Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays

Abstract

Objective: Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs).

Methods: The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014.

Results: Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6).

Conclusions: VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Keywords: pediatrics; spinal cord injury; trauma; traumatic spinal injury; venous thromboembolism.

Figure 1:. Mechanism of injury.

Motor vehicle accidents were the most common mechanism of injury among TSI patients both with and without VTE. A larger proportion of patients with both TSI and VTE experienced motor vehicle accident-related injury, injury to other/homicide attempt, and injury to self/suicide attempt than patients with TSI and no VTE. Sports-related and fall-related injuries were more common among TSI patients with no VTE.

Figure 2:. Factors associated with VTE.

Factors correlated with increased injury severity were significantly associated with VTE development during hospitalization.

Figure 3:. Spinal injury and VTE development.

Injury at any given spinal level is not significantly associated with VTE development. Injury involving multiple spinal levels or spinal cord injury were both significantly associated with VTE development.

Figure 4:. Hospital course and disposition.

Developing VTE was not significantly associated with ICU stay during initial hospital admission. TSI patients with VTE were significantly more likely to experience adverse discharge compared to TSI patients without VTE. VTE does not appear to be associated with increased risk of death or hospice, but the relative rarity of those events may confound this effect.