Spinal Injury Without Neurological Symptoms in Severely Injured Patients: Impact on the Length of Stay?

Abstract

Background The impact of spinal injuries on clinical outcome in most severely injured patients is currently being controversially discussed. At the same time, most of the studies examine patients with post-traumatic neurological disorders. The aim of this study was therefore to analyse severely injured patients with spinal injuries but without neurological symptoms with regard to their clinical outcome. Here the focus was then on the question, whether spinal injury is an independent risk factor increasing length of stay in the intensive care unit and in the hospital in total.

Material and Methods Data of the TraumaRegister DGU^® were retrospectively analysed. Inclusion criteria were: Injury Severity Score ≥ 16, primary admission, age ≥ 16 years, time interval 2009 – 2016, and a full data set on length of stay in the hospital and the intensive care unit, respectively. Following a univariate analysis in the first step, independent risk factors for the length of stay in the intensive care unit and in the hospital in total were investigated using a multivariate regression analysis.

Results 98,240 patients met the inclusion criteria. In this population, patients with Abbreviated Injury Scale (AIS) 2 and 3 spinal injuries were significantly younger (up to 60 years), and injuries were significantly more commonly caused by falls from a great height and traffic accidents (age ≤ 60 years: AIS_Spine 0: 58.4%, AIS_Spine 3: 65%; p < 0.001). Multivariate analysis showed that spinal injury without neurological symptoms is an independent risk factor for increased length of stay in the intensive care unit (odds ratio: + 1.1 d) and in the hospital in total (AIS 3 odds ratio: + 3.4 d).

Conclusion It has been shown for the first time that spinal injury without initial neurological symptoms has a negative impact on the length of stay of most severely injured patients in the intensive care unit and in the hospital in total and thus represents an independent risk factor in this group of patients.

Key words

trauma registry - multivariate regression analysis - outcome - spinal injuries - hospital length of stay

• References/Literatur

• 1 TraumaRegister DGU^®. Allgemeine Jahresberichte des TraumaRegister DGU seit dem Jahr 2000. Jahresbericht 2018. Im Internet (Stand: 21.08.2019): http://www.traumaregister-dgu.de/de/service/downloads.html
• 2 McKinley W, Meade MA, Kirshblum S. et al. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil 2004; 85: 1818-1825
• 3 Konieczny MR, Strüwer J, Jettkant B. et al. Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable?. Spine J 2015; 15: 1713-1718
• 4 Bliemel C, Lefering R, Buecking B. et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg 2014; 76: 366-373
• 5 Stephan K, Huber S, Häberle S. et al. Spinal cord injury–incidence, prognosis, and outcome: an analysis of the TraumaRegister DGU. Spine J 2015; 15: 1994-2001
• 6 Stahel PF, VanderHeiden T, Flierl MA. et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg 2013; 74: 590-596
• 7 Vallier HA, Moore TA, Como JJ. et al. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res 2015; 10: 155
• 8 Huber-Wagner S, Lefering R, Qvick LM. et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373: 1455-1461
• 9 Yoong S, Kothari R, Brooks A. Assessment of sensitivity of whole body CT for major trauma. Eur J Trauma Emerg Surg 2019; 45: 489-492
• 10 Stelfox HT, Velmahos GC, Gettings E. et al. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma 2007; 63: 630-636
• 11 Mendoza AE, Wybourn CA, Charles AG. et al. Routine computed tomography after recent operative exploration for penetrating trauma: what injuries do we miss?. J Trauma Acute Care Surg 2017; 83: 575-578
• 12 Debus F, Lefering R, Lang N. et al. Which factors influence the need for inpatient rehabilitation after severe trauma?. Injury 2016; 47: 2683-2687
• 13 Levy MM, Fink MP, Marshall JC. et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256
• 14 Vincent JL, Moreno R, Takala J. et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996; 22: 707-710
• 15 Labib N, Nouh T, Winocour S. et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma 2011; 71: 1908-1914
• 16 Chatha H, Sammy I, Hickey M. et al. Falling down a flight of stairs: the impact of age and intoxication on injury pattern and severity. Trauma 2018; 20: 169-174
• 17 Jawa RS, Singer AJ, Rutigliano DN. et al. Spinal fractures in older adult patients admitted after low-level falls: 10-year incidence and outcomes. J Am Geriatr Soc 2017; 65: 909-915
• 18 Aghayev E, Thali MJ, Sonnenschein M. et al. Fatal steamer accident; blunt force injuries and drowning in post-mortem MSCT and MRI. Forensic Sci Int 2005; 152: 65-71
• 19 Casali MB, Battistini A, Blandino A. et al. The injury pattern in fatal suicidal falls from a height: an examination of 307 cases. Forensic Sci Int 2014; 244: 57-62
• 20 Gopalakrishnan KC, el Masri WS. Fractures of the sternum associated with spinal injury. J Bone Joint Surg Br 1986; 68: 178-181
• 21 Morgenstern M, von Rüden C, Callsen H. et al. The unstable thoracic cage injury: the concomitant sternal fracture indicates a severe thoracic spine fracture. Injury 2016; 47: 2465-2472
• 22 Andruszkow H, Lefering R, Frink M. et al. Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients. Crit Care 2013; 17: R124
• 23 Fleming J, Hutton CF, Heiser DM. et al. Spinal cord injuries and helicopter emergency medical services, 6,929 patients: A Multicenter Analysis. Air Med J 2016; 35: 33-42
• 24 Hajj J, Blaine N, Salavaci J. et al. The "centrality of sepsis": a review on incidence, mortality, and cost of care. Healthcare (Basel) 2018; 6: E90
• 25 Heuer M, Hussmann B, Schenck M. et al. [Kidney injury and multiple trauma: outcome, course and treatment algorithm. An organ-specific evaluation of 835 patients from the Trauma Register of the DGU]. Unfallchirurg 2012; 115: 700-707
• 26 Lendemans S, Hussmann B, Kauther MD. et al. [Minimally invasive dorsal stabilization of the thoracolumbar spine]. Unfallchirurg 2011; 114: 149-159
• 27 OʼBoynick CP, Kurd MF, Darden BV. et al. Timing of surgery in thoracolumbar trauma: is early intervention safe?. Neurosurg Focus 2014; 37: E7
• 28 Laurer H, Sander A, Maier B. et al. [Fractures of the cervical spine]. Orthopade 2010; 39: 237-246
• 29 Simmel S, Bühren V. [Rehabilitation in the German statutory accident insurance. Guide to the new outpatient and inpatient structures]. Unfallchirurg 2015; 118: 112-121