title: Risk factors for organ dysfunction and failure in patients with acute traumatic cervical spinal cord injury.
abstract: BACKGROUND
  Traumatic injuries to the cervical spine cause significant disability. Much of the morbidity and mortality that occurs in patients afflicted with cervical spinal cord injury (SCI) occurs early after injury due to primary neurologic dysfunction, systemic inflammation, concomitant injuries, treatments to prevent and ameliorate secondary insults, and prolonged immobilization. This study was undertaken to determine the incidence of organ dysfunction and failure using validated measures: the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA). We also sought to determine if certain patient or injury characteristics were associated with the development of organ dysfunction and failure.
  
  
  METHODS
  All patients who sustained isolated blunt cervical SCIs admitted to the R Adams Cowley Shock Trauma Center over a 15-month period were identified. American Spinal Injury Association (ASIA) motor scores, ASIA impairment scale (AIS) scores, and level of injury were recorded. Admission, first daily, worst daily, and aggregate MOD and SOFA scores were assigned for each of six organ systems. A P < 0.05 was considered significant for all statistical tests.
  
  
  RESULTS
  Of 1,028 patients admitted with blunt spine injuries between January, 2007 and March, 2008, 40 patients were identified with an isolated cervical SCI that required an ICU length of stay (LOS) >24 h. Organ failure of at least one organ system occurred in 75% of patients as calculated by MOD score and 85% of patients calculated using SOFA criteria. Multiple organ failure was found in 55% by MOD and 62.5% by SOFA scores. The most frequent system to fail was the cardiovascular system by aggregate MODS (84%), while the respiratory system was the most frequently failed system by aggregate SOFA criteria (70%). There was a strong inverse correlation between ASIA motor score and aggregate MODS and SOFA scores (r = -0.56, P = 0.0002 and r = -0.51, P = 0.0009). AIS was also found to be inversely correlated with the development of organ failure (r = -0.47, P = 0.002 and r = -0.45, P = 0.004) while anatomic level of injury was found to correlate poorly with the incidence of organ failure (r = -0.11, P = 0.5 and r = -0.10, P = 0.5). Only ASIA motor score was significantly associated with sum aggregate organ dysfunction scores when controlling for age and injury severity score (parameter estimate = -0.082, P = 0.0005 for MODS and parameter estimate = -0.057, P = 0.006 for SOFA).
  
  
  CONCLUSIONS
  This study is the first to describe the incidence of organ dysfunction and failure in patients with isolated acute traumatic cervical SCI using validated organ system dysfunction scores. Respiratory, cardiovascular, neurologic, renal, hepatic, and hematologic dysfunction occurred commonly both on admission and over the ICU stay. Respiratory, cardiovascular, and neurologic failure were frequently found, while renal, hepatic, and hematologic failures were uncommon. Multiple organ failure occurred in the majority of patients. ASIA motor score and AIS were found to strongly correlate with the development of organ dysfunction and failure. Level of injury should be used with caution when describing the risk of complications and the need for medical interventions.
authors.affiliation: R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA. dstein@umm.edu
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
authors.forename: Jay
authors.initials: J
authors.lastname: Menaker
authors.forename: Karen
authors.initials: K
authors.lastname: McQuillan
authors.forename: Christopher
authors.initials: C
authors.lastname: Handley
authors.forename: Bizhan
authors.initials: B
authors.lastname: Aarabi
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae; D015331:Cohort Studies; D019937:Diagnostic Techniques and Procedures; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D012307:Risk Factors; D013119:Spinal Cord Injuries / Q000150:complications* / Q000401:mortality; D014949:Wounds, Nonpenetrating / Q000150:complications*
references.citation: Injury. 2009 Sep;40(9):912-8
references.pmid: 19541301
references.citation: Crit Care Clin. 2004 Jan;20(1):25-55
references.pmid: 14979328
references.citation: Crit Care Med. 2005 Mar;33(3):654-60
references.pmid: 15753760
references.citation: J Neurotrauma. 1998 May;15(5):365-74
references.pmid: 9605350
references.citation: Arch Phys Med Rehabil. 1994 Mar;75(3):270-5
references.pmid: 8129577
references.citation: Exp Neurol. 2008 May;211(1):259-70
references.pmid: 18384773
references.citation: Crit Care Med. 1999 Mar;27(3):505-14
references.pmid: 10199529
references.citation: Am Surg. 2008 Sep;74(9):866-72
references.pmid: 18807680
references.citation: Chirurg. 2001 Jun;72(6):723-30
references.pmid: 11469095
references.citation: Spine (Phila Pa 1976). 1994 Oct 15;19(20):2315-20
references.pmid: 7846577
references.citation: Intensive Care Med. 1999 Apr;25(4):389-94
references.pmid: 10342513
references.citation: Intensive Care Med. 2002 Nov;28(11):1619-24
references.pmid: 12415450
references.citation: Arch Surg. 2003 Oct;138(10):1127-9
references.pmid: 14557131
references.citation: Respir Care. 2006 Aug;51(8):853-68;discussion 869-70
references.pmid: 16867197
references.citation: J Spinal Cord Med. 2007;30(5):482-90
references.pmid: 18092565
references.citation: Crit Care Med. 1995 Oct;23(10):1638-52
references.pmid: 7587228
references.citation: Am J Phys Med Rehabil. 2003 Oct;82(10):803-14
references.pmid: 14508412
references.citation: Spinal Cord. 2000 Mar;38(3):197-8
references.pmid: 10795941
references.citation: Crit Care. 2006;10(4):R115
references.pmid: 16882348
references.citation: J Trauma. 2005 Oct;59(4):912-6; discussion 916
references.pmid: 16374281
references.citation: Resuscitation. 2008 Jan;76(1):57-62
references.pmid: 17688997
references.citation: J Trauma. 2008 Dec;65(6):1328-32
references.pmid: 19077622
references.citation: Spine (Phila Pa 1976). 2006 Nov 1;31(23):2674-83
references.pmid: 17077735
references.citation: Spine (Phila Pa 1976). 1995 May 15;20(10):1136-46
references.pmid: 7638656
references.citation: Neurosurg Focus. 2008;25(5):E13
references.pmid: 18980473
references.citation: Arch Phys Med Rehabil. 1999 Nov;80(11):1411-9
references.pmid: 10569435
references.citation: Crit Care Med. 1995 Jun;23(6):1007-17
references.pmid: 7774210
references.citation: Crit Care Med. 1998 Nov;26(11):1793-800
references.pmid: 9824069
references.citation: J Urol. 1986 Aug;136(2):366-9
references.pmid: 3735496
references.citation: Spinal Cord. 2007 Sep;45(9):603-8
references.pmid: 17179977
references.citation: J Formos Med Assoc. 2006 Aug;105(8):653-8
references.pmid: 16935766
references.citation: Arch Phys Med Rehabil. 1990 Mar;71(3):197-200
references.pmid: 2317137
references.citation: J Trauma. 2009 Nov;67(5):936-43
references.pmid: 19901651
references.citation: J Spinal Cord Med. 2008;31(4):360
references.pmid: 18959352
references.citation: Arch Phys Med Rehabil. 1999 Nov;80(11):1402-10
references.pmid: 10569434
references.citation: Crit Care. 2007;11(5):R95
references.pmid: 17784940
references.citation: Chest. 1995 Jul;108(1):226-32
references.pmid: 7606963
references.citation: Injury. 2005 Jul;36 Suppl 2:B2-12
references.pmid: 15993114
references.citation: Intensive Care Med. 1996 Jul;22(7):707-10
references.pmid: 8844239
references.citation: Arch Phys Med Rehabil. 2000 Apr;81(4):506-16
references.pmid: 10768544
references.citation: Can J Anaesth. 1998 Feb;45(2):144-9
references.pmid: 9512849
references.citation: Crit Care Med. 2001 Nov;29(11):2046-50
references.pmid: 11700393
references.citation: J Gastrointestin Liver Dis. 2009 Jun;18(2):197-203
references.pmid: 19565051
references.citation: J Spinal Cord Med. 2007;30(4):309-18
references.pmid: 17853652
references.citation: J Spinal Cord Med. 2007;30(4):319-30
references.pmid: 17853653
references.citation: BJU Int. 2000 Jun;85(9):1014-8
references.pmid: 10848686
references.citation: Shock. 2009 May;31(5):438-47
references.pmid: 18838942
references.citation: Scand J Trauma Resusc Emerg Med. 2009 Sep 27;17:49
references.pmid: 19781105