Comprehensive Analysis Using CT Anthropometry Verifies the Association of Psoas and Masseter Muscle With Traumatic Brain Injury

DOI: https://doi.org/10.21203/rs.3.rs-76634/v1

Abstract

Background: Psoas and masseter muscle are known markers for sarcopenia. However, superiority between them is controversial. Authors planned study to analyze them with prognosis of patients with traumatic brain injury. (TBI)

Methods: Patients with TBI visiting regional trauma center between 2017 January to 2018 December were selected and their medical records were reviewed. TBI patients with abbreviated injury score (AIS) 4 or 5 were selected. Patients with AIS 4 or 5 at chest, abdomen and extremity were excluded. And Patient with hospital stay 1 or 2 days were excluded. Both muscle area were measured at their initial computed tomograpy and psoas muscle index (PMI) and masseter muscle index (MMI) were calculated by both muscle area divided by height squared. (cm2/m2) These muscular parameters along with other medical information were analyzed with mortality and Glasgow outcome scale. (GOS)

Results: After exclusion process, total 179 patients were included to statistical analyses. Their mean age was 58.0 years, and there are 147 male patients. (82.1%) There were 30 patients with mortality. (16.8%) Mean GOS were 3.7 retrospectively. Parameters were analyzed with mortality which is defined as a qualitative outcome. PMA (16.9 vs. 14.4 cm2, P = 0.028) and PMI (5.9 vs. 5.1 cm2/m2, P = 0.004) showed statistical difference. PMI also showed its statistical significance as a risk factor of mortality in logistic regression analysis. (B = -0.336, P = 0.023, Odds ratio (95% confidence interval) = 0.715 (0.535 – 0.954) Also analyses was performed with GOS which is defined as a quantitative outcome. Bivariate correlation analysis showed statistical correlation between PMI and GOS. (correlation coefficient = 0.168, P = 0.003) And PMI (B = 0.184, P = 0.004, variation inflation factor 1.001) showed its significance in multiple regression analysis additionally.

Conclusions: Bigger PM was associated survival and better GOS statistically and could show its superiority as a prognostic marker. Further analyses with more number of patients, more parameters and more precise setting could yield better outcome and increase understanding of relation between sarcopenia and TBI.

Background

Sarcopenia is defined as a progressive and generalized skeletal muscle disorder.[1] It was derived from the Greek phrase poverty of flesh. And it works as an important marker of nutritional, physical status and overall health.[2, 3] It is now recognized as a muscle disease and considered an independent condition by the International Classification of disease, 10th Clinical Modification.[4, 5] Clinically, it is associated with cardiovascular, respiratory and malignant disease.[68] Also individuals’ quality of life and mortality show association to sarcopenia.[9, 10]

There are many methods to assess sarcopenia. Measuring psoas muscle area (PMA) from computed tomography (CT) is one of well known method. It is reported that PMA is related to mortality and quality of life of several critical patients.[1113] Measuring masseter muscle area (MMA) via CT is alternative method to analyze sarcopenia. Masseter muscle is associated with nutritional parameters like obesity, geriatrics.[14] Also it shows association with prognosis of patient with cerebrovascular problem.[15, 16] And Hu et al reported that MMA is associated with early mortality of patients with severe traumatic brain injury (TBI).[17]

Both PMA and MMA have enough evidence to prove themselves as valid markers for prognosis of various patients. However, evidence to verify superiority as a prognostic marker between both muscles are not enough. Hereby, authors planned a study to compare both markers with prognosis of patients with TBI. Comprehensive analyses with qualitative and quantitative parameters were performed.

Methods

Patients with TBI visiting regional trauma center between 2017 January to 2018 December were selected. Their medical information were gathered via retrospective record review. General information like age, sex, height, weight, length of hospital stay and trauma related information like intubation, operation, Glasgow coma score (GCS), abbreviated injury score (AIS), injury severity score (ISS) were checked. As a clinical outcome, Glasgow outcome scale (GOS) and mortality were analyzed together. Patients under endotracheal intubation, GCS 8 or below were regarded as patients with severe TBI. Patients’ body mass index were calculated and those with BMI over 25 were regarded as obesity.

Initial CT images were used to muscle measurement. Common sites were used for anthropometry according to previous study. The cross-sectional area of the psoas muscles was measured at the level of the third lumbar vertebral body bilaterally as PMA.[18] The cross-sectional area of the masseter muscle was measured at 2 cm below the zygomatic arch bilaterally as MMA.[19] Psoas muscle index (PMI) and masseter muscle index (MMI) were calculated by both muscle area divided by height squared. (cm2/m2) Patients with proper CT images were included to the study. If their muscle were injured, in tilted position or had artifacts, they were regarded as improper.

To select major TBI, patients with AIS 4 or 5 were extracted from entire patients with TBI. Then, those with improper CT images were excluded. And patients with AIS 4 or 5 at chest, abdomen or extremity were excluded to reduce bias form other condition. Patients younger than 19 years old and those with missing data were excluded also. Additionally, patients with hospital stay less than 2 days were excluded.

Comprehensive analyses were planned. Mortality was used as qualitative outcome and GOS was used as quantitative outcome. At first, patients were separated into survival group and mortality group. Their medical records were analyzed. An independent t-test was used for quantitative analysis, and Chi-squared tests were used for qualitative analysis. And logistic regression analysis was added to verify risk factor. Correlation between both muscular index and GOS was analyzed with bivariate correlation analysis. Correlation coefficient were calculated after adjustment of Age, BMI, AIS, ISS also. Additionally, multiple regression analysis was performed. All statistical analyses were performed using IBM SPSS Statistics for Windows, V 25.0 (IBM Corp., Armonk, NY). This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived.

Results

There were 357 TBI patients with AIS 4–5. Among them, patients with proper CT images were 243 and 226 patients without injury of chest, abdomen or extremity AIS 4–5 were selected. And 20 patients were excluded for age, 7 patients were excluded for missing data. Additionally, 20 patients were excluded for missing data. Patient’s selection process were summarized at Fig. 1.

After exclusion process, total 179 patients were included to statistical analyses. Their mean age was 58.0 years, and there are 147 male patients. (82.1%) There were 51 patients with obesity, (28.5%) 64 patients with severe TBI (35.8%) and 92 patients after neurosurgery (51.4%) Mean PMA and MMA were 16.5 and 9.8 cm2. Also Mean PMI and MMI were 5.8 and 3.5 cm2/m2. There were 30 patients with mortality. (16.8%) Mean GOS were 3.7 retrospectively. Other basic information is summarized in Table 1.

Table 1

Basic information of enrolled patients

Age (years)

57.95 ± 16.24

Sex

Female

32 (17.9%)

 

Male

147 (82.1%)

Height (cm)

167.59 ± 8.22

Weight (kg)

65.65 ± 11.32

Body mass index (kg/cm2)

23.27 ± 3.03

Obesity

No

128 (71.5%)

 

Yes

51 (28.5%)

Traumatic brain injury

Non-severe

115 (64.2%)

 

Severe

64 (35.8%)

Operation

No

87 (48.6%)

 

Yes

92 (51.4%)

Psoas muscle area (cm2)

16.47 ± 5.60

Masseter muscle area (cm2)

9.76 ± 2.50

Psoas muscle index (cm2/m2)

5.80 ± 1.75

Masseter muscle index (cm2/m2)

3.47 ± 1.75

Abbreviated injury score

 

Head and neck

4.54 ± 5.0

Face

0.36 ± 0.76

Chest

1.03 ± 1.35

Abdomen

0.25 ± 0.75

Extremity

0.75 ± 1.08

External

0.36 ± 0.54

Injury severity score

26.59 ± 6.43

Glasgow outcome score

3.65 ± 1.50

1

30 (16.8%)

2

9 (5.0%)

3

35 (19.6%)

4

24 (13.4%)

5

81 (45.3%)

Mortality

No

149 (83.2%)

 

Yes

30 (16.8%)

Quantitative parameters are presented as mean ± standard deviation. Qualitative parameters are presented as number (percent%).

Parameters were analyzed with mortality which is defined as a qualitative outcome. PMA (16.9 vs. 14.4 cm2, P = 0.028) and PMI (5.9 vs. 5.1 cm2/m2, P = 0.004) showed statistical difference as well as severity of TBI. (P < 0.001) Also AIS of face and external were different statistically. Analysis according to mortality is summarized in Table 2. And Table 3 showed result of logistic regression analysis for mortality. Main risk factor for mortality in patients with TBI is severe TBI itself. However, PMI also showed its statistical significance as a risk factor of mortality. (B = -0.336, P = 0.023, Odds ratio (95% confidence interval) = 0.715 (0.535–0.954) Mean MMA and MMI were decreased in mortality group however, they could not show its significance.

Table 2

Analysis according to mortality

Parameters

Survival

Mortality

p - value

 

N = 149 (83.2%)

N = 30 (16.8%)

 

Age (years)

57.23 ± 16.59

61.53 ± 14.08

0.186

Sex

Female

24 (75.0%)

8 (25.0)

0.168

 

Male

125 (85.0%)

22 (15.0%)

 

Height (cm2)

167.76 ± 8.07

166.73 ± 9.04

0.535

Weight (kg)

65.76 ± 11.23

65.08 ± 11.96

0.767

Body mass index (kg/m2)

23.27 ± 3.08

23.27 ± 2.85

0.999

Obesity

No

106 (82.8%)

22 (17.2%)

0.808

 

Yes

43 (84.3%)

8 (15.7%)

 

Traumatic brain injury

Non-severe

108 (93.9%)

7 (6.1%)

< 0.001

 

Severe

41 (64.1%)

23 (35.9%)

 

Operation

No

77 (88.5%)

10 (11.5%)

0.067

 

Yes

72 (78.3%)

20 (21.7%)

 

Psoas muscle area (cm2)

16.88 ± 5.70

14.43 ± 4.65

0.028

Masseter muscle area (cm2)

9.79 ± 2.54

9.59 ± 2.32

0.694

Psoas muscle index (cm2/m2)

5.94 ± 1.80

5.10 ± 1.27

0.004

Masseter muscle index (cm2/m2)

3.48 ± 0.87

3.45 ± 0.80

0.883

Abbreviated injury score

     

Head and Neck

4.53 ± 0.50

4.60 ± 0.50

0.487

Face

0.40 ± 0.80

0.17 ± 0.46

0.03

Chest

1.03 ± 1.34

1.03 ± 1.40

0.981

Abdomen

0.23 ± 0.72

0.33 ± 0.88

0.513

Extremity

0.77 ± 1.08

0.70 ± 1.12

0.765

External

0.40 ± 0.54

0.17 ± 0.46

0.02

Injury severity score

26.52 ± 6.33

26.90 ± 7.00

0.771

An independent t-test was used for quantitative analysis, and Chi-squared tests were used for qualitative analysis.

Table 3

Result of logistic regression analysis for mortality

Parameters

B

p – value

OR (95% CI)

Psoas muscle index

-0.336

0.023

0.715 (0.535–0.954)

Severe Traumatic brain injury

-2.185

< 0.001

0.112 (0.044–0.287)

OR, odds ratio; CI, confidence interval

Also analyses was performed with GOS which is defined as a quantitative outcome. Bivariate correlation analysis showed statistical correlation between PMI and GOS (correlation coefficient = 0.168, P = 0.003, Fig. 2) Partial correlation analyses was performed after adjustment with age, BMI, AIS and ISS. PMI showed its correlation to GOS in every adjustment, however, MMI could not show its correlation statistically. (Table 4) Result of multiple regression analysis was shown at Table 5 (R2 = 0.048). PMI (B = 0.184, P = 0.004, variation inflation factor 1.001) showed its significance. Similarly with analyses for mortality, MMI could not prove its significance.

Table 4

Results of bivariate and partial correlation analysis with Glasgow Coma Scale

Type of analysis

 

Psoas

muscle index

Masseter muscle index

Bivariate correlation analysis

Kendall's tau_b

Correlation coefficient

0.168

0.061

 

p – value

0.003

0.281

Partial correlation analysis

Adjustment with age, BMI, AIS, ISS

Correlation coefficient

0.176

0.067

 

p – value

0.023

0.390

Adjustment with BMI, AIS, ISS

Correlation coefficient

0.211

0.106

 

p – value

0.006

0.170

Adjustment with AIS, ISS

Correlation coefficient

0.211

0.060

 

p – value

0.005

0.434

BMI, body mass index; AIS, abbreviated injury score; ISS, injury severity score

Table 5

Result of multiple regression analysis with Glasgow outcome scale

Parameters

B

p – value

Variation Inflation Factor

Psoas muscle index

0.184

0.004

1.001

AIS - External

0.476

0.02

1.001

AIS, abbreviated injury score

Discussion

The present study has distinctive characteristics for several reasons. At first, it has a rare purpose of the study. It was planned to compare superiority of PM and SM which were presented as well-known marker for sarcopenia.

Second, the study tried to select severe patients with TBI. Therefore, only TBI patients with AIS 4 or 5 were selected. Also patients with other severe injury were not included to the study. To reduce influence from other injuries, patients with AIS 4 or 5 at chest, abdomen or extremity were excluded. Additionally, patients with hospital stay more than 2 days were selected. Expired trauma patients in this period could have indisputably severe injuries and mortality was non-preventable. On the contrary, there were preventable mortality patients who wished “Do Not Resuscitate”. Or operation agreement of guardians was late. In addition, there were patients that guardians wanted transfer to other hospital. These patients were regarded as improper candidate for analysis and excluded from the study. Consequently, serious TBI patients with reduced possibility of bias were left, although number of analyzed patients were decreased.

Thirdly, comprehensive analyses were planned with qualitative and and quantitative parameters. There was one similar study that analyzed PM and SM.[20] Both parameters were analyzed with only mortality which is qualitative parameters. However, this study adopted not only mortality, but also GOS and tried to compare both parameters comprehensively.

However, authors could not define and analyze about sarcopenia in the present study. Initial target to analyze was not sarcopenia but both PM and MM. Assessment about muscle strength, physical performance were tried, because enrolled patients had traumatic brain injury and cooperation from the patients was difficult. Also it is reported that single muscle would be difficult to represent sarcopenia.[21] Nevertheless, relation between both muscle and prognosis of patients with TBI could be identified statistically. Further study to diagnose sarcopenia within patients with is required.

Conclusion

In conclusion, bigger PM was associated survival and better GOS statistically and could show its superiority as a prognostic marker. Although most significant parameter for mortality was severity of TBI itself. Nevertheless, PM showed its statistical significance in various analyses and prove that skeletal muscle could predict prognosis of TBI patients although its correlation coefficients were low. Survival group showed bigger SM also, however it could not prove statistical difference in this study. Further analyses with more number of patients might show different results because this study has relatively low number of participants. Additionally, further with more parameters and more precise setting could yield better outcome and increase understanding of relation between sarcopenia and TBI.

Abbreviations

PMA

psoas muscle area; CT:computed tomography; MMA:masseter muscle area; TBI:traumatic brain injury; GCS:Glasgow coma score; AIS:abbreviated injury score; ISS:injury severity score; GOS:Glasgow outcome scale; PMI:psoas muscle index; MMI:masseter muscle index

Declarations

Ethics approval and consent: The present study was approved by Uijeongbu St.Mary’s Hospital Institutional Review Board and informed consent was waived.

Consent for publication: Informed consent was waived.

Availability of data and material: The data generated during the current study are not available because data sharing was not approved from the Institutional Review Board.

Competing interests: Authors have nothing to disclose

Funding: None

Author contribution: HC was involved in study conception, acquisition of data, design, analysis, interpretation. YH was involved in study conception, acquisition of data, interpretation. SY was involved in acquisition of data, interpretation, and validation. MK was involved in study conception, design, analysis, interpretation, and writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements: None

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