Temporal trends in major in-hospital and immobility-related complications following traumatic spinal cord injury: a retrospective cohort study

Introduction

Traumatic spinal cord injury (SCI) poses a significant burden to both patients and the healthcare system, often necessitating specialized and resource-intensive care (1,2). SCI can lead to motor, sensory, and autonomic dysfunction, thereby increasing the risk of a wide range of medical complications (3). Existing literature has identified a heightened risk of secondary adverse events during the critical post-injury state (4). These complications can negatively influence patient outcomes and increase hospital resource utilization (5). Characterizing trends in adverse events among this population is essential for informing standards of care and guiding modifications to current clinical practice (6).

Reported complications associated with SCI include pressure ulcers, upper gastrointestinal bleeding, and mental health disorders. One in three patients with SCI is at risk of developing pressure ulcers, often due to immobility, altered skin integrity, and prolonged hospitalizations (7). Additionally, SCI can impair respiratory function through weakened respiratory muscles, reduced vital capacity, decreased lung and chest wall compliance, and ineffective cough, predisposing patients to atelectasis, pneumonia and respiratory failure (8). Bladder dysfunction and impaired sensation below the neurologic level often necessitate the use of indwelling or intermittent catheterization, increasing the risk of catheter-associated urinary tract infections (CAUTI). These infections, amongst other complications, contribute to decreased quality of life and increased morbidity and mortality among individuals with SCI (9).

Existing literature has predominantly focused on long-term complications of traumatic SCI, resulting in a paucity of studies evaluating acute in-hospital complications associated with this SCI (8,10). To address this gap, we sought to evaluate the temporal trends in major adverse events (MAEs) and immobility-related adverse events (IAEs) following acute traumatic SCI, and to identify associated risk factors. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-168/rc) (11).

Methods

Data source

A multicenter retrospective observational cohort study was conducted with data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) from January 2017 to December 2022 (12). The TQIP database collects information from nearly 900 level I–III trauma centers across North America, verified by the ACS and individual states. Data reliability and credibility are ensured using trained data abstractors and inter-rater reliability audits at contributing centers. TQIP collects over 200 variables related to patient, injury, and hospital characteristics for each trauma admission. TQIP data is used with permission of the American College of Surgeons, Chicago, Illinois. The study’s design and methodology received approval from the Unity Health Toronto Research Ethics Board (REB) (No. 20-247). As all data were deidentified, informed consent was waived for this retrospective study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Data from this study are not housed in a public repository due to TQIP data-sharing restrictions but are available from the corresponding author upon reasonable request and subject to ACS approval.

Study cohort

Patients aged 16 years and older who had a traumatic SCI from 2017 through 2022 were eligible. To be included, patients must have had an Abbreviated Injury Scale (AIS) code for cervical, thoracic, or lumbar acute SCI (Table S1) (13-17). Patients under 16 years of age, and those with an AIS severity score of 6 in any body region, indicating non-survivable traumatic injury, were excluded (18). Patients with missing outcome data were excluded. We included patients with both complete (absence of motor or sensory function below injury level) and incomplete (presence of partial motor or sensory function below injury level) neurological injury. A flow diagram detailing the cohort creation is presented in Figure 1.

Figure 1 Flow chart of study cohort derivation, 2017–2022. AIS, abbreviated injury scale.

Primary outcome

The primary outcome was the occurrence of MAE and IAE. MAE were defined as the presence of any one of or more of the following: acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pneumonia or ventilator-associated pneumonia (VAP), severe sepsis, catheter-related bloodstream infection (CLABSI), stroke/cerebrovascular accident (CVA), unplanned ICU admission, intubation, or unplanned return to operating room. IAE included venous thromboembolism [VTE, deep vein thrombosis (DVT) or pulmonary embolism (PE)], decubitus ulcer; surgical site infection (SSI, superficial or deep), and CAUTI.

Exposure

The primary independent variable was the year of injury, which corresponded to the year of hospital admission. Year was treated as a continuous variable.

Covariates

Patient, injury, treatment, and hospital-level variables were selected based on clinical relevance. Patient-level covariates included year of injury, age, sex, race, medical comorbidity. Comorbid status was scored by a modified Charlson Comorbidity Index (CCI). Injury level covariates included spinal level and neurologic severity (‘completeness’) of SCI, fracture status, mechanism of injury, trauma type, and presenting Glasgow Coma Scale (GCS). Treatment variables included whether the patient underwent spinal surgery, which was determined using the International Classification of Diseases, 10^th Revision Procedural Coding System codes (Table S2) (16). Hospital-level covariates included teaching status and hospital type.

Statistical analysis

All data cleaning, analysis and plotting were performed using R version 4.2.1. Descriptive statistics were reported using mean ± standard deviation (SD) for continuous variables and count and percentage for categorical variables. Univariate comparisons were performed using chi-square test for categorical variables and analysis of variance (ANOVA) for continuous variables. Our prespecified level of statistical significance was set to 0.05. Missing data for covariates was less than 5% and imputed as recommended for trauma registry data (Table S3) (19). We employed multiple imputation using the “MICE” package, generating five imputed datasets to handle missing data (20).

Association between year of admission and adverse events

Multivariable regression analyses were used to assess the association between year and outcomes, adjusting for relevant covariates identified a priori based on a conceptual model. For regression analyses, years were centered at 2017, and models were adjusted for age, sex, race, comorbidities, mechanism of injury, presenting GCS, trauma type, neurologic injury, completeness, fracture status, surgery status, hospital type, and teaching status. For each model, adjusted odds ratios (ORs) with 95% confidence intervals were reported.

Subgroup analysis

Regression analyses were repeated after stratifying the SCI cohort by spinal level, recognizing that the degree of functional impairment varies by injury location. A secondary subgroup analysis was conducted among patients who underwent surgery, adjusting for the same covariates and additionally including time to surgery to assess the impact of surgical intervention on adverse event rates.

Factors associated with MAE and IAE

Two composite complication outcomes were examined: (I) MAE; and (II) IAE. Each outcome was operationalized as a binary variable indicating whether at least one relevant complication, as defined under primary outcomes, occurred during hospitalization. Multivariable logistic regression models were constructed for both outcomes using the same covariate structure, including year of admission, demographics (sex, age scaled per 10 years, race, CCI), injury characteristics (neurological level, completeness, fracture status, surgical intervention, mechanism of injury, trauma type, and presenting GCS), and hospital-level characteristics (hospital type and teaching status) (Tables S4,S5). For each model, adjusted OR with 95% confidence intervals was reported. Forest plots were generated to visualize adjusted effect estimates for both complication types.

Results

Overview of patients

The study cohort comprised 78,571 patients with traumatic SCI between 2017 and 2022 (Figure 1). The majority were male, with mean age increasing from 50.87±19.96 years in 2017 to 53.11±20.08 years in 2022 (P<0.001). Comorbidity burden shifted over time, with the proportion of patients having no comorbidities decreasing from 42.3% in 2017 to 38.6% in 2022, and those with severe comorbidity (CCI ≥3) increasing from 27.4% to 32.5% (P<0.001). Cervical injuries predominated throughout the study period (71.3–72.5%), followed by thoracic (18.1–19.3%) and lumbar injuries (8.2–9.4%). Most injuries were incomplete (42.9–44.9%) and falls were the leading mechanism of injury (42.6–44.9%) across study years. All cohort characteristics, stratified by year of admission, are reported in Table 1.

Primary outcomes

Analysis of primary outcomes and subgroup analyses revealed significant trends in adverse events across the study period (Figures 2,3). With regards to MAE, the odds of cardiac arrest increased each year (OR 1.05 per year after 2017, 95% CI: 1.02–1.09, P<0.001), as did CVA (OR 1.08, per year after 2017, 95% CI: 1.02–1.15, P=0.01). Unplanned ICU admissions also rose (OR 1.07, per year after 2017, 95% CI: 1.04–1.09, P<0.001), along with intubation (OR 1.04, per year after 2017, 95% CI: 1.01–1.06, P=0.003) and unplanned returns to the operating room (OR 1.21, per year after 2017, 95% CI: 1.17–1.26, P<0.001) (Table 2). Among IAE, the odds of DVT (OR 1.03, per year after 2017, 95% CI: 1.00–1.06, P=0.04), PE (OR 1.06, per year after 2017, 95% CI: 1.01–1.11, P=0.02) and pressure ulcers (OR 1.07, per year after 2017, 95% CI: 1.04–1.10, P<0.001) increased. Conversely, the odds CAUTI decreased (OR 0.89, per year after 2017, 95% CI: 0.85–0.93, P<0.001) (Table 2).

Figure 2 Proportion of major complications from 2017–2022. (A) Total cohort. (B) Stratified by spinal injury level. AKI, acute kidney injury; ARDS, acute respiratory distress syndrome; CLABSI, central line-associated bloodstream infection; CVA, cerebrovascular accident; ICU, intensive care unit; OR, operating room.

Figure 3 Proportion of immobility related adverse events from 2017–2022. (A) Total cohort. (B) Stratified by spinal injury level. CAUTI, catheter-associated urinary tract infection; DVT, deep vein thrombosis; SSI, surgical site infection.

Primary outcomes stratified by spinal injury level

Subgroup analyses stratified by spinal injury level demonstrated distinct trends across outcomes, as seen in Figures 2B,3B. Within the cervical cohort, the odds of cardiac arrest increased over time (OR 1.06, per year after 2017, 95% CI: 1.02–1.09, P=0.003), a trend also observed in the lumbar cohort (OR 1.21, per year after 2017, 95% CI: 1.03–1.40, P=0.02). The odds of CVA increased in the cervical cohort (OR 1.12, per year after 2017, 95% CI: 1.04–1.20, P=0.002). Unplanned ICU admissions increased across cervical (OR 1.06, per year after 2017, 95% CI: 1.03–1.10, P<0.001) and thoracic cohorts (OR 1.07, per year after 2017, 95% CI: 1.01–1.14, P=0.03). Intubation rates rose in both the cervical (OR 1.03, per year after 2017, 95% CI: 1.00–1.06, P=0.02) and thoracic cohorts (OR 1.06, per year after 2017, 95% CI: 1.00–1.12, P=0.04). Unplanned returns to the operating room increased across all cohorts, with the cervical cohort demonstrating the largest increase (OR 1.23, per year after 2017, 95% CI: 1.17–1.29, P<0.001), followed by the thoracic (OR 1.20, per year after 2017, 95% CI: 1.11–1.29, P<0.001) and lumbar cohorts (OR 1.17, per year after 2017, 95% CI: 1.04–1.31, P=0.007; Table 3).

The odds of developing a DVT (OR 1.04, per year after 2017, 95% CI: 1.00–1.08, P=0.04), PE (OR 1.08, per year after 2017, 95% CI: 1.01–1.15, P=0.01), and pressure ulcer (OR 1.08, per year after 2017, 95% CI: 1.05–1.12, P<0.001) increased in the cervical cohort. The likelihood of CAUTI decreased in the cervical cohort (OR 0.88, per year after 2017, 95% CI: 0.83–0.93, P<0.001, Table 3).

Primary outcomes in SCI patients who underwent surgery

In patients who underwent surgical intervention for SCI, several complications demonstrated significant temporal trends (Table 4). The odds of unplanned ICU admission increased over time (OR 1.05, per year after 2017, 95% CI: 1.02–1.09, P=0.002), as did unplanned return to the operating room (OR 1.19, per year after 2017, 95% CI: 1.14–1.24, P<0.001). The odds of developing DVT (OR 1.04, per year after 2017, 95% CI: 1.00–1.08, P=0.03), PE (OR 1.08, per year after 2017, 95% CI: 1.02–1.14, P=0.01), pressure ulcers (OR 1.07, per year after 2017, 95% CI: 1.04–1.11, P<0.001), and deep SSI (OR 1.13, per year after 2017, 95% CI: 1.00–1.28, P=0.04) all increased over the study period. In contrast, the odds of CAUTI decreased over time (OR 0.90, per year after 2017, 95% CI: 0.85–0.95, P<0.001).

Factors associated with MAE and IAE

Several factors were significantly associated with increased odds of MAE. Year of admission (OR 1.02, 95% CI: 1.01–1.03, P<0.001) and age per 10-year increment (OR 1.05, 95% CI: 1.02–1.08, P<0.001) showed small but significant increases in odds. Higher comorbidity burden demonstrated progressively elevated odds (CCI =2: OR 1.39, 95% CI: 1.26–1.53, P<0.001; CCI =3: OR 1.66, 95% CI: 1.48–1.87, P<0.001). Injury characteristics, including complete spinal cord injuries (OR 2.71, 95% CI: 2.55–2.87, P<0.001), fractures (OR 1.38, 95% CI: 1.31–1.45, P<0.001), and penetrating trauma (OR 1.56, 95% CI: 1.42–1.70, P<0.001) were all associated with increased odds. Lower presenting GCS showed a dose-response relationship with progressively higher odds (GCS 13–14: OR 1.80; GCS 9–12: OR 2.34; GCS 3–8: OR 3.33, all P<0.001; Figure 4).

Figure 4 Forest plots of factors associated with MAEs and IAEs. Multivariable logistic regression results showing ORs with 95% CIs for factors associated with major adverse events (left panel) and immobility-related complications (right panel). The vertical dashed line represents an OR of 1.0 (no effect). CCI, Charlson Comorbidity Index; CI, confidence interval; GCS, Glasgow Coma Scale; IAE, immobility-related adverse event; MAE, major adverse event; MVT, motor vehicle trauma; OR, odds ratio.

Similarly, year of admission (OR 1.03, 95% CI: 1.01–1.04, P<0.001) was significantly associated with increased odds of IAE. Comorbidity burden showed significant associations with CCI =1 (OR 1.18, P<0.001) and CCI =2 (OR 1.19, P=0.006). Complete SCI (OR 3.44, 95% CI: 3.20–3.70, P<0.001), fractures (OR 1.35, 95% CI: 1.27–1.45, P<0.001), motor vehicle trauma (OR 1.22, P<0.001), and penetrating trauma (OR 1.67, P<0.001) were all associated with increased odds of IAE. Lower GCS demonstrated progressively higher odds (GCS 13–14: OR 1.71; GCS 9–12: OR 2.30; GCS 3–8: OR 2.53, all P<0.001).

Discussion

In our multicenter cohort of 78,571 patients with acute traumatic SCI, we observed significant year-over-year increases in several MAE and IAE. Notably, cardiac arrest, CVA, unplanned ICU admission, intubation, and unplanned returns to the OR all demonstrated rising trends. Among immobility-related complications, the rates of DVT, pulmonary embolism, and pressure ulcers significantly increased, whereas CAUTI showed a significant decline. Subgroup analyses stratified by injury level reaffirmed these findings, revealing a greater incidence of in-hospital adverse events within the cervical SCI group. Similarly, within the surgically treated cohort, these trends were present. Several factors, including increasing age, greater comorbidity burden, and more severe injury characteristics, were found to be associated with both MAE and IAE.

One possible explanation for the increased trend in complications is the evolving epidemiology of SCI, characterized by an increasing incidence of traumatic SCI, particularly among older adults (21-23). While our cohort demonstrated relatively small increases in the mean age across the study years, advanced age has been reported to be associated with morbidity and mortality and worse in-hospital outcomes in the context of acute SCI, offering a plausible explanation for the observed rise in complication rates (24). Moreover, older adults, from both a physiological and chronological perspective, present with greater frailty and multiple comorbidities, which place them at elevated risk for post-operative complications (25,26). This was observed in our analysis, wherein from 2017–2022, there was a larger proportion of patients presenting with greater comorbidity burden. Comorbidity burden was also significantly associated with both MAE and IAE in adjusted analysis.

A recent multicenter study reported an increase in cardiac complications following SCI, aligning with our findings (27). The rising incidence of SCI among older adults, coupled with a higher burden of cardiac comorbidities in this population, may place them at increased risk of perioperative cardiac events. Malhotra et al. reported similar findings in pediatric patients with SCI, identifying pressure ulcers, unplanned intubation, and cardiac arrests as the most frequently encountered adverse events, consistent with the results of our study (28). Their analysis also suggested a significantly elevated adjusted risk associated with cervical SCI. Similarly, another study reported urinary tract infections and pressure ulcers to be frequent complications in patients with acute traumatic SCI (29). In recent years, efforts to prevent CAUTI in high-risk populations, such as those with SCI, have gained increasing attention. Nursing-led initiatives through national implementation projects have been effective in reducing both catheter use and injection rates (30). Interventions have focused on provider and patient education, early removal of catheter, prophylactic antibiotics and the use of specialized catheter material (e.g., silver-coated silicone catheters). These strategies have been strongly supported by Infectious Diseases Society of America (31). These strategies may contribute to the observed decreasing trend in CAUTIs and similar large-scale national implementation projects with standardized strategies should be considered for other adverse events, such as pressure ulcers (9,32).

Several studies have shown a significant reduction in time to surgery for both cervical and thoracolumbar SCI between 2010 and 2020, reflecting a broader trend towards earlier intervention (16,33). Current guidelines focus on traumatic SCI patients receiving surgical intervention within 24 hours post-injury, as early surgical management has been associated with both improved neurologic recovery and a reduction of in-hospital complications (17,34-38). Despite a shifting paradigm in the surgical management of SCI patients, our subgroup analysis demonstrated no significant year-over-year reduction in the odds of most complications. This finding is consistent with prior studies that have reported no association between surgical timing and in-hospital complications or adverse events (39-41). The increasing complication rates may be partially explained by the physiologic burden of both the traumatic injury, aging demographic and subsequent surgical intervention (27). Our findings support this, as evidenced by the strong associations we observed between injury severity markers (complete injuries, lower GCS scores, presence of fractures) and both MAE and IAE. Additionally, higher comorbidity burden demonstrated progressively elevated odds of complications.

The results of this study highlight potential gaps in patient care and identify key areas for improving the management and prevention of adverse outcomes following SCI. A better understanding of the complication profile associated with this patient population during the acute hospitalization period can help clinicians recognize high-risk patients earlier and implement targeted interventions. Enhanced surveillance, timely mobilization, respiratory support strategies, and prevention protocols for pressure ulcers, thromboembolism, and infections may help reduce the burden of these events. Furthermore, the identification of trends by injury level, such as complications in the cervical SCI cohort, suggests the need for injury-specific care pathways and multidisciplinary coordination. While there is evidence to support benefits of frequent turning, repositioning and early mobilization of SCI patients, current practice of bed rest, and mobilization timing varies across centers (42,43). A more standardized, unified approach is warranted to optimise patient care following SCI. Ultimately, optimizing early inpatient management may lead to improved functional outcomes, reduced morbidity, and better long-term recovery in individuals with SCI.

The strengths of this study include the use of a large, multicenter dataset, which provides robust population-level insights into the incidence of adverse events in the SCI cohort and enhances the generalizability of our findings across diverse hospital settings. Furthermore, the use of regression modeling enabled adjustment for baseline imbalances, thereby improving the accuracy of adverse event estimates over the study period. However, there are several important limitations. The retrospective design of this study subjects our results to unmeasured confounders and restricts us to the variables collected within the TQIP database. For instance, the severity of neurologic dysfunction was dichotomized into complete vs. incomplete injury, which fails to capture the granularity of SCI. The use of the American Spinal Injury Association Scale would offer improved differentiation and grading of functional impairment, thereby facilitating a more nuanced analysis of the impact of SCI on rates of hospital complications. Additionally, other contributing factors, not captured in our study, such as variability in post-operative care practices and delays in mobilization, may influence the risk of complications in this population. Lastly, due to the lack of temporal data on in-hospital complications, it is not possible to determine the sequence of events, limiting our ability to disentangle the relationship between adverse events and surgical intervention.

Conclusions

This study provides real-world clinical data on the temporal trends in major in-hospital adverse events and IAEs following acute traumatic SCI. The results highlight an increase in the incidence of adverse outcomes following SCI, particularly in those with cervical SCI. As treatment of SCI evolves, understanding changes in temporal trends is crucial in refining treatment protocols, optimizing management strategies and improving both acute, in-hospital and long-term patient outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-168/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-168/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-168/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-168/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study’s design and methodology received approval from the Unity Health Toronto Research Ethics Board (REB) (No. 20-247). As all data were deidentified, informed consent was waived for this retrospective study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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