RESEARCH—HUMAN—CLINICAL STUDIES
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Michael L. Kelly, MD∗
Jack He, MD‡
Mary Jo Roach, PhD§
Timothy A Moore, MD‡
Michael P. Steinmetz, MD¶
Jeffrey A. Claridge, MD‡ || #
∗
Department of Neurosurgery, Case
Western Reserve University School of
Medicine, MetroHealth Medical Center,
Cleveland, Ohio; ‡ Department of Surgery,
Case Western Reserve University School
of Medicine, MetroHealth Medical
Center, Cleveland, Ohio; § Center for
Healthcare Research and Policy, Case
Western Reserve University School
of Medicine, MetroHealth Medical
Center, Cleveland, Ohio; ¶ Department
of Neurosurgery, Cleveland Clinic,
Cleveland, Ohio; || Division of Trauma,
Critical Care, Burns, and Acute Care
Surgery, MetroHealth Medical Center,
Cleveland, Ohio; # Northern Ohio Trauma
System, Case Western Reserve University
School of Medicine, Cleveland, Ohio
A portion of this work was presented as a
poster at the 2017 AANS/CNS Section on
Neurotrauma and Critical Care and
National Neurotrauma Society Meeting
in Snowbird, Utah on July 10, 2017.
Correspondence:
Michael L. Kelly, MD,
Case Western Reserve University, School
of Medicine,
MetroHealth Medical Center,
2500 MetroHealth Drive,
Cleveland, OH 44109-1998.
E-mail: mkelly4@metrohealth.org
Received, April 24, 2018.
Accepted, September 13, 2018.
Copyright 
C 2018 by the
Congress of Neurological Surgeons
NEUROSURGERY
Regionalization of Spine Trauma Care in an Urban
Trauma System in the United States: Decreased Time
to Surgery and Hospital Length of Stay
BACKGROUND: The effect of regionalized trauma care (RT) on hospital-based outcomes
for traumatic spine injury (TSI) in the United States is unknown.
OBJECTIVE: To test the hypothesis that RT would be associated with earlier time to surgery
and decreased length of stay (LOS).
METHODS: TSI patients >14 yr were identified using International Classification of Diseases
Ninth Revision Clinical Modification diagnostic codes. Data from 2008 through 2012 were
analyzed before and after RT in 2010.
RESULTS: A total of 4072 patients were identified; 1904 (47%) pre-RT and 2168 (53%) post-
RT. Injury severity scores, Spine Abbreviated Injury Scale scores, and the percentage of TSIs
with spinal cord injury (tSCI) were similar between time periods. Post-RT TSIs demonstrated
a lower median intensive care unit (ICU) LOS (0 vs 1 d; P < 0.0001), underwent spine surgery
more frequently (13% vs 11%; P = 0.01), and had a higher rate of spine surgery performed
within 24 h of admission (65% vs 55%; P = 0.02). In patients with tSCI post-RT, ICU LOS was
decreased (1 vs 2 d; P < 0.0001) and ventilator days were reduced (average days: 2 vs 3; P =
0.006). The post-RT time period was an independent predictor for spine surgery performed
in less than 24 h for all TSIs (odds ratio [OR] 1.52, 95% confidence interval [CI]: 1.04-2.22, C-
stat = 0.65). Multivariate linear regression analysis demonstrated an independent effect
on reduced ICU LOS post-RT for TSIs (OR –1.68; 95% CI: –2.98 to 0.39; R2 = 0.74) and tSCIs
(OR –2.42, 95% CI: –3.99−0.85; R2 = 0.72).
CONCLUSION: RT is associated with increased surgical rates, earlier time to surgery, and
decreased ICU LOS for patients with TSI.
KEY WORDS: Regionalization, Spinal cord injury, Spine trauma, Surgery, Trauma systems
Neurosurgery 0:1–6, 2018 DOI:10.1093/neuros/nyy452 www.neurosurgery-online.com
R
egionalized trauma care (RT) systems are atized care of spine trauma patients improves
associated with decreased mortality rates outcomes.6,7,8 Differences between healthcare
and improved hospital-based outcomes in systems in the US and Canada create unique
a general trauma population.1-5 In patients with challenges for implementing similar compre-
traumatic spine injury (TSI), evidence of region- hensive spine trauma systems in the US.
alized trauma efforts are less common, partic- Although rare in the US, RT has proven
ularly in the United States. Experience in the effective for improving outcomes for general
Canadian trauma system suggests that system- trauma patients,9 and provides an opportunity
for developing similar comprehensive spine
trauma systems in the US. To our knowledge,
ABBREVIATIONS: AIS, Abbreviated Injury Scale; CI, no study has demonstrated the effect of RT
confidence interval; GCS, Glasgow Coma Scale; ICD- on hospital-based outcomes for patients with
9-CM, International Classification of Diseases ninth spine trauma. Regionalization efforts present an
revision clinical modification; ICU, intensive care opportunity to improve hospital-based outcomes
unit; ISS, Injury Severity Scale; LOS, length of stay ;
OR, odds ratio; RT, regionalized trauma care; tSCI,
in patients with spine injury; potentially
TSIs with spinal cord injury; TSI, traumatic spine reducing delays in timing of surgical intervention
injury and improving functional outcomes.10-14
Regionalization may also improve access to
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KELLY ET AL

spinal cord injury rehabilitation, which has been shown to

improve long-term outcomes.15

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TABLE 1. TSI Baseline Characteristics
Our RT system was established to improve outcomes across Pre-RT (n = 1904) Post-RT (n = 2168) P value
the region through the efficient triage and transfer of trauma
patients to an appropriate level of care across hospital systems.3 Age (IQR) 50 (32,70) 52 (34,72) .02∗
The purpose of this study was to determine if time to surgery Male 984 (52%) 1292 (60%) < .001∗
GCS (IQR) 15 (15,15) 15 (15,15) .5
and length of stay (LOS) in patients with TSI improved after RT.
ISS (IQR) 11 (8,18) 11 (8,17) .7
Our hypothesis was that time to surgery would decrease and LOS Head AIS ≥ 3 297 (16%) 314 (15%) .1
would improve after RT. Spine AIS ≥ 3 468 (25%) 547 (25%) .6
Chest AIS ≥ 3 429 (23%) 528 (24%) .07
Abdomen AIS ≥ 3 106 (6%) 111 (5%) .5
METHODS tSCIs 964 (51%) 1067 (49%) .4
Spine Level
Regionalized System Cervical 617 (32%) 665 (31%) .2
The RT system is a regionalized trauma system comprised of 2 Thoracic 539 (28%) 631 (29%) .6
separate hospital systems with 1 level 1 trauma center and several Lumbar 695 (37%) 789 (36%) .9
additional level 2 trauma centers and affiliated nontrauma hospitals. Penetrating 105 (6%) 85 (4%) .02∗
In 2010, the RT system implemented operational initiatives and Insurance
protocols including a hospital transfer/triage protocol based upon injury Private 846 (44%) 857 (40%) .03∗
mechanism and clinical criteria.9 For spine trauma patients (TSI), triage Government 379 (20%) 464 (21%)
None/Unknown 679 (36%) 847 (39%)
and transfer criteria to the level 1 trauma center included Glasgow
Level 1 admissions 1274 (67%) 1605 (74%) < .001∗
Coma Scale (GCS) < 12, penetrating spine injuries, and any neuro-
Level 2 admissions 630 (33%) 563 (26%)
logical deficit. More information is available from the website: https://
www.northernohiotraumasystem.com. AA = African American; AIS = Abbreviated Injury Scale; GCS = Glasgow Comas Scale;
IQR = Interquartile range; ISS = Injury Severity Score; RT = Regionalization of Trauma;
TSI = traumatic spine injury; tSCI = traumatic spinal cord injury
Hospital-Based Outcomes ∗
Statistically significant.
All patients greater than 14-yr-old with a TSI were identified from the
RT database. The RT database is a multi-institution database composed
of all trauma registry data from participating trauma hospitals. The
database contains all data elements required for the National Trauma
time periods. Categorical variables are presented as percentages and the
Data Bank and is also patient-identified, which makes it unique from
X2 or the Fisher exact test were used for comparisons where appro-
state and national trauma databases. Data elements include demographic
priate. A multivariate linear regression analysis was performed to evaluate
information as well as injury severity measures such as the Injury Severity
independent predictors of time to surgery and LOS among all TSIs and
Scale (ISS), the Abbreviated Injury Scale (AIS), LOS, and hospital
among TSIs with spinal cord injury (tSCIs) across the entire RT region.
procedures. TSIs were identified using International Classification of
We used receiver operator curves to assess model fit by calculating the
Diseases ninth revision clinical modification (ICD-9-CM) diagnostic
area under the curve expressed by the C-statistic or R2 value. P value
codes for vertebral fractures with spinal cord injury (733.13; 805.00-
was set at ≤0.05 and all odds ratios (OR) are expressed with a 95%
08; 805.10-18; 806.00-09; 806.10-19; 806.20-29; 806.30-39; 806.4-5;
confidence interval (CI). Analyses were performed using SPSS software
806.8-9;806.60-62,806.69; and 806.70-72,79, 839.00-839.59, 952.00-
(version 24.0; IBM Inc, Armonk, New York).
952.90) and without spinal cord injury (805.2-805.9, 994.8-995.5).
Spine surgery procedures were identified using ICD-9-CM procedure
codes (3.01, 03.02, 03.09, 03.4, 3.53, 80.50, 80.51, 80.59, 93.41, RESULTS
93.42, 81.00-81.08, 81.30-81.39, 81.62-81.66, 84.51, 84.59-84.65).
Nonprimary procedure codes and procedure codes unrelated to the All TSI Patients
management of TSI were excluded. “Severe” TSI was defined as any TSI A total of 4072 patients with TSI were identified in the RT
patient with a Spine AIS ≥ 3. “RT transfers” were defined as hospital
database, 1904 in the pre-RT time period, and 2168 post-RT.
transfers between RT hospitals. The variable “Spine Surgery ≤ 24 hours”
was calculated as the difference between the recorded time of spine
Baseline characteristics including ISS, body-region specific AIS,
surgery and the recorded time of injury, and therefore, accounts for any percentage of tSCIs, and level of spinal cord injury were similar
additional time related to hospital transfers. We analyzed level 1 and level between groups (Table 1). Post-RT patients were slightly older,
2 trauma center admissions and hospital-based outcomes separately. We more likely to be male, and less likely to have a penetrating TSI.
analyzed RT data from 2008 to 2012, before and after RT initiation Post-RT patients were also less likely to have private insurance.
in 2010. The hospital IRB committee approved this study without any Admissions to the level 1 trauma center increased post-RT (74%
requirement for patient consent. vs 67%; P < .001).
Among all patients with TSI, overall hospital LOS was similar
Statistical Analysis at 4 d; however, intensive care unit (ICU) LOS was lower
All median values are presented with interquartile range in parenthesis post-RT (Table 2). The percentage of patients undergoing spine
and we applied the Mann–Whitney U test for comparisons between surgery increased post-RT (13% vs 11%; P = .01) as well as the

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TABLE 2. TSI Hospital-Based Outcomes TABLE 3. tSCI baseline characteristics

Pre-RT Post-RT Pre-RT Post-RT

(n = 1904) (n = 2168) P value (n = 964) (n = 1067) P value

LOS (IQR) 4 (2,8) 4 (2,7) .4 Age (IQR) 54 (35,77) 57 (36,78) .2

ICU LOS (IQR) 1 (0,4) 0 (0,3) <.001∗ Male 479 (50%) 629 (59%) <.001∗
Ventilator Days (IQR) 0 (0,0) 0 (0,0) – GCS (IQR) 15 (14,15) 15 (14,15) .4
Spine Surgery 206 (11%) 290 (13%) .01∗ ISS (IQR) 11 (8,21) 10 (8,18) .5
Spine Surgery ≤ 24 ha 113 (55%) 189 (65%) .02∗ Head AIS ≥ 3 167 (17%) 170 (16%) .2
Discharge Disposition Spine AIS ≥ 3 390 (41%) 444 (42%) .7
Home 904 (48%) 1039 (48%) .8 Chest AIS ≥ 3 189 (20%) 190 (18%) .6
Acute Rehab 326 (17%) 359 (17%) Abdomen AIS ≥ 3 30 (3%) 39 (4%) .2
SNF/LTAC 457 (24%) 527 (24%) Spine Level
Mortality Cervical 600 (62%) 648 (61%) .9
Hospital 152 (8%) 145 (7%) .1 Thoracic 288 (30%) 295 (28%) .4
Lumbar 236 (25%) 273 (26%) .3
IQR = Interquartile range; ICU = Intensive care unit; LOS = Length of stay;
Penetrating 54 (6%) 38 (4%) .03∗
RT = Regionalization of Trauma; NSGY = Neurosurgery; SNF = Skilled Nursing Facility;
Insurance
TSI = Traumatic spine injury
∗
Statistically significant. Private 385 (40%) 414 (39%) .9
a
Percentages only for those patients who underwent surgery. Government 216 (22%) 236 (22%)
None/Unknown 601 (38%) 417 (39%)
Level 1 admissions 601 (62%) 774 (73%) <.001∗
Level 2 admissions 363 (38%) 293 (28%)
percentage of patients undergoing spine surgery within 24 h of
hospital admission (65% vs 55%; P = .02). AA = African American; AIS = Abbreviated Injury Scale; GCS = Glasgow Comas Scale;
IQR = Interquartile range; ISS = Injury Severity Score; RT = Regionalization of Trauma;
TSI = traumatic spine injury; tSCI = traumatic spinal cord injury
tSCI Patients Only ∗
Statistically significant.
A total of 2031 patients with tSCI were identified during the
study period; 964 patients pre-RT and 1067 post-RT. Baseline
characteristics were similar between groups across ISS, AIS, spinal
level of injury, and insurance status (Table 3). Post-RT tSCIs were TABLE 4. Traumatic Spinal Cord Injury (tSCI) hospital-based
outcomes
more likely to be male and less likely to suffer a penetrating tSCI.
Level 1 trauma center admissions increased from 62% to 73% in Pre-RT Post-RT
the post-RT time period (P < .001). (n = 964) (n = 1067) P value
Among all patients with tSCI, ICU LOS and ventilator days LOS (IQR) 4 (2,8) 4 (2,8) .3
were significantly lower post-RT (Table 4). The percentage of ICU LOS (IQR) 2 (0,4) 1 (0,3) <.001∗
spine surgery increased post-RT (21% vs 15%; P = .01) and there Ventilator Days (IQR) 0 (0,1) 0 (0,0) .006∗
was a trend toward increased spine surgery performed within 24 h Spine Surgery 148 (15%) 227 (21%) .001∗
of hospital admission post-RT (66% vs 57%; P = .08). No differ- Spine Surgery ≤ 24 ha 84 (57%) 150 (66%) .08
ences in discharge disposition or hospital mortality were observed. Discharge Disposition
Home 396 (41%) 455 (43%) .9
Acute Rehab 189 (20%) 206 (19%)
Multivariate Analysis
SNF/LTAC 247 (26%) 256 (24%)
Multivariate logistic regression analysis demonstrated an Other 132 (14%)
independent effect on spine surgery performed within 24 h of Mortality
admission in the post-RT time period for all TSIs (OR, 1.52; 95% Hospital 97 (10%) 102 (10%) .7
CI, 1.04-2.22) and a trend toward significance for tSCIs (OR, IQR = Interquartile range; ICU = Intensive care unit; LOS = Length of stay;
1.50; 95% CI, 0.95-2.34) (Table 5). TSI patients were 50% more RT = Regionalization of Trauma; NSGY = Neurosurgery; SNF = Skilled Nursing Facility;
likely to undergo surgery post-RT. C-statistics for each model TSI = Traumatic spine injury
∗
Statistically significant.
were 0.65 and 0.66, respectively. a
Percentages only for those patients who underwent surgery.
Multivariate linear regression analysis demonstrated an
independent effect on ICU LOS in the post-RT time period for
all TSIs (OR –1.68; 95% CI: –2.98 to 0.39; R2 = .74) (Table 6) DISCUSSION
and for tSCIs only (OR –2.42, 95% CI: –3.99 to 0.85; R2 = .72;
Table 7). ICU LOS was reduced by 0.68 d for TSI patients and Our results demonstrate that regionalization of spine trauma
by 2.4 d for tSCI patients post-RT. The R2 for each model were across hospital systems in an urban US geographic region is
0.74 and 0.72, respectively. associated with more efficient and timely spine trauma care.

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KELLY ET AL

The post-RT time period was associated with increased surgery

TABLE 5. Multivariate Regression Analysis for Spine Surgery ≤ 24 h

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and an increase in surgery performed within 24 h of admission
Logistic regression Logistic regression
for patients with TSI. The post-RT time period was also
all TSIs OR (95% CI) all tSCIs OR (95% CI) associated with decreased ventilator days for patients with tSCI
and decreased ICU LOS for patients with both TSI and
Age .98 (.97-.99)∗ .97 (.96-.99)∗ tSCI.
ISS .98 (.97-.99)∗ .98 (.96-.99)∗
The effect of RT on spine trauma outcomes in the US has
Penetrating .51 (.15-1.78) 1.09 (.21-5.72)
RT 1.52 (1.04-2.22)∗ 1.50 (.95-2.34) not previously been reported to our knowledge. Recent Canadian
C-statistic = .65 C-statistic = .66 studies suggest that an organized, collaborative system of spine
trauma care is associated with more effective medical care,8 better
AA = African American; AIS = Abbreviated Injury Scale; CI = Confidence Interval;
ISS = Injury Severity Score; RT = Regionalization of Trauma; OR = Odds ratio;
access to spinal cord injury rehabilitation,15 and likely better long-
TSI = Traumatic spine injury term outcomes for patient with TSI.10,13 A growing body of liter-
∗
Statistically significant. ature also suggests that reduced time to definitive surgery for
patients with TSI and tSCI is associated with improved outcomes,
reduced complications, and shorter ICU stays.16-21 Moreover, the
treatment of patients with TSI in specialized spine trauma centers
TABLE 6. Multivariate Regression Model for ICU LOS for all TSIs has been associated with improved outcomes as well.13 Our data
suggest a similar phenomenon within our own system as more
Std. 95% Confidence
B Error Interval for B
patients with spine trauma and spinal cord injury were triaged
to the level 1 trauma center with a corresponding decrease in
Lower Upper level 2 trauma center admission within our regionalized system
Age .03 .02 –.01 .06 (Tables 1 and 3).
ISS .05 .03 –.01 .10
Our results suggest how the benefits of trauma systems research
Penetrating 6.02∗∗ 2.37 1.36 10.68
Spine Surgery ≤ 24 hrs –1.40∗ .66 –2.67 –.07
from outside the US might be applied to trauma centers and
Vent Days .93∗ .04 .85 1.01 systems within the US. Prior studies have shown how an overall
Insurance Government –1.43∗∗∗ .72 –2.85 –.01 maturation of trauma centers and trauma care in the US can
RT –1.68∗∗ 0.66 –2.98 –.39 be associated with improved outcomes in a general trauma
Constant 4.55 1.48 1.64 7.46 population.22,23 However, these data have not been applied to
R2 = .74∗ patients with traumatic spine injuries specifically. A large study by
AA = African American; AIS = Abbreviated Injury Scale; CI = Confidence Interval; Harrop et al24 examined triage patterns in the state of Pennsyl-
ISS = Injury Severity Score; OR = Odds ratio; RT = Regionalization of Trauma; vania and found that spine trauma patients showed the longest
Std = Standard; TSI = Traumatic spine injury mean transit times when compared with other traumatic injuries.
∗
P ≤ .001, ∗∗ P ≤ .01, ∗∗∗ P ≤ .05.
These data suggest that spine trauma may be undertriaged even
within established trauma centers and systems. Moreover, a recent
large-scale review of the literature on controversies in spine trauma
care emphasized the variability and inconsistency in surgical care
TABLE 7. Multivariate Regression Model for ICU LOS for Only tSCIs
for patients with TSI across the US.25
Std. 95% Confidence A growing body of literature has demonstrated the effect of
B Error Interval for B trauma regionalization on survival for patients with traumatic
injuries, including traumatic brain injury,5,9,26-28 although many
Lower Upper
Age .028 .020 –.012 .068 of these studies have been done outside the US.1,3,29 Our
ISS .029 .034 –.038 .095 findings, coupled with research from outside the US, suggest that
Penetrating 1.94 2.77 –3.52 7.39 systematized, collaborative models of care improve hospital-based
Spine Surgery ≤ 24 h –.072 .800 –2.29 0.86 outcomes for TSI patients through improved triage, reduced time
Vent Days .91∗ .05 .82 1.00 to definitive treatment, and better access to rehabilitation services.
Insurance Government –1.27 .84 –2.92 .38 However, given the distinct features of the US healthcare system,
RT –2.42∗∗ .80 –3.99 –.85
Constant 5.05 1.77 1.55 8.55
including a lack of specialized spine trauma care within trauma
R2 = .72∗ systems more generally, how such findings might be applied to
trauma centers and systems across the US remains unknown.
AA = African American; AIS = Abbreviated Injury Scale; CI = Confidence Interval; Our study demonstrates how successful implementation of a
ISS = Injury Severity Score; RT = Regionalization of Trauma; Std = Standard; tSCI
Traumatic spine injury with spine fracture regionalized trauma system is associated with improved triage and
∗
P ≤ .001, ∗∗ P ≤ .01. reduced time to definitive care for patients with TSI and provides

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a model for improving spine trauma care for patients with TSI in
other urban trauma regions across the US.
Limitations
Our study was observational and the effect of time and changes
external to the RT may have affected hospital-based outcomes
and should limit any conclusions about causal relationships from
our results. We report known changes that occurred in our
trauma region during the study period. Patients in the post-RT
group were slightly older, had fewer penetrating injuries, and
were less likely to have private insurance; likely due to changes
in demographics after regionalization. However, injury severity
measures including GCS, ISS, AIS, level of tSCI, percentage of
tSCIs were similar between time periods. Our study may also be
limited by its generalizability to other trauma centers and regions
in the US where differences in cost and the structure of healthcare
systems may limit collaborative trauma efforts. However, the
efficient triage and transfer of spine trauma patients to an appro-
priate level of care within any region is a desirable goal that can
be accomplished in a variety of ways. Our study presents one
model for how such a process might be accomplished; but other
models are certainly possible, and we hope our findings might
spur greater innovation in trauma systems research and devel-
opment, particularly for spine trauma patients. Finally, the goal
of the study was to examine hospital-based outcomes and time to
treatment after RT. Future studies could examine functional and
patient-specific outcomes associated with RT in TSI; although
US trauma registries currently provide limited information for
long-term follow-up and lack spine-specific functional outcome
measures.
CONCLUSION
RT is associated with increased surgery, reduced time to
surgery, and decreased LOS for patients with TSI. Our results
suggest that a collaborative model of trauma care with spine-
specific triage protocols and specialized surgical and medical care
can improve hospital-based outcomes in the US.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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COMMENT
T he regionalization of spine trauma patient care, particularly in an
urban setting, intuitively makes sense – but only if the components
of the regionalization team are in sync and function as a true team. When
such is the case, a much larger and more functional network is created
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that helps ensure that spine trauma patients are triaged and transported
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to the closest and most appropriate site for the provision of definitive
surgical and non-surgical care.
The triage strategy with such a system might take into account
bed availability, physician and surgeon availability, urgency of the case,
complexity of the case, as well as many other factors. This would
obviously be individualized for each trauma case.
I applaud the authors for their work, and can only hope that other
systems will work toward this team approach the to the triage of spine
trauma patients in the future.
Ed Benzel
Cleveland, Ohio
www.neurosurgery-online.com