ANALYSIS OF LETHAL OUTCOMES IN PATIENTS WITH SPINE AND SPINAL CORD INJURY IN ACUTE PERIOD Yakushin O.A., Agadzhanyan V.V., Novokshonov A.V.

Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia,

Tsyvyan Novosibirsk Research Center of Traumatology and Orthopedics, Novosibirsk, Russia

Over the long time, the issues of arrangement of specialized medical care for patients with spine and spinal cord injuries are important in terms of medical and social aspects. It is determined by severity of injuries, difficulties of diagnosis and treatment, high rates of lethal outcomes, and high degrees of disability [1, 2, 3].

The statistical findings show the heterogeneous incidence of spine and spinal cord injuries in various regions of the world. In the European countries, the incidence of traumatic injuries to the spinal cord is 10-50 cases per one million of population per year [4], in USA – 18,000-38,000, with 20 % of cases with paraplegia [5, 6]. In the Russian Federation, the complicated spine injury consists 0.7-8 % of cases among all injuries. The highest amount is registered in big industrial cities [7]. In conditions of polytrauma, the amount of spine and spinal cord injuries increases to 14-20 % [8, 9, 10].

Some authors note that the statistical findings do not show the overall picture of incidence of the spine and spinal cord injury (SSCI). According to the literature data, 16-30 % of patients with spinal injuries are not admitted to hospitals due to death within one hour after trauma before arrival of emergency team [11, 12, 13].

The mortality after spinal injury depends on severity of spinal cord trauma, level of injuries, time of special medical care, and development of early or late trauma-related complications. Despite of development and clinical implementation of examination algorithms, modern intensive care and anesthetic techniques, and improvement in surgical techniques, the mortality in various medical facilities remains at the level of 2.4-45.6 % [7, 14].

The five-year analysis of statistical reports of neurosurgery service of Kemerovo region identified a two-fold increase in patients with acute spine and spinal cord injuries in neurosurgery units of the region. The percentage of surgical interventions for treatment of spinal injuries has increased (65.8 % on average). For this period, the hospital mortality in patients with acute spinal cord injuries without consideration of patients with polytrauma was 3.3 %. With total decrease in surgical activity, the high percentage of postsurgical mortality (4.2 %) remains.

Objective – to conduct the analysis of lethal outcomes of treatment of patients with spine and spinal cord injury in the acute period in conditions of a specialized neurosurgery center.

MATERIALS AND METHODS

A retrospective analysis included 306 case histories of acute spine and spinal cord injuries. The patients were treated in the neurosurgery center of Regional Clinical Center of Miners’ Health Protection in 2000-2017. The inclusion criteria were a complicated spine injury, and ISS (Injury Severity Score) ≥ 8 after admission to the clinic. The exclusion criterion was terminal state after admission.

The analysis showed some single spine and spinal cord injuries in 195 (63.7 %) patients. The diagnosis of polytrauma was in 111 (36.3 %) patients with the spine and spinal cord injury as the dominating or concurrent injury. The mean age of patients was 36.5 ± 12.9 (the range – 13-72). There were 249 (81.4 %) men and 57 (18.6 %) women.

138 (45.1 %) patients with SSCI were transported by the special emergency teams within 30 minutes – 3 hours after trauma. 16 (5.2 %) patients were transported by bystanders. 152 (49.7 %) patients were transported by special emergency teams from other medical facilities of Kemerovo region and from the neighboring regions within 6 hours – 3 days.

Home injuries were in 131 (42.8 %) patients, injuries after road traffic accidents – in 103 (33.7 %), occupational injuries – 72 (23.5 %). Cervical spine injuries were identified in 131 (42.8 %) cases, thoracic spine injuries – 79 (25.8 %), lumbar spine injuries – 96 (31.4 %).

According to the results of the clinical and radiologic examination, some unstable spinal injuries were found in 283 (92.5 %) patients. The symptoms of complete disorder of spinal cord conductivity were diagnosed in 163 (53.3 %) cases. The mean ISS was 25.2 ± 12.8.

The surgical management was defined according to the data of complex examination (objective examination, clinical and radiologic data, laboratory data) of patients with complicated spinal injuries. The surgical treatment of spine and spinal cord injuries was conducted for 269 (87.9 %) patients with acute spine and spinal cord injuries.

The patients were distributed into two groups for estimation of the received results. The main group included 185 patients who received the standard decompressive stabilizing operations in combination with microsurgical interventions for the spinal cord and its linings. The comparison group included 121 patients with classic decompressive stabilizing surgeries (from ventral or dorsal approach) or patients who did not receive any surgical interventions.

The statistical analysis was conducted with IBM SPSS Statistics 21 (Statistical Product and Service Solutions – SPSS). The extensive coefficients (%) characterizing the relation of members to the integral were determined. The qualitative signs were presented as absolute and relative (%) values. The quantitative signs were presented as mean arithmetic (M) and quadratic deviation of mean arithmetic values (SD) in the ordered sample, as Me (LQ-UQ), where Me – median, (LQ-UQ) – interquartile range (LQ – 25 %, UQ – 75 % quartiles). The critical level of significance (p) was less than 0.05. The relationships were identified with univariate and multivariate logistic regression.

The study was conducted in compliance with Helsinki Declare – Ethical Principles for Medical Research with Human Subjects, and the Rules for Clinical Practice in the Russian Federation, with approval from the local ethical committee. The study was observational. The informed consent was not required.

RESULTS AND DISCUSSION

At the hospital treatment stage (2000-2017), 58 patients with acute spine and spinal cord injuries died. The hospital mortality was 18.9 % of all treated patients with acute SSCI. Among all deceased patients, 31 (53.4 %) patients had the single spine and spinal cord injury, 27 (46.6 %) – polytrauma with SSCI as dominating (9 cases) and concurrent (18 cases) injury. The mean age was 41.2 (41.2 ± 14.6). The age varied from 19 to 75. The postsurgical mortality was 17.1 % among all patients who had received surgery in the acute period of trauma.

After admission, 29 patients with single spine and spinal cord injury, and 22 patients with polytrauma showed the symptoms of complete disorder of spinal cord conductance (type A according to ASIA/ISCSCI). The mean ISS was 24.1, in patients with polytrauma – 44.3.

The multivariative analysis with the contingency tables showed that a probability of lethal outcome was higher in the first day after trauma in men with cervical spine injuries and complete disorder of spinal cord conductance in the age category > 41 (the table 1).

Table 1

Estimation of risk of lethal outcome in patients with spine and spinal cord injury

	Odds ratio (deceased/survived)	95 % confidence interval
	Odds ratio (deceased/survived)	Lower limit	Upper limit
Single SSCI (n = 195)
Age of 41 and older	1.543	0.979	2.432
Men	1.252	1.159	1.352
day 1	1.213	0.990	1.488
CS	1.834	1.461	2.302
Complete disorder of conductance in SC	2.645	2.109	3.318
SSCI (polytrauma) (n = 111)
Age of 41 and older	1.222	0.708	2.111
Men	1.244	1.029	1.505
Day 1	1.436	1.159	1.779
CS	2.722	1.537	4.820
Complete disorder of conductance in SC	1.267	0.997	1.612

Note: bold type shows the odds ratio (p < 0.05)

There were 55 (22.4 %) men and 3 women (5 %) among 58 deceased patients with acute spine and spinal cord injuries. The total mortality increased in male patients at the age of 41-60 and older. The maximal mortality was 66.7 % in males at the age older 61 (the table 2). According to our opinion, it was determined by decompensation of concurrent somatic pathology at the background of trauma and the course of traumatic disease.

Table 2

Distribution of patients according to age, gender and level of hospital mortality

Age	N		Mortality (N)		Mortality %
Age	Male	Female	Male	Female	Male	Female	Total
15-20	17	8	2	1	11.8	12.5	12
21-30	78	18	15	1	19.2	5.6	20.4
31-40	73	10	14	-	19.2	-	16.9
41-50	36	10	7	-	19.4	-	15.2
51-60	33	13	11	1	33.3	7.7	26.1
61 и >	9	1	6	-	66.7	-	60
Total	246	60	55	3	22.4	5	18.9
Total	306		58		18.9

The total mortality was 30.8 % for cervical spine injuries, 17.9 % – for thoracic spine, 4.1 % – for lumbar spine in all treated patients in dependence of an injury level. Our results correlate with the literature data. After calculation of total mortality in patients with acute SSCI in comparison to all treated patients, the percentage of lethal outcomes was 2-2.5 times lower in dependence of an injury level. The level of total mortality in patients with single acute SSCI was 15.9 %, with multiple and associated injuries – 24.3 % (the table 3).

Table 3

Distribution of patients according to injury level and hospital mortality

Injury level		N	Mortality
Injury level		N	N	%	General %*	General, %**
Cervical spine	Single	100	26	26	30.8	13.1
Cervical spine	Polytrauma	30	14	46.7	30.8	13.1
Thoracic spine	Single	33	3	9.1	17.9	4.6
Thoracic spine	Polytrauma	45	11	24.4	17.9	4.6
Lumbar spine	Single	62	2	3.2	4.1	1.3
Lumbar spine	Polytrauma	36	2	5.6	4.1	1.3
Total	Single	195	31	15.9#	18.9
Total	Polytrauma	111	27	24.3##	18.9
Total		306	58	18.9

Note: * – percentage of all treated patients with SSCI in dependence injury level; ** – percentage of all treated patients with SSCI in acute period; # – percentage of all treated patients with single SSCI in acute period; ## – percentage of all treated patients with multiple and concomitant injuries in acute period.

During estimation of hospital mortality in dependence on an injury level and time of admission, a feature was found. The maximal mortality was registered in patients who were admitted to the hospital within 24 hours after trauma (84.5 %). The mortality was decreasing on the days 2-3 after admission. In the first day, the mortality was higher in patients with SSCI who were admitted within 6 hours after trauma (63.3 %). It was determined by the acute phase of spinal shock.

The analysis of mortality in dependence on the volume of surgical intervention showed the following data. Active surgical management with microsurgical techniques caused the decrease in total mortality in patients with complete disorder of spinal cord conductance from 36.5 % in the comparison group to 26.9 % in the main group. In patients with symptoms of incomplete disorder of conductance, the total mortality decreased from 6.2 % in the comparison group to 2.8 % in the main group.

The main causes of lethal outcomes at the hospital treatment stage were:

1. One lethal case after cardiac tamponade in the acute period of traumatic disease. The hospital treatment stage lasted for less than three hours. The one-day surgery was 1.8 %.

2. In 11 (18.9 %) cases, the patients died after pulmonary embolism: 1 case – within 24 hours after admission, 10 cases – after two weeks at the stage of treatment in the special units.

3. In 46 (79.3 %) cases, the lethal outcomes were registered at the background of increasing multiple organ failure. 17 patients died after 3 weeks as result of secondary purulent septic complications, 22 patients – within 14 days as result of increasing spinal cord edema. 4 patients died after severe traumatic brain injury with increasing brain edema. In one case, the cause of multiple organ failure was acute disorder of cerebral perfusion of ischemic type. Two cases were associated with hemorrhagic shock at the background of massive gastrointestinal bleeding.

CONCLUSION

1. The high risk of lethal outcome was in patients in the acute period of spine and spinal cord injuries with cervical spine affection, at the age older 41, with clinical symptoms of complete disorder of spinal cord conductance.

2. The main cause of lethal outcomes in the early period of treatment of complicated spinal trauma was acute cardiovascular failure with pulmonary embolism (18.9 %). In 79.3 % of cases, the mortality was determined by multiple organ failure within 14 days at the background of increasing spinal cord edema, and after development of secondary purulent septic complications in later time intervals.

3. For patients with spine and spinal cord injuries, timely surgical treatment with microsurgical techniques, and realization of early rehabilitation allow decreasing the total mortality in complete disorder of spinal cord conductance (decrease to 26.9 %) and with incomplete disorder of conductance (to 2.8 %).

Information on financing and conflict of interest

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interest relating to this article.