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Kalbas Y, Klingebiel FKL, Halvachizadeh S, Kumabe Y, Scherer J, Teuben M, Pfeifer R, Pape HC. Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES. Eur J Trauma Emerg Surg 2024; 50:657-669. [PMID: 36820896 PMCID: PMC11249440 DOI: 10.1007/s00068-023-02245-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology. METHODS A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades. RESULTS 4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000. CONCLUSION Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland.
| | - Felix Karl-Ludwig Klingebiel
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Yohei Kumabe
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Julian Scherer
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery and Harald-Tscherne Laboratory, University Hospital Zurich, University of Zurich, Ramistr. 100, 8091, Zurich, Switzerland
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Hax J, Teuben M, Halvachizadeh S, Berk T, Scherer J, Jensen KO, Lefering R, Pape HC, Sprengel K. Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries. Global Spine J 2023:21925682231216082. [PMID: 37963389 DOI: 10.1177/21925682231216082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome. METHODS The TraumaRegister DGU® was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined. RESULTS 12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%). CONCLUSIONS The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.
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Affiliation(s)
- Jakob Hax
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Department of Hip and Knee Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | | | - Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Julian Scherer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Orthopaedic Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Trauma, Hirslanden Clinic St. Anna and University of Lucerne, Lucerne, Switzerland
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Khaing ZZ, Chen JY, Safarians G, Ezubeik S, Pedroncelli N, Duquette RD, Prasse T, Seidlits SK. Clinical Trials Targeting Secondary Damage after Traumatic Spinal Cord Injury. Int J Mol Sci 2023; 24:3824. [PMID: 36835233 PMCID: PMC9960771 DOI: 10.3390/ijms24043824] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Spinal cord injury (SCI) often causes loss of sensory and motor function resulting in a significant reduction in quality of life for patients. Currently, no therapies are available that can repair spinal cord tissue. After the primary SCI, an acute inflammatory response induces further tissue damage in a process known as secondary injury. Targeting secondary injury to prevent additional tissue damage during the acute and subacute phases of SCI represents a promising strategy to improve patient outcomes. Here, we review clinical trials of neuroprotective therapeutics expected to mitigate secondary injury, focusing primarily on those in the last decade. The strategies discussed are broadly categorized as acute-phase procedural/surgical interventions, systemically delivered pharmacological agents, and cell-based therapies. In addition, we summarize the potential for combinatorial therapies and considerations.
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Affiliation(s)
- Zin Z. Khaing
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
| | - Jessica Y. Chen
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Gevick Safarians
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Sohib Ezubeik
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Nicolas Pedroncelli
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Rebecca D. Duquette
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
| | - Tobias Prasse
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50931 Cologne, Germany
| | - Stephanie K. Seidlits
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
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Balcescu C, Odeh K, Rosinski A, Nudelman B, Schlauch A, Shah I, Ungurean Jr. V, Prasad P, Leasure J, Stepansky F, Piple A, Kondrashov D. Pyogenic spinal infections warrant a total spine MRI. J Bone Jt Infect 2023; 8:1-9. [PMID: 36687464 PMCID: PMC9850241 DOI: 10.5194/jbji-8-1-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/19/2022] [Indexed: 01/04/2023] Open
Abstract
Study design: retrospective case series. Objective: the presenting clinical symptoms of spinal infections are often nonspecific and a delay in diagnosis can lead to adverse patient outcomes. The morbidity and mortality of patients with multifocal spinal infections is significantly higher compared to unifocal infections. The purpose of the current study was to analyse the risk factors for multifocal spinal infections. Methods: we conducted a retrospective review of all pyogenic non-tuberculous spinal infections treated surgically at a single tertiary care medical center from 2006-2020. The medical records, imaging studies, and laboratory data of 43 patients during this time period were reviewed and analysed after receiving Institutional Review Board approval. Univariate and multivariate analyses were performed to identify factors associated with a multifocal spinal infection. Results: 15 patients (35 %) had multifocal infections. In univariate analysis, there was a significant association with chronic kidney disease ( p = 0.040 ), gender ( p = 0.003 ), a white blood cell count ( p = 0.011 ), and cervical ( p < 0.001 ) or thoracic ( p < 0 .001) involvement. In multivariate analysis, both cervical and thoracic involvement remained statistically significant ( p = 0.001 and p < 0.001 , respectively). Conclusions: patients with infections in the thoracic or cervical region are more likely to have a multifocal infection. Multifocal pyogenic spinal infections remain a common entity and a total spine MRI should be performed to aid in prompt diagnosis.
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Affiliation(s)
- Cristian Balcescu
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | - Alexander Rosinski
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | - Brandon Nudelman
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | - Adam Schlauch
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | - Ishan Shah
- San Francisco Orthopaedic Residency Program, St. Mary's Medical
Center, San Francisco, CA 94117, USA
| | | | - Priya Prasad
- Department of Internal Medicine, University of California San
Francisco, San Francisco, CA 94143, USA
| | | | - Flora Stepansky
- Department of Radiology, St. Mary's Medical Center, San Francisco, CA
94117, USA
| | - Amit Piple
- The Taylor Collaboration, San Francisco, CA 94117, USA
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Sousa A, Rodrigues C, Barros L, Serrano P, Rodrigues-Pinto R. Early Versus Late Spine Surgery in Severely Injured Patients-Which Is the Appropriate Timing for Surgery? Global Spine J 2022; 12:1781-1785. [PMID: 33472431 PMCID: PMC9609529 DOI: 10.1177/2192568221989292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study conducted at tertiary spinal trauma referral center. OBJECTIVE We aimed to determine if early definitive management of spine fractures in patients admitted to the Intensive Care Unit (ICU) shortens the intubation time and the length of stay (LOS), without increasing mortality. METHODS The medical records of all patients admitted to the ICU and submitted to surgical stabilization of spine fractures were reviewed over a 10-year period. Time to surgery, number of fractured vertebrae, degree of neurological injury, Simplified Acute Physiology Score (SAPS II), ASA score and associated trauma were evaluated. Surgeries performed on the first 72 hours after trauma were defined as "early surgeries." Intubation time, LOS on ICU, overall LOS and mortality rate were compared between patients operated early and late. RESULTS Fifty patients were included, 21 with cervical fractures, 23 thoracic and 6 lumbar. Baseline characteristics did not differ between patients in both groups. Patients with early surgical stabilization had significantly shorter intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. After multivariate adjustments overall LOS was significantly shorter in patients operated earlier. CONCLUSIONS Early spinal stabilization (<72 hours) of severely injured patients is beneficial and shortens the intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. Although some patients may require a delay in treatment due to necessary medical stabilization, every reasonable effort should be made to treat patients with unstable spinal fractures as early as possible. LEVEL OF EVIDENCE OF THE STUDY Level III.
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Affiliation(s)
- Arnaldo Sousa
- Spinal Unit/Unidade Vertebro-Medular
(UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto,
Portugal,Instituto de Ciências Biomédicas Abel
Salazar, Universidade do Porto, Portugal
| | - Cláudia Rodrigues
- Spinal Unit/Unidade Vertebro-Medular
(UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto,
Portugal,Instituto de Ciências Biomédicas Abel
Salazar, Universidade do Porto, Portugal
| | - Luís Barros
- Spinal Unit/Unidade Vertebro-Medular
(UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto,
Portugal,Instituto de Ciências Biomédicas Abel
Salazar, Universidade do Porto, Portugal
| | - Pedro Serrano
- Spinal Unit/Unidade Vertebro-Medular
(UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto,
Portugal,Instituto de Ciências Biomédicas Abel
Salazar, Universidade do Porto, Portugal
| | - Ricardo Rodrigues-Pinto
- Spinal Unit/Unidade Vertebro-Medular
(UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto,
Portugal,Instituto de Ciências Biomédicas Abel
Salazar, Universidade do Porto, Portugal,Ricardo Rodrigues-Pinto, Spinal Unit/Unidade
Vertebro-Medular (UVM), Department of Orthopaedics, Centro Hospitalar
Universitário do Porto, Largo Prof. Abel Salazar 4099-001, Porto, Portugal.
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Qiu Y, Chen Y, Xie Y, Xie H, Dong J. Comparative analysis of the efficacy of early and late surgical intervention for acute spinal cord injury: A systematic review and meta-analysis based on 16 studies. Int J Surg 2021; 94:106098. [PMID: 34509672 DOI: 10.1016/j.ijsu.2021.106098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/05/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Spinal cord injuries (SCI) are a devastating condition and can lead to severe functional and psychosocial problems. However, the influence of the timing of the surgical intervention for acute SCI remains debated, with substantial variability in clinical practice. Thus, this study aims to compare the efficacy of early and late surgical intervention for acute SCI. METHODS A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to January 10, 2021 was conducted for relevant studies that compared early and late acute SCI. Neurological outcomes were assessed by American Spinal Injury Association (ASIA). Early surgery was defined as the surgical intervention within 24 h after spinal injury. The primary outcome was the change of ASIA score from baseline to follow-up time after spinal injury. Second primary outcomes were clinical outcomes including neurological improvement rate, mortality, length of stay (LOS), charges ($), complications and ASIA Impairment Scale (AIS). All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 3977 SCI patients were identified finally. Our pooled results indicated that, compared with late surgery, patients who underwent early surgery experienced more ASIA score improvement, with pooled MDs of 2.32 points (95% CI 1.07-3.57; P = 0.0003) in total motor scores, 5.13 points (95% CI 3.94-6.32; P < 0.0001) in light touch scores, and 4.49 points (95% CI 2.22-6.76; P = 0.0001) in pin prick scores respectively. In addition, patients receiving early surgery experienced more total motor score after surgery (MD 3.30; 95% CI 0.82-5.79; P = 0.009). Patients who had early surgery also had higher neurological improvement rate (OR 1.66; 95% CI 1.19-2.31; P = 0.003), shorter LOS (MD -4.77; 95% CI -7.42 to -2.12), less charges ($) (MD -0.33; 95% CI -0.43 to -0.22), lower incidence of complications (OR 0.62; 95% CI 0.48-0.81), and higher AIS improvement rate (OR 1.71; 95% CI 1.20-2.44) respectively. CONCLUSIONS Compared with late surgery, acute SCI patients who underwent early surgery experienced greater recovery after spinal injury, with better neurological improvement, shorter LOS, less charges and lower incidence of complications.
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Affiliation(s)
- Yuanyuan Qiu
- Rehabilitation Center, Beijing Daxing District Hospital of Traditional Chinese and Western Medicine, Beijing, 100076, China Department of Rehabilitation Medicine, Beijing Tongren Hospital of Capital Medical University, Beijing, 100073, China Department of Rehabilitation Medicine, Beijing Friendship Hospital of Capital Medical University, Beijing, 100050, China Rehabilitation Department, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, 100020, China
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Abstract
OBJECTIVES To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma. DESIGN Retrospective cohort study. SETTING Academic Level-1 Trauma Center. PATIENTS MA users and matched controls. INTERVENTION MA use. MAIN OUTCOME MEASUREMENTS Infection, Deep Vein Thrombosis (DVT), and nonunion. RESULTS Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up. CONCLUSIONS MA use is associated with increased inpatient and outpatient complications. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Qadir I, Riew KD, Alam SR, Akram R, Waqas M, Aziz A. Timing of Surgery in Thoracolumbar Spine Injury: Impact on Neurological Outcome. Global Spine J 2020; 10:826-831. [PMID: 32905717 PMCID: PMC7485084 DOI: 10.1177/2192568219876258] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE We aimed to evaluate the improvement in neurological deficit following early versus late decompression and stabilization of thoracolumbar junctional fractures. METHODS This is a retrospective evaluation of all patients with a traumatic spinal cord injury (SCI) from T11 to L2 treated at a teaching hospital between 2010 and 2017. Grouped analysis was performed comparing the cohort of patients who received early surgery within 24 hours (group 1) with those operated within 24 to 72 hours (group 2) and more than 72 hours after SCI (group 3). The primary outcome was the change in ASIA (American Spinal Injury Association) motor score at 12-month follow-up. RESULTS There were 317 patients (225 males and 92 females with mean age of 31.55 ± 12.43 years). A total of 144, 77, and 96 patients belonged to groups 1, 2, and 3 respectively. Improvement of at least 1 grade on ASIA classification was observed in 80, 45, and 33 patients in groups 1, 2, and 3 respectively (P = .001). Overall, 32, 12, and 10 patients improved ≥2 grades on ASIA classification in groups 1, 2, and 3, respectively (P = .069). On logistic regression analysis, early surgery and severity of initial injury (complete [ASIA A] vs incomplete SCI [ASIA B-D]) were found to significantly influence the potential for neurologic improvement (P = .004 and P < .0001, respectively). CONCLUSION We believe that the earlier the decompression, the better. The 72-hour cutoff represents the most promising time window during which surgical decompression has the potential to confer a neuroprotective effect in the setting of incomplete SCI (ASIA B-D) in the distal region of the spinal cord (conus medullaris).
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Affiliation(s)
- Irfan Qadir
- Ghurki Trust Teaching Hospital, Lahore, Pakistan,Irfan Qadir, Department of Orthopaedic and Spine Surgery, Ghurki Trust Teaching Hospital, Jallo Mor, Lahore, Pakistan.
| | | | | | - Rizwan Akram
- Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | | | - Amer Aziz
- Ghurki Trust Teaching Hospital, Lahore, Pakistan
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Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit? J Clin Med 2020; 9:jcm9061760. [PMID: 32517132 PMCID: PMC7356187 DOI: 10.3390/jcm9061760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/21/2020] [Accepted: 06/03/2020] [Indexed: 01/23/2023] Open
Abstract
Background: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured patients both in general and in respect to spinal injury severity. Methods: A retrospective analysis of multiple-injured patients with an associated spinal trauma within the thoracic or lumbar spine (injury severity score (ISS) >16, age >16 years) was performed from January 2012 to December 2016 in two Level I trauma centres. Demographic data, circumstances of the accident, and ISS, as well as time to spinal surgery were documented. The evaluated outcome parameters were length of stay in the intensive care unit (ICU) (iLOS) and length of stay (LOS) in the hospital, duration of mechanical ventilation, onset of sepsis, and multiple organ dysfunction syndrome (MODS), as well as mortality. Statistical analysis was performed using SPSS. Results: A total of 113 multiple-injured patients with spinal stabilization and a complete dataset were included in the study. Of these, 71 multiple-injured patients (63%) presented with an AOSpine A-type spinal injury, whereas 42 (37%) had an AOSpine B-/C-type spinal injury. Forty-nine multiple-injured patients (43.4%) were surgically treated for their spinal injury within 24 h after trauma, and showed a significantly reduced length of stay in the ICU (7.31 vs. 14.56 days; p < 0.001) and hospital stay (23.85 vs. 33.95 days; p = 0.048), as well as a significantly reduced prevalence of sepsis compared to those surgically treated later than 24 h (3 vs. 7; p = 0.023). These adverse effects were even more pronounced in the case where cutoffs were increased to either 72 h or 96 h. Independent risk factors for a delay in spinal surgery were a higher ISS (p = 0.036), a thoracic spine injury (p = 0.001), an AOSpine A-type spinal injury (p = 0.048), and an intact neurological status (p < 0.001). In multiple-injured patients with AOSpine A-type spinal injuries, an increased time to spinal surgery was only an independent risk factor for an increased LOS; however, in multiple-injured patients with B-/C-type spinal injuries, an increased time to spinal surgery was an independent risk factor for increased iLOS, LOS, and the development of sepsis. Conclusion: Our data support the concept of early spinal stabilization in multiple-injured patients with AOSpine B-/C-type injuries, especially of the thoracic spine. However, in multiple-injured patients with AOSpine A-type injuries, the beneficial impact of early spinal stabilization has been overemphasized in former studies, and the benefit should be weighed out against the risk of patients’ deterioration during early spinal stabilization.
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10
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Hager S, Eberbach H, Lefering R, Hammer TO, Kubosch D, Jäger C, Südkamp NP, Bayer J. Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med 2020; 28:42. [PMID: 32448190 PMCID: PMC7245984 DOI: 10.1186/s13049-020-00737-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay. Methods Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AISThorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AISSpine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AISspine): AISLS = 3, AISLS = 4–5, AISTS = 3 and AISTS = 4–5, respectively. Results 1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AISTS = 3) or lumbar spine (AISLS = 3) significantly benefit from early surgical intervention concerning ventilation time (AISLS = 3 only), ARDS, multiple organ failure, sepsis rate (AISTS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AISTS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital. Conclusions Multiply injured patients with at least serious thoracic trauma (AISThorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.
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Affiliation(s)
- Sven Hager
- Department of Surgery, Bautzen Hospital, Oberlausitz-Kliniken gGmbH, Am Stadtwall 3, 02625, Bautzen, Germany
| | - Helge Eberbach
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, University Witten/Herdecke, Faculty of Health, Ostmerheimer Str. 200, 51109, Köln, Germany
| | - Thorsten O Hammer
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - David Kubosch
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Jäger
- Department of Anesthesiology and Critical Care, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Norbert P Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jörg Bayer
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.
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11
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Goulet J, Richard-Denis A, Mac-Thiong JM. The use of classification and regression tree analysis to identify the optimal surgical timing for improving neurological outcomes following motor-complete thoracolumbar traumatic spinal cord injury. Spinal Cord 2020; 58:682-688. [DOI: 10.1038/s41393-020-0412-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/28/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022]
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12
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Zhang Y, Hou G, Ji W, Rao F, Zhou R, Gao S, Mao L, Zhou F. Persistent oppression and simple decompression both exacerbate spinal cord ascorbate levels. Int J Med Sci 2020; 17:1167-1176. [PMID: 32547312 PMCID: PMC7294922 DOI: 10.7150/ijms.41289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 05/08/2020] [Indexed: 12/01/2022] Open
Abstract
Background: Surgical decompression after acute spinal cord injury has become the consensus of orthopaedic surgeons. However, the choice of surgical decompression time window after acute spinal cord injury has been one of the most controversial topics in orthopaedics. Objective: We apply an online electrochemical system (OECS) for continuously monitoring the ascorbate of the rats' spinal cord to determine the extent to which ascorbate levels were influenced by contusion or sustained compression. Methods: Adult Sprague-Dawley rats (n=10) were instrumented for ascorbate concentration recording and received T11 drop spinal cord injury (SCI). The Group A (n=5) were treated with immediately decompression after SCI. The Group B (n=5) were contused and oppressed until 1 h after the injury to decompress. Results: The ascorbate level of spinal cord increased immediately by contusion injury and reached to 1.62 μmol/L ± 0.61 μmol/L (217.30% ± 95.09% of the basal level) at the time point of 60 min after the injury. Compared with the Group A, the ascorbate level in Group B increased more significantly at 1 h after the injury, reaching to 3.76 μmol/L ± 1.75 μmol/L (430.25% ± 101.30% of the basal level). Meanwhile, we also found that the decompression after 1 hour of continuous compression will cause delayed peaks of ascorbate reaching to 5.71 μmol/L ± 2.69 μmol/L (627.73% ± 188.11% of the basal level). Conclusion: Our study provides first-hand direct experimental evidence indicating ascorbate is directly involved in secondary spinal cord injury and exhibits the dynamic time course of microenvironment changes after continuous compression injury of the spinal cord.
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Affiliation(s)
- Yawen Zhang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, The Chinese Academy of Sciences (CAS), Beijing, China
| | - Guojin Hou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Wenliang Ji
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, The Chinese Academy of Sciences (CAS), Beijing, China
| | - Feng Rao
- Trauma Medicine Centre, Peking University People's Hospital, Beijing, China
| | - Rubing Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Shan Gao
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Lanqun Mao
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, The Chinese Academy of Sciences (CAS), Beijing, China
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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Burke JF, Yue JK, Ngwenya LB, Winkler EA, Talbott JF, Pan JZ, Ferguson AR, Beattie MS, Bresnahan JC, Haefeli J, Whetstone WD, Suen CG, Huang MC, Manley GT, Tarapore PE, Dhall SS. Ultra-Early (<12 Hours) Surgery Correlates With Higher Rate of American Spinal Injury Association Impairment Scale Conversion After Cervical Spinal Cord Injury. Neurosurgery 2018; 85:199-203. [DOI: 10.1093/neuros/nyy537] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 10/16/2018] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
Cervical spinal cord injury (SCI) is a devastating condition with very few treatment options. It remains unclear if early surgery correlated with conversion of American Spinal Injury Association Impairment Scale (AIS) grade A injuries to higher grades.
OBJECTIVE
To determine the optimal time to surgery after cervical SCI through retrospective analysis.
METHODS
We collected data from 48 patients with cervical SCI. Based on the time from Emergency Department (ED) presentation to surgical decompression, we grouped patients into ultra-early (decompression within 12 h of presentation), early (within 12-24 h), and late groups (>24 h). We compared the improvement in AIS grade from admission to discharge, controlling for confounding factors such as AIS grade on admission, injury severity, and age. The mean time from injury to ED for this group of patients was 17 min.
RESULTS
Patients who received surgery within 12 h after presentation had a relative improvement in AIS grade from admission to discharge: the ultra-early group improved on average 1.3. AIS grades compared to 0.5 in the early group (P = .02). In addition, 88.8% of patients with an AIS grade A converted to a higher grade (AIS B or better) in the ultra-early group, compared to 38.4% in the early and late groups (P = .054).
CONCLUSION
These data suggest that surgical decompression after SCI that takes place within 12 h may lead to a relative improved neurological recovery compared to surgery that takes place after 12 h.
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Affiliation(s)
- John F Burke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Laura B Ngwenya
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Jason F Talbott
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Radiology, University of California San Francisco, San Francisco, California
| | - Jonathan Z Pan
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- Department of Neurological Surgery, Veterans Affairs Medical Center, San Francisco, California
| | - Michael S Beattie
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Jacqueline C Bresnahan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Jenny Haefeli
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - William D Whetstone
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | - Catherine G Suen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
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Ghajarzadeh M, Saberi H. Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran. Spinal Cord 2018; 57:150-155. [PMID: 30201998 DOI: 10.1038/s41393-018-0189-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Cross-sectional retrospective study. OBJECTIVE To describe the transportation mode to hospital and timing of spinal cord decompression and stabilization (D&S), length of hospital stay, frequency of pressure injuries, and sepsis during hospitalization. SETTING Brain and Spinal Injury Research Center, Tehran, Iran. METHODS Eight hundred and thirty patients with traumatic spinal cord injury (TSCI) were enrolled. Mode of transportation and length of time to reach the first hospital, length of hospital stay (LOS), and the time span between hospital arrival and decompression and stabilization (D&S) were recorded. RESULTS Fifty-nine percent of the enrolled individuals were transported to the first hospital by ambulance, while 41% were transferred by vehicles without medical equipment and personnel. Median length of time to reach the first hospital was 1 h for both ambulance and non-equipped car groups, with no statistically significant difference (p = 0.1). Median LOS, frequencies of pressure injuries, and sepsis based on the injury levels were not significantly different between two transportation modalities. One hundred and seventy-seven individuals had early surgery, and 254 had late surgery. Median LOS was 13 days in the early surgery group and 20 days in the late surgery group (p = 0.002). Frequencies of pressure injuries and sepsis were not significantly different between the late and early surgery groups for various injury levels. CONCLUSION About 59% of our patients had been transported to a hospital by non-medical personnel. Those with late surgery had significantly longer LOS. Improving TSCI patients' transportation method and early surgical interventions, if possible, may be considered.
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Affiliation(s)
- Mahsa Ghajarzadeh
- Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hooshang Saberi
- Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran.
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15
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Kim M, Hong SK, Jeon SR, Roh SW, Lee S. Early (≤48 Hours) versus Late (>48 Hours) Surgery in Spinal Cord Injury: Treatment Outcomes and Risk Factors for Spinal Cord Injury. World Neurosurg 2018; 118:e513-e525. [PMID: 30257304 DOI: 10.1016/j.wneu.2018.06.225] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Surgical management of spinal cord injury (SCI) is challenging. There is no standard guideline regarding the timing of surgery, although physicians have prioritized early surgery over the past decades. Although better outcomes have been observed from these studies, the definition of early surgery has been controversial, although mostly limited to 24-hours after injury. For some hospitals, this early surgery could be difficult to implement in practice. Hence, we re-evaluated the timing of early surgery as surgery within 48 hours and investigated the surgical outcomes of SCI depending on whether surgery was performed early (≤48 hours) or late (>48 hours). The primary outcomes were improvement in the American Spinal Injury Association Impairment Scale (AIS) grade in early and late surgery groups. METHODS This study was a retrospective cohort study in individuals aged 15-85 years, who underwent surgery for SCI between 2005 and 2016. The rate of AIS grade improvements was measured at 6 months after injury. Of the 86 enrolled patients, 31 (mean, 40.9 ± 12.64 hours) and 55 (mean, 168.25 ± 93.01 hours) patients were assigned to the early and late surgery groups, respectively. RESULTS AIS grade improvement was significantly greater in the early than in the late group (P = 0.039). In the early group, there was no significant difference in neurologic improvements among the AIS B, C, and D groups, but the AIS A group showed a significant improvement (P = 0.015). This finding was not observed in the late group (P = 0.060). AIS grade improvement was also significantly greater in the incomplete SCI group than in the complete SCI group, for all measurements (early, P = 0.007, late, P = 0.009). Other factors that significantly affected clinical outcomes were AIS grade on admission and the level of the injury.
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Affiliation(s)
- Moinay Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Woo Roh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Division of Neurosurgical Critical Care, Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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16
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Lee DY, Park YJ, Kim HJ, Ahn HS, Hwang SC, Kim DH. Early surgical decompression within 8 hours for traumatic spinal cord injury: Is it beneficial? A meta-analysis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:101-108. [PMID: 29289419 PMCID: PMC6136335 DOI: 10.1016/j.aott.2017.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/17/2017] [Accepted: 12/03/2017] [Indexed: 01/11/2023]
Abstract
Introduction The aim of this study is to evaluate whether early (<8 h) surgical decompression is better in improving neurologic outcomes than late (≥8 h) surgical decompression for traumatic spinal cord injury (tSCI). Methods The various electronic databases were used to detect relevant articles published up until May 2016 that compared the outcomes of early versus late surgery for tSCI. Data searching, extraction, analysis, and quality assessment were performed according to Cochrane Collaboration guidelines. The results are presented as relative ratio (RR) for binary outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). Results Seven studies were finally included in this meta-analysis. There were significant differences between the 2 groups in neurologic improvement (MD = 0.54, 95% CI = −18.52 to −7.02, P < 0.0001) and length of hospital stay (MD = −12.77, 95% CI = 0.34–0.74, P < 0.00001). However, no significant differences were found between the 2 groups in perioperative complications (OR = 0.95, 95% CI = 0.35–2.61, P = 0.92). Conclusions Early surgical decompression within 8 h after tSCI was beneficial in terms of neurologic improvement compared with late surgery. Early surgical decompression (within 8 h) is recommended for patients with tSCI. Level of evidence Level III, therapeutic study.
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17
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Lubelski D, Tharin S, Como JJ, Steinmetz MP, Vallier H, Moore T. Surgical timing for cervical and upper thoracic injuries in patients with polytrauma. J Neurosurg Spine 2017; 27:633-637. [DOI: 10.3171/2017.4.spine16933] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEFew studies have investigated the advantages of early spinal stabilization in the patient with polytrauma in terms of reduction of morbidity and mortality. Previous analyses have shown that early stabilization may reduce ICU stay, with no effect on complication rates.METHODSThe authors prospectively observed 340 polytrauma patients with an Injury Severity Score (ISS) of greater than 16 at a single Level 1 trauma center who were treated in accordance with a protocol termed “early appropriate care,” which emphasizes operative treatment of various fractures within 36 hours of injury. Of these patients, 46 had upper thoracic and/or cervical spine injuries. The authors retrospectively compared patients treated according to protocol versus those who were not. Continuous variables were compared using independent t-tests and categorical variables using Fisher’s exact test. Logistic regression analysis was performed to account for baseline confounding factors.RESULTSFourteen of 46 patients (30%) did not undergo surgery within 36 hours. These patients were significantly more likely to be older than those in the protocol group (53 vs 38 years, p = 0.008) and have greater body mass index (BMI; 33 vs 27, p = 0.02), and they were less likely to have a spinal cord injury (SCI) (82% did not have an SCI vs 44% in the protocol group, p = 0.04). In terms of outcomes, patients in the protocol-breach group had significantly more total ventilator days (13 vs 6 days, p = 0.02) and total ICU days (16 vs 9 days, p = 0.03). Infection rates were 14% in the protocol-breach group and 3% in the protocol group (p = 0.2) Total complications trended toward being statistically significantly more common in the protocol-breach group (57% vs 31%). After controlling for potential confounding variables by logistic regression (including age, sex, BMI, race, and SCI), total complications were significantly (p < 0.05) greater in the protocol-breach group (OR 29, 95% CI 1.9–1828). This indicates that the odds of developing “any complication” were 29 times greater if treatment was delayed more than 36 hours.CONCLUSIONSEarly surgical stabilization in the polytrauma patient with a cervical or upper thoracic spine injury is associated with fewer complications and improved outcomes. Hospitals may consider the benefit of protocols that promote early stabilization in this patient population.
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Affiliation(s)
- Daniel Lubelski
- 1Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Center for Spine Health, and Department of Neurological Surgery, Cleveland Clinic, Cleveland
- 5Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Suzanne Tharin
- 6Department of Neurosurgery, Stanford University, Palo Alto, California
| | | | - Michael P. Steinmetz
- 1Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Center for Spine Health, and Department of Neurological Surgery, Cleveland Clinic, Cleveland
| | | | - Timothy Moore
- 3Orthopaedic Surgery, and
- 4Neurosciences, MetroHealth Medical Center, Cleveland, Ohio
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Zhao C, Zhang B, Shi J, Li Y, Pang L. Spontaneous Reduction of Fractured Thoracolumbar Spine With Complete Dislocation: Case Report With Literature Review. Orthop Nurs 2017; 36:350-355. [PMID: 28930904 DOI: 10.1097/nor.0000000000000391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Fractures and dislocations with complete lateral displacement of the spine at the lumbar and thoracic levels are some of the most severe types of thoracolumbar trauma. They are usually caused by high-energy trauma and accompanied by extreme, life-threatening injuries and neurological deficits that vary in severity, which may delay operative intervention. It is often difficult to reduce such a complex fracture-dislocation because of the force that the muscles exert on the bone and the injured part of the spinal cord. No absolute guidelines for reduction, fixation, decompression, and fusion of this type of injury have been established. We report a rare case of spontaneous reduction of the fractured thoracolumbar spine with complete dislocation and discuss the management of such severe injuries through review of the existing literature.
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Affiliation(s)
- Chen Zhao
- Chen Zhao, MS, The Second Affiliated Hospital of Xi'an Medical University, Baqiao District, Xi'an, Shaanxi Province, China Bing Zhang, BS, The Second Affiliated Hospital of Xi'an Medical University, Baqiao District, Xi'an, Shaanxi Province, China. Jiandang Shi, MD, General Hospital of Ningxia Medical University, Xingqing District, Victory Street, Yinchuan City, Ningxia Province, China. Yaping Li, BS, General Hospital of Ningxia Medical University, Xingqing District, Victory Street, Yinchuan City, Ningxia Province, China. Long Pang, MD, General Hospital of Ningxia Medical University, Xingqing District, Victory Street, Yinchuan City, Ningxia Province, China
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Frenzel S, Krenn P, Heinz T, Negrin LL. Does the applied polytrauma definition notably influence outcome and patient population? - a retrospective analysis. Scand J Trauma Resusc Emerg Med 2017; 25:87. [PMID: 28859678 PMCID: PMC5577783 DOI: 10.1186/s13049-017-0400-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 06/02/2017] [Indexed: 11/11/2022] Open
Abstract
Background Although the term “polytrauma” has been in use for decades, no generally accepted definition exists. The aim of this study was to demonstrate that different polytrauma definitions applied to a specific patient population result in diverse subgroups of individuals, who in turn present a varying outcome. Methods All patients (≥18 years) treated at our level I trauma center within a time period of three years were classified according to 11 selected polytrauma definitions and included in our study, if they were rated “polytraumatized” by at least one of these definitions. All patients, who met the criteria of a certain definition, were combined to the relevant definition-positive group, thus resulting in 11 patient subgroups. Their demographic data (number of patients, mean patient age, mean Injury Severity Score value, median number of ventilator days, median length of stay at the intensive care unit and at the hospital, mortality rate and odds ratio) were statistically compared. Results Three hundred seventy-five patients (73% male) with a mean age of 47 years met the inclusion criteria and were allocated to the relevant subgroups; their patient number varied from 55 to 346 and their mean Injury Severity Score value ranged from 4 to 75. Not surprisingly, all examined parameters were subject to variations. Whereas most definition-positive groups showed a mortality rate of about 21% to 30%, 18% of the individuals, who met the criteria according to Blacker, and 40% of the polytrauma victims according to Schalamon died. The Pape 1-, Schalamon-, and Berlin-positive groups presented a significant odds ratio with regard to mortality that considerably exceeded 1. Discussion A polytrauma definition can only be a reliable tool in classifying trauma victims if it provides a significant odds ratio with regard to mortality that considerably exceeds 1 and if it succeeds in capturing patients with multiple severe injuries and a higher mortality rate without reducing the number of polytraumatized patients to a not representatively small number. Conclusions Solely the Berlin definition resulted in a patient number reflecting clinical reality, thus enabling a transparent evaluation of treatment results provided by different institutions and allowing objective comparison of published studies.
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Affiliation(s)
- Stephan Frenzel
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, 1090, Vienna, Austria
| | - Philipp Krenn
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Heinz
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, 1090, Vienna, Austria
| | - Lukas Leopold Negrin
- Department of Trauma Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, 1090, Vienna, Austria.
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Polytrauma Patients With Associated Spine Fractures: An Assessment of Surgical Intervention on Patient Outcome. Clin Spine Surg 2017; 30:E38-E43. [PMID: 28107241 DOI: 10.1097/bsd.0b013e31829eb82c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To examine perioperative characteristics among polytraumatized patients with operative, unstable spine fractures with and without concomitant operative long bone injuries. SUMMARY OF BACKGROUND DATA Treatment of polytrauma patients has delicate and time-sensitive protocols to ensure successful recovery. The literature defines standards for vertebral injury and surgical intervention. DATA Severely polytraumatized patients with an Injury Severity Score (ISS)≥15 were divided according to those with operative spine fractures with operative long bone fractures (OSFLBF) and those with operative spine fractures alone (OSFA). METHODS Patients were compared by sex, age, mechanism of injury (MOI), ISS, location of injuries, time spent inpatient before procedure(s), total time in the operating room, type of procedure(s) performed, estimated operative blood loss, complications, length of stay (LOS), and time to discharge. RESULTS In a 12-year period, >600 patients were admitted to our level I trauma center with polytrauma and unstable spine fracture. Twelve had sustained operative unstable spine injuries and 21 had unstable spine injuries with a long bone injury requiring operative stabilization. Significant differences in ISS, LOS, MOI, region of vertebral injury, or total operating room time between the 2 groups were not observed. Differences were seen concerning average blood loss during surgery and time spent inpatient before entering the operating room. OSFLBF patients were discharged at a faster rate after 20 days compared with OSFSA patients. CONCLUSIONS No differences in ISS, LOS, MOI, region of vertebral injury or vertebral procedure, or total operating room time were observed. Blood loss was more substantial in the OSFLBF group, but it spent fewer days in the hospital preoperatively. Despite a nonstatistical difference in LOS, a larger proportion of OSFA patients remained in the hospital after being inpatient for >20 days, reducing the risk for iatrogenic complication in that group compared with OSFA. LEVEL OF EVIDENCE III, retrospective comparative.
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21
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Srinivas BH, Rajesh A, Purohit AK. Factors affecting outcome of acute cervical spine injury: A prospective study. Asian J Neurosurg 2017; 12:416-423. [PMID: 28761518 PMCID: PMC5532925 DOI: 10.4103/1793-5482.180942] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown. The aim of the study was to evaluate the factors influencing the outcome following acute cervical spine injury. Materials and Methods: A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, imageological factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up. Results: A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patient with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% patients. Percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine. Conclusions: Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have worst improvement in neurological status at 6 months follow-up.
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Affiliation(s)
| | - Alugolu Rajesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - A K Purohit
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Reich MS, Dolenc AJ, Moore TA, Vallier HA. Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients? J Orthop Surg Res 2016; 11:106. [PMID: 27671737 PMCID: PMC5037639 DOI: 10.1186/s13018-016-0441-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/15/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications. METHODS Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death. RESULTS Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046). CONCLUSIONS EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients. LEVEL OF EVIDENCE level II prospective, comparative study.
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Affiliation(s)
- M S Reich
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - A J Dolenc
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - T A Moore
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - H A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
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Abstract
STUDY DESIGN A systematic review of the literature for clinical and preclinical evidence related to timing of decompression following spinal cord injury (SCI). OBJECTIVE A review of the literature in search of consensus on what constitutes the ideal time frame for surgical management of SCI. SUMMARY OF BACKGROUND DATA Optimal timing for surgical management of SCI remains poorly defined. Despite multiple preclinical and clinical studies, there is still lack of consensus on the optimal time for surgery in SCI. METHODS We systematically reviewed the literature for clinical and preclinical evidence related to timing of decompression following SCI. For clinical studies, our review included papers published in English after January 1, 1990. For preclinical studies, we limited our review to papers published after January 2001. The OVID-Medline and Web of Science databases were reviewed for preclinical studies, and the OVID-Medline, Cochrane, and Embase databases were reviewed for clinical studies. RESULTS A total of 8792 preclinical articles were identified. Of those, only 14 met our inclusion criteria and were included in the analysis. A total of 25,190 clinical articles were identified. Of those, only 30 studies met our inclusion criteria and were included for analysis. Clinical studies reported on a total of 5236 patients, of whom 1665 underwent early decompression and 3571 underwent late decompression. There was significant variability in the definition of early and late decompression in both clinical and preclinical studies. Preclinical data were in favor of early decompression. From a clinical standpoint, there was only level II evidence proving safety and feasibility of early decompression with no definite evidence of improved outcome for any of the two groups. CONCLUSION There is growing evidence in favor of early decompression following SCI. Early decompression was proven to be clinically safe and feasible, but there is still no definite proof that early decompression leads to improved outcomes. LEVEL OF EVIDENCE 5.
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Liu JM, Long XH, Zhou Y, Peng HW, Liu ZL, Huang SH. Is Urgent Decompression Superior to Delayed Surgery for Traumatic Spinal Cord Injury? A Meta-Analysis. World Neurosurg 2016; 87:124-31. [DOI: 10.1016/j.wneu.2015.11.098] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/29/2015] [Accepted: 11/30/2015] [Indexed: 01/11/2023]
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Bourassa-Moreau É, Mac-Thiong JM, Li A, Ehrmann Feldman D, Gagnon DH, Thompson C, Parent S. Do Patients with Complete Spinal Cord Injury Benefit from Early Surgical Decompression? Analysis of Neurological Improvement in a Prospective Cohort Study. J Neurotrauma 2016; 33:301-6. [DOI: 10.1089/neu.2015.3957] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Étienne Bourassa-Moreau
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
| | - Jean-Marc Mac-Thiong
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
- CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Ang Li
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
| | | | - Dany H. Gagnon
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Stefan Parent
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Hôpital du Sacré-Coeur, Montreal, Quebec, Canada
- CHU Sainte-Justine, Montreal, Quebec, Canada
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Abstract
STUDY DESIGN A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and 2011. OBJECTIVE The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma. METHODS Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery. RESULTS Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance. CONCLUSION Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI.
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Konieczny MR, Strüwer J, Jettkant B, Schinkel C, Kälicke T, Muhr G, Frangen TM. Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable? Spine J 2015; 15:1713-8. [PMID: 24139863 DOI: 10.1016/j.spinee.2013.07.469] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 06/24/2013] [Accepted: 07/22/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Many institutions' retrospective studies investigated the effect of the timing of surgery on outcomes of polytraumatized patients with severe lesions of the thoracic spine and mainly found a better outcome for patients who were operated on less than 72 hours posttrauma. PURPOSE We conducted a prospective study in a Level I trauma center to validate the retrospective data and to investigate other variables, in addition to the timing of surgery that may influence patient outcomes. STUDY DESIGN Prospective observational clinical study. PATIENT SAMPLE Within this prospective study at a Level I trauma center, we enrolled 38 multiple injured patients with unstable fractures of vertebral column from Level Th1 to L1. Further inclusion criteria consisted of an injury severity score of 16 or more and an intensive care unit (ICU) stay of more than 7 days. The age of included patients was limited from 16 or more to 75 or less years. OUTCOME MEASURES Hospital stay, stay on ICU, and mortality. METHODS Twenty-two patients were operated on less than or equal to 72 hours posttrauma, and 16 received late surgery greater than or equal to 72 hours posttrauma. RESULTS Patients who received early surgery had a significantly higher mortality rate (p<.01) than those who received late surgery. Sixty-seven percent of our patients who had an initial hemoglobin (Hb) less than 10 mg/dL died. Seventy-five percent of those patients who had an Hb less than 10 mg/dL and received a thoracic drain died. CONCLUSIONS Although some reports indicate advantages for early surgery for thoracic spine trauma in the polytraumatized patient, careful patient selection should be used. Based on the results of this prospective study, early surgery for thoracic spine trauma in patients with concomitant severe thoracic trauma and low initial Hb levels may pose a risk for poor clinical outcomes.
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Affiliation(s)
- Markus R Konieczny
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany; Department of Orthopedic Surgery, University Hospital Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Johannes Strüwer
- Department of Orthopedics and Rheumatology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany
| | - Birger Jettkant
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Christian Schinkel
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany; Department of Traumatology, Klinikum Memmingen, Bismarckstraße 23, 87700 Memmingen, Germany
| | - Thomas Kälicke
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany; Department of Traumatology, St Josefs Hospital Bonn-Beul, Hermannstraße 37, 53225 Bonn, Germany
| | - Gert Muhr
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Thomas M Frangen
- Department of Traumatology, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany; Department of Orthopedics and Traumatology, Elisabeth-Klinik Bigge, Heinrich-Sommer-Straße 4, 59939 Olsberg, Germany
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Chávez JP, Atanasio JMP, García EAM, Zuno JCDLF, González RT. Damage control in thoracic and lumbar unstable fractures in polytrauma. Systematic review. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-1851201514020r131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
<p>The objective of this systematic review was to integrate the information from existing studies to determine the level of evidence and grade of recommendation of the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients. Eighteen papers were collected from different databases by keywords and Mesh terms; the level of evidence and grade of recommendation, the characteristics of the participants, the time of fracture fixation, the type of approach and technique used, the length of stay in the intensive care unit, the days of dependence on mechanical ventilator, and the incidence of complications in patients were assessed. The largest proportion of the studies were classified as level 4 evidence and grade C of recommendation which is favorable to the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients as a positive recommendation, although not conclusive. Most papers advocate fracture stabilization within 72 hours of the injury which is associated with a lower incidence of complications, hospital stay, stay in the intensive care unit and lower mortality.</p>
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Affiliation(s)
- Javier Peña Chávez
- Dr. Victorio De La Fuente Narváez High Specialty Medical Unit. Federal District, Mexico
| | | | | | | | - Rubén Torres González
- Dr. Victorio De La Fuente Narváez High Specialty Medical Unit. Federal District, Mexico
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Acute cauda equina syndrome caused by a disk herniation-is emergent surgery the correct option? Surgical decompression remains the standard of care. Spine (Phila Pa 1976) 2015; 40:639-41. [PMID: 25714850 DOI: 10.1097/brs.0000000000000848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Jug M, Kejžar N, Vesel M, Al Mawed S, Dobravec M, Herman S, Bajrović FF. Neurological Recovery after Traumatic Cervical Spinal Cord Injury Is Superior if Surgical Decompression and Instrumented Fusion Are Performed within 8 Hours versus 8 to 24 Hours after Injury: A Single Center Experience. J Neurotrauma 2015; 32:1385-92. [PMID: 25658291 DOI: 10.1089/neu.2014.3767] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A prospective study was performed to evaluate the impact of surgical decompression (SD) and instrumented fusion within 8 h versus 8-24 h after injury on neurological recovery after cervical traumatic spinal cord injury (tSCI) in patients operated on in the UMC Ljubljana, Slovenia. Only patients with the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A through C and with MRI-confirmed spinal cord compression were enrolled. The primary outcome was the change in AIS grade at the 6-month follow-up. Of the 48 enrolled patients, 22 patients who underwent surgery within 8 h (group 8 h) and 20 patients who underwent surgery between 8 and 24 h (Group 8-24 h) after injury concluded the study. At admission, there was no statistically significant difference in AIS grade between the study groups. At the 6-month follow-up, an improvement of at least two AIS grades was found in 45.5% of patients in group 8 h and in 10% of patients in group 8-24 h (p=0.017). The median improvement in the ASIA motor score was 38.5 (10.0-61.0) motor points in group 8 h and 15.0 (8.8-34.0) motor points in group 8-24 h (p=0.0468). In a multivariate analysis, adjusted for the preoperative AIS grade and the degree of spinal canal compromise, the odds of an at least two-grade AIS improvement were at least 106% higher for patients in group 8 h than for patients in group 8-24 h (odds ratio=11.08, p=0.004). No statistically significant difference was found in the rate of perioperative complications, pneumonia, and the number of ventilator-dependent days or the mortality between the groups. Our results suggest that the patients with tSCI who undergo SD within 8 h after injury have superior neurological outcomes than patients who undergo SD 8-24 h after injury, without any increase in the rate of adverse effects.
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Affiliation(s)
- Marko Jug
- 1 Spine Unit, Department of Traumatology, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Nataša Kejžar
- 2 Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana , Slovenia
| | - Miloš Vesel
- 1 Spine Unit, Department of Traumatology, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Said Al Mawed
- 1 Spine Unit, Department of Traumatology, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Marko Dobravec
- 1 Spine Unit, Department of Traumatology, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Simon Herman
- 1 Spine Unit, Department of Traumatology, University Medical Centre Ljubljana , Ljubljana, Slovenia
| | - Fajko F Bajrović
- 3 Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia .,4 Department of Neurology, University Medical Centre Ljubljana , Ljubljana, Slovenia
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Galvin JW, Freedman BA, Schoenfeld AJ, Cap AP, Mok JM. Morbidity of early spine surgery in the multiply injured patient. Arch Orthop Trauma Surg 2014; 134:1211-7. [PMID: 25077784 DOI: 10.1007/s00402-014-2068-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The optimal timing of surgery for multiply injured patients with operative spinal injuries remains unknown. The purported benefits of early intervention must be weighed against the morbidity of surgery in the early post-injury period. The performance of spine surgery in the Afghanistan theater permits analysis of the morbidity of early surgery on military casualties. The objective is to compare surgical morbidity of early spinal surgery in multiply injured patients versus stable patients. MATERIALS AND METHODS Patients were retrospectively categorized as stable or borderline unstable depending on the presence of at least one of the following: ISS >40, ISS >20 and chest injury, exploratory laparotomy or thoracotomy, lactate >2.5 mEq/L, platelet <110,000/mm(3), or >10 U PRBCs transfused pre-operatively. Surgical morbidity, complications, and neurologic improvement between the two groups were compared retrospectively. RESULTS 30 casualties underwent 31 spine surgeries during a 12-month period. 16 of 30 patients met criteria indicating a borderline unstable patient. Although there were no significant differences in the procedures performed for stable and borderline unstable patients as measured by the Surgical Invasiveness Index (7.5 vs. 6.9, p = 0.8), borderline unstable patients had significantly higher operative time (4.3 vs. 3.0 h, p = 0.01), blood loss (1,372 vs. 366 mL, p = 0.001), PRBCs transfused intra-op (3.88 vs. 0.14 U, p < 0.001), and total PRBCs transfused in theater (10.18 vs. 0.31 U, p < 0.001). CONCLUSIONS The results indicate that published criteria defining a borderline unstable patient may have a role in predicting increased morbidity of early spine surgery. The perceived benefits of early intervention should be weighed against the greater risks of performing extensive spinal surgeries on multiply injured patients in the early post-injury period, especially in the setting of combat trauma.
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Affiliation(s)
- J W Galvin
- Orthopaedic Surgery Service, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, Washington, 98431, USA
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Giorgi H, Blondel B, Adetchessi T, Dufour H, Tropiano P, Fuentes S. Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients. Orthop Traumatol Surg Res 2014; 100:449-54. [PMID: 25082775 DOI: 10.1016/j.otsr.2014.03.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 03/12/2014] [Accepted: 03/27/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Care of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation. MATERIALS AND METHODS All severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure. RESULTS In all, 10 patients (average age of 40 years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4 days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1 month of the initial surgery. DISCUSSION The strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- H Giorgi
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France
| | - B Blondel
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France
| | - T Adetchessi
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France
| | - H Dufour
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France
| | - P Tropiano
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France
| | - S Fuentes
- Unité de Chirurgie rachidienne, Hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille, France.
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Sundaram PS, Kanniyan K, Bijarnia I. A Case Report on Extruded Disc Acting as Buttonhole reventing Reduction in Traumatic Fracture and Lateral Dislocation of L1-l2 Vertebrae. J Orthop Case Rep 2014; 4:49-52. [PMID: 27298983 PMCID: PMC4719327 DOI: 10.13107/jocr.2250-0685.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION There is a scanty literature support describing the incidence, mechanism of lateral dislocations of thoracolumbar spine and its management describing the reduction techniques. Hereby we present an interesting case of extruded disc acting as buttonhole preventing the reduction of lateral dislocation of L1-L2 vertebrae and this would be the first of its variety to be described ever in literature. CASE REPORT A 30 year old female was referred to our hospital on post trauma day 7 with bilateral fascet fracture and lateral dislocation of L1-L2 vertebrae and fracture humerus on right arm following a road traffic accident. She presented with clinical signs consistent of cauda equina lesion. She underwent surgical reduction and TLIF L1-L2. On one year follow-up X-Rays showed maintenance of dorsolumbar saggital alignment without collapse. CONCLUSION Dislocations of spine are three column injuries, are highly unstable requiring surgical stabilisation. Posterior instrumentation is the routinely followed technique to achieve reduction and for posterolateral fusion. In this case lateral dislocation was reduced only after removal of the laterally extruded disc. After complete discectomy TLIF was considered a good option for restoring disc space height and maintaining saggital balance.
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Affiliation(s)
- P Shanmuga Sundaram
- Department of Orthopaedics, Saveetha Medical College Hospital, Thandalam, Chennai., India
| | - Kalaivanan Kanniyan
- Department of Orthopaedics, Saveetha Medical College Hospital, Thandalam, Chennai., India
| | - Isha Bijarnia
- Department of Orthopaedics, Saveetha Medical College Hospital, Thandalam, Chennai., India
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Complications Associated with Surgical Treatment of Traumatic Spinal Fractures: A Review of the Scoliosis Research Society Morbidity and Mortality Database. World Neurosurg 2014; 81:818-24. [DOI: 10.1016/j.wneu.2013.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/13/2012] [Accepted: 02/02/2013] [Indexed: 11/20/2022]
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Clinical results of early stabilization of spine fractures in polytrauma patients. J Crit Care 2014; 29:694.e7-9. [PMID: 24636930 DOI: 10.1016/j.jcrc.2014.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 03/01/2014] [Accepted: 03/02/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of study was to evaluate the clinical results of early stabilization of spine fractures in polytrauma patients. MATERIALS AND METHODS Between August 2003, and May 2012, 166 polytrauma patients with thoracolumbar spine fractures were included. Patients were divided into 2 groups according to injury-to-operation time (time cut-off, 72 hours). Patients were also subdivided into 4 groups according to injury severity score (ISS), and the clinical course was evaluated. RESULTS Group A showed shorter hospital length of stay, intensive care unit, and ventilator days than group B. For each of these categories, the differences between the 2 groups were statistically significant (P=.004, P=.044, and P=.043). Patients with moderate to severe injury (ISS, ≥26), those who were treated with early stabilization showed shorter hospital length of stay, intensive care unit, and ventilator days than the patients with mild to moderate injury (ISS, <26), and the differences were statistically significant (P=.004, P=.006, and P=.006). CONCLUSION Polytrauma patients whose spine fractures were stabilized within 72 hours had better clinical outcomes than those with late stabilization. In addition, more severely injured patients (ISS, ≥26) benefited more from early stabilization.
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Bourassa-Moreau É, Mac-Thiong JM, Feldman DE, Thompson C, Parent S. Non-Neurological Outcomes after Complete Traumatic Spinal Cord Injury: The Impact of Surgical Timing. J Neurotrauma 2013; 30:1596-601. [DOI: 10.1089/neu.2013.2957] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Étienne Bourassa-Moreau
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Hôpital du Sacré-Coeur, Montreal, Canada
| | - Jean-Marc Mac-Thiong
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Hôpital du Sacré-Coeur, Montreal, Canada
- CHU Sainte-Justine, Montreal, Canada
| | | | | | - Stefan Parent
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Hôpital du Sacré-Coeur, Montreal, Canada
- CHU Sainte-Justine, Montreal, Canada
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Complications in acute phase hospitalization of traumatic spinal cord injury: does surgical timing matter? J Trauma Acute Care Surg 2013; 74:849-54. [PMID: 23425747 DOI: 10.1097/ta.0b013e31827e1381] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Optimal timing of surgery after a traumatic spinal cord injury (SCI) is one of the most controversial subjects in spine surgery. We assessed the relationship between surgical timing and the occurrence of nonneurologic postoperative complications during acute hospital stay for patients with a traumatic SCI. METHODS A retrospective cohort study was performed in a single institution. Four hundred thirty-one cases of traumatic SCI were reviewed, and postoperative complications were recorded from the medical charts. Patients were compared using two different surgical timing cutoffs (24 hours and 72 hours). Logistic regression analyses were modeled for complication occurrence. The effect of surgical timing on complication rate was adjusted for potential confounding variables such as the level of injury, American Spinal Injury Association (ASIA) grade, Injury Severity Score (ISS), age, sex, Charlson Comorbidity Index, and Surgical Invasiveness Index. RESULTS Patients operated on earlier were younger, had less comorbidity, had a higher ISS, and were more likely to have a cervical lesion and a complete injury (ASIA A). A reduction in the global rate of complications as well as in the rate of pneumonias and pressure ulcers were predicted by surgery performed earlier than 72 hours and 24 hours. Increasing age, more severe ASIA grade, and cervical lesion as well as increased Charlson Comorbidity Index, ISS, and SII were also statistically related to the occurrence of complications. CONCLUSION This study showed that a shorter surgical delay after a traumatic SCI decreases the rate of complications during the acute phase hospitalization. We suggest that patients with traumatic SCI should be promptly operated on earlier than 24 hours following the injury to reduce complications while optimizing neurologic recovery. If medical or practical reasons preclude timing less than 24 hours, efforts should still be made to perform surgery earlier than 72 hours following the SCI. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic/care management study, level IV.
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Pneumaticos SG, Triantafyllopoulos GK, Giannoudis PV. Advances made in the treatment of thoracolumbar fractures: current trends and future directions. Injury 2013; 44:703-12. [PMID: 23287553 DOI: 10.1016/j.injury.2012.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2012] [Indexed: 02/02/2023]
Abstract
Thoracolumbar fractures are common injuries after blunt trauma and are accompanied with significant morbidity, including neurologic deficit. Parallel to the evolution of initial management during the past few years, efforts have been concentrated on determining clear indications for surgical treatment, as there is no agreement over superiority of conservative or operative treatment. Various classification systems have been used for identifying those injuries requiring surgical intervention. Moreover, novel trends in surgical techniques, including minimal invasive surgery, implants and rehabilitation protocols have provided new, promising aspects regarding the treatment and outcomes of thoracolumbar fractures. The present review focuses on these recent advances.
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Affiliation(s)
- Spyros G Pneumaticos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Athens, Greece.
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Xing D, Chen Y, Ma JX, Song DH, Wang J, Yang Y, Feng R, Lu J, Ma XL. A methodological systematic review of early versus late stabilization of thoracolumbar spine fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:2157-66. [PMID: 23263169 DOI: 10.1007/s00586-012-2624-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/29/2012] [Accepted: 12/09/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The optimal timing of stabilization in patients with traumatic thoracolumbar fractures remains controversial. There is currently a lack of consensus on the timing of surgical stabilization, which is limited by the reality that a randomized controlled trial to evaluate early versus late stabilization is difficult to perform. Therefore, the objective of this study was to determine the benefits, safety and costs of early stabilization compared with late stabilization using data available in the current literature. METHODS An electronic literature search was performed in Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials for relevant studies evaluating the timing of surgery in patients with thoracolumbar fractures. Two reviewers independently analyzed and selected each study on the basis of the eligibility criteria. The quality of the included studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE). Any disagreements were resolved by consensus. RESULTS Ten studies involving 2,512 subjects were identified. These studies demonstrated that early stabilization shortened the hospital length of stay, intensive care unit length of stay, ventilator days and reduced morbidity and hospital expenses for patients with thoracic fractures. However, reduced morbidity and hospital expenses were not observed with stabilization of lumbar fractures. Owing to the very low level of evidence, no conclusion could be made regarding the effect of early stabilization on mortality. CONCLUSIONS We could adhere to the recommendation that patients with traumatic thoracolumbar fractures should undergo early stabilization, which may reduce the hospital length of stay, intensive care unit length of stay, ventilator days, morbidity and hospital expenses, particularly when the thoracic spine is involved. Individual patient characteristics should be concerned carefully. However, the definite conclusion cannot be made due to the heterogeneity of the included studies and low level of evidence. Further prospective studies are required to confirm whether there are benefits to early stabilization compared with late stabilization.
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Affiliation(s)
- Dan Xing
- Department of Orthopaedics Institute, Tianjin Hospital, 406 Jiefang Nan Street, Hexi District, Tianjin, 300211, China
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Aarabi B, Simard JM, Kufera JA, Alexander M, Zacherl KM, Mirvis SE, Shanmuganathan K, Schwartzbauer G, Maulucci CM, Slavin J, Ali K, Massetti J, Eisenberg HM. Intramedullary lesion expansion on magnetic resonance imaging in patients with motor complete cervical spinal cord injury. J Neurosurg Spine 2012; 17:243-50. [PMID: 22794535 PMCID: PMC3534760 DOI: 10.3171/2012.6.spine12122] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT The authors performed a study to determine if lesion expansion occurs in humans during the early hours after spinal cord injury (SCI), as has been established in rodent models of SCI, and to identify factors that might predict lesion expansion. METHODS The authors studied 42 patients with acute cervical SCI and admission American Spinal Injury Association Impairment Scale Grades A (35 patients) and B (7 patients) in whom 2 consecutive MRI scans were obtained 3-134 hours after trauma. They recorded demographic data, clinical information, Injury Severity Score (ISS), admission MRI-documented spinal canal and cord characteristics, and management strategies. RESULTS The characteristics of the cohort were as follows: male/female ratio 37:5; mean age, 34.6 years; and cause of injury, motor vehicle collision, falls, and sport injuries in 40 of 42 cases. The first MRI study was performed 6.8 ±2.7 hours (mean ± SD) after injury, and the second was performed 54.5 ± 32.3 hours after injury. The rostrocaudal intramedullary length of the lesion on the first MRI scan was 59.2 ± 16.1 mm, whereas its length on the second was 88.5 ± 31.9 mm. The principal factors associated with lesion length on the first MRI study were the time between injury and imaging (p = 0.05) and the time to decompression (p = 0.03). The lesion's rate of rostrocaudal intramedullary expansion in the interval between the first and second MRI was 0.9 ± 0.8 mm/hour. The principal factors associated with the rate of expansion were the maximum spinal cord compression (p = 0.03) and the mechanism of injury (p = 0.05). CONCLUSIONS Spinal cord injury in humans is characterized by lesion expansion during the hours following trauma. Lesion expansion has a positive relationship with spinal cord compression and may be mitigated by early surgical decompression. Lesion expansion may be a novel surrogate measure by which to assess therapeutic effects in surgical or drug trials.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Blair JA, Patzkowski JC, Schoenfeld AJ, Cross Rivera JD, Grenier ES, Lehman RA, Hsu JR. Are spine injuries sustained in battle truly different? Spine J 2012; 12:824-9. [PMID: 22000726 DOI: 10.1016/j.spinee.2011.09.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 06/22/2011] [Accepted: 09/07/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research. PURPOSE Compare the severity and prognosis of battle and nonbattle injuries to the spine. STUDY DESIGN Retrospective study. PATIENT SAMPLE American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). METHODS The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs). RESULTS Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16). CONCLUSIONS Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.
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Affiliation(s)
- James A Blair
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA.
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Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012; 7:e32037. [PMID: 22384132 PMCID: PMC3285644 DOI: 10.1371/journal.pone.0032037] [Citation(s) in RCA: 698] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 01/18/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI. METHODS We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality. FINDINGS A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21). CONCLUSION Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.
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Affiliation(s)
- Michael G Fehlings
- Divisions of Neurosurgery and Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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The Effect of Operative Timing on Functional Outcome After Isolated Spinal Trauma. ACTA ACUST UNITED AC 2011; 71:1668-72. [DOI: 10.1097/ta.0b013e31823246a5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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In-hospital mortality and surgical utilization in severely polytraumatized patients with and without spinal injury. ACTA ACUST UNITED AC 2011; 71:E71-8. [PMID: 21399541 DOI: 10.1097/ta.0b013e3182092eac] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients who sustain major trauma experience multisystem injuries including those affecting the spine. We hypothesize that recovery after spinal injuries differs from those affecting other systems. The purpose of our study was to compare in-hospital mortality and surgical resource utilization in severely polytraumatized patient with and without spinal injury. METHODS We assembled a cohort of patients with severe polytrauma (Injury Severity Score [ISS]>15) and spinal injury and matched them to a cohort without spinal injury for age, gender, ISS, and mechanism of injury. In patients presenting to a Level I trauma center, we compared in-hospital patient mortality, the number of surgical procedures, and duration required for ventilatory support, intensive care unit (ICU) length of stay (LOS), and in-hospital LOS comparing matched groups. We performed a subanalysis of those who sustained severe fracture types and those with neurologic impairment. RESULTS From 114 matched pairs, we found no significant differences in mortality rates or numbers of surgical procedures performed between the groups. Patients with spine injury, however, were observed to experience a prolonged duration of ventilation, ICU and in-hospital LOS compared with their matched cohort. Severe fracture patterns and the presence of neurologic involvement amplified the effect on these outcomes. CONCLUSIONS In this study, we conclude that the presence of a spinal injury in the setting of severe polytrauma (ISS>15) is associated with a prolonged course of ventilatory support, ICU, and in-hospital LOS. Trauma hospitals treating patients with spinal fracture should be aware of differences in the use of health services for this patient population.
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Pakzad H, Roffey DM, Knight H, Dagenais S, Yelle JD, Wai EK. Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes. Can J Surg 2011; 54:270-6. [PMID: 21651838 DOI: 10.1503/cjs.008810] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates mobilization and theoretically reduces associated complications. METHODS We identified consecutive patients without neurologic injury requiring stabilization surgery for a spinal fracture at an academic tertiary-care hospital over a 12-year period. Incidences of postoperative complications were prospectively evaluated. We analyzed results based on the time elapsed before the final surgical stabilization procedure. Multivariate analyses were performed to explore the effects of potential confounders. RESULTS A total of 83 patients (60 men, 23 women; mean age 39.4 yr) met the eligibility criteria and were enrolled. The mean Injury Severity Score (ISS) was 27.1 (range 12.0-57.0); 35% of patients had a cervical fracture and 65% had a thoraco-lumbar fracture. No statistically significant associations were uncovered between time to surgical stabilization and age, ISS or comorbidities. Comparing patients stabilized after 24 hours with those stabilized within 24 hours, there was an almost 8-fold greater risk of a complication related to prolonged recumbency (p = 0.007). We observed similar effects for other types of complications. Delays of more than 72 hours had a negative effect on complication rates; these effects remained significant after multivariate adjustments for age, comorbidity and ISS. CONCLUSION This study demonstrates a strong relation between timing of surgical stabilization of spinal fractures in multitrauma patients without neurologic injuries and complications. Further studies with larger samples may allow for better adjustment of potentially confounding factors and identify subgroups in which this effect is most pronounced.
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Affiliation(s)
- Hossein Pakzad
- Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ont
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Wilson JR, Fehlings MG. Emerging approaches to the surgical management of acute traumatic spinal cord injury. Neurotherapeutics 2011; 8:187-94. [PMID: 21373951 PMCID: PMC3101827 DOI: 10.1007/s13311-011-0027-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Traumatic, spinal cord injury (SCI) is a potentially catastrophic event causing major impact at both a personal and societal level. To date, virtually all therapies that have shown promise at the preclinical stage of study have failed to translate into clinically effective treatments. Surgery is performed in the setting of SCI, with the goals of decompressing the spinal cord and restoring spinal stability. Although a consensus regarding the optimal timing of surgical decompression for SCI has not been reached, much of the preclinical and clinical evidence, as well as a recent international survey of spine surgeons, support performing early surgery (<24 hours). Results of the multicenter, Surgical Trial in Acute Spinal Cord Injury Study (STASCIS), expected later this year, should further clarify this important management issue. The overall goal of this review is to provide an update regarding the current status of surgical therapy for traumatic SCI by reviewing relevant pathophysiology, laboratory, and clinical evidence, as well as to introduce radiologic and clinical tools that aid in the surgical decision-making process.
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Affiliation(s)
- Jefferson R. Wilson
- Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Ontario M5G 2C4 Canada
| | - Michael G. Fehlings
- Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Ontario M5G 2C4 Canada
- University of Toronto, Krembil Neuroscience Center, 399 Bathurst St, Toronto Western Hospital, Toronto, Ontario M5G 2C4 Canada
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Abstract
BACKGROUND Spinal cord injury (SCI) is a devastating event often resulting in permanent neurologic deficit. Research has revealed an understanding of mechanisms that occur after the primary injury and contribute to functional loss. By targeting these secondary mechanisms of injury, clinicians may be able to offer improved recovery after SCI. QUESTIONS/PURPOSES In this review, we highlight advances in the field of SCI by framing three questions: (1) What is the preclinical evidence for the neuroprotective agent riluzole that has allowed this agent to move into clinical trials? (2) What is the preclinical evidence for Rho antagonists that have allowed this group of compounds to move into clinical trials? (3) What is the evidence for early surgical decompression after SCI? METHODS We conducted a systematic review of MEDLINE and EMBASE-cited articles related to SCI to address these questions. RESULTS As a result of an improved understanding of the secondary mechanisms of SCI, specific clinical strategies have been established. We highlight three strategies that have made their way from bench to bedside: the sodium-glutamate antagonist riluzole, the Rho inhibitor Cethrin, and early surgical decompression. Each of these modalities is under clinical investigation. We highlight the fundamental science that led to this development. CONCLUSIONS As our understanding of the fundamental mechanisms of SCI improves, we must keep abreast of these discoveries to translate them into therapies that will hopefully benefit patients. We summarize this process of bench to bedside with regard to SCI.
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Predictors of complications after spinal stabilization of thoracolumbar spine injuries. ACTA ACUST UNITED AC 2011; 69:1497-500. [PMID: 20404758 DOI: 10.1097/ta.0b013e3181cc853b] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of complications after major traumatic spinal injury and surgical stabilization is a challenge. The purpose of this study is to identify factors predictive of a complication after surgical stabilization of thoracolumbar spine injuries. METHODS A review of subjects prospectively enrolled in a multicenter database for spine trauma was performed. Standard demographic data, Glasgow Coma Scores, Injury Severity Score, American Spinal Injury Association score, Charlson Comorbiditiy Index (CCI), mechanism of injury, administration of methylprednisolone (National Acute Spinal Cord Injury II, III), time from injury to surgery, and surgical approach were evaluated. All perioperative complications within 6 months of surgery were recorded. Multivariate logistic regression analysis was performed to identify factors predictive of the occurrence of a complication after surgical stabilization of a thoracolumbar injury. RESULTS There were 230 patients (57 women, 173 men), 35% were smokers. The mean age at injury was 41.8 ± 17.8 years. The majority of patients (52%) had no neurologic deficits. Nineteen percent had complete cord injuries whereas 29% had incomplete cord injuries. The mean admission ISS was 9.2 ± 7.8, mean CCI was 0.2 ± 0.7, mean Glasgow Coma Score was 14.6 ± 1.6. NASCIS II and III was instituted in 15.5% and 4.2% of all patients, respectively; mean time from injury to surgery was 8.9 ± 59 days. The incidence of complications was 79% (minor 30%, major 49%). No factors predictive of a minor complication were identified. Factors predictive of the occurrence of a major complication were administration of high-dose steroids, ASIA score, and CCI. CONCLUSION The severity of neurologic injury, number of comorbidities, and use of the high-dose steroids independently increase the risk of having a major complication after surgical stabilization of thoracolumbar spine fractures.
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE To determine whether early spinal stabilization in the multiple trauma patient is safe and does not increase morbidity or mortality. SUMMARY OF BACKGROUND DATA There is no consensus regarding the timing of surgical stabilization of the injured spine, especially in patients with multiple trauma. Designing and performing randomized clinical trials to evaluate early versus late surgery is difficult. METHODS Between January 1990 and July 2009, a computer-aided search using the keywords Spine or Spinal, Trauma, Spinal Cord Injury, and Surgery was done that included MEDLINE, EMBASE, HealthSTAR, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, PsycINFO, and PsychLit. Articles dealing only with neurologic improvement that did not mention other non-neurologic factors that were affected by early surgery were excluded. The authors selected and assessed the studies to be included in the analysis. An unblinded assessment of the quality of the study was done using the Gradeing of Recommendation, Assessment, Development and Evaluation approach to rank each article for its relevance to the topic. RESULTS Eleven articles directly comparing 2 cohorts that had early or late surgery were identified. All of the studies evaluated consistently demonstrated shorter hospital and intensive care unit length of stays, fewer days on mechanical ventilation, and lower pulmonary complications in patients who are treated with early spine decompression and stabilization. These advantages are more marked in patients with polytrauma. Data regarding morbidity and mortality rates are more variable. CONCLUSION There is strong evidence within the literature that early surgical stabilization consistently leads to shorter hospital stays, shorter intensive care unit stays, less days on mechanical ventilation, and lower pulmonary complications. This effect is more evident in patients who have more severe injuries as measured by Injury Severity Score. This benefit is seen in both, spinal cord injured and noncord-injured patients. There is also some evidence that early stabilization does not increase the complication rates compared to late surgery.
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The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. ACTA ACUST UNITED AC 2010; 68:1208-12. [PMID: 19826315 DOI: 10.1097/ta.0b013e3181a0e558] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma. METHODS We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure. RESULTS : Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all. CONCLUSIONS Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.
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