Venous Thromboembolism After Spinal Cord Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children

doi:10.1016/j.apmr.2005.07.286

Archives of Physical Medicine and Rehabilitation

Volume 86, Issue 12, December 2005, Pages 2240-2247

https://doi.org/10.1016/j.apmr.2005.07.286 Get rights and content

Abstract

Jones T, Ugalde V, Franks P, Zhou H, White RH. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children.

Objective

To analyze the incidence of venous thromboembolism (VTE) after spinal cord injury (SCI).

Design

Retrospective cohort analysis of all SCI cases (16,240) in California from 1991 through 2001.

Setting

All public hospitals in California.

Participants

Subjects (cases) coded as having complete or incomplete SCI.

Interventions

Not applicable.

Main Outcome Measure

Diagnosis of VTE or death within 91 days of the day of hospital admission.

Results

For all cases, the 91-day cumulative incidence of VTE was 5.4%. In a multivariate model, significant predictors of VTE included male sex (odds ratio [OR]=1.4; 95% confidence interval [CI], 1.2–1.7), African-American race (OR=1.6; 95% CI, 1.3–1.9), complete paraplegia versus tetraplegia (OR=1.8; 95% CI, 1.4–2.3), and presence of 3 or more comorbid conditions versus none (OR=1.6; 95% CI, 1.3–2.1). Age less than 14 years was predictive of not developing VTE (OR=0.2; 95% CI, 0.1–0.7). The incidence of VTE did not change significantly over the 11-year time period (P=.07), and VTE was not a significant predictor of death in the first 91 days after hospitalization.

Conclusions

The incidence of VTE in SCI patients in California did not change between 1991 and 2001. We identified specific risk factors for VTE. Further studies are needed to determine if prompt initiation of medical prophylaxis in high risk subjects reduces the incidence of symptomatic VTE.

Section snippets

Design and Database

The California Patient Discharge Data Set has been described elsewhere.¹⁴ All nonfederal hospitals supply specific information about each inpatient, including basic demographic data, the principal diagnosis, up to 24 secondary diagnoses, a principal procedure, and as many as 20 secondary procedures, using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Since July 1990, encrypted record linkage numbers have made it possible to link serial

Results

There were 16,240 cases coded as having SCI during the 11-year study period. The demographic and clinical characteristics of the entire cohort and of the cases that did or did not develop VTE within 1 year of hospitalization are summarized in table 1. The subjects’ mean age was 44 years, and the average length of index hospitalization was 18 days. Figure 1 shows the age and sex distribution of the SCI cohort. As shown in figure 2, the standardized incidence (http://www.census.gov/popest/archives

Discussion

Comprehensive analysis of the incidence of VTE among SCI patients has been hampered because of the small numbers of patients reported in most series,9, 12, 22 and by the highly select nature of the cases enrolled in registry studies.¹ To overcome these problems, we analyzed a large population-based SCI cohort. There were 2 unexpected findings: no change in the risk-adjusted incidence of VTE between 1991 and 2001, and no evidence that VTE was a significant predictor of death within 3 months of

Conclusions

The incidence of VTE within 91 days of acute SCI averaged 5.4%, with a range of 3% to 12%, depending on whether specific risk factors were present. Unexpectedly, the incidence did not change significantly during the 11-year period. If further studies verify that VTE is indeed associated with the specific risk factors we identified, the incidence of VTE might be further reduced by identifying the highest risk patients as soon as possible after hospital admission and initiating a

References (35)

D. Chen et al.
Medical complications during acute rehabilitation following spinal cord injury—current experience of the Model Systems
Arch Phys Med Rehabil
(1999)
S.I. Weingarden
Deep venous thrombosis in spinal cord injury; overview of the problem
Chest
(1992)
W.H. Geerts et al.
Prevention of venous thromboembolismthe Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
(2004)
M.J. DeVivo et al.
Recent trends in mortality and causes of death among persons with spinal cord injury
Arch Phys Med Rehabil
(1999)
R.H. White et al.
ICD-9-CM codes poorly identified venous thromboembolism during pregnancy
J Clin Epidemiol
(2004)
N. Zakai et al.
Risk factors for venous thrombosis in medical inpatientsvalidation of a thrombosis risk score
J Thromb Haemostasis
(2004)
M. Cushman et al.
Deep vein thrombosis and pulmonary embolism in two cohortsthe longitudinal investigation of thromboembolism etiology
Am J Med
(2004)
D. Green et al.
Fatal pulmonary embolism in spinal cord injury
Chest
(1994)
T.E. Seeman et al.
Cumulative biological risk and socio-economic differences in mortalityMacArthur studies of successful aging
Soc Sci Med
(2004)
R. Radecki et al.
Deep vein thrombosis in the disabled pediatric population
Arch Phys Med Rehabil
(1994)

K. Deep et al.

Prophylaxis of thromboembolism in spinal injuries—results of enoxaparin used in 276 patients

Spinal Cord

(2001)

Prevention of venous thromboembolism in the acute treatment phase after spinal cord injurya randomized, multicenter trial comparing low-dose heparin plus intermittent pneumatic compression with enoxaparin

J Trauma

(2003)

D. Green

Diagnosis, prevalence, and management of thromboembolism in patients with spinal cord injury

J Spinal Cord Med

(2003)

W. Waring et al.

Acute spinal cord injuries and the incidence of clinically occurring thromboembolic disease

Paraplegia

(1991)

W.H. Geerts et al.

A prospective study of venous thromboembolism after major trauma

N Engl J Med

(1994)

D. Green et al.

Spinal Cord Injury Risk Assessment for Thromboembolism (SPIRATE Study)

Am J Phys Med Rehabil

(2003)

D.C. Green

Prevention of thromboembolism in spinal cord injury. Consortium for spinal cord medicine clinical practice guidelines

(1999)

Cited by (103)

The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis
2023, American Journal of Surgery
Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures.
Analysis of the 2017 NRD. Adults (≥18 years) with a primary diagnosis of spinal fracture who were managed non-operatively were included. Patients that died on index admission, were on pre-injury anticoagulants, and those with spinal cord injuries were excluded. Outcomes were rates of DVT, PE, and VTE during index admission, and at 1-month and 6-months after discharge. Multivariate regression analysis was performed to identify independent predictors of 6-month readmission with VTE.
41,337 patients were identified. Mean age was 61 ± 22 years, and the median ISS was 17[9–22]. Vertebral fractures were: 11% sacrococcygeal; 29% lumbar; 19% thoracic; 20% cervical; and 21% multiple levels. During the index admission, 392(0.9%) patients developed DVT, 281(0.7%) developed PE, and 601(1.5%) VTE. Within 1-month of discharge, 177(0.4%) patients were readmitted with DVT, 142(0.3%) with PE, and 268(0.6%) with VTE. Within 6-months of discharge, 352(0.9%) patients were readmitted with DVT, 250(0.6%) with PE, and 513(1.2%) with VTE. Among those who were readmitted within 6-months with VTE, mortality was 6.7%. On multivariate analysis, older age(OR = 1.01,p < 0.01), higher ISS(OR = 1.03,p < 0.001), thoracic level of spinal fracture(OR = 1.37,p = 0.04), and discharge to skilled nursing facility, rehabilitation center, or care facility(OR = 1.73,p < 0.001) were independently associated with 6-month readmission due to VTE.
VTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture. Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.
Guidelines for management of pediatric acute hyperextension spinal cord injury
2023, Chinese Journal of Traumatology - English Edition
Pediatric acute hyperextension spinal cord injury (SCI) named as PAHSCI by us, is a special type of thoracolumbar SCI without radiographic abnormality and highly related to back-bend in dance training, which has been increasingly reported. At present, it has become the leading cause of SCI in children, and brings a heavy social and economic burden. Both domestic and foreign academic institutions and dance education organizations lack a correct understanding of PAHSCI and relevant standards, specifications or guidelines. In order to provide standardized guidance, the expert team formulated this guideline based on the principles of science and practicability, starting from the diagnosis, differential diagnosis, etiology, admission evaluation, treatment, complications and prevention. This guideline puts forward 23 recommendations for 14 related issues.
Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications
2021, Journal of Surgical Research
Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST).
We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression.
We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (β = 0.079, [−0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (β = −0.011, [−0.298 to 0.471]; P = 0.35).
Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio.
Level III therapeutic.
Operative spinal trauma: Thromboprophylaxis with low molecular weight heparin or a direct oral anticoagulant
2019, Journal of Thrombosis and Haemostasis
Citation Excerpt :
The overall morbidity of VTE in trauma patients can range from a silent DVT to a fatal saddle PE.6-8 However, after acute spinal trauma, especially in the presence of a spinal cord injury, the reported incidence of VTE events can rise significantly, from 5% to 70%.9,10 Because of the increasing burden of VTE in trauma patients, the American College of Chest Physicians (ACCP) and the Eastern Association for the Surgery of Trauma (EAST) have recommended the use of low‐dose unfractionated heparin (UFH) or low molecular weight heparin (LMWH) with or without mechanical prophylaxis for the prevention of VTE complications.11,12
Spinal trauma patients are at high risk for venous thromboembolism (VTE).
To compare the impacts of direct oral anticoagulants (DOACs) and low molecular weight heparin (LMWH) as thromboprophylactic agents on outcomes in operative spinal trauma patients.
A 2‐year (2015‐2016) retrospective cohort analysis of such patients (spine Abbreviated Injury Scale [AIS] ≥ 3 and other AIS < 3) who received LMWH or DOACs was performed. Propensity score matching (1:2 ratio) followed stratification into two groups. Outcomes included rates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE), packed red blood cell (pRBC) transfusion, operative interventions for spinal cord decompression, and mortality.
Of 6036 patients, 810 (270 receiving DOACs; 540 receiving LMWH) were matched. The mean age was 62 ± 15 years, 58% were male, and the median Injury Severity Score was 12 (10‐18). Matched groups were similar in demographics, injury parameters, emergency department vital signs, hospital stay, rates of inferior vena cava filter placement, and timing of initiation of thromboprophylaxis. The overall rate of in‐hospital DVT was 5.6%, the overall rate of in‐hospital PE was 1.6%, and the mortality rate was 2.5%. DOAC patients were less likely to develop DVT (1.8% vs 7.4%) and PE (0.3% vs 2.1%). There were no differences in postprophylaxis pRBC transfusion requirements, postprophylaxis decompressive procedures on the spinal cord, or mortality.
In operative spinal trauma patients, thromboprophylaxis with DOACs appears to be associated with lower rates of DVT and PE. Further prospective clinical trials should evaluate the role of DOACs in preventing VTE events in spinal trauma patients.
Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine
2023, Annals of Intensive Care
Safety and comparative efficacy of initiating low-molecular-weight heparin within 24 hours of injury or surgery for venous thromboembolism prophylaxis in patients with spinal cord injury: a prospective TRACK-SCI registry study
2023, Neurosurgical Focus

View all citing articles on Scopus

: Supported by the Hibbard E. Williams Endowment for Medical Research, UC Davis.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

View full text

Original articleVenous Thromboembolism After Spinal Cord Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measure

Results

Conclusions

Section snippets

Design and Database

Results

Discussion

Conclusions

Arch Phys Med Rehabil

Chest

Chest

Arch Phys Med Rehabil

J Clin Epidemiol

J Thromb Haemostasis

Am J Med

Chest

Soc Sci Med

Arch Phys Med Rehabil

Prophylaxis of thromboembolism in spinal injuries—results of enoxaparin used in 276 patients

Spinal Cord

Prevention of venous thromboembolism in the acute treatment phase after spinal cord injurya randomized, multicenter trial comparing low-dose heparin plus intermittent pneumatic compression with enoxaparin

J Trauma

Diagnosis, prevalence, and management of thromboembolism in patients with spinal cord injury

J Spinal Cord Med

Acute spinal cord injuries and the incidence of clinically occurring thromboembolic disease

Paraplegia

A prospective study of venous thromboembolism after major trauma

N Engl J Med

Spinal Cord Injury Risk Assessment for Thromboembolism (SPIRATE Study)

Am J Phys Med Rehabil

Prevention of thromboembolism in spinal cord injury. Consortium for spinal cord medicine clinical practice guidelines

Original article
Venous Thromboembolism After Spinal Cord Injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children