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Long-Term Posttraumatic Survival of Spinal Fracture Patients in Northern Finland

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Long-Term Posttraumatic Survival of Spinal Fracture Patients in Northern Finland SPINE Volume 43, Number 23, pp 1657–1663 ß 2018 Wolters Kluwer Health, Inc. All rights reserved. EPIDEMIOLOGY Long-term Posttraumatic Survival of Spinal Fracture Patients in Northern Finland Ville Niemi-Nikkola, BM,Ã,y Nelli Saijets, BM,Ã,y Henriikka Ylipoussu, BM,Ã,y Pietari Kinnunen, MD, PhD,z Juha Pesa¨la¨,MD,z Pirkka Ma¨kela¨,MD,z Markku Alen, MD, PhD,Ã,§ Mauri Kallinen, MD, PhD,Ã,§ and Aki Vainionpa¨a¨, MD, PhDÃ,§,{ age groups of 50 to 64 years and over 65 years, the most Study Design. A retrospective epidemiological study. important risk factors for death were males with hazard ratios of Objective. To reveal the long-term survival and causes of death 3.0 and 1.6, respectively, and low fall as trauma mechanism after traumatic spinal fracture (TSF) and to determine the with hazard ratios of 9.4 and 10.2, respectively. possible factors predicting death. Conclusion. Traumatic spinal fractures are associated with Summary of Background Data. Increased mortality follow- increased mortality compared with the general population, high ing osteoporotic spinal fracture has been represented in several mortality focusing especially on older people and men. The studies. Earlier studies concerning mortality after TSF have increase seems to be comparable to the increase following hip focused on specific types of fractures, or else only the mortality fracture. Patients who sustain spinal fracture due to falling need of the acute phases has been documented. In-hospital mortality special attention in care, due to the observation that low fall as has varied between 0.1% and 4.1%. Methods. The study sample of 947 patients including all trauma mechanism increased the risk of death significantly. Key words: cause of death, epidemiology, falling, long-term patients with TSF admitted to Oulu University Hospital, Finland, survival, mortality, spinal fracture, spinal injury, survival, between January 1, 2007 and December 31, 2011. TSFs were trauma, traumatic spinal fracture, vertebral fracture. identified using International Classification of Diseases 10th Level of Evidence: 3 revision or Nordic Classification of Surgical Procedures codes Spine 2018;43:1657–1663 and all patient records were manually reviewed. Times and causes of death, obtained from Statistics Finland’s Archive of Death Certificates, were available until the end 2016 and 2015, respectively. he annual incidence of traumatic spinal injury in Results. At the end of the follow-up 227 (24.0%) had died. Northern Finland has been documented to be 26/ Mortality was 6.8% after the first year and 19.1% after 5 years. 100,000, with 99.4% of patients sustaining a spinal T 1 Mortality was increased in all age groups compared with the fracture. Existing spinal injury is known to increase mor- general population, 1-year standardized mortality ratios ranging tality in trauma patients.2 The increased mortality following from 3.1 in over 65-year-olds to 19.8 in under 30-year-olds. In osteoporotic spinal fracture as well as after spinal cord injury has been represented in many studies. The standard- ized mortality ratio (SMR) after a spinal fracture has been From the ÃDepartment of Medical Rehabilitation, Oulu University Hospital, documented to be between 2.4 and 2.5 for men and 1.7 and Oulu, Finland; yFaculty of Medicine, University of Oulu, Oulu, Finland; 3,4 z 1.9 for women. After spinal cord injury, SMR was 2.7 in a Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu 5 University Hospital, Oulu, Finland; §Center for Life Course Epidemiology Finnish 30-year follow-up. Research, University of Oulu, Oulu, Finland; and {Department of Rehabili- Earlier studies about long-term mortality after traumatic tation, Seina¨joki Central Hospital, Seina¨joki, Finland. spinal fractures (TSFs) have focused on specific types of Acknowledgment date: March 8, 2018. Acceptance date: April 2, 2018. fracture, or else only the mortality of acute phases has been The manuscript submitted does not contain information about medical documented. Most studies cover only a specific age group, device(s)/ drug(s). commonly the elderly. In-hospital short-term mortality has The Northern Ostrobothnia Hospital District (State Research Funding; VTR) 6–9 funds were received in support of this work. varied between 0.1% and 4.1% in different studies. It has Relevant financial activities outside the submitted work: payment for been shown that long-term mortality after trauma is signifi- lecture, travel/accommodations/meeting expenses. cant, and must be taken into account when studying 10 Address correspondence and reprint requests to Ville Niemi-Nikkola, BM, mortality. Department of Medical Rehabilitation, Oulu University Hospital, P.O. Box Increased long-term mortality after severe trauma and 21, FI-90029 Oulu, Finland; E-mail: [email protected] hip fracture is well documented. However, knowledge DOI: 10.1097/BRS.0000000000002687 about long-term survival after TSF is limited. The aim of Spine www.spinejournal.com 1657 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. EPIDEMIOLOGY Posttraumatic Survival of Spinal Fracture Patients in Finland Niemi-Nikkola et al the study was to reveal the long-term survival and causes of etiology was recorded according to ICD-10 external causes death after TSFs in Northern Finland and to determine the and grouped according to International Spinal Cord Society possible factors predicting death. (ISCoS) Core Dataset modified to differentiate low falls (<1 m) and high falls (>1m).12 Information of associated MATERIALS AND METHODS injuries was gathered according to ISCoS Core Dataset This is a retrospective study of TSFs admitted to Oulu definitions. As a modification, criteria of traumatic brain University Hospital (Oulu UH), Oulu, Finland. Oulu UH is injury were broadened to include cases with diagnostic the only tertiary level trauma center in its own hospital district findings in head computed tomography (CT) or magnetic (population 398 205 in 2011). In addition, Oulu UH is a resonance imaging (MRI) or cases with moderate to severe tertiary level referral center for four other central hospital traumatic brain injury diagnosed in neuropsychological districts (population in total 398,205þ339,475 ¼ 737,680 in testing afterward. Times and causes of deaths were 2011) for the rest of Northern Finland.11 obtained from Statistics Finland’s Archive of Death Certif- The study sample included patients suffering from TSF icates and annual population number, number of deaths, with date of injury between January 1, 2007 and December and death causes of the general population were obtained 31, 2011. Patient information was collected from the hos- from Official Statistics of Finland.13,14 The data acquisition pital care register including all inpatient and outpatient started in January 2014. Times of deaths from Statistics visits and surgical procedures. Traumatic spinal injuries Finland’s Archive of Death Certificates were available until were identified with International Classification of Diseases the end 2016 and causes of deaths until the end 2015, 10th revision (ICD-10) codes or Nordic Classification of providing a maximum and minimum follow up time of 9 Surgical Procedures (NCSP) codes. Study approval was and 5 years for mortality, respectively, and 4 years follow- obtained from Oulu University Hospital administration. up for causes of death. An ethics committee statement was not required for the The observed deaths during the first year after the frac- register study. ture were used in the calculation of SMRs. Expected deaths AnautomatedsearchwithICD-10andNCSPcodes were calculated using the average 1-year mortality accord- (Table 1) revealed 1884 hits with admission dates from ing to gender and age group in the general population of January 1, 2007 to April 31, 2012. Furthermore, an Northern Finland 2007–2011. SMRs were calculated for extended period in automated searchwasusedtoidentify the complete sample and for different age groups. To mini- those patients with delayed referral. After elimination of mize the effect of difference in age distribution of the general duplicates 1310 different patients were identified and population and the study sample, the SMR of the oldest age reviewed to assess eligibility and collect data (patient and group of over 65 years was age-adjusted, dividing it to injury characteristics, associated injuries and length of groups of 65 to 74 years, 75 to 84, and over 85 years stay). During the review, we excluded patients who did old. Student t test was used to analyze group differences not meet the inclusion criteria of TSF (e.g., osteoporotic in continuous and x2 test in categorical variables. Kaplan- fractures without evident trauma or traumatic spinal cord Meier curves were used to determine survival ratios and Cox injury without a fracture) or injury date. A total of 965 proportional hazard regression with forward stepwise patients met the criteria for TSF and after excluding 18 method to determine hazard ratios. SPSS version 23 foreigners (mortality data not available) the study sample (IBM, Armonk, NY) was used to perform all the statistical consisted of 947 patients. Injury characteristics and analyses. RESULTS TABLE 1. Diagnosis and Procedure Codes for Patient characteristics are represented in Table 2. At the end the Inclusion of Subject of the follow-up 227 (24.0%) of the 947 patients had died. ICD-10: traumatic ICD-10: Traumatic The mean age at death was 75.9 (SD 15.2). For men, the spine injuries spinal cord injuries NCSP mean age was 71.1 (SD 15.4, n ¼ 132) and for women 82.6 (SD 12.0, n ¼ 95) (P < 0.01). S12.0–9 S14.0 NAJ00 S13.0–3 S14.1 NAJ10 Survival S17.8–9 S24.0 NAJ12 The 1- and 5-year mortality rates were 6.8% and 19.1% S22.0–1 S24.1 NAJ20 overall, 7.4% and 19.3% for men, 5.8% and 18.8% for S23.0–2 S34.0 NAJ22 women, respectively.
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