Date & Time

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.).
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 date should be recorded as 8888-88-88.

When parts of the examination are done on different dates, the date of the examination should be the day on which most parts of the examination were done.

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

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C19247 Subject ID SubIDNam Subject identification ID Subject identification ID Subject Alphanumeric

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

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 1.00 2014-06-05 13:10:49.0 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets 255

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C06006 SCI Classification sensory neurological level left result SCIClssSensNeuroLvlLftReslt Result of the most caudal segment of the spinal cord on the left side of the body with normal sensory function for pinprick and light touch. Result of the most caudal segment of the spinal cord on the left side of the body with normal sensory function for pinprick and light touch. Sensory Level - Left C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 Alphanumeric

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.

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C55476 Congenital genetic spinal cord injury etiology specify text CongGenetSCIEtioSpTxt The free text field to describe the congenital or genetic etiology of spinal cord injury The free text field to describe the congenital or genetic etiology of spinal cord injury Congenital or genetic etiology (e.g., spina bifida), Specify: Alphanumeric Adult;Pediatric Supplemental 1.00 2015-03-04 14:29:49.0 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets 255

Free-Form Entry

C00007 Birth date BirthDate Date (and time, if applicable and known) the participant/subject was born Date (and time, if applicable and known) the participant/subject was born Date of Birth Date or Date & Time

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.).

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Free-Form Entry

793
C06007 SCI Classification sensory neurological level right result SCIClssSensNeuroLvlRtReslt Result of the most caudal segment of the spinal cord on the right side of the body with normal sensory function for pinprick and light touch. Result of the most caudal segment of the spinal cord on the right side of the body with normal sensory function for pinprick and light touch. Sensory Level - Right C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 Alphanumeric

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.

DeVivo M, Biering-SØrensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C55478 Spinal cord dysfunction non traumatic other specify text SpnlCordDysfNonTraumSpTxt The free text field to describe the other type of non-traumatic spinal cord dysfunction The free text field to describe the other type of non-traumatic spinal cord dysfunction Other non-traumatic spinal cord dysfunction, Specify: Alphanumeric

Use code 5 (other traumatic cause) for birth injuries or all other known (specified) or unknown 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. It is possible to specify the cause.

Adult;Pediatric Supplemental 1.00 2015-03-04 14:29:49.0 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets 255

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C00035 Gender type GenderTyp Self-reported gender of the participant/subject. Self-reported gender of the participant/subject.. Gender Alphanumeric

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).

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. The NIH Guidelines on Inclusion of Women and Minorities as Subjects in Clinical Research: The Office of Management and Budget (OMB) Directive No. 15 - http://grants.nih.gov/grants/funding/women_min/women_min.htm<br />Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a<br />review. Lancet. 2016 Jul 23;388(10042):412-36. Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

2200604
C06008 SCI Classification motor neurological level left result SCIClssMtrNeuroLvlLftReslt Result of the lowest key muscle on the left side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5). Result of the lowest key muscle on the left side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5). Motor Level - Left C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 Alphanumeric

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.
The motor level (the lowest normal motor segment - which may differ by side of body) is defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. Right and left levels are documented separately
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 motor level should be recorded as X99.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C04802 Death date and time DeathDateTime Date (and time, if known) of participant's/subject's death Date (and time, if known) of participant's/subject's death Date of Death: Date or Date & Time

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".

Adult;Pediatric Supplemental 3.00 2013-07-24 11:38:01.2 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

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2004152
C06009 SCI Classification motor neurological level right result SCIClssMtrNeuroLvlRteReslt Result of the lowest key muscle on the right side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5). Result of the lowest key muscle on the right side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5). Motor Level - Right C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99 Alphanumeric

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.
The motor level (the lowest normal motor segment - which may differ by side of body) is defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. Right and left levels are documented separately
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 motor level should be recorded as X99.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C05134 Therapy rehabilitation start date time TherpyRehabStrtDateTime Date (and time, if applicable and known) on which the therapy or rehabilitation started Date (and time, if applicable and known) on which the therapy or rehabilitation started Rehabilitation admission date Date or Date & Time

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.

Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

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C06010 ASIA Impairment Scale ASIAImprmntScale Scale for the participant's/subject's impairment level on The American Spinal Injury Association (ASIA) Impairment Scale classification, which attempts to quantitate the degree of impairment Scale for the participant's/subject's impairment level on the American Spinal Injury Association (ASIA) Impairment Scale classification, which attempts to quantitate the degree of impairment ASIA Impairment Scale A;B;C;D;E;U Complete Injury. No motor or sensory function is preserved in the sacral segments S4-S5.;Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.;Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3.;Incomplete. Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.;Normal. Motor and sensory function are normal.;Unknown or not applicable. Alphanumeric

When an associated injury (e.g., traumatic brain injury) or certain non-neurologic impairments interfere with the performance of a complete neurological examination, the ASIA Impairment Scale should be coded Unknown. For an individual to receive a grade of B, C, or D, he/she must be incomplete, that is, have sensory or motor function in the sacral segments S4-S5. Any sensation felt in the anal area during this part of the exam signifies that the patient is sensory incomplete (at least grade B). In addition, for an individual to receive a grade of C or D, the individual must have either (1) voluntary anal sphincter contraction or (2) sparing of motor function more than three levels below the motor level.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C05400 Injury date time InjDateTime Date (and time, if applicable and known) of injury Date (and time, if applicable and known) of injury Date of Injury Date or Date & Time

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.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Free-Form Entry

C06411 Inpatient final discharge date and time InpatFinalDischrgDateTime Date (and time, if applicable and known) of discharge from the last inpatient hospital when all planned acute care and rehabilitation phases of treatment are completed. Date of discharge from the last inpatient hospital when all planned acute care and rehabilitation phases of treatment are completed. Date of Final Inpatient Discharge Date or Date & Time

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.).
On this date, patients will typically be discharged home (with no further planned inpatient admissions) or discharged to a long-term care facility. Outpatient rehabilitation or a home rehabilitation program may continue after this date, or limited rehabilitation therapy may continue in the long-term care facility. If the patient dies during inpatient hospitalization, this will be the date of death.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Free-Form Entry

C05408 Hospital admission date and time HospitlAdmissDateTime Date (and time, if applicable and known) the participant/subject was admitted to the hospital Date (and time, if applicable and known) the participant/subject was admitted to the hospital Date of Acute Care Hospital Admisson Date or Date & Time

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.).

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

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C06412 Injury vertebral indicator InjVertbrlInd Whether there was a spinal fracture and/or dislocation in addition to the spinal cord injury. Spinal fracture or dislocation is defined as any break, rupture, or crack through or between any part(s) of the vertebral column from the occiput to the coccyx. Whether there was a spinal fracture and/or dislocation in addition to the spinal cord injury. Spinal fracture or dislocation is defined as any break, rupture, or crack through or between any part(s) of the vertebral column from the occiput to the coccyx. Vertebral Injury 0;1;9 0=No;1=Yes;9=Unknown Numeric values

Choose one
Spinal fracture or dislocation is defined as any break, rupture, or crack through or between any part(s) of the vertebral column from the occiput to the coccyx.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C06000 Site identifier number SiteIDNum Unique identification number given to the study site to distinguish the location where data is recorded. Unique identification number given to the study site to distinguish the location where data is recorded. Site Alphanumeric

The site identifiers or IDs should be assigned by the study.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets 255

Free-Form Entry

C06413 Spinal surgery indicator SpnalSurgryInd Whether any of the following spinal surgical procedures were performed during the inpatient hospitalization following spinal cord injury: laminectomy, neural canal restoration, reduction, spinal fusion, or internal fixation of the spine. Laminectomy is defined as removal of normal intact lamina or foreign body at the site of spinal cord damage. Neural canal restoration is defined as the removal of bone or disk fragments, blood clots, or foreign bodies (such as bullet fragments) from the spinal canal. Reduction is defined as replacement of one or more dislocated, subluxed or angulated vertebra into anatomic or near anatomic alignment. Spinal fusion is defined as the addition of a bone graft to the vertebrae for the purpose of achieving intervertebral fusion or stability. Internal fixation of the spine is defined as attaching rods, plates, wires, etc. to the spine (individually or in combination) to provide internal surgical stabilization of the vertebral column. Whether any of the following spinal surgical procedures were performed during the inpatient hospitalization following spinal cord injury: laminectomy, neural canal restoration, reduction, spinal fusion, or internal fixation of the spine. Spinal Surgery 0;1;9 0=No;1=Yes;9=Unknown Numeric values

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.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C06003 Injury associate spinal cord injury indicator InjAssocSCIInd Whether any of the following pre-specified major injuries occurred at the same time as the spinal cord injury: moderate to severe traumatic brain injury (Glasgow Coma Scale 12 or below at discharge), non-vertebral fractures requiring surgery, severe facial injuries affecting sense organs, major chest injury requiring chest-tube or mechanical ventilation, traumatic amputations of an arm or leg (or injuries severe enough to require surgical amputation), severe hemorrhaging, or damage to any internal organ requiring surgery. Whether any of a variety of pre-specified major injuries occurred at the same time as the spinal cord injury. Associated Injury 0;1;9 0=No;1=Yes;9=Unknown Numeric values

Choose one - Do not include other associated injuries not listed above, negative findings from exploratory surgery, and do not include injuries that pre-date the spinal cord injury.

Biering-S&Oslash;rensen F, DeVivo MJ, Charlifue S, Chen Y, New PW, Noonan V, Post MWM, Vogel L. International Spinal Cord Injury Core Data Set (version 2.0)-including standardization of reporting. Spinal Cord. 2017;55(8):759-764. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

C06414 Spinal cord injury etiology type SpnalCrdInjEtlgyTyp Etiology of the spinal cord injury. Traumatic spinal cord injury is impairment of the spinal cord or cauda equina function resulting from the application of an external force of any magnitude. Etiology of the spinal cord injury. Traumatic spinal cord injury is impairment of the spinal cord or cauda equina function resulting from the application of an external force of any magnitude. Spinal Cord Injury Etiology 1;2;3;4;Unspecified or Unknown;Congenital or genetic etiology (e.g. spina bifida);Tumor-benign;Vascular etiology;Other non-traumatic spinal cord dysfunction;Degenerative non-traumatic etiology;Tumor- malignant;Infection (e.g. bacterial, viral);Birth injury or other traumatic cause 1 = Sports/leisure;2 = Assault;3 = Transport;4 = Fall;Unspecified or Unknown;Congenital or genetic etiology (e.g. spina bifida);Tumor-benign;Vascular etiology (e.g., ischemia, hemorrhagic, malformations);Other non-traumatic spinal cord dysfunction;Degenerative non-traumatic etiology;Tumor- malignant;Infection (e.g. bacterial, viral);Birth injury or other traumatic cause Alphanumeric

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.

DeVivo M, Biering-S&Oslash;rensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Adult;Pediatric Supplemental 3.10 2018-07-27 00:00:00.0 International SCI Core Data Set v2.0 The International SCI Data Sets The International SCI Data Sets

Single Pre-Defined Value Selected

CSV