Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury.

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.

Valor pronóstico de la resonancia magnética precoz en la morbilidad y mortalidad de la lesión medular traumática / Prognostic value of early magnetic resonance imaging in the morbidity and mortality of traumatic spinal cord injury

Objetivo Valorar en individuos con lesión medular traumática (LMT) la relación en re la mortalidad y la necesidad de UCI y las alteraciones objetivadas mediante resonancia magnética (RM) precoz, analizando alteraciones parenquimatosas, disrupción de ligamentos vertebrales (DLV) y compresión del cordón medular (CCM). Diseño Estudio retrospectivo. Ámbito Hospital de tercer nivel, unidad de lesionados medulares y UCI. Pacientes Individuos con LMT aguda entre los años 2010 y 2019. Intervenciones Análisis de RM realizada en las primeras 72horas. Variables de interés Ingreso en UCI y mortalidad. Resultados Recogidos 269 casos. El patrón que se asoció a una mayor mortalidad fue la hemorragia (16,7%) por 12,5% de los edemas a un nivel y 6,5% de los edemas a múltiples niveles (p=0,125). Lo mismo aconteció con los ingresos en UCI: 69,0% en hemorragia por 60,2% en edema múltiple y 46,3% en edemas cortos (p=0,018). Con respecto a la CCM, la mortalidad fue del 13,4% con 59,2% de ingresos en UCI por 2,2% y 42,2% de quienes no presentaban compresión (p=0,020 y p=0,003). Las cifras de éxitus e ingreso en UCI en los individuos con DLV fueron del 15,0% y el 67,3%, respectivamente, por un 6,2% y 44,4% de los individuos sin DLV (p<0,001 y p=0,013). Conclusiones La presencia de hemorragia medular, CCM y DLV se asoció a una mayor necesidad de UCI. Existe un significativo aumento de la mortalidad en los casos con CCM y DLV (AU)

Objective To assess in individuals with traumatic spinal cord injury (TSCI) the relationship between mortality and need for ICU and early magnetic resonance imaging (MRI), analyzing spinal parenchymal alterations, disruption of vertebral ligaments (DVL) and spinal cord compression (SCC). Design Retrospective study. Setting Third-level hospital, Spinal Cord Injury Unit and ICU. Patients Individuals with acute TSCI between 2010 and 2019. Interventio Analysis of MRI performed in the first 72h. Variables of interest Admission to ICU and mortality. Results 269 cases collected. The pattern that demonstrated higher mortality was cord hemorrhage (16.7%) for 12.5% of single-level edema and 6.5% of multilevel edema (p=0.125). The same happened with ICU admissions: 69.0% in hemorrhage, 60.2% in multilevel edema and 46.3% in short edema (p=0.018). Analyzing CCM, mortality was 13.4% with 59.2% of ICU admissions, for 2.2% and 42.2% of individuals without cord compression (p=0.020 and p=0.003). The figures of death and ICU admission among cord injuries with DVL were 15.0% and 67.3%, for 6.2% and 44.4% of the individuals without DLV (p<0.001 and p=0.013). Conclusions The presence of spinal cord hemorrhage, SCC and DVL was associated with a higher admission in ICU. A significant increase in mortality was observed in cases with SCC and DVL (AU)

Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: A meta-analysis.

OBJECTIVE: An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed. METHODS: Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. RESULTS: One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups <.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively. CONCLUSIONS: Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

Características clínicas y pronóstico de la lesión medular traumática en pacientes mayores de 75 años / Clinical characteristics and prognosis of spinal cord injury in individuals over 75 years old

Objetivos Analizar la incidencia y las características de la lesión medular (LM) traumática en la población geriátrica de Galicia (España), el manejo hospitalario y el pronóstico vital y funcional. Material y métodos Estudio comparativo retrospectivo. Se incluyen los pacientes ingresados por LM traumática aguda entre enero de 2010 y diciembre de 2016. Se establecen 2 grupos: mayores y menores de 75 años, actuando los últimos como grupo control. Resultados Recogidos 379 pacientes (27,2% ≥75 años). La etiología más frecuente en el grupo ≥75 años fueron las caídas: 80,6%. El 65,7% presentaban lesiones medulares incompletas con un índice motor (IM) medio de 44,9/100. Al alta el 90,8% eran dependientes, precisando silla de ruedas el 53,8%. La mortalidad hospitalaria fue del 34,9%. En comparación con el grupo control, los pacientes mayores sufrieron más lesiones cervicales (74,8 vs. 51,2%; p<0,001), mayor retraso diagnóstico (31,1 vs. 9,2%; p<0,001) y mortalidad hospitalaria (34,9 vs. 3,2%; p<0,001). Se realizaron menos intervenciones quirúrgicas y con mayor demora. Los porcentajes de ingreso en la UCI, ventilación mecánica y realización de traqueostomía fueron similares. No se encontraron diferencias significativas en cuanto a evolución neurológica según la escala American Spinal Injury Association (ASIA) (p=0,46) o el IM (p=0,48). Conclusiones 1) La frecuencia de LM traumática en ancianos en Galicia es elevada; 2) La evolución neurológica medida por el ASIA es similar a pacientes más jóvenes, si bien el nivel de dependencia al alta es mayor; 3) El nivel de cuidados hospitalarios es similar en ambos grupos salvo por la indicación quirúrgica, y 4) La mortalidad hospitalaria es alta (AU)

Objective To analyze the incidence and characteristics of traumatic spinal cord injury (SCI) in geriatric population of Galicia (Spain), hospital management and functional prognosis. Methods Comparative retrospective study. Patients admitted with acute traumatic SCI during the time period between January 2010 and December 2016 were included. Two groups established: The elderly over and under 75 years of age, with the latter acting as a control group. Results Three hundred seventy-nine patients were studied (27.2% ≥75 years). The main etiology in the >75 years group were falls: 80.6%. There were 65.7% who presented incomplete spinal cord injuries with mean motor index (MI) of 44.9/100. Upon discharge, 90.8% were dependent. Hospital mortality was 34.9%. Those >75 years suffered from more cervical injuries (74.8 vs. 51.2%; p<0.001), longer delay in diagnosis (31.1 vs. 9.2%; p<0.001) and higher hospital mortality (34.9 vs. 3.2%; p<0.001). Fewer surgical interventions were performed, with a longer delay. Percentages for admission into ICU, mechanical ventilation and performing a tracheostomy proved to be similar. There were no significant differences found in the evolution according to the ASIA scale or the MI. Conclusions 1) The frequency of traumatic SCI in the elderly in Galicia is high; 2) Neurological evolution is similar to younger patients but the level of dependence is higher; 3) The level of care provided is similar in both groups, except for the surgical indication, and 4) Hospital mortality is high (AU)

Characteristics and Survival of Patients with Acute Traumatic Spinal Cord Injury Above T6 with Prolonged Intensive Care Unit Stays.

OBJECTIVE: To characterize patients with acute traumatic spinal cord injury (ATSCI) above T6 who were admitted to the intensive care unit (ICU) for ≥30 days and their 1-year mortality compared with patients admitted for <30 days. METHODS: A retrospective observational study was performed on 211 patients with an acute traumatic spinal cord injury above T6 who were admitted to an ICU between 1998 and 2017. Multivariate logistic regression analysis was performed to determine the relationship between an ICU stay ≥30 days and mortality after ICU discharge. RESULTS: Of patients, 29.4% were admitted to the ICU for ≥30 days, accounting for 53.4% of total days of ICU stays generated by all patients. An ICU stay ≥30 days was not identified as an independent risk factor for mortality (1-year survival: 88.5% vs. 88.1%; adjusted hazard ratio [HR] 0.80, P = 0.699). Variables identified as predictors of 1-year post-ICU discharge mortality were severity at admission according to the Acute Physiology and Chronic Health Evaluation II score (HR 1.18) and the American Spinal Injury Association Impairment Scale motor score (HR 0.97). Among patients who required invasive mechanical ventilation, a longer duration of the respiratory support was associated with increased mortality (HR 1.01). CONCLUSIONS: Three out of 10 patients with acute traumatic spinal cord injury above T6 require prolonged stays in the ICU. Variables found to be associated with 1-year post-ICU discharge mortality in these patients were American Spinal Injury Association Impairment Scale motor score, severity, and greater duration of invasive mechanical ventilation, but not an ICU stay ≥30 days.

Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the Vascular Quality Initiative database.

BACKGROUND: Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, owing to concerns regarding catheter-related complications. However, these risks are balanced by the widely accepted benefits of CSFDs during open repair to prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns, limiting the development of practice guidelines. Therefore, the purpose of the present analysis was to evaluate the differences between patients who developed SCI despite preoperative CSFD placement and those treated with therapeutic postoperative CSFD placement. METHODS: All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2019 were analyzed. CSFD use over time, the factors associated with preoperative prophylactic vs postoperative therapeutic CSFD placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using the Kaplan-Meier method. RESULTS: A total of 3406 TEVAR/cEVAR procedures met the inclusion criteria, with an overall SCI rate of 2.3% (n = 88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative CSFD use was similar over time (2014, 30%; vs 2018, 27%; P = .8). After further exclusions to evaluate CSFD use in those who had developed SCI, 72 patients were available for analysis, 48 with SCI and prophylactic CSFD placement and 24 with SCI and therapeutic CSFD placement. Specific to SCI, the patient demographics and comorbidities were not significantly different between the prophylactic and therapeutic groups, with the exception of previous aortic surgery, which was more common in the prophylactic CSFD cohort (46% vs 23%; P < .001). The SCI outcome was significantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P = .04). SCI patients receiving a postoperative therapeutic CSFD had had worse survival than those with a preoperative prophylactic CSFD (50% ± 10% vs 71% ± 9%; log-rank P = .1; Wilcoxon P = .05). CONCLUSIONS: Prophylactic CSFD use with TEVAR/cEVAR remained stable during the study period. Of the SCI patients, postoperative therapeutic CSFD placement was associated with worse sustained neurologic outcomes and overall survival compared with preoperative prophylactic CSFD placement. These findings highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSFD placement in association with TEVAR/cEVAR.

Survival among patients with severe high cervical spine injuries - a TraumaRegister DGU® database study.

BACKGROUND: Trauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group. METHODS: In a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group. RESULTS: Six hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%. CONCLUSIONS: An AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

COVID-19 and Spinal Cord Injury: Clinical Presentation, Clinical Course, and Clinical Outcomes: A Rapid Systematic Review.

Persons living with spinal cord injury (SCI) are potentially at risk for severe COVID-19 disease given that they often have decreased lung capacity and may lack the ability to effectively evacuate their lungs. Known risk factors for negative outcomes after COVID-19, such as obesity, diabetes, and cardiovascular disease, disproportionally affect people with SCI and raise concerns for the mortality risk among persons with SCI. A rapid systematic review of English, Spanish, Portuguese, and Chinese literature on COVID-19 and SCI was performed using the keywords "spinal cord injury" and "COVID-19." We included studies that provided information on clinical presentation, characteristics, course, and outcomes of COVID-19 disease in SCI. We excluded studies on patients who did not have an SCI before severe acute respiratory syndrome coronavirus-2 infection or did not report clinical information. We included 10 studies in total: nine studies with a total of 171 patients and a survey study of 783 healthcare professionals. Fever (74%), cough (52%), and dyspnea (33%) were the most frequently reported symptoms, and 63% showed abnormalities on X-ray imaging. In the included case series and reports (N = 31), only 1 patient required mechanical ventilation, but 3 patients died (10%). The mortality rate in a large registry study (N = 140) was 19%. Clinical presentation of COVID-19 in SCI patients was similar to the general population, and though adverse events and intensive care unit admission were low, the mortality rate was high (10-19%). No prognostic factors for severe disease or mortality could be identified. Registration (PROSPERO): CRD42020196565.

Risk factors for spinal cord injury and complications of cerebrospinal fluid drainage in patients undergoing fenestrated and branched endovascular aneurysm repair.

OBJECTIVE: Spinal cord injury (SCI) is one of the most devastating complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cerebrospinal fluid drainage (CSFD) is routinely used to prevent and to treat SCI during open TAAA repair. However, the risks and benefits of CSFD during fenestrated-branched endovascular aneurysm repair (F/B-EVAR) are unclear. This study aimed to determine the risk of SCI after F/B-EVAR and to assess the risks and benefits of CSFD. METHODS: We analyzed 106 consecutive patients with TAAAs treated with F/B-EVAR from 2014 to 2019 in a prospective physician-sponsored investigational device exemption study (G130193). Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F/B-EVAR devices or the Cook t-Branch devices (Cook Medical, Bloomington, Ind). CSFD was used at the discretion of the principal investigator. Risk factors for SCI were identified, and CSFD complications were assessed. RESULTS: Prophylactic CSFD was used in 78 patients (73.6%), and 28 patients (26.4%) underwent F/B-EVAR without CSFD. Four patients (3.8%) with prophylactic CSFD developed SCI, including two patients (1.9%) with permanent paraplegia (Tarlov grade 1-2) and two patients (1.9%) with paraparesis (Tarlov grade 3). Multivariate analysis revealed that greater extent of thoracic aortic coverage (odds ratio, 1.06; 95% confidence interval, 1.00-1.11; P = .02) and intraoperative blood loss (odds ratio, 1.00; 95% confidence interval, 1.00-1.002; P = .04) were the significant risk factors for SCI. Six patients (7.6% [6/78]) experienced major CSFD-related complications, including subarachnoid hemorrhage in 2.6% (2), spinal hematoma in 2.6% (2), cerebellar hemorrhage in 1.3% (1), and spinal drain fracture requiring surgical laminectomy in 1.3% (1). Minor CSFD-related complications occurred in 20 patients (25.6% [20/78]), including paresthesia during CSFD insertion (10), minimal bloody cerebrospinal fluid (7), drain malfunction (2), and reflex hypotension (1). Technical difficulties during CSFD catheter placement were noted in seven patients (9.0%). Excluding four patients with SCI, intensive care unit stay was 3.3 ± 4.0 days in the CSFD group vs 1.2 ± 0.9 days in the no-CSFD group (P = .007). Total hospital length of stay was 6.0 ± 4.9 days in the CSFD group vs 3.5 ± 1.9 days in the no-CSFD group (P = .01). CONCLUSIONS: The incidence of SCI after F/B-EVAR with selective CSFD was low, and risk factors for SCI were greater with extent of thoracic aortic coverage and intraoperative blood loss. However, the incidence of major CSFD-related complications exceeded the incidence of SCI, and CSFD significantly increased both intensive care unit and total hospital length of stay. Therefore, routine prophylactic CSFD may not be justified, and a prospective randomized trial of CSFD in patients undergoing F/B-EVAR seems appropriate.

Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis.

BACKGROUND: Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. METHODS: We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). RESULTS: Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. CONCLUSIONS: Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.

Mortality and secondary complications four years after traumatic spinal cord injury in Cape Town, South Africa.

STUDY DESIGN: A prospective, regional, population-based study. OBJECTIVES: (1) Determine the mortality rate and factors associated with it 4 years after a TSCI and (2) The point prevalence of secondary medical complications of survivors at 4 years. SETTING: Communities of the Cape metropolitan area, South Africa. METHODS: All persons (n = 145) sustaining a TSCI from 15 September 2013 to 14 September 2014 were eligible for follow-up at 4 years. Participants were contacted after 4 years. The next of kin, via verbal autopsy, was used to establish cause of death. Those who were alive at 4 years were asked to indicate any secondary medical complications. Logistic regression techniques were used to identify independently associated risk indicators for death and development of secondary complications, respectively. RESULTS: Of the initial 145 persons, 87 were included and accounted for. Of these, 21 (24%) had died, 55 (63%) were alive and completed the survey, and 11 (13%) were classified as alive but did not submit the survey. The main cause of death reported was septicaemia (n = 7; 33%), followed by unknown natural causes (n = 7; 33%), then pressure injuries (n = 5; 24%). Out of the 55 persons alive, 89% had at least one medical complication at the time of enquiry, while more than 50% experienced 6 or more complications. The most common complications were pain (80%), muscle spasms (76%), sleeping problems (56%), and bladder dysfunction (44%). CONCLUSIONS: Almost one-quarter of persons with TSCI have died 4 years after injury. Also, secondary complications were found to be highly prevalent at 4 years. This information could be used to develop secondary complications prevention programmes to reduce premature deaths. SPONSORSHIP: This study was funded by the Medical Research Council of South Africa within the Research Capacity Development Initiative.

Factors Associated With In-Hospital Outcomes of Traumatic Spinal Cord Injury: 10-year Analysis of the US National Inpatient Sample.

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.

Attrition from specialised rehabilitation associated with an elevated mortality risk: results from a vital status tracing study in Swiss spinal cord injured patients.

INTRODUCTION: Study drop-out and attrition from treating clinics is common among persons with chronic health conditions. However, if attrition is associated with adverse health outcomes, it may bias or mislead inferences for health policy and resource allocation. METHODS: This retrospective cohort study uses data attained through the Swiss Spinal Cord Injury (SwiSCI) cohort study on persons with spinal cord injury (SCI). Vital status (VS) was ascertained either through clinic medical records (MRs) or through municipalities in a secondary tracing effort. Flexible parametric survival models were used to investigate risk factors for going lost to clinic (LTC) and the association of LTC with subsequent risk of mortality. RESULTS: 1924 individuals were included in the tracing study; for 1608 of these cases, contemporary VS was initially checked in the MRs. VS was ascertained for 704 cases of the 1608 cases initially checked in MRs; of the remaining cases (n=904), nearly 90% were identified in municipalities (n=804). LTC was associated with a nearly fourfold higher risk of mortality (HR=3.62; 95% CI 2.18 to 6.02) among persons with traumatic SCI. Extended driving time (ie, less than 30 min compared with 30 min and longer to reach the nearest specialised rehabilitation facility) was associated with an increased risk of mortality (HR=1.51, 95% CI 1.02 to 2.22) for individuals with non-traumatic SCI. CONCLUSION: The differential risk of LTC according to sociodemographic and SCI lesion characteristics underscores the importance of accounting for attrition in cohort studies on chronic disease populations requiring long-term care. In addition, given the associated risk of mortality, LTC is an issue of concern to clinicians and policy makers aiming to optimise the long-term survival of community-dwelling individuals with traumatic SCI. Future studies are necessary to verify whether it is possible to improve survival prospects of individuals LTC through more persistent outreach and targeted care.

In-Hospital Mortality for the Elderly with Acute Traumatic Spinal Cord Injury.

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65-76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.

1-Year Mortality and Surgery Incidence in Older US Adults with Cervical Spine Fracture.

BACKGROUND: Traumatic cervical spinal cord injuries (SCIs) can be lethal and are especially dangerous for older adults. Falls from standing and risk factors for a cervical fracture and spinal cord injury increase with age. This study estimates the 1-year mortality for patients with a cervical fracture and resultant SCI and compares the mortality rate with that from an isolated cervical fracture. METHODS: We performed a retrospective cohort study of U.S. Medicare patients older than 65 years of age. International Classification of Diseases (ICD)-9 codes were used to identify patients with a cervical fracture without SCI and patients with a cervical fracture with SCI between 2007 and 2014. Our primary outcome was 1-year mortality cumulative incidence rate; our secondary outcome was the cumulative incidence rate of surgical intervention. Propensity weighted analysis was performed to balance covariates between the groups. RESULTS: The SCI cohort had a 1-year mortality of 36.5%, compared with 31.1% in patients with an isolated cervical fracture (risk difference 5.4% (2.9%-7.9%)). Patients with an SCI were also more likely to undergo surgical intervention compared with those without a SCI (23.1% and 10.3%, respectively; risk difference 12.8% (10.8%-14.9%)). CONCLUSIONS: Using well-adjusted population-level data in older adults, this study estimates the 1-year mortality after SCI in older adults to be 36.5%. The mortality after a cervical fracture with SCI was 5 percentage points higher than in patients without SCI, and this difference is smaller than one might expect, likely representing the frailty of this population and unmeasured covariates.

Complications and mortality after acute traumatic spinal cord injury in Saint Petersburg, Russia.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: We studied complications during early rehabilitation and their relation to length of stay (LOS) in the hospital as well as to survival in people with traumatic spinal cord injury (TSCI). SETTING: All specialized hospitals of Saint Petersburg. METHODS: We analysed all charts of patients admitted with acute TSCI to the city hospitals, 2012-2016. Patient characteristics, complications, time and cause of death, and LOS were recorded. Mean values with standard deviations and t-tests were used. We analysed mortality rate using the Kaplan-Meier method and calculated relative risks (RRs). RESULTS: A total of 311 patients with TSCI were included. Complications occurred in 34% of patients; most were respiratory complications and pressure ulcers. Complications occurred more often in those with concomitant traumatic brain injury (TBI) (RR = 1.4, 95% CI: 1.2-1.8). All complications prolonged LOS (median, 11 days) and increased mortality in the acute phase (p < 0.001). In the early phase, 15% died, with a median time to death of 13 days. Respiratory complications markedly increased the death rate (RR = 18, 95% CI: 15-22). Mortality rate correlated also with age, TSCI severity and level, and concomitant TBI. Alcohol/drug consumption before TSCI increased the likelihood for complications (RR = 1.7, 95% CI: 1.3-2.1) and mortality (RR = 2.2, 95% CI: 1.6-3.1). CONCLUSION: Focus on prevention as well as early and optimal treatment of complications, together with no or low alcohol/drug consumption may reduce mortality in the early phase after TSCI and at the same time shorten LOS.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Effect of Frailty on Outcome after Traumatic Spinal Cord Injury.

Frailty negatively affects outcome in elective spine surgery populations. This study sought to determine the effect of frailty on patient outcome after traumatic spinal cord injury (tSCI). Patients with tSCI were identified from our prospectively collected database from 2004 to 2016. We examined effect of patient age, admission Total Motor Score (TMS), and Modified Frailty Index (mFI) on adverse events (AEs), acute length of stay (LOS), in-hospital mortality, and discharge destination (home vs. other). Subgroup analysis (for three age groups: <60, 61-75, and 76+ years), and multi-variable analysis was performed to investigate the impact of age, TMS, and mFI on outcome. For the 634 patients, the mean age was 50.3 years, 77% were male, and falls were the main cause of injury (46.5%). On bivariate analysis, mFI, age at injury, and TMS were predictors of AEs, acute LOS, and in-hospital mortality. After statistical adjustment, mFI was a predictor of LOS (p = 0.0375), but not of AEs (p = 0.1428) or in-hospital mortality (p = 0.1245). In patients <60 years of age, mFI predicted number of AEs, acute LOS, and in-hospital mortality. In those aged 61-75, TMS predicted AEs, LOS, and mortality. In those 76+ years of age, mFI no longer predicted outcome. Age, mFI, and TMS on admission are important determinants of outcome in patients with tSCI. mFI predicts outcomes in those <75 years of age only. The inter-relationship of advanced age and decreased physiological reserve is complex in acute tSCI, warranting further study. Identifying frailty in younger patients with tSCI may be useful for peri-operative optimization, risk stratification, and patient counseling.

Cervical Spinal Cord Injury Shows Markedly Lower than Predicted Mortality (>72 Hours After Multiple Trauma) From Sepsis and Multiple Organ Failure.

BACKGROUND: Sepsis and multiple organ failure (MOF) remain one of the main causes of death after multiple trauma. Trauma- and infection-associated immune reactions play an important role in the pathomechanism of MOF, but the exact pathways remain unknown. Spinal cord injury (SCI) may lead to an altered immune response, and some studies suggest a prognostic advantage for such patients having sepsis or multiple trauma. Yet these findings need to be evaluated in larger cohorts of trauma patients. METHODS: Retrospective, multicenter study, using the data of the TraumaRegister DGU. Patients with and without SCI surviving the initial first 72 hours after trauma were matched according to injury pattern and age. Comparative analysis considered morbidity (sepsis, MOF) and hospital mortality. RESULTS: The study population included 800 matched pairs. As intended by the matching process, patients with cervical SCI had an otherwise comparable injury pattern but a higher severity of trauma (mean Injury Severity Score: 36 vs 29, mean number of diagnosis: 5.6 vs 4.4). They had a higher rate of sepsis (15.9% vs 10.9%, P = .005) and MOF (35.9% vs 24.1%, P < .001) while mortality revealed no significant difference (9.5% vs 9.9%, P = .866). CONCLUSIONS: Cervical SCI leads to an increased rate of sepsis and MOF but appears to be favorable with respect to outcome of sepsis and MOF following multiple trauma. Further research should focus on the pathomechanisms and the possible arising therapeutic options.

Multidrug-resistant gram-negative organisms and association with 1-year mortality, readmission, and length of stay in Veterans with spinal cord injuries and disorders.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The goal of this study was to assess the impact of multidrug resistant gram-negative organisms (MDRGNOs) on outcomes in those with SCI/D. SETTING: VA SCI System of Care, Department of Veterans Affairs, United States. METHODS: Multidrug resistance (MDR) was defined as being non-susceptible to ≥1 antibiotic in ≥3 antibiotic classes. Multivariable cluster-adjusted regression models were fit to assess the association of MDRGNOs with 1-year mortality, 30-day readmission, and postculture length of stay (LOS) stratified by case setting patients. Only the first culture per patient during the study period was included. RESULTS: A total of 8,681 individuals with SCI/D had a culture with gram-negative bacteria during the study period, of which 33.0% had a MDRGNO. Overall, 954 (10.9%) died within 1 year of culture date. Poisson regression showed that MDR was associated with 1-year mortality among outpatients (IRR: 1.28, 95% CI, 1.06-1.54) and long-term care patients (OR: 2.06, 95% CI, 1.28-3.31). MDR significantly impacted postculture LOS in inpatients, as evidenced by a 10% longer LOS in MDR vs. non-MDR (IRR: 1.10, 95% CI, 1.02-1.19). MDR was not associated with increased 30-day readmission. CONCLUSIONS: MDRGNOs are prevalent in SCI/D and MDR may result in poor outcomes. Further attention to prevention of infections, antibiotic stewardship, and management are warranted in this population.