Study design: Retrospective. Objectives: To determine the predictors of mortality in veterans with traumatic spinal cord injury (tSCI). Setting: Tertiary clinic in the state of Oklahoma. Methods: One hundred and forty-seven patients with tSCI who were enrolled in our Spinal Cord Injury program from 1 January 2000 to 31 December 2011 were retrospectively studied. The study sample was divided into two groups, based on the survival status by 31 December 2011. Results: In this sample of 147 patients with tSCI, survival at the end of the 12-year study period was 60%. There were three major causes of death: infection-related, such as pneumonia (21%), urinary infection (14%), and infection of the pressure ulcers (11%); cardiovascular-related, such as congestive heart failure (16%), coronary arterial disease (13%), and atrial fibrillation (2%); and cancer-related (16%). In veterans with complete SCI, deaths were mainly infection-related and occurred in the hospital (51%), while deaths in veterans with incomplete SCI were primarily cardiovascular and cancer-related and occurred in the community. A Cox regression analysis showed the age at the time of injury to be the main predictor of SCI-related mortality. Conclusion: This study suggests that an older age at the time of injury is a significant predictor of mortality following tSCI with patients more likely to die from cardiovascular deaths than the general population. These findings support the need for preventative strategies, including a focus on cardiovascular risk factor management, in order to decrease long-term mortality. INTRODUCTION According to the National Spinal Cord Injury Statistical Center, it is estimated that the annual incidence of traumatic spinal cord injury (tSCI), not including those who die at the scene of the accident, is B40 cases per million in the United States or 12 000 new cases each year. The number of people in the United States who were alive in 2009 with SCI was approximately 262 000 persons. 1 With recent medical advances, the survival rate for patients with tSCI has greatly improved, with life expectancy approaching that of the general population. There have also been historical changes in the leading cause of death following SCI. Although renal failure and urinary tract infections were once the leading causes of death among persons with tSCI, 2 advances in urological management have addressed this. Today, the leading causes of death are infection, respiratory, and cardiovascular diseases. 1,3–6 Nonetheless, the mortality rates remain significantly greater in the first 2 years following injury owing to increased medical and surgical complications. Prognostic factors for increased survival have been young age at the time of injury, incomplete and lower spinal injury level. 7 The combination of these risk and prognostic factors has been examined in four large studies (Australia, Denmark, United Kingdom and the United States), which have looked at predictors of survival after tSCI over a time period greater than 10 years. However, these studies were undertaken in different time periods, within different medical care systems, and used different methods of assessing the severity of SCI, thus making a comprehensive comparison difficult. The study authors, Lidal et al., 3 followed 387 patients from Denmark over a 20-year period. Predictors of mortality in this sample were increased age at the time of injury, higher injury level (cervical), depression, alcohol/substance abuse and pre-injury heart disease. The main causes of death were pneumonia (16%), coronary heart disease (13%) and urogenital causes (13%). The study authors concluded that their high mortality rate was due in part to preventable SCI-related complications and stressed the importance of addressing these treatable factors. The next study, by O'Connor 4 , followed 2892 patients with tSCI in Australia over a 12-year period and found age at the time of injury (445 years), level of injury, male gender and severity of injury to be the main predictors of mortality. Whitneck et al. 5 followed 834 patients with tSCI in the United Kingdom over a 40-year period and found that 24% of the deaths were due to genito-urinary, followed by cardiovascular (23%) and respiratory (14%), causes. Renal deaths were more common in paraplegics, and respiratory failure was more common in tetraplegics. Furthermore, they found that the cause of mortality in tSCI was more attributable to the aging process as these patients were living longer and closely approximated the general population. Finally, Samsa et al. 6 followed 5545 veterans over a 40-year period. They showed that older age at the time of injury was a strong predictor of poor long-term survival. The level of injury was a predictor of short-term mortality. Urogenital causes and infection were responsible for 10% of the deaths.
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