Neurocritical Care

, Volume 13, Issue 1, pp 29–39

Risk Factors for Organ Dysfunction and Failure in Patients with Acute Traumatic Cervical Spinal Cord Injury

  • Deborah M. Stein
  • Jay Menaker
  • Karen McQuillan
  • Christopher Handley
  • Bizhan Aarabi
  • Thomas M. Scalea
Original Article
  • 417 Downloads

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.

Keywords

Organ failure Organ dysfunction Spinal cord injury 

References

  1. 1.
    National Spinal Cord Injury Statistical Center (2009) Spinal cord injury facts. http://www.fscip.org/facts.htm.
  2. 2.
    DeVivo MJ, Krause JS, Lammertse DP. Recent trends in mortality and causes of death among persons with spinal cord injury. Arch Phys Med Rehabil. 1999;80:1411–9.CrossRefPubMedGoogle Scholar
  3. 3.
    McKinley WO, Jackson AB, Cardenas DD, et al. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil. 1999;80:1402–10.CrossRefPubMedGoogle Scholar
  4. 4.
    DeVivo MJ, Ivie III. CS. Life expectancy on ventilator-dependent persons with spinal cord injury. Chest. 1995;108:226–32. doi:10.1378/chest.108.1.226.Google Scholar
  5. 5.
    Chesnut RM. Management of brain and spine injuries. Crit Care Clin. 2004;20:25–55. doi:10.1016/S0749-0704(03)00090-3.CrossRefPubMedGoogle Scholar
  6. 6.
    Licina P, Nowitzke AM. Approach and consideration regarding the patient with spinal injury. Int J Care Injured. 2005;36:S-B2–12. doi:10.1016/j.injury.2005.06.010.Google Scholar
  7. 7.
    Dewar D, Moore FA, Moore EE, et al. Postinjury multiple organ failure. Int J Care Injured. 2009;40:912–8.Google Scholar
  8. 8.
    Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23(10):1638–52.CrossRefPubMedGoogle Scholar
  9. 9.
    Vincent JL, Moreno R, Takala J, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22:707–10.CrossRefPubMedGoogle Scholar
  10. 10.
    Cook R, Cook D, Tilley J, et al. Multiple organ dysfunction: baseline and serial component scores. Crit Care Med. 2001;29(11):2046–50.CrossRefPubMedGoogle Scholar
  11. 11.
    Bota DP, Melot C, Ferreira FL, et al. The multiple organ dysfunction score (MODS) versus the sequential organ failure assessment (SOFA) score in outcome prediction. Intensive Care Med. 2002;28:1619–24.CrossRefGoogle Scholar
  12. 12.
    Grotz M, von Griensven M, Stalp M, et al. Scoring multiple organ failure after severe trauma. Comparison of the Goris, Marshall and Moore scores. Chirurg. 2001;72(6):723–30.CrossRefPubMedGoogle Scholar
  13. 13.
    Frink M, van Griensven M, Kobbe P, et al. IL-6 predicts organ dysfunction and mortality in patients with multiple injuries. Scand J Trauma Resusc Emerg Med. 2009;17(1):49.CrossRefPubMedGoogle Scholar
  14. 14.
    Antonelli M, Moreno R, Vincent JL, et al. Application of SOFA score to trauma patients. Intensive Care Med. 1999;25:389–94.CrossRefPubMedGoogle Scholar
  15. 15.
    Ulvik A, Kvåle R, Wentzel-Larsen T, et al. Multiple organ failure after trauma affects even long-term survival and functional status. Crit Care. 2007;11:R95. doi:10.1186/cc6111.CrossRefPubMedGoogle Scholar
  16. 16.
    Zygun DA, Kortbeek JB, Fick GH, et al. Non-neurologic organ dysfunction in severe traumatic brain injury. Crit Care Med. 2005;33(3):654–60.CrossRefPubMedGoogle Scholar
  17. 17.
    Zygun D, Berthiaume L, Laupland K, et al. SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study. Crit Care. 2006;10:R115. doi:10.1186/cc5007.CrossRefPubMedGoogle Scholar
  18. 18.
    Heuer M, Taeger G, Kaiser GM, et al. Prognostic factors of liver injury in polytraumatic patients. Results from 895 severe abdominal trauma cases. J Gastrointestin Liver Dis. 2009;18(2):197–203.PubMedGoogle Scholar
  19. 19.
    Sauaia A, Moore EE, Johnson JL, et al. Validation of post-injury multiple organ failure scores. Shock. 2009;31(5):438–47.CrossRefPubMedGoogle Scholar
  20. 20.
    Abbreviated Injury Scale, 2005. Association for the advancement of automotive medicine: Barrington, IL; 2005.Google Scholar
  21. 21.
    Apuzzo MLJ. Pharmacological therapy after acute cervical spinal cord injury. In: Guidelines for the management of acute cervical spine and spinal cord injuries, chap 9. Neurosurgery. 2002;50(3):63–72.Google Scholar
  22. 22.
    Blood pressure management after acute spinal cord injury. In: Guidelines for the management of acute cervical spine and spinal cord injuries, chap 8. Neurosurgery. 2002;50(3):S58–S62.Google Scholar
  23. 23.
    American Spinal Injury Association/International Medical Society of Paraplegia. International standards for neurological and functional classification of spinal cord injury-Revised 2000. Chicago, IL: ASIA; 2002.Google Scholar
  24. 24.
    International Standards for the Classification of Spinal Cord Injury. Motor Exam Guide. Downloaded from http://www.asia-spinalinjury.org/publications/Motor_Exam_Guide.pdf.
  25. 25.
    Standard Neurological Classification of Spinal Cord Injury. Downloaded from http://www.asia-spinalinjury.org/publications/2006_Classif_worksheet.pdf.
  26. 26.
    Marshall JC. The multiple organ dysfunction (MOD) score. Sepsis. 1997;1:49–52.CrossRefGoogle Scholar
  27. 27.
    Vincent JL, de Mondonca A, Cantraine F, et al. Use the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med. 1998;26(11):1793–800.PubMedGoogle Scholar
  28. 28.
    Gruber A, Reinprecht A, Illievich UM, et al. Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage. Crit Care Med. 1999;27(3):505–14.CrossRefPubMedGoogle Scholar
  29. 29.
    Solenski NJ, Haley EC, Kassell NF, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Crit Care Med. 1995;23(6):992–3.CrossRefGoogle Scholar
  30. 30.
    Lan MY, Wu SJ, Chang YY, et al. Neurologic and non-neurologic predictors of mortality in ischemic stroke patients admitted to the intensive care unit. J Formos Med Assoc. 2006;105(8):653–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Kemp CD, Johnson JC, Riordan WP, et al. How we die: the impact of neurologic organ dysfunction after severe traumatic brain injury. J Am Coll Surg. 2008;74(9):866–72.Google Scholar
  32. 32.
    Gris D, Hamilton EF, Weaver LC. The systemic inflammatory response after spinal cord injury damages the lungs and kidneys. Exp Neurol. 2008;211:259–70.CrossRefPubMedGoogle Scholar
  33. 33.
    Kattail D, Furlan JC, Fehlings MG. Epidemiology and clinical outcomes of acute spine trauma and spinal cord injury: experience from a specialized spine trauma center in Canada in comparison with a large national registry. J Trauma. 2009;67(5):936–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Claxton AR, Wong DT, Chung F, et al. Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury. Can J Anaesth. 1998;45(2):144–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Bilello JF, Davis JW, Cunningham MA, et al. Cervical spinal cord injury and the need for cardiovascular intervention. Arch Surg. 2003;138:1127–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Fletcher DJ, Taddonio RF, Byrne DW, et al. Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine. 1995;20(10):1136–46.CrossRefPubMedGoogle Scholar
  37. 37.
    Jackson AB, Groomes TE. Incidence of respiratory complications following spinal cord injury. Arch Phys Med Rehabil. 1994;75(3):270–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Como JJ, Sutton ERH, McCunn M, et al. Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit. J Trauma. 2005;59(4):912–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Zimmer MB, Nantwi K, Goshgarian HG. Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options. J Spinal Cord Med. 2007;30:319–30.PubMedGoogle Scholar
  40. 40.
    Brown R, DiMarco A, Hoit JD, et al. Respiratory dysfunction and management in spinal cord injury. Respir Care. 2006;51(8):853–70.PubMedGoogle Scholar
  41. 41.
    Fishburn MJ, Mariano RJ, Ditunno JF Jr. Atelectasis and pneumonia in acute spinal cord injury. Arch Phys Med Rehabil. 1990;71:197–200.PubMedGoogle Scholar
  42. 42.
    Berlly M, Shem K. Respiratory management during the first five days after spinal cord injury. J Spinal Cord Med. 2007;30(4):309–18.PubMedGoogle Scholar
  43. 43.
    Lemons VR, Wagner FC Jr. Respiratory complications after cervical spinal cord injury. Spine. 1994;19(20):2315–20.PubMedGoogle Scholar
  44. 44.
    Winslow C, Rozovsky J. Effect of spinal cord injury on the respiratory system. Am J Phys Med Rehabil. 2003;82:803–14.CrossRefPubMedGoogle Scholar
  45. 45.
    Guly HR, Bouamra O, Lecky FE. The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department. Resuscitation. 2008;76:57–62.CrossRefPubMedGoogle Scholar
  46. 46.
    Tuli S, Tuli J, Coleman WP, et al. Hemodynamic parameters and timing of surgical decompression in acute cervical spinal cord injury. J Spinal Cord Med. 2007;30:482–90.PubMedGoogle Scholar
  47. 47.
    Teasell RW, Arnold JM, Krassioukov A, et al. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rahbil. 2000;81(4):506–16.CrossRefGoogle Scholar
  48. 48.
    Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurg Focus. 2008;25(5):E13.CrossRefPubMedGoogle Scholar
  49. 49.
    Mairov DN, Fehlings MG, Krassioukov AV. Relationship between severity of spinal cord injury and abnormalities in neurogenic cardiovascular control in conscious rats. J Neurotrauma. 1998;15(5):365–74.CrossRefGoogle Scholar
  50. 50.
    MacDiarmid SA, McIntyre WJ, Anthony A, et al. Monitoring of renal function in patients with spinal cord injury. Brit J Urol. 2000;85(9):1014–8.Google Scholar
  51. 51.
    Mohler JL, Barton SD, Blouin RA, et al. The valuation of creatinine clearance in spinal cord injury patients. J Urol. 1986;136:366.PubMedGoogle Scholar
  52. 52.
    Vaidyanathan S, Watt JWH, Singh G, et al. Dosage of once-daily gentamicin in spinal cord injury patients. Spinal Cord. 2000;38:197–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Garcia-Lopez P, Martinez-Cruz A, Guizar-Sahagún G, et al. Acute spinal cord injury changes the disposition of some, but not all drugs given intravenously. Spinal Cord. 2007;45:603–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Furlan JC, Krassioukov AV, Fehlings MG. Hematologic abnormalities within the first week after acute isolated traumatic cervical spinal cord injury: a case control cohort study. Spine. 2006;31(23):2674–83.CrossRefPubMedGoogle Scholar
  55. 55.
    Wing P, Dalsey W, Alvarez E, et al. Early acute management in adults with spinal cord injury. A clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):408–79.Google Scholar
  56. 56.
    Hassid VJ, Schinco MA, Tepas JJ, et al. Definitive establishment of airway control is critical for optimal outcome in lower cervical spinal cord injury. J Trauma. 2008;65:1328–32.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Deborah M. Stein
    • 1
    • 2
  • Jay Menaker
    • 1
  • Karen McQuillan
    • 1
  • Christopher Handley
    • 1
  • Bizhan Aarabi
    • 1
  • Thomas M. Scalea
    • 1
  1. 1.R Adams Cowley Shock Trauma CenterUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Division of Critical Care/Program in Trauma, R Adams Cowley Shock Trauma CenterUniversity of Maryland Medical Center, University of Maryland School of MedicineBaltimoreUSA

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