Frailty and In-Hospital Mortality Following Complete Cervical Spinal Cord Injury

Study Design: Retrospective multicenter cohort study. Objective: To evaluate the independent association between frailty and in-hospital mortality among adults with complete cervical spinal cord injury (SCI) who underwent surgical intervention. Summary of Background Data: Traumatic cervical SCI is a devastating condition associated with high rates of morbidity and early mortality. While advanced age and injury severity are established risk factors, frailty has emerged as a promising marker of physiological vulnerability. However, its prognostic value in complete cervical SCI remains unclear. Materials and Methods: Data were obtained from the American College of Surgeons Trauma Quality Improvement Program (TQIP) between 2017 and 2022. Adults (≥18 y) with blunt traumatic complete cervical SCI who underwent spinal surgery were included. Frailty was measured using the modified Frailty Index (mFI-5) and categorized as robust (0), prefrail (1), or frail (≥2). The primary outcome was all-cause in-hospital mortality, analyzed using Kaplan-Meier and Cox proportional hazards models, adjusting for demographic, clinical, injury-related, and hospital-level variables. A subgroup analysis was performed in patients aged 65 years or older. A predictive model for in-hospital mortality was developed using LASSO logistic regression. Results: Among 9457 patients, 70% were robust, 18% prefrail, and 12% frail. In-hospital mortality rates were 6% (robust), 15% (prefrail), and 23% (frail). Kaplan-Meier curves showed stepwise decreases in survival with increasing frailty (log-rank P <0.001). In adjusted Cox models, frailty was independently associated with mortality (HR: 1.45; 95% CI: 1.19–1.77; P <0.001), an association that persisted in patients aged 65 years or older (HR: 1.58; 95% CI: 1.11–2.26). The LASSO prediction model demonstrated good discrimination (AUC=0.811), with frailty among the top predictors of mortality. Conclusions: Frailty is an independent predictor of in-hospital mortality in adults undergoing surgery for complete cervical SCI. These findings support routine frailty assessment to enhance early risk stratification, prognostication, and patient-centered decision-making in spinal trauma care.