Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 35-41

Prospective study to evaluate the incidence of deep-vein thrombosis in patients with acute traumatic spinal cord injury


1 Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
2 Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
3 Department of Radiodiagnosis and Immaging, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

Date of Submission15-Feb-2020
Date of Decision17-Mar-2020
Date of Acceptance22-Mar-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Roop Singh
Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_21_20

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  Abstract 


Introduction: Deep-vein thrombosis (DVT) is one of the precarious complications of spinal cord injury (SCI). The present study was aimed to determine the incidence of DVT in acute traumatic SCI in the Indian population, factors associated with DVT, and to evaluate the role of D-dimer and color Doppler in establishing the diagnosis. Patients and Methods: Fifty patients with acute SCI presenting to a tertiary care center within 48 h of injury were clinically evaluated for the level, extent, and severity of SCI according to the ASIA standards. The local examination for the assessment of DVT was conducted. D-dimer test and color Doppler for DVT were performed at initial presentation, on day 7 and 14, 1 month, 3 months, and 6 months. Results: Three patients developed DVT between 14 days to 1 month. Overall DVT incidence was found to be 6%. Neurological level (P < 0.05) and the severity of the deficit (P < 0.001) were found to be associated with DVT. Patients with DVT had significantly more thigh and calf circumference at 1 month. Significantly higher levels of D-dimer were observed right from initial presentations to 6 months. Color Doppler was positive in all the three cases of DVT. Conclusions: The incidence of DVT is low in SCI patients in India, but it is not a rare complication. The occurrence of DVT has a significant correlation with factors such as the level and severity of injury. Frequent clinical examinations including the thigh and calf circumference along with D-dimer level estimation are good screening indicators, and color Doppler is an effective tool for establishing a definitive diagnosis of DVT in SCI patients.

Keywords: ASIA, color Doppler, D-dimer, deep-vein thrombosis, spinal cord injury


How to cite this article:
Singh R, Kaur K, Mittal A, Sen J. Prospective study to evaluate the incidence of deep-vein thrombosis in patients with acute traumatic spinal cord injury. Indian J Vasc Endovasc Surg 2021;8:35-41

How to cite this URL:
Singh R, Kaur K, Mittal A, Sen J. Prospective study to evaluate the incidence of deep-vein thrombosis in patients with acute traumatic spinal cord injury. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 26];8:35-41. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/35/309705




  Introduction Top


Spinal cord injury (SCI) is a crippling medical emergency that leads to severe physical disabilities for affected individuals.[1] Besides damage within the spinal cord, SCI can cause several secondary complications, such as deep-vein thrombosis (DVT), pulmonary embolism, postural hypotension, neuropathic pain, and spasticity.[2] DVT is one of the precarious complications of acute traumatic SCI.[3] It is the prime complication of the acute phase of SCI that can lead to chronic thrombophlebitis, swelling, pulmonary embolism, or death.[4],[5],[6]

The incidence of DVT is 1–2 people/1000 annually in the Western populations.[7] In contrast, a lower incidence of DVT (1.3%–6.1%) is reported in the Asian population. The greater incidence of DVT is seen in paraplegics, in patients with increasing age, acute-care phase, prolonged immobilization, and head injury.[8],[9],[10],[11]

Three important factors, i.e. hypercoagulability, endothelial injury, and venous stasis, known as Virchow's triad was recognized for thrombus formation. SCI often precipitates one or all of these risk factors leading to a high risk of thromboembolism.[12] Direct injury to blood vessels can cause intimal damage leading to thrombosis. In addition, prolonged bed rest, immobilization, and hypoperfusion promote venous stasis. Decreased levels of antithrombin III and suppression of fibrinolysis may cause hypercoagulability in trauma patients.[13]

Precise and early diagnosis of DVT is pivotal in enabling timely intervention and management. However, the diagnosis of DVT clinically is unreliable. Different methods such as D-dimer, venous ultrasound, and venous plethysmography were established as acceptable noninvasive methods for diagnosing DVT.[14],[15] Venography is a definitive test for DVT, but is an invasive study. The D-dimer assay is a rapid, noninvasive, and inexpensive test and measures fibrin degradationproducts. D-dimers, as fibrin is the main component of thrombosis formation.[16] It is highly sensitive, but the presence of D-dimers in other disease states reduces the specificity of the test.[17] Duplex ultrasound is a cost-effective tool for DVT surveillance in individuals with acute traumatic SCI.

The present study was aimed to determine the incidence of DVT in acute traumatic SCI in the Indian population; factors associated with DVT, and to evaluate the role of D-dimer and color Doppler in establishing the diagnosis.


  Patients and Methods Top


This prospective study was approved by the institutional ethical committee and informed consent from all of the participants was obtained. We enrolled 50 patients with acute SCI presenting within 48 h of injury in the study. Patients with nontraumatic causes for SCI, presenting over 48 h of injury, prior history of DVT earlier in life, and any known history of bleeding diathesis were excluded from the study.

A detailed, informative history of the patient was taken. We conducted a thorough general physical and neurological examination of the patients. Clinical assessment (sensory score, motor score, and zone of partial preservation) was made at the time of initial presentation, 7th day, 14th day, 1 month, 3 months, and 6 months according to the international guidelines.[18] Plain roentgenogram examination (lateral, anteroposterior film) was done. We carried out routine and required laboratory investigations. Fifteen patients who needed surgery for unstable vertebral column injuries were operated as per requirement; rest of the patients were managed conservatively. Patients were discharged after rehabilitation and sent back home for community reintegration.

We conducted a local examination for the assessment of DVT. We assessed patients for skin changes, pitting edema, development of collateral superficial veins, Homans' sign, and Moses test. We also measured the thigh and calf. They were further subjected to D-Dimer test and color Doppler on both legs from groin to ankle (linear probe, 8 to 15 Hz). All the clinical evaluation, D-Dimer test and color Doppler for DVT was done at initial presentation, on days 7 and 14, 1 month, 3 months, and 6 months. As per hospital policy, no chemoprophylaxis is given routinely; only patients with a history/high risk/or who develop DVT are given chemoprophylaxis. Hospital has holistic rehabilitation protocol. More stress is laid on the prevention of DVT by active participation of patients in physiotherapy and rehabilitation in SCI patients.


  Results Top


The mean age of the patients was 33.38 ± 12.97 years. There was a male preponderance in the study with 40 (80%) males and 10 (20%) females. The mode of injury in most of the patients (62%) was fall, followed by roadside accidents in 28% of the patients. When an occupation survey was done, we found that most of the patients to be farmers (30%), followed by laborers (28%) and students (22%). A majority of patients reported to the hospital within 10 h (58%). Mean duration of hospital stay was 33.2 ± 5.7 days. All the patients completed minimum of 6 months of follow-up.

[Table 1] depicts the clinical presentation of the SCI patients shows that pain, swelling, weakness, and deformity were the universal presenting symptoms in this series of patients initially. The level of injury was noted and injury to the lumbar spine accounted for the maximum number of cases (42%) followed by the cervical spine (26%), thoracic spine (24%), and thoracolumbar (8%) spine.
Table 1: Symptoms and clinical examination at the time of presentation up to 6 months follow-up in the study population

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[Table 2] shows the neurological status at the time of injury and subsequent follow-ups of patients according to the ASIA score. There was an improvement in neurological status in due course, but it was not significant.
Table 2: Neurological status as assessed by Asia score at the time of presentation up to 6 months follow-up in the study population

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Thirty-five patients of 50 were conservatively managed and the other 15 were managed surgically. Two patients managed conservatively developed DVT, and one patient with surgically stabilized spine developed DVT. We observed no statistically significant difference in the incidence of DVT between operated and nonoperated patients.

Clinical evaluation for DVT and D-dimers levels of all the patients are shown in [Table 3]. Overall DVT incidence was calculated, and we found it to be 6% in this study. Detailed comparison of DVT-positive and -negative patients are displayed in [Table 4].
Table 3: Specific clinical examination for deep-vein thrombosis and D-dimer levels at the time of presentation up to 6 months follow-up in the study population

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Table 4: Comparison of various parameters among deep-vein thrombosis positive and deep-vein thrombosis negative patients

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  Discussion Top


DVT, as one of the major complications after SCI, is a potentially catastrophic condition. Depending on the age of the patient, type of lesion, management modalities, and diagnostic methods, DVT incidence varies from population-to-population and country-to-country as documented in a series of studies.[19],[20],[21],[22] The present study was aimed to evaluate the incidence of DVT in patients with acute traumatic spine injury in the Indian population.

The demographic profile of the present study is comparable to the literature. The incidence of SCI was more common in young, with the male predominance in the present study showing an increased incidence of DVT in males of the younger age group. We found that falling from height is the most common cause of SCI in the current study and the literature. Roadside accidents follow falling from height.[23] The occurrence of SCI is frequent among farmers in the present study, as agriculture is the chief occupation in this part of India. Most injured patients reported to the hospital within 10 h following injury in our study. Matsumoto et al. also observed a median period from injury to hospitalization less than 1-day post-injury similar to our study.[23] However, in contrast, Mackiewicz-Milewska et al. reported the mean time of 21 months (range 3.5 to 124 months) from injury to admission.[24] All the above studies concluded that the time gap did not have any significant association with the occurrence of DVT as the majority of DVT cases in patients with SCI are seen within the 1st 3 months of injury with a peak incidence between the 7th and 14th days.

Pain, urinary retention, incontinence, and weakness in the lower limbs were the most common symptoms during the initial presentation of the current study. Weakness in the upper limbs, swelling, deformity, etc.- were other less common symptoms in patients with SCI. Significant improvements in pain, swelling, and weakness in the lower limbs were observed at 6 months follow-up (P < 0.001). However, incontinence persisted in numerous patients. We observed fewer signs of recovery in patients with weakness of the upper limbs. On examination tenderness, deformity and decreased muscle tone at the time of presentation were common findings, which recovered significantly (P < 0.001) at 6 months. Improvement in MIS and SIS score was also observed and the change in the score was statistically significant (P < 0.001) at 6 months when compared with baseline values. In this study, the majoity of cases (42%) encountered lumbar spine injury followed by the cervical spine (26%) and thoracic spine (24%). Cervical spine injury was observed in a majority of cases followed by injury at the thoracic level by Do et al.[19] (46.4%), Matsumoto et al.[23] (65.5%), and Mackiewicz-Milewska et al.[24] (52.3%), which was in contrast to the present study. However, Ballu et al.[25] reported that the most common injury was injury to the cervical spine (52.83%), followed by the lumbar spine (22.64%). The most common neurological level of injury was L1-L5 (44%). A significant association (P < 0.05) was noted between the neurological level of injury and the presence of DVT with cervical and thoracic levels. However, Abdulsamad et al. observed that the most common neurological injury level was the thoracic (95%), followed by the cervical (92%) and lumbar (72%) and a statistically significant association between the lumbar neurological level of injury compared to other levels and the presence of DVT (P = 0.011) was found.[26] Distribution of DVT patients according to the ASIA grade was noted. In the present study, out of three patients having DVT, one had ASIA score A and one each had ASIA score C and D. Similarly, Matsumoto et al. reported that 32%, 7%, and 28% of patients with ASIA grade A, grade B, and C, respectively, developed DVT. The maximum number of patients (34%) who developed DVT was in grade D.[23] Ballu et al.[25] found 41.5% of patients with ASIA A, 22.6% with ASIA B, 8.7% and 18.8% patients in C and D, respectively, whereas Abdulsamad et al.[26] observed 73.4% of patients with ASIA grade A. A majority of investigators opined that patients with the complete motor deficits are more likely to develop DVT.

Clinical, laboratory and color Doppler examinations were conducted in all the patients thoroughly to establish any evidence of DVT. In the present study, we have not used any specific tool to assess the risk factors, although multiple scoring systems are available to identify high-risk patients.[26],[27],[28],[29] Wells Score and Capirini risk assessment model are the most widely used tools to identify risk of the development of DVT.[26],[27],[28],[29] Ballu et al. reported that D-dimer test in combination with the Wells score was found to be a useful screening test and could reduce the need for further test if negative.[25]

In the present study, based on clinical examination, we found three patients to be DVT positive [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d. We observed skin changes in two patients, which appeared on day 14 in one patient and at 1 month in the second patient. We found this change to be nonsignificant in the DVT-positive patients (P = 0.153) in our study. Ballu et al. reported a skin change in one patient out of 5 DVT positive patients and they found pedal edema as another prominent clinical feature.[25] Mackiewicz et al. observed typical clinical symptoms such as swelling, redness, and tenderness in two patients out of five reported cases of DVT. They considered tenderness as a nonsignificant symptom for DVT in SCI patients, as pain sensations are impaired in these individuals.[24] Fever and pedal edema are described as the only relevant symptoms of significance by a few investigators.[30] Most researchers summarize that all these clinical findings are not reliable diagnostic findings for DVT,[30] but Aggarwal and Mathur[31] reported fever as an important clinical noteworthy sign for diagnosing DVT.
Figure 1: (a) Magnetic resonance image (Sagittal) of 28-year-old male paraplegic with dorsal twelfth vertebra fracture. (b) Posterior stabilization with pedicle screw fixation was done. Postoperative antero-posterior radiograph showing good stabilization. (c) Patient developed DVT in right lower limb at one month. Clinical photograph showing swelling of right lower limb. (d) Color Doppler image shows echogenic thrombus and non compressible distal vein

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In the present study, significant increase in thigh circumference at 1 month (P < 0.001) and similarly, significant increase in calf circumference were observed at 1, 3, and 6 months (P < 0.01, P < 0.05, and P < 0.001), respectively [Table 3] in patients having a clinical suspicion of DVT. In the present study, increments of 5 cm of thigh circumference and 4 cm in calf circumference were considered remarkable in DVT-positive patients. Similarly, Ballu et al. observed that thigh and calf circumference are important clinical signs in DVT-positive cases. They observed increased thigh circumference in one and calf circumference in four subjects. An increment of 3 to 5cm was considered being significant.[25] Saraf et al. had a different opinion regarding these circumferences. They considered it as a nonsensitive and nondiagnostic indicator because of the supposition that changes in leg circumference because of the progressive wasting of the muscles in SCI patients can cause a disparity in dimensions.[30]

Homan's sign and Moses test were negative initially but later found to be positive in one subject on day 14 and two patients at 1 month in the present study. Ballu et al. did not observe positive Homan's sign in their DVT-positive patients. The common presumption of both studies is that Homan's sign and Moses test were an unreliable way of testing DVT in SCI patients.[25]

In the current study, mean D-dimer levels in DVT-positive patients (743.33 ± 119.3) when compared to the nonDVT patient (271.2 ± 121.3) was found to be highly significant (P < 0.01). An increased level of D-dimer levels was found at day 7. These increased D-dimer levels were observed in both DVT and nonDVT patients, which maybe because of the body response to the trauma. In the present study, we made a notable observation that the patients who developed DVT later also had higher D-dimer values at the initial presentation. Matsumoto et al. observed that the mean D-dimer level on DVT detection was 14.6 ± 11.8 μg/ml, with no significant differences between those who developed DVT and those who did not at any time points. Though D-dimer measurement was preponderantly used for the diagnosis of DVT, they inferred that both sensitivity and specificity of D-dimer was low which indicates that D-dimer alone is not a sufficient mean of diagnosing DVT.[23] Ballu et al. suggested that we can safely rule out DVT if D-dimer is negative, and they labeled it as a good screening indicator with the sensitivity and specificity of 83.3% and 72.2%, respectively.[25] An increase in the mean value of D-dimer in DVT patients was also observed by Mackiewicz-Milewska et al.[24] The current study and other authors discern that D-dimer can also be a helpful diagnostic screening test with high sensitivity, but low specificity as D-dimer levels can be elevated in patients without DVT. Elevated D-dimer levels can be present the following major trauma, infections, neoplasms, surgery, and elderly above the age of 80 years. Hence, the following conditions should be ruled out before establishing the final diagnosis.[24]

We carried Doppler US on all the enrolled patients. The purpose of screening all the patients was also to detect clinically nonsuspicious patients. We found three patients who were clinically positive for the signs of DVT positive on Doppler. We detected one patient positive on the 14th day and the other two were positive at a 1-month evaluation. Two patients had distal and one patient had both proximal and distal DVT on color Doppler examination. These patients received low-molecular-weight heparin (Enoxaparin) 60 mg subcutaneously once a day for 5 days and tablet Warfarin 3–4 mg once a day with serial PT/INR monitoring fortnightly till symptoms resolved or thrombus resolved. Matsumoto et al. in a prospective study reported that DVT can develop at the very-acute stage in patients with SCI. They concluded that diagnostic reliability was higher with leg ultrasonography. The sensitivity of USG in detecting DVT is reported to be 98%–100% and specificity to be 95%–100%. Hence, they regarded it as an excellent noninvasive screening test for DVT.[23] Saraf et al. found 7 DVT-positive cases, with proximal DVT in three patients. Four patients were diagnosed by color Doppler and three by venography. They reported color Doppler to be one of the diagnostic modes for DVT but considered venography preferable over color Doppler.[30] Mackiewicz-Milewska et al. considered imaging study like color Doppler as a diagnostic tool for DVT as it is a commonly utilized test, relatively economical, and non-invasive. The specificity of color Doppler in detecting symptomatic DVT of the proximal veins such as femoral and popliteal was 96.8%–99%, while sensitivity was 96.1%–100%. However, the detection of DVT in the distal vein has low specificity (50%–70%) and sensitivity (60%).[24] Ballu et al. appraised color Doppler as a useful diagnostic tool in predicting DVT. Distal DVT in calf muscle was more common in their patients. They deduced that distal DVT was more common among the Asian population, whereas proximal DVT was more common in Caucasians.[25] Wei et al. in a meta-analysis revealed that the DVT prevalence rate among SCI patients in Asia or rehabilitation institutes was higher than that among those in non-Asia or hospitals. They reached the perspective that proximal DVT was associated with chronic diseases and other preexisting risk factors. On the other hand, distal DVT had a common occurrence in patients with trauma and immobilization.[32]

In the current study, we found DVT in two patients who were managed conservatively and one patient that had undergone operative management and one each with cervical seventh, dorsal sixth and dorsal twelfth vertebral level of injury with the nonsignificant association. The two patients who developed skin changes were DVT-positive on color Doppler, but these clinical features were found to be nonsignificant parameters. Variation in the incidence of DVT in SCI patients has been reported in the literature. Wei et al. in the meta-analysis showed a higher incidence of DVT in the Asian population.[32] In contrast, few other studies reported a lower incidence of DVT in the Asian population compared to the Western population. The reason for the less incidence of DVT in the Asian and African populations might be because of genetic factors, such as inherited resistance to thrombosis formation, environmental factors or the low socioeconomic status of our rural patients, leading to lower consumption of a fat-rich diet, and warmer climatic conditions and so on. Other factors may include the practice of massage and passive exercises by the attendants and the high prevalence of blood group “O” which has been known to decrease the risk of DVT.[33],[34]

In the present study, the incidence of DVT in SCI patients came out to be 6% with a peak occurrence between 14 days and 1 month and more incidence of distal DVT over proximal. This 6% incidence in the present study is fairly high, similar to other reports of SCI from other parts of Asia.[8],[9],[19],[30],[31],[35],[36] The incidence of DVT had a noteworthy association with thigh and calf circumference and with D-dimer levels. All three positive patients confirmed on color Doppler had a significant increase in the thigh and calf circumference (P < 0.01) and simultaneously had a remarkable increase in D-dimer levels. Hence, it was concluded that the thigh and calf circumference, D-dimer levels and color Doppler in conjunction are useful tools for establishing the diagnosis of DVT.


  Conclusions Top


In the present study, although the incidence of DVT is low in SCI patients in India, it is not a rare complication. The occurrence of DVT in SCI patients has no significant correlation with factors such as age, sex, and type of management; but has a significant correlation with the level and severity of the injury. Frequent clinical examinations including the thigh and calf circumference along with D-dimer levels are good screening indicators to rule out DVT, whereas color Doppler is a simple, noninvasive and cost-effective diagnostic tool for establishing a a definitive diagnosis of DVT in SCI patients.

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Conflicts of interes

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[PUBMED]  [Full text]  
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