Objective: To evaluate compliance with American College of Surgeons (ACS) guidelines and whether trauma center designation, hospital traumatic spinal cord injury (TSCI) case volume or spinal surgery volume is associated with paralysis. We hypothesized a priori that trauma center care, by contrast to nontrauma center care, is associated with reduced paralysis at discharge.
Summary background data: Approximately 11,000 persons incur a TSCI in the United States annually. The ACS recommends all TSCI patients be taken to a level I or II trauma center.
Methods: We studied 4121 patients diagnosed with TSCI by ICD-9-CM criteria in the 2001 hospital discharge files of 7 states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia, Washington), who were treated in 100 trauma centers and 601 nontrauma centers. We performed multivariate analyses, including a propensity score quintile approach, adjusting for differences in case mix and clustering by hospital and by state. We also studied 3125 patients using the expanded modified Medicare Provider Analysis and Review records for the years 1996, 2001, and 2006 to assess temporal trends in paralysis by trauma center designation.
Results: Mortality was 7.5%, and 16.3% were discharged with paralysis. Only 57.9% (n = 2378) received care at a designated trauma center. Trauma centers had a 16-fold higher admission caseload (20.7 vs. 1.3; P < 0.001) and 30-fold higher surgical volume (9.6 vs. 0.3; P < 0.001). In the multivariate propensity analysis, paralysis was significantly lower at trauma centers (adjusted odds ratio 0.67; 95% confidence interval, 0.53-0.85; P = 0.001). Higher surgical volume, not higher admission volume, was associated with lower risk of paralysis. Indeed, at nontrauma centers, higher admission caseload was associated with worse outcome. There was no significant difference in mortality.
Conclusions: Trauma center care is associated with reduced paralysis after TSCI, possibly because of greater use of spinal surgery. National guidelines to triage all such patients to trauma centers are followed little more than half the time.