Methodological systematic review: mortality in elderly patients with cervical spine injury: a critical appraisal of the reporting of baseline characteristics, follow-up, cause of death, and analysis of risk factors

Outcomes and survival analysis of adult cervical deformity patients with 10-year follow-up

BACKGROUND

Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk.

PURPOSE

To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Two hundred ninety ACD patients.

OUTCOME MEASURES

Morbidity and mortality data.

METHODS

Operative ACD patients ≥18 years with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as expired versus living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups.

RESULTS

Sixty-six total patients were included (60.97±10.19 years, 48% female, 28.03±7.28 kg/m2). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949).

CONCLUSIONS

Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability postoperatively.

Risk Factors for Early Mortality in Older Patients with Traumatic Cervical Spine Injuries-A Multicenter Retrospective Study of 1512 Cases

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Risk factors for thirty-day morbidity and mortality after spinal trauma

BACKGROUND

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined.

METHODS

Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed.

RESULTS

The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay.

CONCLUSION

Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

Health outcomes and costs of acute traumatic spinal injury in New South Wales, Australia

BACKGROUND CONTEXT

Traumatic spinal injuries are often associated with both long-term disability, higher frequency of hospital readmissions, and high medical costs for individuals of all ages. Age differences in terms of injury profile and health outcomes among those who sustain a spinal cord injury have been identified. However, factors that may influence health outcomes among those with a spinal injury have not been extensively examined at a population level.

PURPOSE

The present study aims to describe the characteristics of traumatic spinal injury, identify factors predictive of mortality, and estimate the cost of hospital treatment for younger and older people.

STUDY DESIGN/SETTING

This is a population-based retrospective epidemiological study using linked hospitalization and mortality records during January 1, 2010 to June 30, 2014 in New South Wales, Australia.

PATIENT SAMPLE

The present study included 13,429 hospitalizations.

OUTCOME MEASURES

Mortality within 30 and 90 days of hospitalization, hospital length of stay (LOS), and hospitalization costs were determined.

METHODS

Hospitalizations with a principal diagnosis of spinal cord injury or spinal fractures were used to identify traumatic spinal injuries. Age-standardized incidence rates were calculated and negative binomial regression was used to examine statistical significant changes over time. Cox proportional hazard regression was used to examine the effect of risk factors on survival at 90 days.

RESULTS

There were 13,429 hospitalizations, with 52.4% of individuals aged ≥65 years. The hospitalization rates for individuals aged ≤64 and ≥65 years were both estimated to significantly increase per year by 3.3% (95% confidence interval [CI] 0.97-5.79, p<.006) and 3.3% (95% CI 1.02-5.71, p=.005), respectively. For individuals aged ≥65 years, there were a higher proportion of women injured, comorbid conditions, injuries after a fall in the home or aged care facility, a longer hospital LOS, unplanned hospital admissions, and deaths than individual aged ≤64 years. The average cost per index hospitalization was AUD$23,808 for individuals aged ≤64 years and AUD$31,187 for individuals aged ≥65 years with a total estimated cost of AUD$371 million. Mortality risk at 90 days was increased for individuals who had one or more comorbidities, a higher injury severity score, and if their injury occurred in the home or an aged care facility.

CONCLUSIONS

Spinal injury represents a substantial cost and results in debilitating injuries, particularly for older individuals. Spinal injury prevention efforts for older people should focus on the implementation of fall injury prevention, whereas for younger individuals, prevention measures should target road safety.

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders

OBJECTIVE

The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.

METHODS

A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.

RESULTS

Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.

CONCLUSION

Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

Mortality Rate and Predicting Factors of Traumatic Thoracolumbar Spinal Cord Injury; A Systematic Review and Meta-Analysis

Objective

To estimate the summation of mortality rate and the contributing factors in patients with traumatic thoracolumbar spinal cord injuries (TLSCI).

Methods

A systematic search of observational studies that evaluated the mortality associated with TLSCI in MEDLINE and EMBASE was conducted. The study quality was evaluated using a modified quality assessment tool previously designed for observational studies.

Results

Twenty-four observational studies involving 11,205 patients were included, published between January 1, 1997, and February 6, 2016. Ten studies were of high quality, thirteen were of moderate quality, and one study was of low quality. Seventeen reports described risk factors for mortality and eleven of these studies used a multiple regression models to adjust for confounders. The reported mortality rate ranged from 0 to 37.7% overall and between 0 and 10.4% in-hospital. The sum of mortality for in-hospital, 6-month, and 12-month were 5.2%, 26.12%, 4.3%, respectively. The mortality at 7.7 years follow-up was 10.07% and for 14 years follow-up reports ranged from 13.47% to 21.46%. Associated data such as age at injury, male to female ratio, pre-existing comorbidities, concomitant injuries, duration of follow-up, and cause of death have been underreported in studies investigating the mortality rate after TLSCI.

Conclusion

There is no study was found that accurately assessed mortality in the thoracolumbar spine, while there is general agreement that traumatic thoracolumbar spinal cord injuries are important.

Age and Other Risk Factors Influencing Long-Term Mortality in Patients With Traumatic Cervical Spine Fracture

Objective

To identify clinical or demographic variables that influence long-term mortality, as well as in-hospital mortality, with a particular focus on the effects of age.

Summary and Background Data

Cervical spine fractures with or without spinal cord injury (SCI) disproportionately impact the elderly who constitute an increasing percentage of the US population.

Methods

We analyzed data collected for 10 years at a state-designated level I trauma center to identify variables that influenced in-hospital and long-term mortality among elderly patients with traumatic cervical spine fracture with or without SCI. Acute in-hospital mortality was determined from hospital records and long-term mortality within the study period (2003-2013) was determined from the National Death Index. Univariate and multivariate regression analyses were used to identify factors influencing survival.

Results

Data from patients (N = 632) with cervical spine fractures were analyzed, the majority (66%) of whom were geriatric (older than age 64). Most patients (62%) had a mild/moderate injury severity score (ISS; median, interquartile range: 6, 5). Patients with SCI had significantly longer lengths of stay (14.1 days), days on a ventilator (3.5 days), and higher ISS (14.9) than patients without SCI (P < .0001 for all). Falls were the leading mechanism of injury for patients older than age 64. Univariate analysis identified that long-term survival decreased significantly for all patients older than age 65 (hazard ratio [HR]: 1.07; P < .0001). Multivariate analysis demonstrated age (HR: 1.08; P < .0001), gender (HR: 1.60; P < .0007), and SCI status (HR: 1.45, P < .02) significantly influenced survival during the study period.

Conclusion

This study identified age, gender, and SCI status as significant variables for this study population influencing long-term survival among patients with cervical spine fractures. Our results support the growing notion that cervical spine injuries in geriatric patients with trauma may warrant additional research.

Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review

BACKGROUND

Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT).

PURPOSE

To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014.

STUDY SELECTION

English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars.

DATA EXTRACTION

Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol.

DATA SYNTHESIS

Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients).

LIMITATIONS

Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly.

CONCLUSION

Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice.

PRIMARY FUNDING SOURCE

None.

Management of upper cervical spine fractures in elderly patients: current trends and outcomes

Upper cervical spine fractures in the elderly represent serious injuries. Their frequency is on the rise. Their early accurate diagnosis might be compromised by the existence of extensive degenerative changes and deformities. Adequate stabilisation allowing fracture healing is of paramount importance. However, the debate is ongoing as to the best protocol that can be applied taking into consideration the presence of comorbidities and the increase risk of mortality in this frail patient population. A literature review, based on PubMed, related to protocols reporting on fracture fixation of the upper cervical spine, fractures (C1-C2) was carried out. Papers including information about type of fracture, treatment carried out, complication rates, mortality and morbidities were eligible to be included in this study. Fourteen papers met the inclusion criteria. Six reported on all types of injuries of the upper cervical spine, and eight only odontoid fractures (C2). Overall mortality rate ranged between 0 to 31.4%. Overall morbidity rate was from 10.3 to 90.9%. No significant difference was identified between three types of treatment (rigid collar cuff without fracture reduction, halo cast with reduction of fracture displacement, and surgical treatment). Halo-cast got the highest rate of complications. Surgical treatment got a mortality rate from 0 to 40.0%, and a morbidity rate from 10.3 to 62.5%. Non-union rate ranged between 8.9 to 62.5%. Elderly patients with upper cervical spine fractures must be notified that these injuries are associated with high incidence of non-union, morbidity and mortality.

Early predictors of health-related quality of life outcomes in polytrauma patients with spine injuries: a level 1 trauma center study

Study Design Retrospective review on clinical-quality trauma registry prospective data. Objective To identify early predictors of suboptimal health status in polytrauma patients with spine injuries. Methods A retrospective review on a prospective cohort was performed on spine-injured polytrauma patients with successful discharge from May 2009 to January 2011. The Short Form 12-Questionnaire Health Survey (SF-12) was used in the health status assessment of these patients. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, blood sugar level, vital signs, brain trauma severity, comorbidities, coagulation profile, spine trauma-related neurologic status, and spine injury characteristics of the patients. Results The SF-12 had a 52.3% completion rate from 915 patients. The patients who completed the SF-12 were younger, and there were fewer patients with severe spinal cord injuries (American Spinal Injury Association classifications A, B, and C). Other comparison parameters were satisfactorily matched. Multivariate logistic regression revealed five early predictive factors with statistical significance (p ≤ 0.05). They were (1) tachycardia (odds ratio [OR] = 1.88; confidence interval [CI] = 1.11 to 3.19), (2) hyperglycemia (OR = 2.65; CI = 1.51 to 4.65), (3) multiple chronic comorbidities (OR = 2.98; CI = 1.68 to 5.26), and (4) thoracic spine injuries (OR = 1.54; CI = 1.01 to 2.37). There were no independent early predictive factors identified for suboptimal mental health-related qualify of life outcomes. Conclusion Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes.

Complications of upper cervical spine trauma in elderly subjects. A systematic review of the literature

The frequency of cervical spine trauma in elderly patients is increasing with most injuries occurring in the upper cervical spine. These fractures are associated with a risk of sometimes life-threatening complications, although very few studies have specifically analyzed this. The goal of this study was to identify the incidence of complications in the literature (mortality and morbidity) following upper cervical spine trauma in elderly patients.

METHODS

A systematic search was performed on the MEDLINE database without limiting the search by language or date to identify all studies reporting the rate of complications after upper cervical spine trauma in patients over the age of 60.

RESULTS

Twenty-four observational studies were included, four were comparative. These studies included a total of 857 patients, mean age 76. Nearly all traumas were odontoid process fractures, and most were treated surgically (57%). The median mortality rate was 9.2% (Q1-Q3: 2.5-19.6) and the median rate of short-term complications was 15.4% (Q1-Q3: 5.8-26.9). The main late stage complication was nonunion, which developed in a mean 10 to 12% depending on the type of treatment.

CONCLUSION

Complications following cervical spine trauma are frequent in elderly patients whatever the type of treatment. Knowledge of the rate of complications in the literature and the potential risk factors is essential for the clinician to improve the information provided to patients and to prevent complications.

TYPE OF STUDY

Systematic review of the literature. Level of evidence IV.

Spinal cord injuries related to cervical spine fractures in elderly patients: factors affecting mortality

BACKGROUND CONTEXT

Spinal cord injuries (SCIs) related to cervical spine (C-spine) fractures can cause significant morbidity and mortality. Aggressive treatment often required to manage instability associated with C-spine fractures is complicated and hazardous in the elderly population.

PURPOSE

To determine the mortality rate of elderly patients with SCIs related to C-spine fractures and identify factors that contribute toward a higher risk for negative outcomes.

STUDY DESIGN/SETTING

Retrospective cohort study at two Level 1 trauma centers.

PATIENT SAMPLE

Thirty-seven consecutive patients aged 60 years and older who had SCIs related to C-spine fractures.

OUTCOME MEASURES

Level of injury, injury severity, preinjury medical comorbidities, treatment (operative vs. nonoperative), and cause of death.

METHODS

Hospital medical records were reviewed independently. Baseline radiographs and computed tomography or magnetic resonance imaging scans were examined to permit categorization according to the mechanistic classification by Allen and Ferguson of subaxial C-spine injuries. Univariate logistic regression analyses were performed to identify factors related to in-hospital mortality and ambulation at discharge. There were no funding sources or potential conflicts of interest to disclose.

RESULTS

The in-hospital mortality rate was 38%. Respiratory failure was the leading cause of death. Preinjury medical comorbidities, age, and operative versus nonoperative treatment did not affect mortality. Injury level at or above C4 was associated with a 7.1 times higher risk of mortality compared with injuries below C4 (p=.01). Complete SCI was associated with a 5.1 times higher risk of mortality compared with incomplete SCI (p=.03). Neurological recovery was uncommon. Apart from severity of initial SCI, no other factor was related to ambulatory disposition at discharge.

CONCLUSIONS

In this elderly population, neurological recovery was poor and the in-hospital mortality rate was high. The strongest risk factors for mortality were injury level and severity of SCI. Although each case of SCI related to C-spine fractures is different, physicians may be able to use these findings to help better determine the prognosis and guide subsequent treatment.

Early predictors of functional disability after spine trauma: a level 1 trauma center study

STUDY DESIGN

Retrospective review on prospective cohort and explicit chart review.

OBJECTIVE

To identify early spine trauma predictors of functional disability and to assess management compliance to established spine trauma treatment algorithms.

SUMMARY OF BACKGROUND DATA

Identification of early (within 48 hours) spine trauma predictors of functional disability is novel and may assist in the management of patients with trauma. Also, with significant global variation, spine trauma treatment algorithms are essential.

METHODS

Analysis was performed on patients with spine trauma from May 1, 2009, to January 1, 2011. Functional outcomes were determined using the Glasgow Outcome Scale (GOS) at 1 year. Univariate and multivariate regressions were applied to investigate the effects of the injury severity score, age, blood sugar level, vital signs, traumatic brain injury, comorbidities, coagulation profile, neurology, and spine injury characteristics. A compliance study was performed using the SLIC and TLICS spine trauma algorithms.

RESULTS

The completion rate for the GOS was 58.8%. The completed GOS cohort was 4.2 years younger in terms of mean age, had more number of patients with severe polytrauma, but less number of patients with severe spinal cord injuries (ASIA [American Spinal Injury Association] A, B, and C) in comparison with the uncompleted GOS cohort. Multivariate logistic regression revealed 3 independent early spine trauma predictors of functional disability with statistical significance (P < 0.05). They were (1) hypotension (OR [odds ratio] = 1.98; CI [confidence interval] = 1.13-3.49), (2) hyperglycemia (OR = 1.67; CI = 1.09-2.56), and (3) moderate/severe traumatic brain injury (OR = 5.88; CI = 1.71-20.16). There were 305 patients with subaxial cervical spine injuries and 653 patients with thoracolumbar spine injuries. The subaxial cervical spine injury classification and thoracolumbar injury classification and severity score compliance studies returned agreements of 96.1% and 98.9%, respectively.

CONCLUSION

Early independent spine trauma predictors of functional disability identified in a level 1 trauma center with high compliance to the subaxial cervical spine injury classification and thoracolumbar injury classification and severity score algorithms were hypotension, hyperglycemia, and moderate or severe traumatic brain injury. Spine trauma injury variables alone were shown not to be predictive of functional disability.

LEVEL OF EVIDENCE

3.

Predictors for mortality in elderly patients with cervical spine injury: a systematic methodological review

STUDY DESIGN

Systematic methodological review.

OBJECTIVE

Identify predictors for cervical spine injury (CSI) mortality in elderly patients by reviewing the available literature.

SUMMARY OF BACKGROUND DATA

The proportion of active elderly individuals in society is increasing. This population is at high risk for CSI mortality. The results of studies identifying predictors for CSI mortality in the elderly population are often inconclusive or even conflicting. Currently, there is no set of predictors that can adequately identify and describe CSI mortality risk for the elderly. Thus, we performed a systematic review to identify the predictors for mortality in elderly patients with CSI.

METHODS

We performed searches in the MEDLINE, EMBASE, ScienceDirect, and OVID databases (articles published prior to May 2012) for noninterventional studies that evaluated predictors for CSI mortality in the elderly. Only those observational studies with eligible data were included. Study quality was assessed using a modified quality assessment tool that was designed previously for an observational study. Study outcomes were combined with study quality scores using a best-evidence synthesis model.

RESULTS

Twenty-three observational studies involving 2325 patients were included. These studies were published between 1993 and 2011. According to the quality assessment criteria, 8 studies were of high quality, 11 studies were of moderate quality, and 4 studies were of low quality. We identified 3 strong evidence predictors for CSI mortality, including pre-existing comorbidities, spinal cord injury, and age. We also identified 3 moderate evidence predictors, 7 limited evidence predictors and 1 conflicting evidence predictor.

CONCLUSION

Although there is no conclusive evidence regarding the mortality of elderly patients with CSI, these data provide information that can help us to make recommendations and to counsel patients and their families. Special attention should be paid to the 3 strong predictors. Further studies will be required to validate these predictors.

Early predictors of mortality after spine trauma: a level 1 Australian trauma center study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To identify early independent mortality predictors after spine trauma.

SUMMARY OF BACKGROUND DATA

Spine trauma consists of spinal cord and spine column injury. The ability to identify early (within 24 hours) risk factors predictive of mortality in spine trauma has the potential to reduce mortality and improve spine trauma management.

METHODS

Analysis was performed on 215 spine column and/or spinal cord injured patients from July 2008 to August 2011. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, mechanism of injury, blood glucose level, vital signs, brain trauma severity, morbidity before trauma, coagulation profile, neurological status, and spine injuries on the risk of in-hospital death.

RESULTS

Applying a multivariate logistic regression model, there were 7 independent early predictive factors for mortality after spine injury. They were (1) Injury Severity Score more than 15 (odds ratio [OR] = 3.67; P = 0.009), (2) abnormal coagulation profile (OR = 6; P < 0.0001), (3) patients 65 years or older (OR = 3.49; P = 0.007), (4) hypotension (OR = 2.9; P = 0.033), (5) tachycardia (OR = 4.04; P = 0.005), (6) hypoxia (OR = 2.9; P = 0.033), and (7) multiple comorbidities (OR = 3.49; P = 0.007). Severe traumatic brain injury was also associated with mortality but was excluded from multivariate analysis because there were no patients with this variable in the comparison group.

CONCLUSION

Mortality predictors for spine trauma patients are similar to those for general trauma patients. Spine injury variables were shown not to be independent predictors of spine trauma mortality.

What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications

Since Böhler published the first categorization of spinal injuries based on plain radiographic examinations in 1929, numerous classifications have been proposed. Despite all these efforts, however, only a few have been tested for reliability and validity. This methodological, conceptual review summarizes that a spinal injury classification system should be clinically relevant, reliable and accurate. The clinical relevance of a classification is directly related to its content validity. The ideal content of a spinal injury classification should only include injury characteristics of the vertebral column, is primarily based on the increasingly routinely performed CT imaging, and is clearly distinctive from severity scales and treatment algorithms. Clearly defined observation and conversion criteria are crucial determinants of classification systems' reliability and accuracy. Ideally, two principle spinal injury characteristics should be easy to discern on diagnostic images: the specific location and morphology of the injured spinal structure. Given the current evidence and diagnostic imaging technology, descriptions of the mechanisms of injury and ligamentous injury should not be included in a spinal injury classification. The presence of concomitant neurologic deficits can be integrated in a spinal injury severity scale, which in turn can be considered in a spinal injury treatment algorithm. Ideally, a validation pathway of a spinal injury classification system should be completed prior to its clinical and scientific implementation. This review provides a methodological concept which might be considered prior to the synthesis of new or modified spinal injury classifications.