Factors Associated With In-Hospital Outcomes of Traumatic Spinal Cord Injury

10-Year Analysis of the US National Inpatient Sample

Feng Gao, MD, PhD; Hongyu Chu, MM; Liang Chen, MD; Liangjie Du, MD; Mingliang Yang, MD; Jun Li, MD; Degang Yang, MD; Hong Zhang, MD; Jianjun Li, MD; Chetwyn Chan, BSc, MSc, PhD

Disclosures

J Am Acad Orthop Surg. 2020;28(17):707-716. 

In This Article

Abstract and Introduction

Abstract

Introduction: Traumatic spinal cord injury (SCI) is a life-altering event. Motor vehicle accidents and falls are common causes of traumatic SCI, and SCI outcomes may be affected by patients' ages and injury sites. This study aimed to investigate the factors associated with unfavorable in-hospital outcomes, focusing on the impact of patients' ages and SCI lesion sites.

Methods: Data of 25,988 patients hospitalized with traumatic SCI in the US National Inpatient Sample (NIS) database from 2005 to 2014 were extracted and analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with SCI outcomes, including in-hospital deaths, adverse discharge, and prolonged hospital stays.

Results: Multivariate analysis revealed that the oldest ages (>65 years) were significantly associated with increased in-hospital mortality compared with the youngest ages at all lesion sites (cervical, odds ratio [OR]: 5.474, 95% confidence interval [CI]: 4.465 to 6.709; thoracic, OR: 5.940, 95% CI: 3.881 to 9.091; and lumbosacral, OR: 6.254, 95% CI: 2.920 to 13.394). Older ages were also significantly associated with increased adverse outcomes at all sites (cervical, OR: 2.460, 95% CI: 2.180 to 2.777; thoracic, OR: 2.347, 95% CI: 1.900 to 2.900; and lumbosacral, OR: 2.743, 95% CI: 2.133 to 3.527). Intermediate ages (35 to 64) were also significantly associated with increased in-hospital death and adverse discharge at cervical and thoracic SCIs, but not at lumbosacral sites.

Discussion: For hospitalized patients with traumatic SCI, older age independently predicts worse in-hospital outcomes, with greatest effects seen in patients aged 65 years and older. Study findings suggest that extra vigilance and targeted management strategies are warranted in managing SCI patients aged 65 years and older during hospitalization.

Introduction

Traumatic spinal cord injury (SCI) is a life-altering event. The motor, sensory, and autonomic systems may be adversely affected, and deficits can be permanent. Besides creating a burden for the patient and family members, the societal financial ramifications of traumatic SCI can be substantial.[1,2] Studies of patients with traumatic SCI have often used instruments by which to assess patients' quality of life, finding that the transition from being able to walk to having to use a wheelchair for mobility has a particularly adverse effect on one's quality of life, including increased levels of depression.[3,4] In addition, SCI is associated with elevated mortality rates. A Bangladesh study that investigated the survival of patients with SCI found that the 2-year survival rate was 87% for all patients, but the rate for patients who had to use a wheelchair was significantly lower (81%).[5] A study carried out in the United States, in which the data were obtained from the National Inpatient Sample (NIS) database for the years 1993 to 2012, also found that about 20% of patients died during the past 2 years of the study, 2010 to 2012.[6]

The International Standards for Neurological and Functional Classification of SCI is used to describe the level and extent of injury based on systematic examinations of motor and sensory neurological functions.[7,8] SCIs can be traumatic or nontraumatic. Since 2005, the most common traumatic SCI causes have been motor vehicle accidents (39.2%); falls (28.3%); violence, primarily gunshot wounds (14.6%); and sports (8.0%).[9] Emerging evidence, however, from longitudinal studies in Scotland and China suggests that an important shift has occurred in the most common causes of SCI over time.[2,10] SCIs from a penetrating injury tend to be worse than those from blunt-force injuries.[11,12] Nontraumatic SCIs are also common. Ankylosing spondylitis and other inflammatory diseases can lead to spinal fractures.[13,14] Other nontraumatic causes include autoimmune, infectious, neoplastic, vascular, and hereditary degenerative diseases.[15,16] Postmenopausal women aged older than 45 years who are diagnosed with osteoporosis are also at risk of vertebral fractures.[17]

Age has been found to affect the characteristics and outcomes of traumatic SCI. Traumatic SCIs from motor vehicle accidents are more common in younger patients, whereas older patients are more likely to have traumatic SCIs after accidental falls.[18] In addition, older patients have an increased risk for complications associated with care and an increased risk of mortality during hospitalization.[1,19]

Following the context of previous studies, this study aimed to investigate the clinical characteristics of traumatic SCI among different ages, factors associated with unfavorable in-hospital outcomes after traumatic SCI, and the impact of patients' ages on outcomes among given SCI sites.

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