Systemic inflammatory response syndrome in patients with spinal cord injury: does its presence at admission affect patient outcomes?

Clinical article

Full access

Object

The object in this study was to determine whether the presence of systemic inflammatory response syndrome (SIRS) in patients with traumatic spinal cord injury (SCI) on admission is related to subsequent clinical outcome in terms of length of stay (LOS), complications, and mortality.

Methods

The authors retrospectively reviewed the charts of 193 patients with acute traumatic SCI who had been hospitalized at their institution between 2006 and 2012. Patients were excluded from analysis if they had insufficient SIRS data, a cauda equina injury, a previous SCI, a preexisting neurological condition, or a condition on admission that prevented appropriate neurological assessment. Complications were counted only once per patient and were considered minor if they were severe enough to warrant treatment and major if they were life threatening. Demographics, injury characteristics, and outcomes were compared between individuals who had 2 or more SIRS criteria (SIRS+) and those who had 0 or 1 SIRS criterion (SIRS−) at admission. Multivariate logistic regression (enter method) was used to determine the relative contribution of SIRS+ at admission in predicting the outcomes of mortality, LOS in the intensive care unit (ICU), hospital LOS, and at least one major complication during the acute hospitalization. The American Spinal Injury Association Impairment Scale grade and patient age were included as covariates.

Results

Ninety-three patients were eligible for analysis. At admission 47.3% of patients had 2 or more SIRS criteria. The SIRS+ patients had higher Injury Severity Scores (24.3 ±10.6 vs 30.2 ±11.3) and a higher frequency of both at least one major complication during acute hospitalization (26.5% vs 50.0%) and a fracture-dislocation pattern of injury (26.5% vs 59.1%) than the SIRS− patients (p < 0.05 for each comparison). The SIRS+ patients had a longer median hospital stay (14 vs 18 days) and longer median ICU stay (0 vs 5 days). However, mortality was not different between the groups. Having SIRS on admission predicted an ICU LOS > 10 days, hospital LOS > 25 days, and at least one complication during the acute hospitalization.

Conclusions

A protocol to identify SCI patients with SIRS at admission may be beneficial with respect to preventing adverse outcomes and decreasing hospital costs.

Abbreviations used in this paper:AIS = American Spinal Injury Association Impairment Scale; AUC = area under the curve; BUN = blood urea nitrogen; DVT = deep venous thrombosis; ICU = intensive care unit; ISS = Injury Severity Score; LOS = length of stay; SCI = spinal cord injury; SIRS = systemic inflammatory response syndrome; UTI = urinary tract infection.

Abstract

Object

The object in this study was to determine whether the presence of systemic inflammatory response syndrome (SIRS) in patients with traumatic spinal cord injury (SCI) on admission is related to subsequent clinical outcome in terms of length of stay (LOS), complications, and mortality.

Methods

The authors retrospectively reviewed the charts of 193 patients with acute traumatic SCI who had been hospitalized at their institution between 2006 and 2012. Patients were excluded from analysis if they had insufficient SIRS data, a cauda equina injury, a previous SCI, a preexisting neurological condition, or a condition on admission that prevented appropriate neurological assessment. Complications were counted only once per patient and were considered minor if they were severe enough to warrant treatment and major if they were life threatening. Demographics, injury characteristics, and outcomes were compared between individuals who had 2 or more SIRS criteria (SIRS+) and those who had 0 or 1 SIRS criterion (SIRS−) at admission. Multivariate logistic regression (enter method) was used to determine the relative contribution of SIRS+ at admission in predicting the outcomes of mortality, LOS in the intensive care unit (ICU), hospital LOS, and at least one major complication during the acute hospitalization. The American Spinal Injury Association Impairment Scale grade and patient age were included as covariates.

Results

Ninety-three patients were eligible for analysis. At admission 47.3% of patients had 2 or more SIRS criteria. The SIRS+ patients had higher Injury Severity Scores (24.3 ±10.6 vs 30.2 ±11.3) and a higher frequency of both at least one major complication during acute hospitalization (26.5% vs 50.0%) and a fracture-dislocation pattern of injury (26.5% vs 59.1%) than the SIRS− patients (p < 0.05 for each comparison). The SIRS+ patients had a longer median hospital stay (14 vs 18 days) and longer median ICU stay (0 vs 5 days). However, mortality was not different between the groups. Having SIRS on admission predicted an ICU LOS > 10 days, hospital LOS > 25 days, and at least one complication during the acute hospitalization.

Conclusions

A protocol to identify SCI patients with SIRS at admission may be beneficial with respect to preventing adverse outcomes and decreasing hospital costs.

Individuals who suffer an acute traumatic spinal cord injury (SCI) are at an increased risk for a variety of medical complications, including pneumonia, urinary tract infections (UTIs), deep venous thrombosis (DVT), pulmonary emboli, infected pressure sores, multiple organ failure, and septicemia, all of which contribute significantly to the morbidity and mortality of SCI.13,30 Alterations in the immune system are thought to predispose patients to these complications.8,9,26 It is well recognized that severe trauma triggers an immediate systemic inflammatory response.11,15,17,22 This response is initiated in the absence of bacterial infection and is characterized by the activation of components of the complement system, a variety of cytokines and chemokines, and other acute phase proteins, coupled with acute neutrophilia and lymphopenia and an increased capacity for neutrophil oxidative burst systemically.1,16,20,26 Overwhelming systemic inflammation leads to tissue injury, organ dysfunction, and potential organ failure.11,16,31

The clinical presentation of this process is the systemic inflammatory response syndrome (SIRS), which is recognized when 2 or more of the following criteria are present: temperature > 36°C or < 30°C, heart rate > 90 or < 50 bpm, respiratory rate > 20 breaths/minute or PaCO2 < 32 mm Hg, or white blood cell count > 12,000 or < 4000 cells/mm3 or greater than 10% band forms.5 Systemic inflammatory response syndrome is present in approximately 30% of general trauma patients, up to 50% of intensive care unit (ICU) patients, and over 80% of surgical ICU patients.3,21,24,27 Multiple studies have shown that SIRS is a significant independent predictor of outcome. In a cohort of 4887 trauma patients, Napolitano et al.24 demonstrated that those with an SIRS score > 2 (that is, with 2 or more SIRS criteria) at admission were 5 times more likely to die than patients without SIRS (SIRS Score 0), and that an SIRS score > 2 at admission was a useful independent predictor of hospital length of stay (LOS) after controlling for age and Injury Severity Score (ISS). In another prospective study of 1850 patients by Bochicchio et al.,3 the patients who had an SIRS score > 2 were 1.5–4.7 times more likely to develop a nosocomial infection. Additionally, in injuries affecting the CNS, including stroke and subarachnoid hemorrhage, the admission SIRS score was a useful predictor of a poor functional outcome and prolonged LOS.4,36 The proportion of patients with SIRS and its effect on outcome has not been studied in the SCI population, which represents a unique cohort of the critically injured population. Therefore, the purpose of this study was to determine whether the presence of SIRS in patients with acute traumatic SCI relates to and predicts outcome measures such as LOS, complications, and mortality.

Methods

After obtaining approval from our institutional research ethics board, we retrospectively examined a consecutive series of 193 SCI patients entered in the National Trauma Registry and admitted to our level 1 trauma center between March 2006 and March 2012. Patients included for analysis were those with a cervical, thoracic, or lumbar SCI documented by physical examination and MRI. Patients were excluded from the study if they had insufficient SIRS data, a cauda equina injury, a previous SCI, a preexisting neurological condition, or a condition on admission that prevented appropriate neurological assessment.

The following data were extracted from the medical records: general demographics, ISS, associated trauma, level of SCI, American Spinal Injury Association Impairment Scale (AIS) grade at admission, first recorded temperature, heart rate, respiratory rate and oxygen saturation on admission to the London Health Sciences Centre, hospital LOS, and ICU LOS. From laboratory reports we obtained data on the initial hospital trauma blood work, which included complete white blood cell count, blood glucose, blood urea nitrogen (BUN), serum creatinine, and plasma aspartate aminotransferase. The incidence of complications was defined as the percentage of patients who developed a specific complication during their initial hospitalization. A recurrent complication was counted only once per patient. Complications were considered minor if they were severe enough to warrant treatment and major if they were life threatening. A UTI was indicated by a urine culture with more than 10,000 colony-forming units/ml. Deep venous thrombosis included positive results with venous Doppler ultrasound. Pneumonia was indicated by chest radiographic findings and positive culture. Wound infection and sepsis were indicated by positive cultures of the wound or blood requiring treatment, respectively.

The SIRS criteria as defined by the American College of Chest Physicians/Society of Critical Care Medicine 1992 Consensus Conference and listed above were used in this study.5 Each criterion present at admission was given a score of 1. Systemic inflammatory response syndrome was defined as the presence of 2 or more criteria (SIRS+ [score ≥ 2]). The SIRS+ patients were compared with the patients without SIRS (SIRS− [score of 0 or 1])

Data analysis was performed using PASW Statistics version 18 (SPSS Inc.). The mean and standard deviation were used to describe continuous parametric variables, and the median and range were used to describe continuous nonparametric variables. Categorical variables were described with percentages. Comparisons between SIRS+ and SIRS− were made using the Student t-test for continuous parametric variables and the Mann-Whitney U-test for continuous nonparametric variables. Comparisons of categorical variables were made using the chi-square test or Fisher's exact test. All p values < 0.05 were considered significant. Multivariate logistic regression (enter method) was used to determine the relative contribution of having SIRS at admission (> 2 SIRS criteria) for predicting outcomes including mortality, ICU LOS > 10 days, hospital LOS > 25 days, and having a least 1 major complication during the acute hospitalization. The AIS grade, patient age, patient sex, and ISS > 25 were included as covariates, as they have been demonstrated to be potent predictors of outcome in the SCI population.12,32,33 An ISS > 25 was chosen to represent multiple injuries because an incomplete SCI assigns a score of 16. Hosmer-Lemeshow and global chi-square tests were used to assess goodness of fit. The discriminative ability of the models in predicting outcome was determined by the area under the curve (AUC) through the construction of receiver operating characteristic (ROC) curves. The AUC values > 0.70 were considered indicative of acceptable predictive ability.

Results

Patient Demographics

Of the 193 patients with a blunt spinal injury admitted to our facility between March 2006 and March 2012, 93 patients with traumatic SCI satisfied all eligibility criteria and were included in the study cohort. Forty-four (47.3%) of the 93 patients had 2 or more SIRS criteria at the time of admission (Table 1). Approximately one-quarter of the patients (24.7%) did not fulfill any of the diagnostic criteria for SIRS, and 28.0% fulfilled only 1 criterion. In individuals with SCI, the SIRS criteria that were most commonly positive were white blood cell count (51.6%) and heart rate (32.3%), followed by temperature (23.7%) and respiratory rate (18.3%).

TABLE 1:

Frequency of SIRS criteria at admission in 93 patients with SCI

No. of SIRS CriteriaNo. of Patients (%)
023 (24.7)
126 (28.0)
228 (30.1)
314 (15.1)
42 (2.2)

Table 2 contains details about the patient population. The mean age at injury was 44.1 ± 18.6 years, and 81.7% of the patients were male. Individuals in the SIRS+ and SIRS− groups were similar in age, single neurological level of SCI, and severity of SCI (as determined by AIS grade on admission). However, the SIRS+ individuals had significantly greater ISSs (24.3 ± 10.6 vs 30.2 ± 11.3, p = 0.01) and more commonly suffered a fracture-dislocation injury (26 patients [59.1%]) than the SIRS− group. In contrast, central cord syndrome caused by hyperextension was the most common injury type in the SIRS− group (17 patients [34.7%]). Almost one-half of the patients (46.2%) had additional trauma associated with their SCI. However, the incidence of SIRS+ was similar in patients who had multiple trauma and patients who had an isolated SCI (40.8% vs 52.3%, p = 0.30).

TABLE 2:

Demographics and injury characteristics in 93 patients with SCI*

ParameterNo. (%)p Value
TotalSIRS−SIRS+
no. of patients934944
mean age at injury (yrs)44.1 ± 18.646.8 ± 19.941.1 ± 16.60.14
ISS27.0 ± 11.224.3 ± 10.630.2 ± 11.30.01
sex0.78
 M76 (81.7)41 (83.7)35 (79.5)
 F17 (18.3)8 (16.3)9 (20.5)
level of SCI0.38
 cervical55 (59.1)30 (61.2)25 (56.8)
 thoracic22 (23.7)9 (18.4)13 (29.5)
 lumbar16 (17.2)10 (20.4)6 (13.6)
AIS grade0.08
 A37 (39.8)17 (34.7)20 (45.5)
 B14 (15.1)4 (8.2)10 (22.7)
 C13 (14.0)9 (18.4)4 (9.1)
 D29 (31.2)19 (38.8)10 (22.7)
spinal column injury0.02
 hyperextension22 (23.7)17 (34.7)5 (11.4)
 flexion-distraction7 (7.5)4 (8.2)3 (6.8)
 burst fracture23 (24.7)14 (28.6)9 (20.4)
 fracture-dislocation39 (41.9)13 (26.5)26 (59.1)
 other2 (2.2)1 (2.0)1 (2.3)
surgical approach0.58
 anterior18 (19.4)10 (20.4)8 (18.2)
 posterior58 (62.4)29 (59.2)29 (65.9)
 anteroposterior9 (9.7)4 (8.2)5 (11.4)
 none8 (8.6)6 (12.2)2 (4.5)
ICU admission49 (52.7)21 (42.9)28 (63.6)0.06
comorbid illness43 (46.2)23 (46.9)20 (45.5)1.00
associated trauma43 (46.2)20 (40.8)23 (52.3)0.30

Values represent the means ± standard deviation unless indicated otherwise.

The p values were derived using the Student t-test or the chi-square test.

Patient Outcomes

For the overall cohort, the median hospital LOS was 16 days (range 1–189 days), and the median ICU LOS was 1 day (range 0–87 days; Table 3). Patients in the SIRS+ group had a significantly longer hospital LOS (18 days, range 1–189 days) than the SIRS− group (14 days, range 1–91 days; p = 0.03). A similar number of patients in the SIRS+ and SIRS− groups required ICU care (63.6% vs 42.9%, p = 0.06); however, patients in the SIRS+ group had a longer ICU LOS than the SIRS− patients (median 5 days [range 0–87 days] vs median 0 days [range 0–46 days], respectively; p < 0.001).

TABLE 3:

Outcomes in 93 patients with SCI

ParameterTotalSIRS−SIRS+p Value*
no. of deaths (%)11 (11.8)5 (10.2)6 (13.6)0.75
median hospital LOS in days (range)16 (1–189)14 (1–91)18 (1–189)0.03
median ICU LOS in days (range)1 (0–87)0 (0–46)5 (0–87)<0.001

The p value was derived using the Fisher's exact test for mortality and the Mann-Whitney U-test for hospital and ICU LOS.

The in-hospital mortality was 11.8%. The mortality rate in the SIRS+ cohort was not different from that in the SIRS− group (13.6% vs 10.2%, respectively; p = 0.75). The mean age of those who died was 70.1 ±19.7 years as opposed to 40.3 ±15.1 years in the patients who survived to hospital discharge (p < 0.001).

Complications

Overall, the incidence of complications was 82.8% (37.6% major and 45.2% minor; Table 4). The most common major complication was pneumonia (20.4%) followed by cardiac complications (8.6%) and acute respiratory failure (8.6%). Urinary tract infections were the most common minor complication (29.0%). Having a least one major complication was 1.7 times more common in the SIRS+ group than in the SIRS− group (p = 0.03). However, patients in the SIRS+ group had a similar frequency of minor complications and multiple complications (at least one major plus at least one minor complication). The types of complications did not differ between the groups.

TABLE 4:

Complications in 93 patients with SCI*

ComplicationNo. (%)RR (95% CI)p Value
TotalSIRS−SIRS+
frequency
 at least 1 major35 (37.6)13 (26.5)22 (50.0)1.7 (1.1–2.5)0.03
 at least 1 minor42 (45.2)19 (38.8)23 (52.3)1.3 (0.8–2.0)0.22
 combination of at least 1 major & at least 1 minor23 (24.7)10 (20.4)13 (29.5)1.3 (0.8–2.0)0.35
major
 pneumonia19 (20.4)8 (16.3)11 (25.0)1.3 (0.8–2.1)0.32
 cardiac complications8 (8.6)3 (6.1)5 (11.4)1.4 (0.8–2.4)0.47
 respiratory failure8 (8.6)4 (8.2)4 (9.1)1.0 (0.5–2.2)1.00
 sepsis7 (7.5)3 (6.1)4 (9.1)1.2 (0.6–2.4)0.70
 rhabdomyolysis1 (1.1)0 (0)1 (2.3)0.47
minor
 neuropathic pain5 (5.4)3 (6.1)2 (4.5)0.8 (0.3–2.5)1.00
 UTI27 (29.0)13 (26.5)14 (31.8)1.1 (0.7–1.8)0.65
 wound infection10 (10.8)5 (10.2)5 (11.4)1.1 (0.5–2.1)1.00
 ileus2 (2.2)1 (2.0)1 (2.3)1.1 (0.3–4.3)1.00
 DVT3 (3.2)1 (2.0)2 (4.5)0.7 (0.1–3.5)1.00
 ulcer3 (3.2)0 (0)3 (6.8)

Categories of complications are mutually exclusive. RR = relative risk; — = not applicable.

The relative risk was calculated by dividing the incidence in the SIRS+ group by the incidence in the SIRS− group. For complications with an incidence of 0 in at least one group, the relative risk could not be calculated.

The p value was derived using the Fisher's exact test.

Clinical Laboratory Parameters at Admission

Laboratory parameters, including glucose, creatinine, and BUN, were not significantly different in the SIRS+ versus the SIRS− group. Neither was there a significant difference in oxygen saturation between the SIRS+ and SIRS− groups (Table 5).

TABLE 5:

Clinical laboratory parameters on admission of 93 patients with SCI*

ParameterSIRS−SIRS+p Value
glucose (mmol/L)9.3 ± 11.58.1 ± 3.60.52
O2 saturation (%)97.1 ± 2.698.1 ± 3.10.11
creatinine (μmol/L)79.7 ± 21.279.7 ± 20.40.90
BUN (mmol/L)5.2 ± 2.44.7 ± 2.00.29
AST (U/L)57.2 ± 60.374.4 ± 64.10.24

Values are expressed as the means ± standard deviation. AST = plasma aspartate aminotransferase.

The p value was derived using the Student t-test.

Admission SIRS Criteria as Predictors of Adverse Outcomes

Table 6 displays the results of logistic regression. After adjusting for differences in age, sex, ISS, and AIS grade, analysis revealed that the presence of 2 or more admission SIRS criteria is a significant predictor for developing at least one major complication during the acute hospitalization (p = 0.04), having an ICU LOS > 10 days (p = 0.005), or having a hospital LOS > 25 days (p = 0.010). The final models had good fit (χ2 = 10.9, p = 0.21; χ2 = 15.4, p = 0.06; χ2 = 8.4, p = 0.40, respectively) and discriminatory ability (AUC = 0.766, 0.861, and 0.847, respectively). Having 2 or more SIRS criteria at admission was not predictive of mortality (p = 0.11).

TABLE 6:

Predictability of complications and LOS in 93 patients with SCI*

OutcomeAdjusted OR (95% CI)p Value
mortality7.4 (0.6–88.5)0.11
at least 1 major complication2.9 (1.1–8.2)0.04
ICU LOS >10 days6.1 (1.7–21.9)0.005
hospital LOS >25 days4.9 (1.5–16.6)0.010

Predictor variable for each outcome was 2 or more SIRS criteria.

Statistical analysis by multivariate logistical regression adjusted for age, AIS grade, sex, and ISS > 25.

Discussion

The present study supports the notion that SIRS criteria have important prognostic implications. Controlling for age, AIS grade, sex, and ISS, our data demonstrate that patients with 2 or more SIRS criteria on admission have a greater risk of a major complication, longer hospital stay, and longer ICU stay than patients with traumatic SCI who do not have SIRS on admission.

To our knowledge this study is the first to document the prevalence and prognostic importance of SIRS criteria in the spinal cord–injured population. Forty-seven percent of spinal cord–injured individuals in the present study had SIRS on admission, which is approximately 10% higher than the rate previously reported for trauma patients.24 This rate is not surprising given that SCI, especially high-level SCI, causes profound physiological derangement of cardiovascular, respiratory, hematopoietic, and thermoregulatory systems. However, we found no association between having 2 or more SIRS criteria on admission and the level of SCI or AIS grade. In agreement with previous studies in general trauma patients, spinal cord–injured individuals with SIRS+ on admission also had a higher overall injury score (ISS > 25) and a higher-energy injury pattern (fracture dislocation vs hyperextension) than those without SIRS.3,21,28 Furthermore, the incidence of SIRS+ was similar between patients who had an SCI together with associated trauma and patients who had an isolated SCI. Collectively, these findings suggest that having SIRS on admission reflects the severity of the overall inflammatory response rather than the severity or level of SCI alone. These findings have been validated at the cellular level by Bao et al.,1 who demonstrated that insult to the spinal cord causes a particularly intense induction of oxidative burst and associated enzymes in the circulating neutrophils and monocytes that is significantly greater in patients after SCI than in patients after trauma without CNS damage. Although numerous studies have demonstrated the value of SIRS criteria in predicting mortality in the general trauma population,3,17,21,25,28 our study of patients with traumatic SCI did not. However, because mortality in our cohort was associated with an older age (> 70 years), because 6 of the 11 patients who died had had supportive care withdrawn, and because the absolute mortality number was relatively small, we believe the finding of no prognostic value in SIRS criteria for predicting death is probably not definitive.

Spinal cord injury patients who had more than 2 SIRS criteria on admission were more likely to experience a major complication during their acute hospitalization. The types and incidence of complications, including pneumonia, cardiac arrest, respiratory failure, and UTIs, were representative of those reported in prior studies in trauma patients, including SCI patients.12,13,28 Our findings agree with those from a recent retrospective review of 411 cervical spinal cord–injured patients revealing that the severity of the initial AIS grade, a high-energy injury mechanism, an older age, comorbid illness, and steroid administration predict the occurrence of complications.32 Similarly, Dimar et al.12 confirmed that the severity of neurological injury, number of comorbidities, and use of high-dose steroids independently increase the risk of complications after surgical stabilization of thoracolumbar spine fractures. We believe the SIRS score is an additional factor, easily attained at the bedside, that can be incorporated into prediction modeling for complications in individual patient management. Early identification of high-risk patients may prevent complications, improve patient outcomes, and reduce resource utilization and cost. Limiting systemic inflammation without causing immune suppression using an anti-integrin strategy has been shown to protect the spinal cord, tissues, and organs as well as improve functional outcomes in animal models of SCI.2,19 Therefore, SIRS criteria may be useful for identifying patients for enrollment into interventional trials on SCI aimed at pharmacological treatment of ongoing systemic inflammation.

The traditional SIRS paradigm suggests that an overabundant deregulated early innate inflammatory response induces early multiple organ failure either by a massive initial insult (one hit) or by “secondary hits.” Subsequently, a suppressive adaptive immune response terminates the proinflammatory response and precipitates late organ failure. More recently, this paradigm has been revised by analysis at the genetic level whereby the proinflammatory response occurs at the same time as the anti-inflammatory response as opposed to occurring sequentially, and it is the degree and duration of the dysregulated immune-inflammatory state that determines a complicated versus an uncomplicated outcome.35 In patients with SIRS, infections, ischemia/reperfusion, or surgical interventions may further prolong the dysregulated immune-inflammatory state and increase a patient's morbidity and mortality.27 Authors of numerous studies, including the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS), have concluded that early decompression surgery is safe, improves neurological function, and is associated with a shorter ICU stay, shorter hospital stay, and a reduced incidence of complications when performed in patients without contraindications such as life-threatening polytrauma or major medical comorbidities.6,7,14,15,34 This beneficial effect of early surgery has also been demonstrated in the stabilization of long-bone fractures and isolated spinal fractures.23,25,29 For the subpopulation with acute SCI and SIRS, future studies should be aimed at elucidating the temporal relationship of the systemic inflammatory response and the impact of surgical intervention on the exacerbation of SIRS.

Although there is no doubt that the presence of SIRS has prognostic value, the SIRS score has been criticized for lacking specificity and for being too sensitive, thus making it difficult to differentiate a beneficial inflammatory response from a pathological response that produces organ failure.18 In the near future, genetic profiling, additional criteria specific to the patient with SCI, and biomarkers such as procalcitonin may be increasingly used to better classify and predict outcome.10

A limitation of our study is its relatively small sample size; therefore, a larger patient population may provide additional significant information. Moreover, our study was retrospective in nature, and despite our attempts to prevent all potential sources of bias, it remains vulnerable to the relevant biases associated with any retrospective study. Our exclusion of patients with incomplete data for calculating the SIRS score may have produced a potential selection bias. A further limitation resulting from the retrospective data collection is our inability to control for confounders, including the length of time from injury to admission and whether the patient was in spinal shock at the time the SIRS criteria were measured. We were also unable to report on the effect of SIRS on long-term functional recovery. Although we specifically examined immediate outcomes (acute and subacute period) in traumatic SCI patients with SIRS, longer-term studies may allow prognostication in patients who experience adverse outcomes in the immediate hospitalization period.

Conclusions

Data in this study demonstrated that patients who suffer a traumatic SCI and have 2 or more SIRS criteria on admission are more likely to have complications, a longer ICU stay, and a longer hospital stay than traumatic SCI patients without SIRS. Determining SIRS criteria on admission is a simple and rapid method of identifying high-risk SCI patients at the bedside and may be beneficial in preventing adverse outcomes and decreasing hospital costs. These results warrant further investigation in a larger study cohort.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Bailey, Kesani, Urquhart, Gurr. Acquisition of data: Kesani, Urquhart, Bedard, Leelapattana. Analysis and interpretation of data: Bailey, Kesani, Urquhart, Siddiqi, Gurr. Drafting the article: Bailey, Kesani, Urquhart. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Bailey. Statistical analysis: Urquhart. Administrative/technical/material support: Urquhart, Leelapattana. Study supervision: Bailey.

References

  • 1

    Bao FBailey CSGurr KRBailey SIRosas-Arellano MPDekaban GA: Increased oxidative activity in human blood neutrophils and monocytes after spinal cord injury. Exp Neurol 215:3083162009

  • 2

    Bao FBrown ADekaban GAOmana VWeaver LC: CD11d integrin blockade reduces the systemic inflammatory response syndrome after spinal cord injury. Exp Neurol 231:2722832011

  • 3

    Bochicchio GVNapolitano LMJoshi MMcCarter RJ JrScalea TM: Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients. J Trauma 50:8178202001

  • 4

    Boehme AKKapoor NAlbright KCLyerly MJRawal PVBavarsad Shahripour R: Systemic inflammatory response syndrome in tissue-type plasminogen activator-treated patients is associated with worse short-term functional outcome. Stroke 44:232123232013. (Erratum in Stroke 44: e141 2013)

  • 5

    Bone RCBalk RACerra FBDellinger RPFein AMKnaus WA: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:164416551992

  • 6

    Cadotte DWFehlings MG: Spinal cord injury: a systematic review of current treatment options. Clin Orthop Relat Res 469:7327412011

  • 7

    Cadotte DWSingh AFehlings MG: The timing of surgical decompression for spinal cord injury. F1000 Med Rep 2:672010

  • 8

    Campagnolo DIDixon DSchwartz JBartlett JAKeller SE: Altered innate immunity following spinal cord injury. Spinal Cord 46:4774812008

  • 9

    Campbell SJPerry VHPitossi FJButchart AGChertoff MWaters S: Central nervous system injury triggers hepatic CC and CXC chemokine expression that is associated with leukocyte mobilization and recruitment to both the central nervous system and the liver. Am J Pathol 166:148714972005

  • 10

    Ciriello VGudipati SStavrou PZKanakaris NKBellamy MCGiannoudis PV: Biomarkers predicting sepsis in polytrauma patients: current evidence. Injury 44:168016922013

  • 11

    Dewar DMoore FAMoore EEBalogh Z: Postinjury multiple organ failure. Injury 40:9129182009

  • 12

    Dimar JRFisher CVaccaro AROkonkwo DODvorak MFehlings M: Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma 69:149715002010

  • 13

    Fletcher DJTaddonio RFByrne DWWexler LMCayten CGNealon SM: Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine (Phila Pa 1976) 20:113611461995

  • 14

    Furlan JCNoonan VCadotte DWFehlings MG: Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma 28:137113992011

  • 15

    Gentile LFCuenca AGEfron PAAng DBihorac AMcKinley BA: Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg 72:149115012012

  • 16

    Gris DHamilton EFWeaver LC: The systemic inflammatory response after spinal cord injury damages lungs and kidneys. Exp Neurol 211:2592702008

  • 17

    Hundt HFleming JCPhillips JTLawendy AGurr KRBailey SI: Assessment of hepatic inflammation after spinal cord injury using intravital microscopy. Injury 42:6916962011

  • 18

    Klein Klouwenberg PMCOng DSYBonten MJMCremer OL: Classification of sepsis, severe sepsis and septic shock: the impact of minor variations in data capture and definition of SIRS criteria. Intensive Care Med 38:8118192012

  • 19

    Kwon BKOkon EHillyer JMann CBaptiste DWeaver LC: A systematic review of non-invasive pharmacologic neuroprotective treatments for acute spinal cord injury. J Neurotrauma 28:154515882011

  • 20

    Lenz AFranklin GACheadle WG: Systemic inflammation after trauma. Injury 38:133613452007

  • 21

    Malone DLKuhls DNapolitano LMMcCarter RScalea T: Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma. J Trauma 51:4584632001

  • 22

    Moore FAMoore EE: Evolving concepts in the pathogenesis of postinjury multiple organ failure. Surg Clin North Am 75:2572771995

  • 23

    Nahm NJComo JJWilber JHVallier HA: Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 71:1751852011

  • 24

    Napolitano LMFerrer TMcCarter RJ JrScalea TM: Systemic inflammatory response syndrome score at admission independently predicts mortality and length of stay in trauma patients. J Trauma 49:6476532000

  • 25

    Pallister IEmpson K: The effects of surgical fracture fixation on the systemic inflammatory response to major trauma. J Am Acad Orthop Surg 13:931002005

  • 26

    Partrick DAMoore FAMoore EEBarnett CC JrSilliman CC: Neutrophil priming and activation in the pathogenesis of postinjury multiple organ failure. New Horiz 4:1942101996

  • 27

    Roberts IYates DSandercock PFarrell BWasserberg JLomas G: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 364:132113282004

  • 28

    Sakamoto YMashiko KMatsumoto HHara YKutsukata NYokota H: Systemic inflammatory response syndrome score at admission predicts injury severity, organ damage and serum neutrophil elastase production in trauma patients. J Nippon Med Sch 77:1381442010

  • 29

    Stahel PFFlierl MAMoore EESmith WRBeauchamp KMDwyer A: Advocating “spine damage control” as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. J Trauma Manag Outcomes 3:62009

  • 30

    Stein DMMenaker JMcQuillan KHandley CAarabi BScalea TM: Risk factors for organ dysfunction and failure in patients with acute traumatic cervical spinal cord injury. Neurocrit Care 13:29392010

  • 31

    Talmor MHydo LBarie PS: Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation. Arch Surg 134:81871999

  • 32

    Wilson JRArnold PMSingh AKalsi-Ryan SFehlings MG: Clinical prediction model for acute inpatient complications after traumatic cervical spinal cord injury: a subanalysis from the Surgical Timing in Acute Spinal Cord Injury Study. J Neurosurg Spine 17:1 Suppl46512012

  • 33

    Wilson JRCadotte DWFehlings MG: Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine 17:1 Suppl11262012

  • 34

    Wilson JRFehlings MG: Emerging approaches to the surgical management of acute traumatic spinal cord injury. Neurotherapeutics 8:1871942011

  • 35

    Xiao WMindrinos MNSeok JCuschieri JCuenca AGGao H: A genomic storm in critically injured humans. J Exp Med 208:258125902011

  • 36

    Yoshimoto YTanaka YHoya K: Acute systemic inflammatory response syndrome in subarachnoid hemorrhage. Stroke 32:198919932001

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Drs. Kesani and Urquhart contributed equally to this work.

Address correspondence to: Christopher S. Bailey, M.D., London Health Sciences Centre, Victoria Hospital, 800 Commissioners Rd. E., E1 313, London, ON N6A-5W9, Canada. email: chris.bailey@lhsc.on.ca.

Please include this information when citing this paper: published online May 16, 2014; DOI: 10.3171/2014.3.SPINE13784.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Bao FBailey CSGurr KRBailey SIRosas-Arellano MPDekaban GA: Increased oxidative activity in human blood neutrophils and monocytes after spinal cord injury. Exp Neurol 215:3083162009

2

Bao FBrown ADekaban GAOmana VWeaver LC: CD11d integrin blockade reduces the systemic inflammatory response syndrome after spinal cord injury. Exp Neurol 231:2722832011

3

Bochicchio GVNapolitano LMJoshi MMcCarter RJ JrScalea TM: Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients. J Trauma 50:8178202001

4

Boehme AKKapoor NAlbright KCLyerly MJRawal PVBavarsad Shahripour R: Systemic inflammatory response syndrome in tissue-type plasminogen activator-treated patients is associated with worse short-term functional outcome. Stroke 44:232123232013. (Erratum in Stroke 44: e141 2013)

5

Bone RCBalk RACerra FBDellinger RPFein AMKnaus WA: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:164416551992

6

Cadotte DWFehlings MG: Spinal cord injury: a systematic review of current treatment options. Clin Orthop Relat Res 469:7327412011

7

Cadotte DWSingh AFehlings MG: The timing of surgical decompression for spinal cord injury. F1000 Med Rep 2:672010

8

Campagnolo DIDixon DSchwartz JBartlett JAKeller SE: Altered innate immunity following spinal cord injury. Spinal Cord 46:4774812008

9

Campbell SJPerry VHPitossi FJButchart AGChertoff MWaters S: Central nervous system injury triggers hepatic CC and CXC chemokine expression that is associated with leukocyte mobilization and recruitment to both the central nervous system and the liver. Am J Pathol 166:148714972005

10

Ciriello VGudipati SStavrou PZKanakaris NKBellamy MCGiannoudis PV: Biomarkers predicting sepsis in polytrauma patients: current evidence. Injury 44:168016922013

11

Dewar DMoore FAMoore EEBalogh Z: Postinjury multiple organ failure. Injury 40:9129182009

12

Dimar JRFisher CVaccaro AROkonkwo DODvorak MFehlings M: Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma 69:149715002010

13

Fletcher DJTaddonio RFByrne DWWexler LMCayten CGNealon SM: Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine (Phila Pa 1976) 20:113611461995

14

Furlan JCNoonan VCadotte DWFehlings MG: Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma 28:137113992011

15

Gentile LFCuenca AGEfron PAAng DBihorac AMcKinley BA: Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg 72:149115012012

16

Gris DHamilton EFWeaver LC: The systemic inflammatory response after spinal cord injury damages lungs and kidneys. Exp Neurol 211:2592702008

17

Hundt HFleming JCPhillips JTLawendy AGurr KRBailey SI: Assessment of hepatic inflammation after spinal cord injury using intravital microscopy. Injury 42:6916962011

18

Klein Klouwenberg PMCOng DSYBonten MJMCremer OL: Classification of sepsis, severe sepsis and septic shock: the impact of minor variations in data capture and definition of SIRS criteria. Intensive Care Med 38:8118192012

19

Kwon BKOkon EHillyer JMann CBaptiste DWeaver LC: A systematic review of non-invasive pharmacologic neuroprotective treatments for acute spinal cord injury. J Neurotrauma 28:154515882011

20

Lenz AFranklin GACheadle WG: Systemic inflammation after trauma. Injury 38:133613452007

21

Malone DLKuhls DNapolitano LMMcCarter RScalea T: Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma. J Trauma 51:4584632001

22

Moore FAMoore EE: Evolving concepts in the pathogenesis of postinjury multiple organ failure. Surg Clin North Am 75:2572771995

23

Nahm NJComo JJWilber JHVallier HA: Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 71:1751852011

24

Napolitano LMFerrer TMcCarter RJ JrScalea TM: Systemic inflammatory response syndrome score at admission independently predicts mortality and length of stay in trauma patients. J Trauma 49:6476532000

25

Pallister IEmpson K: The effects of surgical fracture fixation on the systemic inflammatory response to major trauma. J Am Acad Orthop Surg 13:931002005

26

Partrick DAMoore FAMoore EEBarnett CC JrSilliman CC: Neutrophil priming and activation in the pathogenesis of postinjury multiple organ failure. New Horiz 4:1942101996

27

Roberts IYates DSandercock PFarrell BWasserberg JLomas G: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 364:132113282004

28

Sakamoto YMashiko KMatsumoto HHara YKutsukata NYokota H: Systemic inflammatory response syndrome score at admission predicts injury severity, organ damage and serum neutrophil elastase production in trauma patients. J Nippon Med Sch 77:1381442010

29

Stahel PFFlierl MAMoore EESmith WRBeauchamp KMDwyer A: Advocating “spine damage control” as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. J Trauma Manag Outcomes 3:62009

30

Stein DMMenaker JMcQuillan KHandley CAarabi BScalea TM: Risk factors for organ dysfunction and failure in patients with acute traumatic cervical spinal cord injury. Neurocrit Care 13:29392010

31

Talmor MHydo LBarie PS: Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation. Arch Surg 134:81871999

32

Wilson JRArnold PMSingh AKalsi-Ryan SFehlings MG: Clinical prediction model for acute inpatient complications after traumatic cervical spinal cord injury: a subanalysis from the Surgical Timing in Acute Spinal Cord Injury Study. J Neurosurg Spine 17:1 Suppl46512012

33

Wilson JRCadotte DWFehlings MG: Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine 17:1 Suppl11262012

34

Wilson JRFehlings MG: Emerging approaches to the surgical management of acute traumatic spinal cord injury. Neurotherapeutics 8:1871942011

35

Xiao WMindrinos MNSeok JCuschieri JCuenca AGGao H: A genomic storm in critically injured humans. J Exp Med 208:258125902011

36

Yoshimoto YTanaka YHoya K: Acute systemic inflammatory response syndrome in subarachnoid hemorrhage. Stroke 32:198919932001

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 95 95 31
PDF Downloads 122 122 14
EPUB Downloads 0 0 0

PubMed

Google Scholar