Introduction
Traumatic injuries are an important cause of death among young people, and although
spinal cord traumas (SCTs) represent only a minority of injuries suffered by all trauma
patients, their social, financial, and familial influences are extremely relevant
and often more significant than those of other injuries.[1]
[2]
[3]
The SCT is injury that results in the sequel sensory, motor, and autonomic functions.[4] The diagnostic precision is very important to the success of the treatment.[5] Additionally, the presence of associated lesion,[6]
[7]
[8] neurologic severity of the injury, and spinal segment may contribute negatively
to prognosis. Therefore, it becomes relevant to carry out a more thorough and comprehensive
study in order to determine the factors that can really influence the prognosis of
patients with SCT.
This study aims to analyze the prognostic factors in patients with SCT on a tertiary
hospital.
Methods
A total of 321 patients with SCT were studied during the period from January 2008
to June 2012. All patients were admitted in the emergency department of the Hospital
de Base, in São Jose do Rio Preto/Brazil. The data extracted from the original database
for this study included general patients characteristics, mechanisms of trauma, level
and regions of SCT, and final disposition/outcome, especially regarding death. The
analysis focused on patient-related data (age at trauma incident, sex), cause of accident
(fall, traffic accident involving car, motorcycle, bicycle, or pedestrian; sports;
miscellaneous), anatomical distribution (C0–C2; C3–C7; T1–T10; T11–L2; L3–S1), neurologic
status (American Spine Injury Association scale [ASIA]),[9] associated injuries, length of hospital stay, and in-hospital complications/mortality.
The tests used for statistical analysis were Dunn's test for length of stay and chi-square
test for assessing the association between variables and relative risk, being considered
p <0.05, as statistically significant.
The research was approved by the research ethics committee of the Faculty of Medicine
from São José do Rio Preto (FAMERP), protocol 4823/2009. Subjects signed the informed consent form. When patient
had the worst diagnosis or changes in level of consciousness, the written informed
consent was given by a close relative. The study was conducted in compliance with
the Declaration of Helsinki.
Results
Patient-Related Data
The study group (total of 321 patients) consisted of 231 males (72%) and 90 females
(28%) patients. The overall male-to-female ratio was 2.6:1. The mean age of patients
with spinal fractures was 42.7 years, ranging from 5 to 93 years. The highest rate
of SCT was observed in the patients aged 21 to 30 years; however, women older than
50 years had a risk of 1.43 (p = 0.04, chi-square test) more often than men in the same age group. The distribution
of SCT according to patient age and sex is shown in [Fig. 1].
Fig. 1 Age and sex distribution.
Etiology of Injury
The etiology of SCT and their frequencies along with the neurologic status, clinical
complications, associated lesions, and anatomical distribution are summarized in [Table 1]. Automobile accidents were the most common etiology of trauma with 133 patients
(41%), followed by accidental falls with 89 (28%) patients. Automobile accidents were
also involved most frequently with neurologic deficits revealing 23 patients (7%)
ASIA-A on admission and 25 (8%) patients ASIA-B/C/D; accidental falls were second
most frequent with 14 (4%) patients ASIA-A on admission and 21 (7%) patients ASIA-B/C/D;
and motorcyclists were the third with 13 (4%) patients ASIA-A and 13 (4%) patients
ASIA-B/C/D.
Table 1
Etiology of trauma and neurologic status/anatomical distribution
Etiology
|
Total
|
A
|
ASIA
|
Complic. (n = 117)
|
Injury associate (n = 187)
|
B, C, D
|
E
|
01
|
02
|
03
|
01
|
02
|
03
|
Cars
|
133
|
23
|
25
|
85
|
12
|
09
|
01
|
31
|
19
|
11
|
Motorcycle
|
49
|
13
|
13
|
23
|
9
|
03
|
01
|
10
|
07
|
06
|
Fall
|
89
|
14
|
21
|
54
|
11
|
09
|
03
|
12
|
03
|
01
|
Sports
|
21
|
04
|
07
|
10
|
03
|
01
|
01
|
04
|
01
|
0
|
Diving
|
13
|
06
|
05
|
02
|
0
|
03
|
02
|
05
|
0
|
0
|
Gunshot
|
08
|
06
|
01
|
01
|
01
|
0
|
01
|
05
|
02
|
0
|
Miscellaneous
|
08
|
02
|
03
|
03
|
01
|
0
|
01
|
02
|
0
|
0
|
Total of patients
|
321
|
68
|
75
|
178
|
37
|
25
|
10
|
69
|
32
|
18
|
Total
|
321
|
68
|
75
|
178
|
37
|
50
|
30
|
69
|
64
|
54
|
Cervical high
|
Cervical lower
|
Segments
|
Thoracic
|
Thoracolumbar
|
Lumbosacral
|
Two segments
|
MORT
|
TI (days)
|
20
|
58
|
15
|
28
|
03
|
09
|
13
|
9.8 ( ± 12.5)
|
01
|
16
|
12
|
12
|
03
|
05
|
0
|
11.8 ( ± 13,9)
|
03
|
22
|
07
|
36
|
08
|
13
|
10
|
9.3 ( ± 10,2)
|
03
|
13
|
0
|
03
|
01
|
01
|
02
|
17.3 ( ± 31.6)
|
0
|
10
|
0
|
0
|
0
|
03
|
0
|
15.5 ( ± 22.6)
|
01
|
01
|
04
|
0
|
0
|
02
|
0
|
31.5 ( ± 39,8)
|
0
|
01
|
03
|
01
|
01
|
02
|
0
|
7.7 ( ± 5.2)
|
28
|
121
|
41
|
80
|
16
|
35
|
25
|
11.2 ( ± 15.91)
|
28
|
121
|
41
|
80
|
16
|
35
|
25
|
11.2 ( ± 15.91)
|
Abbreviations: Complic., complications; HT, hospital time; MORT, mortality.
Only the etiologies, automobile accidents, motorcycle accidents, and gunshots were
significantly associated with a greater number of associated lesions (chi-square test,
p <0.001, with 95% of total dependence). No other significant association was found.
Anatomical Distribution
The 321 patients in our study population sustained 559 injuries. These injuries were
categorized into five anatomical regions: high cervical (C0–C2), low cervical (C3–C7),
thoracic (T1–T10), thoracolumbar transition (T11–L2), and lumbar-sacral (L3–S1). The
low cervical region was the most common segment of spinal fracture with 121 patients
(38%), followed by thoracolumbar transition with 80 patients (25%), thoracic with
41 patients (13%), high cervical with 28 patients (7.2%), and lumbar-sacral with 16
patients (5%). Of the 321 patients with SCT, 35 (11%) had multiple injuries involving
different areas of the spine ([Table 2]).
Table 2
Anatomical distribution and neurologic status
Segments
|
Total
|
HT (days)
|
ASIA
|
Complications
|
Injury associated
|
Mortality
|
A
|
B, C, D
|
E
|
01
|
02
|
03
|
01
|
02
|
03
|
Cervical high (C0–C2)
|
28
|
14.3 (±22.7)
|
01
|
02
|
25
|
03
|
03
|
01
|
11
|
02
|
04
|
05
|
Cervical lower (C3–C7)
|
121
|
14.3 (±20.1)
|
36
|
38
|
47
|
14
|
13
|
06
|
24
|
17
|
06
|
13
|
Thoracic (T1–T10)
|
41
|
11.5 (±11.5)
|
17
|
10
|
14
|
07
|
06
|
0
|
08
|
06
|
04
|
03
|
Thoracolumbar (T11–L2)
|
80
|
6.7 (±7.3)
|
05
|
14
|
61
|
11
|
02
|
01
|
14
|
03
|
04
|
02
|
Lumbosacral (L3–S1)
|
16
|
3.8 (±3.2)
|
0
|
03
|
13
|
01
|
0
|
0
|
01
|
02
|
0
|
0
|
Two segments injury
|
35
|
10.9 (±12.3)
|
09
|
08
|
18
|
01
|
01
|
02
|
11
|
02
|
0
|
02
|
Total DE patients
|
321
|
11.2 (±15.9)
|
68
|
75
|
178
|
37
|
25
|
10
|
69
|
32
|
18
|
25
|
Accurate Total
|
356
|
11.2 (±15.9)
|
68
|
75
|
178
|
37
|
50
|
30
|
69
|
64
|
54
|
25
|
Abbreviations: HT, hospital time.
An interesting relation between the etiology of trauma and the fracture region was
found in the patients who suffered spinal fractures. Traffic accidents, motorcycle
accidents, and sports injuries resulted more often in low cervical spine injuries.
On the other hand, accidental falls resulted in thoracolumbar transitional region
fractures more often than in other segments of the spine ([Table 1]). The most common level of observed spinal fracture was C6 (14.3%), followed by
C5 (12.9%) and L1 (9.3%).
Evaluating the association between the anatomical distribution of the SCT and the
number of associated injuries with the chi-square test, our study demonstrated that
with higher level of the fracture along the spine, the number of associated injuries
increases (p = 0.001), as shown [Fig. 2A], with 80% of the total dependence explained. Using the same study, we found an association
(p = 0.0004, chi-square test) with the anatomical distribution of the lesion with the
number of complications. The dependence diagram with 97% of the explanation of the
total dependence showed that 60% of the dependence comes from a higher number of complications
as higher level of SCT ([Fig. 2B]).
Fig. 2 (A) Anatomical distribution of the spinal cord injury and the number of associated injuries
(chi-square test, p = 0.001). (B) Anatomical distribution of the associated lesions and number of complications (chi-square
test, p < 0.001).
Patients with cervical spine injury had significantly increased neurologic deficit,
clinical complications, and injuries associated with a risk of death 2.4 times more
compared with other segments of the spine (p < 0.05, chi-square test).
Neurologic Status
Using the ASIA classification system, theses spinal cord injuries were divided into
three groups of patients: ASIA-A (patients exhibiting complete motor and sensitive
deficit), ASIA-B/C/D (patients exhibiting incomplete motor or sensitive deficit),
and ASIA-E (patients exhibiting no motor or sensitive deficit).
The total of 143 patients suffered SCT with neurologic deficit ([Table 3]).The most frequent fractured anatomical region associated with complete and incomplete
motor and sensorial deficit (ASIA-A and ASIA-B/C/D) was the low cervical region.
Table 3
Neurologic status and associated lesions/complications
ASIA
|
Total
|
Average length of hospitalization (days)
|
Complications
|
Injury associated
|
Mortality
|
1
|
2
|
3
|
1
|
2
|
3
|
A
|
68
|
21.9 (±23.5)[a]
|
15
|
14
|
8
|
18
|
7
|
3
|
13
|
B, C, D
|
75
|
9.8 (±12)b
|
7
|
7
|
0
|
14
|
8
|
2
|
6
|
E
|
178
|
7.6 (±11.5)c
|
15
|
4
|
2
|
37
|
17
|
13
|
6
|
Total
|
321
|
11.2 (±15.9)
|
37
|
25
|
10
|
69
|
32
|
18
|
25
|
a,b,c Statistical difference of p < 0.05 by Dunn test.
Using the chi-square test, the present study founded a significant association between
the neurologic status and the number of complications (dependence diagram with 97%
of resolution). We demonstrated that the number of clinical complications rises progressively
while the neurologic status of patients with spinal injuries gets worst (p < 0.001) ([Fig. 3]).
Fig. 3 Neurologic status and clinical complications (chi-square test, p < 0.001).
Patients with ASIA-A showed 57% of clinical complications, 4.24 higher risk of mortality
(p = 0.0001), and length of stay (21.9 ± 23.5 days) significantly higher than the other,
through of chi-square test.
Associated Injuries
One hundred nineteen patients (37%) sustained a cumulative of 187 associated injuries.
Of the patients with associated injuries, 48 (40%) sustained a head injury, 20 (17%)
suffered a thoracic injury, 15 (13%) suffered facial injury, 11 (9%) suffered abdominal
injury, 14 (12%) suffered superior limb fracture, 12 (10%) suffered inferior limb
fracture, and 67 (36%) suffered others associated lesions. The two most common etiologies
of trauma underlying the SCT accompanying these injuries were automobile accidents
(61 [51%] patients), motorcycle accidents (23 [19%] patients), and accidental falls
(16 [13%] patients) ([Table 1]).
Length of Hospital Stay/In-Hospital Complications/Mortality
The mean duration of hospital stay for all patients who were admitted in our hospital
presenting SCT was 11.2 ± 15.9 days. Patients who sustained injuries due to gunshot
had the longest hospital stay of 31.5 ± 39.8 days, compared with other etiologies
of trauma ([Table 1]). Patients presenting with SCT on the cervical region had the longest hospital stay
of 14.3 ± 20.1 days, compared with other anatomical regions ([Table 2]). Patients presenting with complete motor and sensitive neurologic deficits (ASIA-A)
had the longest hospital stay of 21.9 ± 23.5 days ([Table 3]).
The per-patient in-hospital complication rate was 22% (72 patients), with 37 patients
(51%) presenting with one complication, 25 (35%) with two complications, and 10 (14%)
with three complications. The three most commons complications included pneumonia
in 30 patients (42%), urinary tract infection in 18 patients (25%), and atelectasis
in 6 patients (8%). Bedsores were notified in three patients (4%). The etiology of
injury most common with complications was automobile accident ([Table 1]).
The in-hospital mortality rate was 8% (25 patients). Low cervical region presented
the highest risk of in-hospital mortality registering 13 deaths (11%) between all
anatomical distributions of spinal fractures ([Table 2]). The complete motor and sensitive deficit (ASIA-A) registered 13 deaths (19%).
Discussion
SCTs are common occurrences in neurosurgical practice. They account for an important
proportion of care, disability, and ethical issues. They can be present in association
with other conditions, and its early recognition may be difficult in these cases.
The number of patients with spinal trauma has been found to range from 900 to 1,200
per million persons per year.[10]
[11]
[12] The high rate of complications observed in patients with SCT is due to forces involved
in trauma or to the neurologic status of these patients.[13] The rate of complications have been found to vary between studies.[14]
[15]
[16]
[17]
The present study evaluated the presence of associated lesions and the in-hospital
clinical complications of patients admitted with SCT treated at a single tertiary
institute between January 2008 and June 2012. Our series prospectively evaluated 321
patients suffering from SF, including only those who required specialized investigation
and treatment while excluding patients who did not survive the trauma at the time
of accident. Thus, our series represents only patients with a real need for posttrauma
treatment.
The average age of our patients was 42.68 years, with the majority aged between 20
and 40 years ([Fig. 1]). In agreement with most published series, we found a high male:female ratio 2.6:1.[18]
[19]
[20]
[21] The three main etiologies of spine injury found included automobile accidents, accidental
falls, and motorcycle accidents. The most affected anatomical region was the low cervical,
being C6 the most injury vertebra. The fractures in the cervical are potentially more
severe and can result in devastating consequences if treatment is not appropriate.[22]
Twenty-two percent of patients with SCT had some type of clinical complication, the
most common being pneumonia, observed in 42% of patients with complications. Of patients
with complete motor and sensitive deficit (ASIA-A), 54% presented with any clinical
complication during hospital stay ([Table 3]). These results suggest that those who lose the ability to walk were at higher risk
for developing any clinical complication. According to Santos et al,[15] this is particularly true to infections of the respiratory tract. Our study showed
a statistically significant association between the neurologic status of patients
with SCT and the number of complications, demonstrating that those with worst injuries
usually present with a higher number of clinical complications.
The study of anatomical segment of SCT also revealed a higher occurrence of clinical
complications, worst neurologic status, and death between patients with low cervical
spine injury ([Table 2]). Twenty-seven percent of patients with low cervical spine injury had some clinical
complication, 30% presented on admission as ASIA-A, and 11% died. According to Kawu
et al,[16] the risk factors associated with mortality following spine cord injury were age,
Glasgow Coma Scale inferior of nine, cervical spine injury, and complete neurologic
injury and those for clinical complications were cervical spine injury and ASIA-A.
Our study showed statistically that patients with higher levels of SCT along the spine
present with more associated lesions and clinical complications during in-hospital
care.
Associated lesions were identified in 37% of patients sustaining a cumulative of 187
associated injuries. The most common was head trauma, which represented 40% of all
associated injuries. According to Holly et al[7] and Lourenco et al,[23] because of the etiology and mechanisms of trauma in the cervical region, the head
and the chest are at great risk of associated injuries.
Conclusion
The SCT was more common in men, but women older than 50 years presented with a higher
risk than men of the same age. Automobile accidents, motorcycle accidents, and gunshots
resulted in more injuries associated. The cervical spine involvement was directly
related to an increase in the number of associated injuries, complications, and mortality.
Already, the neurologic status ASIA-A was associated with an increase in the number
of complications, length of stay, and mortality. We conclude that the predictive factors
of prognosis in these patients included age, sex, cause of injury, anatomic distribution,
and neurologic status.