Epidemiological data indicate that falls from height represent one of the leading causes of traumatic injury in cats, ranking second only to traffic-related accidents in some regions⁵. Multiple studies have reported that younger cats are disproportionately affected, particularly those under two years of age which has been attributed to increased activity levels, play behavior, and limited experience with environmental hazards^6,7. A pronounced seasonal distribution has also been consistently observed, with a higher incidence of HRS during warmer months when windows and balconies are more frequently left open, thereby increasing exposure to fall-related risks^8,9.

Clinically, HRS is associated with a broad spectrum of injuries involving multiple anatomical systems. Extremity fractures are among the most commonly reported findings, with hind limb and femoral fractures occurring more frequently than forelimb injuries¹⁰. Thoracic trauma, including pulmonary contusions and pneumothorax, as well as head injuries, abdominal lesions, and spinal trauma, have also been widely documented^1,11. Importantly, life-threatening conditions such as hemorrhagic shock and traumatic brain injury may be present even in cats that appear clinically stable at initial presentation¹².

The relationship between fall height and injury severity remains controversial. Some authors have proposed a linear increase in trauma severity with increasing fall height^13-15, whereas others have reported a curvilinear association^2,12, suggesting that falls from lower heights may result in more severe head and spinal injuries due to insufficient time for postural adjustment during descent¹⁶. Conversely, higher falls have been more frequently associated with limb fractures, potentially reflecting the effects of terminal velocity and landing biomechanics⁸. These conflicting findings underscore the complex interaction between biomechanical, environmental, and behavioral factors involved in feline falls and highlight the importance of analytical approaches capable of evaluating multiple variables simultaneously.

Head trauma and altered levels of consciousness have been identified as important determinants of outcome in feline trauma patients, with several studies reporting an association between neurological impairment and increased mortality^17,18. The Modified Glasgow Coma Scale (MGCS), adapted for use in veterinary medicine, provides a structured and reproducible method for assessing neurological function through the evaluation of motor activity, brainstem reflexes, and level of consciousness¹⁹. Although MGCS has been widely applied in small animal trauma, its use in cats with HRS has more often been incorporated as part of general trauma assessment rather than examined as a primary outcome measure, and data regarding factors independently associated with MGCS scores in this specific population remain limited.

Therefore, this study aimed to retrospectively evaluate the cats presented after high rise falls in order to identify trauma severity indicators and initial clinical variables associated with neurological status as assessed by the MGCS and with the development of complications during hospitalization. We hypothesized that indicators reflecting trauma severity and early clinical condition at presentation would be independently associated with neurological impairment and the occurrence of complications, whereas demographic characteristics including age, sex, neuter status, and breed category would not demonstrate significant associations when analysed concurrently.

Medical records were retrieved from the hospital?s electronic and paper-based archive system and included emergency admission forms, clinical examination records, diagnostic imaging reports, laboratory data, and discharge or outcome notes. Only cases in which the traumatic event was explicitly recorded as a fall from an elevated structure, including windows, balconies, or similar heights, were considered for evaluation. Each case was reviewed individually, and the data extraction was performed using a standardized data collection form to ensure consistency across the records.

The Case Selection: Inclusion and Exclusion Criteria: An initial screening identified 420 feline trauma presentations associated with suspected or documented falls from height. The cases were included if they met all of the following criteria: (i) documentation of high-rise fall as the primary trauma mechanism; (ii) recorded fall height expressed as number of floors or sufficient descriptive information allowing conversion to floor number; (iii) a complete neurological assessment at admission with all components of the MGCS, including motor activity, brainstem reflexes, and level of consciousness; (iv) documented clinical, radiographic, or ultrasonographic findings enabling identification of traumatic injuries or complications; and (v) availability of essential demographic and physical data, including age, sex, and body weight.

Cases were excluded if one or more of the following conditions were present: incomplete MGCS component data or recording of only a total MGCS score without individual sub scores; absence of documented traumatic findings or complication records; duplicate entries related to the same fall event; trauma etiologies other than falling, including traffic accidents, blunt force trauma, crush injuries, penetrating injuries, or unknown causes; or substantial missing clinical data precluding reliable analysis. Duplicate records were identified by cross-referencing patient identification, admission date and time, trauma history, and clinical findings, and only the initial presentation for each fall event was retained.

Demographic and Clinical Variables: For each included case, the demographic variables extracted from the records included age (months), sex (male or female), neuter status (neutered or intact), breed classification, and body weight (kg) measured at admission. Breeds were grouped into four categories: Tabby, British, Scottish, and Other breeds. Environmental variables included fall height expressed as the number of floors and the ground type at the impact site, categorized as concrete, soil, asphalt, or other surfaces based on owner-reported history or emergency intake documentation.

Neurological Assessment: Neurological status at presentation was assessed using the MGCS adapted for veterinary patients. Three components of neurological function are assessed and rated on a scale from 1 to 6: brainstem reflexes, motor activity, and consciousness level. A cumulative score is computed on a scale from 3 to 18, with a diminished score signifying increased trauma severity. The Animal Trauma Triage Score (ATT) is a veterinary metric employed to assess the severity of trauma. The grading system has six categories: perfusion, cardiac, respiratory, eye/muscle/integument, skeletal, and neurological. Each category receives a score between 0 and 3, resulting in a total score that ranges from 0 to 18. Based on total scores, neurological impairment was categorized as good^15-18, guarded (9-14), or grave (3-8). A higher score signifies more severity of injury²⁰.

Definition and Classification of Complications: Complications were defined as the presence of one or more clinically relevant traumatic abnormalities identified during the initial diagnostic evaluation. Documented complications included forelimb fractures, hind limb fractures, spinal injuries, head trauma, abdominal findings, respiratory system abnormalities, and clinical signs consistent with shock. For regression analyses, complication status was recorded as a binary variable indicating the presence or absence of at least one complication. Additionally, the anatomical distribution of complications was recorded for descriptive analysis.

Statistical Analyses: All statistical analyses were performed with SPSS, version 27.0 (SPSS Inc; IBM Corp). The distribution of continuous variables was evaluated with the Shapiro?Wilk test. Normally distributed variables were summarized as mean ± standard deviation, whereas non-normally distributed variables were reported as median (minimum?maximum). Categorical variables were expressed as frequencies and percentages. Prior to regression analyses, model assumptions were evaluated. For the multivariable linear regression model assessing factors associated with MGCS score, normality of residuals was examined using visual inspection of residual plots and normal probability plots, and homoscedasticity was assessed using residuals versus fitted value plots. Linearity between continuous predictors and the dependent variable was evaluated graphically. A multivariable linear regression model was constructed to identify independent factors associated with the MGCS score. Age (months), body weight, sex, neuter status, breed category (Tabby, British Shorthair, Scottish Fold, Other), ground type at the impact site (Concrete, Soil, Asphalt, Other), and fall height (number of floors) were included as predictor variables. Model coefficients, standard errors, and corresponding p-values were reported.

Independent risk factors for the development of complications were evaluated using multivariable logistic regression. The binary complication variable was defined as the presence of at least one clinically relevant abnormality, including forelimb or hind limb fractures, spinal injury, head trauma, abdominal findings, respiratory abnormalities, or clinical signs of shock. The same predictor variables used in the MGCS model were included. Linearity of continuous predictors with the logit was assessed graphically, and overall model fit was evaluated using goodness-of-fit statistics. Odds ratios (ORs) with 95% confidence intervals (CIs) were presented. Multicollinearity among predictors was assessed using variance inflation factors (VIF), and no significant collinearity was detected. Categories with low cell counts were regrouped to improve model stability. A two-tailed p-value <0.05 was considered statistically significant.

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Table 1: Baseline demographic and clinical characteristics of cats presenting with high-rise syndrome (n=174)

The median MGCS score on presentation was 18 (range 3?18), with 85.1% of cats classified as having good impairment, 6.9% as guarded, and 8.0% as grave impairment (Table 2). Trauma-related injuries were documented in 87.4% of all cats, demonstrating a high overall injury burden. Anatomical distribution of complications revealed that hindlimb fractures were the most frequent finding (37.9%), followed by respiratory system abnormalities (29.3%) and head trauma (27.6%). Forelimb fractures occurred in 24.7% of cats, abdominal injuries in 10.9%, shock in 9.2%, and spinal injuries in 6.3%.

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Table 2: Distribution of MGCS impairment categories in cats on presentation (n=174)

In the multivariable linear regression analysis, none of the evaluated demographic or physical variables showed a statistically significant independent association with MGCS score. Specifically, age (p=0.34), body weight (p=0.81), sex (p=0.51), neuter status (p=0.63), breed category (all p>0.25), and landing surface (all p>0.30) were not significantly associated with MGCS after adjustment for all other variables included in the model. Fall height demonstrated a negative regression coefficient (?=?0.29), indicating a trend toward lower MGCS scores with increasing fall height, although this association did not reach statistical significance (p=0.10) (Table 3). Fall height emerged as the sole independent predictor of complication development (OR=1.62; 95% CI:1.14?2.31; p=0.008), indicating that each additional floor of fall height increased the likelihood of sustaining at least one complication by approximately 62%. Other variables, including age, body weight, sex, neuter status, breed group, and ground type, were not significantly associated with complication risk (all p>0.20) (Table 4).

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Table 3: Multivariable linear regression analysis of factors associated with Modified Glasgow Coma Scale (MGCS) score at admission in cats with high-rise syndrome (n=174)

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Table 4: Multivariable logistic regression analysis of factors associated with the presence of ?1 complication in cats with high-rise syndrome (n=174)

The high prevalence of complications in this cohort underscores that HRS is typically characterised by polytrauma with clinically relevant lesions affecting multiple organ systems. In keeping with established descriptions of feline HRS, the most frequent complication category comprised extremity injuries, with hindlimb fractures predominating, followed by respiratory system abnormalities and head trauma. This distribution is consistent with the prevailing pattern reported in retrospective series, in which orthopaedic trauma represents the dominant lesion category and femoral or pelvic fractures occur with high frequency^10,12. Thoracic trauma has similarly been emphasized as a major contributor to morbidity in HRS, and the comparatively high proportion of respiratory abnormalities in the present study aligns with repeated observations that pulmonary contusions and pneumothorax remain central components of the syndrome^1,21. Conversely, the relatively low frequency of spinal injuries parallels earlier reports indicating that, although spinal trauma can be severe when present, it is documented less commonly than appendicular or thoracic injuries in cats sustaining high-rise falls^2,10. Taken together, these findings indicate that an apparently stable neurological presentation does not exclude the presence of clinically relevant thoracic or orthopedic injuries, which may be identified through clinical, neurological, and radiographic examination in cats presenting after high-rise falls.

Fall height emerged as the sole independent predictor of complication development, with the odds of sustaining at least one clinically relevant lesion increasing with each additional floor. This pattern supports the biomechanical rationale that greater vertical distance increases impact energy transfer and, in turn, the likelihood of clinically apparent traumatic lesions, even if the precise relationship between height and severity is not necessarily linear across all injury types^1,22. Prior retrospective studies have similarly linked increasing fall height to higher frequencies of severe orthopedic and thoracic injuries, although reported associations have varied across cohorts and analytic approaches^2,10,14. The present findings extend this literature by demonstrating that the effect of fall height persists after adjustment for demographic variables and environmental factors, suggesting that height operates as a robust determinant of overall injury burden within the constraints of retrospective clinical data. The absence of independent effects for age, sex, neuter status, breed grouping, body weight, or landing surface in the multivariable model further suggests that these factors, at least as recorded in routine clinical documentation, are less influential than fall height in predicting whether a cat will sustain a clinically relevant complication once a fall has occurred.

2^,16. Several methodological and biological factors may further explain the absence of a statistically significant association. First, MGCS scores in the present cohort demonstrated a marked ceiling effect, with the majority of cats presenting with good neurological impairment or near-normal scores, thereby limiting score variability and reducing the ability to detect height-related differences. Second, the relatively low dispersion of MGCS values may have constrained statistical power, particularly in a retrospective clinical population enriched for survivors reaching hospital admission. Third, as neurological status was assessed retrospectively from medical records, subtle or transient neurological deficits may have been under-recognised or inconsistently documented, introducing additional measurement variability. Beyond these methodological considerations, a plausible biological interpretation is that neurological impairment in high-rise syndrome is shaped by a complex interplay of impact biomechanics and situational dynamics not captured by floor number alone, including body orientation during descent, the capacity for postural adjustment before landing, and the localisation of impact forces to the head and cervical region versus the thorax and appendicular skeleton^1,23. Under this framework, greater heights may increase the probability of musculoskeletal and thoracic injury through increased impact energy, whereas neurological injury may depend more strongly on impact configuration and site-specific energy transmission, producing variability that weakens a simple height?MGCS relationship within clinical samples. Clinically, these results reinforce that preserved mentation and near-normal MGCS at admission should not be interpreted as reassurance against clinically important trauma elsewhere, particularly given the high overall complication prevalence and the prominent contribution of thoracic and orthopaedic injuries to morbidity in feline HRS^1,21.

Several limitations of this study should be acknowledged. The retrospective design limited control over data completeness and standardization of clinical assessments, and variability in record quality may have influenced injury classification. Fall height was recorded as the number of floors rather than as an exact vertical distance, which may have introduced variability related to differences in building structure. Additionally, expressing the fall height as a multiple of the coefficient may not fully reflect the variation in the actual fall distance. Complication status was defined broadly to capture overall injury burden, increasing sensitivity for detecting clinically relevant trauma but potentially reducing specificity with respect to injury severity. Neurological status was assessed only at admission using MGCS, and longitudinal neurological outcomes could not be evaluated due to the absence of standardized follow-up data. As a single-center study conducted at a tertiary veterinary hospital, the findings may not be fully generalizable to other clinical settings. The retrospective design and fixed sample size limited statistical power, and non-significant associations should therefore be interpreted with caution. Finally, mortality and survival analyses were not included in the present study. The primary aim was to identify predictors of neurological status at admission and the development of complications rather than outcome-based endpoints. In addition, the retrospective design resulted in incomplete and non-standardized outcome data, as a proportion of cats were discharged early, referred to other clinics, or lost to follow-up, precluding reliable survival analysis. Furthermore, the study population was inherently enriched for cats that survived long enough to reach hospital admission, introducing potential survivorship bias.

In conclusion, fall height is an independent predictor of complication development in cats with HRS, whereas neurological status at admission, as assessed by MGCS, is not significantly influenced by fall height or by demographic and environmental factors. These findings indicate that vertical distance primarily affects overall injury burden rather than the degree of neurological impairment. Clinically, cats presenting with preserved MGCS scores may still harbor substantial traumatic injuries, emphasizing the need for comprehensive diagnostic evaluation regardless of apparent neurological stability. The results refine current understanding of prognostic factors in HRS and support a system-based approach to the assessment and management of feline trauma patients.

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