Timing of Thoracic Spine Stabilization in Trauma Patients: Impact on Clinical Course and Outcome

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries

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.

Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries

Objectives

During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills.

Materials and Methods

In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP.

Results

The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise.

Conclusion

Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

A four year experience treating incomplete thoracolumbar spine injuries in an East African country

Background

Traumatic spine injuries are one of the most common causes of disability and mortality.

Objective

To assess post op neurologic status in patients with incomplete thoracic and lumbar spine injuries at two teaching hospitals in Addis Ababa, Ethiopia.

Methods

Institution based retrospective cross-sectional study was conducted among 60 hospitalized patients in these hospitals from February 1, 2017-January 31, 2021.

Results

Forty five (75.0%) of the study participants were males. The mean age was 30.77 years (range: 12-65 year). Only 8(13.3%) patients were operated within 3 days of trauma. The most common injury site was the thoracolumbar junction (T11-L2) in 80.0%. Significant number of patients (56.7%) had sphincters dysfunction. Pedicle screw fixation with or without laminectomy was performed in 98.3%. After minimum six month follow up, 37(61.7%) patients had access to the physiotherapy. Thirty seven (61.7%) patients were non ambulatory (AIS B and C) at presentation, of which 29 (78.4%) were ambulatory on the follow-up. Overall, 54(90%) patients had neurologic improvement on the follow up and 37(61.7%) returned to work. Preoperative neurologic status and sphincter function were found to be significantly associated with treatment outcome with P value 0 .000 and 0.002 respectively.

Conclusion

This study shows despite limited availability of post op physiotherapy, significant number of patientsreturned to work post-surgery. Preoperative neurologic function was an independent predictor of post-operative outcome.

Early Surgical Treatment of Thoracolumbar Fractures With Thoracolumbar Injury Classification and Severity Scores Less Than 4

BACKGROUND

Thoracolumbar fractures (TLFs) are the most common spinal fractures seen in patients with trauma. The Thoracolumbar Injury Classification and Severity (TLICS) classification system is commonly used to help clinicians make more consistent and objective decisions in assessing the indications for surgical intervention in patients with thoracolumbar fractures. Patients with TLICS scores <4 are treated conservatively, but a percentage of them will have failed conservative treatment and require surgery at a later date.

METHODS

All patients who received an orthopaedic consult between January 2016 and December 2020 were screened for inclusion and exclusion criteria. For patients meeting the study requirements, deidentified data were collected including demographics, diagnostics workup, and hospital course. Data analysis was conducted comparing length of stay, time between first consult and surgery, and time between surgery and discharge among each group.

RESULTS

1.4% of patients with a TLICS score <4 not treated surgically at initial hospital stay required surgery at a later date. Patients with a TLICS score <4 treated conservatively had a statistically significant shorter hospital stay compared with those treated surgically. However, when time between initial consult and surgery was factored into the total duration of hospital stay for those treated surgically, the duration was statistically equivalent to those treated nonsurgically.

CONCLUSION

For patients with a TLICS score <4 with delayed mobilization after 3 days in the hospital or polytraumatic injuries, surgical stabilization at initial presentation can decrease the percentage of patients who fail conservative care and require delayed surgery. Patients treated surgically have a longer length of stay than those treated conservatively, but there is no difference in stay when time between consult and surgery was accounted for. In addition, initial surgery in patients with delayed mobilization can prevent long waits to surgery, while conservative measures are exhausted.

LEVEL III EVIDENCE

Retrospective cohort study.

Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality

BACKGROUND CONTEXT

The management of trauma patients with ankylosing spinal disorders has become an issue of increasing interest. Geriatric patients frequently sustain unstable extension type vertebral fractures with ankylosed spines. In this population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide.

PURPOSE

We aim to assess the relationship between the timing of surgery for unstable vertebral fractures in ankylosed spines in the geriatric population and patient outcomes.

STUDY DESIGN/SETTING

Retrospective clinical study conducted in a tertiary hospital.

PATIENT SAMPLE

Patients included were those diagnosed with isolated thoracolumbar extension type fractures and a spinal ankylosing disorder over 65 years old following minor trauma and with no additional injuries or neurological deficit.

OUTCOME MEASURES

Primary outcome measures included postoperative medical complications and mortality at 1 and 6 months. Secondary outcome measures included rehospitalization rates, length of stay, and surgical site infections.

METHODS

We searched our department's database for all that met our inclusion criteria who underwent surgery. The difference in patient outcomes that underwent early surgery defined as less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed.

RESULTS

A total of 82 patients underwent surgery following a diagnosis of an extension type thoracolumbar fracture at our institution between 2015 and 2021. Of these, 50 met inclusion criteria. Nineteen patients underwent surgery less than 72 hours from diagnosis and 31 more than 72 hours from diagnosis. No difference was found in age, functional status, and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=.005) was found. Mortality at six-months was significantly different between the groups as well (p=.035). There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month, and perioperative mortality.

CONCLUSIONS

Time to surgery affects complication rates and six-month mortality in geriatric patients with spinal ankylosing disorders presenting with an isolated unstable hyperextension type thoracolumbar fracture. Early surgery of less than 72 hours from presentation in this patient population is recommended.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case

BACKGROUND

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue.

OBSERVATIONS

Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery.

LESSONS

Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Early Versus Late Spine Surgery in Severely Injured Patients-Which Is the Appropriate Timing for Surgery?

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.

Concomitant injuries in patients with thoracic vertebral body fractures-a systematic literature review

PURPOSE

The aim of this study was to give a systematic overview over the rate and location of concomitant injuries, the probability of suffering from neurological deficits, and to give evidence of the timing of surgery in severely injured patients with unstable thoracic vertebral body fractures.

METHODS

This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to November 2020 dealing with unstable fractures of the mid-thoracic spine.

RESULTS

Altogether, 1109 articles were retrieved from the literature search. A total of 1095 articles were excluded. Thus, 16 remaining original articles were included in this systematic review depicting the topics timing of surgery in polytraumatized patients, outcome neurologic deficits, and impact of concomitant injuries. The overall level of evidence of the vast majority of studies is low.

CONCLUSION

The evidence of the available literature is low. The cited studies reveal that thoracic spinal fractures are associated with a high number of neurological deficits and concomitant injuries, particularly of the thoracic cage and the lung. Thereby, diagnostic algorithm should include computer tomography of the whole thoracic cage if there is any clinical sign of concomitant injuries. Patients with incomplete neurologic deficits benefit from early surgery consisting of decompression and long-segmental stabilization.

Early postoperative complications of thoracolumbar fractures in patients with multiple trauma according to the surgical timing

INTRODUCTION AND OBJETCTIVES

Our objective was to compare the rate of complications in thoracolumbar fractures that occurred during the early postoperative period in patients with multiple high-energy trauma according to the time of surgery. As a secondary objective, to estimate which variables were associated with surgery before 72h.

MATERIAL AND METHODS

Retrospective analysis of a series of patients with thoracolumbar fractures and multiple associated injuries in other anatomical regions due to high energy trauma. Surgically treated in an occupational trauma referral center, by the same surgical team and during the period between January 2013 and December 2019.

RESULTS

We analyzed a sample of 40 patients (39 men and 1 woman). The rate of complications was independent of surgical delay (before and after 72h) (p=0.827). There were statistically significant differences between early and later surgery groups in the variables age, systolic blood pressure, initial SOFA score and presence of neurological damage (p=0.014; p=0.029; p=0.032; p=0.012). The overall surgical delay was correlated with the SOFA score (p=0.007).

CONCLUSION

The rate of early postoperative complications did not show significant differences between the early and late surgery groups. We observed that the patients who had been operated before 72h from trauma were younger, had more association with neurological syntoms, presented higher blood pressure values and less physiological damage. Surgical delay was positively correlated with SOFA score on arrival.

Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation

OBJECTIVES

We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5.

INTERVENTION

These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days).

MAIN OUTCOME MEASURES

Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications.

RESULTS

Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications.

CONCLUSIONS

Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury

STUDY DESIGN

Large multicenter retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury.

SUMMARY OF BACKGROUND DATA

Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury.

MATERIALS AND METHODS

We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities.

RESULTS

Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001).

CONCLUSIONS

Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization.

LEVEL OF EVIDENCE

Level III.

Earlier Surgery Reduces Complications in Acute Traumatic Thoracolumbar Spinal Cord Injury: Analysis of a Multi-Center Cohort of 4108 Patients

Early surgical intervention to decompress the spinal cord and stabilize the spinal column in patients with acute traumatic thoracolumbar spinal cord injury (TLSCI) may lessen the risk of developing complications and improve outcomes. However, there has yet to be agreement on what constitutes "early" surgery; reported thresholds range from 8 to 72 h. To address this knowledge gap, we conducted an observational cohort study using data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) from 2010 to 2016. The association between time from hospital arrival to surgical intervention and risk of major complications was assessed using restricted cubic splines. Propensity score matching was then used to assess the association between delayed surgery and risk of complications. Across 354 trauma centers 4108 adult TLSCI patients who underwent surgery were included. Median time-to-surgery was 18.8 h (interquartile range [IQR]: 7.4-40.9 h). The spline model suggests the risk of major complication rises consistently after a 12-h surgical wait-time. After propensity score matching, the odds of major complication were significantly lower for those receiving surgery within 12 h (odds ratio [OR] 0.77, 95% confidence interval [CI]: 0.64 to 0.94). This was also true for immobility-related complications (OR 0.79, 95% CI: 0.64 to 0.97). Patients in the early group spent 1.5 fewer days in the critical care unit on average (95% CI: -2.09 to -0.88). Although surgery within 12 h may not always be feasible, these data suggest that whenever possible surgeons should strive to reduce the amount of time between hospital arrival and surgical intervention, and health care systems should support this endeavor.

Management of acute spinal cord injury: A summary of the evidence pertaining to the acute management, operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity. Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls. The Individual, societal and economic costs are enormous. Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery. This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department. We review the initial assessment, criteria for imaging and clearing the spine, and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.

Cement Augmented Anterior Reconstruction and Decompression without Posterior Instrumentation: A Less Invasive Surgical Option for Osteoporotic Thoracolumbar Fracture with Cord Compression

Objective

We investigated the clinical and radiological outcomes of a cement augmented anterior reconstruction and decompression without pedicle screw fixation in patients with osteoporotic thoracolumbar vertebral fracture with myelopathy.

Methods

There were 2 male and 6 female patients with thoracolumbar fracture and myelopathy included in the study. The mean follow-up period was more than 1 years. The anterolateral decompression and cement augmented anterior reconstruction with poly(methyl methacrylate) (PMMA) was performed. Demographic data, clinical outcomes, perioperative parameters and radiologic parameter were retrospectively evaluated.

Results

The symptoms due to myelopathy were improved in all patients. The preoperative median visual analog scale score for lower back and leg were 8.5 that improved 4.25 and 3 at last follow up. The preoperative function state showed a median Oswestry Disability Index score 61.5 that improved 33. After surgery, preoperative encroachment of the spinal canal (5.12 mm, 37%) was disappeared. The median height of fractured vertebral body significantly increased from 7.83 to 12.63 mm. At the last follow-up point, the median height was 9.91 mm. The median kyphotic deformity was improved from 22.12° to 14.31°. At the final follow-up, the improvement was preserved (median value: 15.03). The acute complication according to PMMA such as leakage and embolization was none, but adjacent compression fracture as late complication according to cement augmentation was. One patient developed surgical site infection.

Conclusion

On the basis of the preliminary results, we considered that anterolateral decompression and PMMA augmentation might be an optimal method for treating osteoporotic fracture with myelopathy in elderly patients or those with multiple medical comorbidities.

Effect of length time to surgery on postoperative hospital length of stay among neurosurgical patients

Background:

In most hospitals, inpatient urgent surgery is triaged based on the degree of urgency and time of surgical booking. A longer wait for semi-urgent surgery due to sharing resources between specialties might impact the postoperative course. The objective of this study is to determine the effect of length time to semi- urgent surgery on postoperative hospital length of stay among neurosurgical patients.

Methods:

A retrospective cohort study was conducted included all admitted adult patients placed on semi-urgent University of Alberta Hospital surgical list between 2008 and 2013. Linear and logistic regression analyses were performed. The main exposure variable was time from surgical booking to the time of surgery, and the outcome variable was time from surgery to discharge.

Results:

A total of 1367 neurosurgical cases were included in the study. The mean age was 54.3 years. The mean length of time in the hospital before and after surgery was 1.2 and 12.5 days, respectively. Overall, the time from booking to surgery did not affect the time from surgery to discharge. Increased age, higher ASA score, and surgeries performed after 24 h from booking in the group of patients who were discharged to another facility were associated with a longer postoperative stay.

Conclusion:

Neurosurgery patients booked for surgery to be done within 24 h waited longer to have their procedure completed. Overall, there was no significant association between length of time waiting for surgery and postoperative stay, although there was an increase in postoperative stays among patients who were discharged to another facility and had their surgeries performed after 24 h.

Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit?

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.

Acute Spinal Cord Injury: A Systematic Review Investigating miRNA Families Involved

Acute traumatic spinal cord injury (SCI) involves primary and secondary injury mechanisms. The primary mechanism is related to the initial traumatic damage caused by the damaging impact and this damage is irreversible. Secondary mechanisms, which begin as early as a few minutes after the initial trauma, include processes such as spinal cord ischemia, cellular excitotoxicity, ionic dysregulation, and free radical-mediated peroxidation. SCI is featured by different forms of injury, investigating the pathology and degree of clinical diagnosis and treatment strategies, the animal models that have allowed us to better understand this entity and, finally, the role of new diagnostic and prognostic tools such as miRNA could improve our ability to manage this pathological entity. Autopsy could benefit from improvements in miRNA research: the specificity and sensitivity of miRNAs could help physicians in determining the cause of death, besides the time of death.

Timing of Operative Intervention in Traumatic Spine Injuries Without Neurological Deficit

BACKGROUND

Numerous studies have demonstrated the benefits of early decompression and stabilization in unstable spine injuries with incomplete neurological deficits. However, a clear consensus on timing to operative intervention still does not exist in those with a normal neurological exam and unstable spine.

OBJECTIVE

To determine the optimal timing of operative intervention in traumatic spine injuries without neurological deficit.

METHODS

Retrospective chart review at a single institution was performed including patients with traumatic spine injuries without neurological deficit admitted from December 2001 to August 2012. Estimated intraoperative blood loss (EBL), in-hospital complications, postoperative hospital length of stay (HLOS), intensive care unit length of stay (ICULOS), and ventilator days were recorded. Delayed surgery was defined as surgery 72 h after admission.

RESULTS

A total of 456 patients were included for analysis. There was a trend towards statistical significance between the time to operative intervention and EBL in bivariate analysis (P = .07). In the risk-adjusted multivariable analysis delayed vs early surgery was not associated with increased EBL or complications. Delayed surgery was associated with increased ICULOS (odds ratio [OR] = 2.19; 95% confidence interval [CI]: 1.38-3.51; P = .001), ventilator days (OR = 2.09; 95% CI: 1.28-3.43; P = .004), and increased postoperative HLOS (OR = 1.84; 95% CI: 1.22-2.76; P = .004).

CONCLUSION

Earlier operative intervention was associated with decreased ICULOS, ventilator days, and postoperative HLOS and did not show a statistically significant increase in EBL or complications. Earlier operative intervention for traumatic spine injuries without neurological deficit provides better outcomes compared to delayed surgery.

Surgical timing for cervical and upper thoracic injuries in patients with polytrauma

OBJECTIVE

Few 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.

METHODS

The 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.

RESULTS

Fourteen 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.

CONCLUSIONS

Early 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.

Risk factors for pulmonary complication following fixation of spine fractures

BACKGROUND CONTEXT

Previous studies have suggested pulmonary complications are common among patients undergoing fixation for traumatic spine fractures. This leads to prolonged hospital stay, worse functional outcomes, and increased economic burden. However, only limited prognostic information exists regarding which patients are at greatest risk for pulmonary complications.

PURPOSE

This study aimed to identify factors predictive of perioperative pulmonary complications in patients undergoing fixation of spine fractures.

STUDY DESIGN/SETTING

A retrospective review in a level 1 trauma center was carried out.

PATIENT SAMPLE

The patient sample comprised 302 patients with spinal fractures who underwent operative fixation.

OUTCOME MEASURES

The outcome measures were postoperative pulmonary complications (physiological and functional measures).

MATERIALS AND METHODS

Demographic and injury features were recorded, including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, mechanism of injury, injury characteristics, and neurologic status. Treatment details, including surgery length, timing, and approach were reviewed. Postoperative pulmonary complications were recorded after a minimum of 6 months' follow-up.

RESULTS

Forty-seven pulmonary complications occurred in 42 patients (14%), including pneumonia (35), adult respiratory distress syndrome (ARDS) (10), and pulmonary embolism (2). Logistic regression found spinal cord injury (SCI) to be most predictive of pulmonary complications (odds ratio [OR]=4.4, 95% confidence interval [CI] 1.9-10.1), followed by severe chest injury (OR 2.7, 95% CI 1.1-6.9), male gender (OR 2.7, 95% CI 1.1-6.8), and ASA classification (OR 2.3, 95% CI 1.4-4.0). Pulmonary complications were associated with significantly longer hospital stays (23.9 vs. 7.7 days, p<.01), stays in the intensive care unit (ICU) (19.9 vs. 3.4 days, p<.01), and increased ventilator times (13.8 days vs. 1.9 days, p<.01).

CONCLUSIONS

Several factors predicted development of pulmonary complications after operative spinal fracture, including SCI, severe chest injury, male gender, and higher ASA classification. Practitioners should be especially vigilant for of postoperative complications and associated injuries following upper-thoracic spine fractures. Future study must focus on appropriate interventions necessary for reducing complications in these high-risk patients.

Does Surgical Intervention or Timing of Surgery Have an Effect on Neurological Recovery in the Setting of a Thoracolumbar Burst Fracture?

Traumatic thoracolumbar burst fractures are one of the most common forms of spinal trauma with the majority occurring at the junctional area where mechanical load is maximal (AOSpine Thoracolumbar Spine Injury Classification System Subtype A3 or A4). Burst fractures entail the involvement of the middle column, and therefore, they are typically associated with bone fragment in the spinal canal, which may cause compression of the spinal cord, conus medullaris, cauda equina, or a combination of these. Fortunately, approximately half of the patients with thoracolumbar burst fractures are neurologically intact due to the wide canal diameter. Recent evidences have revealed that functional outcomes in the long term may be equivalent between operative and nonoperative management for neurologically intact thoracolumbar burst fractures. Nevertheless, consensus has not been met regarding the optimal treatment strategy for those with neurological deficits. The present review article summarizes the contemporary evidences to discuss the role of nonoperative management in the presence of neurological deficits and the optimal timing of decompression surgery for neurological recovery. In summary, although operative management is generally recommended for thoracolumbar fracture with significant neurological deficits, the evidence is weak, and nonoperative management can also be an option for those with solitary radicular symptoms. With regards to timing of operative management, high-quality studies comparing early and delayed intervention are lacking. Extrapolating from the evidence in cervical spine injury leads to an assumption that early intervention would also be beneficial for neurological recovery, but further studies are warranted to answer these questions.

Early Spinal Surgery Following Thoracolumbar Spinal Cord Injury: Process of Care From Trauma to Theater

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aims of this study were to (1) determine the timing of surgery for traumatic thoracolumbar spinal cord injury (TLSCI) between 2010 and 2014 and (2) identify major delays in the process of care from accident scene to surgery.

SUMMARY OF BACKGROUND DATA

Early spinal surgery may promote neurological recovery and reduce acute complications after TLSCI; however, it is difficult to achieve due to logistical issues and the frequent presence of other nonlife-threatening injuries.

METHODS

Data were extracted from the medical records of 46 cases of acute traumatic TLSCI (AIS level T1-L1) aged between 15 and 70 years. Patients with life-threatening injuries, not requiring spinal surgery or with poor general health, were excluded.

RESULTS

The median time to surgery was 27 hours [interquartile range (IQR): 20-43 hours] and improved from 27 hours in 2010 to 22 hours in 2014. Cases admitted via a pre-surgical hospital had a longer median time to surgery than direct surgical hospital admissions (28 vs. 24 hours, respectively). The median time from completion of radiological investigations to surgery was 18 hours, suggesting that theater access and organization of a surgical team were the major factors contributing to surgical delay. Number of vertebral levels fractured (≥5) and upper thoracic level of injury (T1-8) were also found to be associated with surgical delay.

CONCLUSION

Earlier spinal surgery in TLSCI would be facilitated by direct surgical hospital admission and improved access to the operating theater and surgical teams.

LEVEL OF EVIDENCE

3.

Assessment of resuscitation as measured by markers of metabolic acidosis and features of injury

AIMS

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

PATIENTS AND METHODS

A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).

RESULTS

In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications.

CONCLUSIONS

This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. Cite this article: Bone Joint J 2017;99-B:122-7.

Correlation Between Timing of Surgery and Outcome in ThoracoLumbar Fractures: Does Early Surgery Influence Neurological Recovery and Functional Restoration? A Multivariate Analysis of Results in Our Experience

BACKGROUND

Treatment for spinal trauma is affected by both nonmodifiable and modifiable variables. The aim of this study was to compare early surgery with intermediate and late surgery to determine the benefits of spinal reconstruction in neurological recovery and functional restoration in patients with thoracolumbar fractures.

METHODS

In order to identify correlations between treatment timing, fracture site, neurological recovery, American Spinal Injury Association (ASIA) score restoration, and rehabilitation prognosis in patients with thoracic and lumbar fractures, we conducted a multivariate analysis of the results of surgery, at our institution, in 166 consecutive patients with unstable thoracolumbar fractures with or without neurological impairment. We conducted a literature review (1988-2012) and compared our results with those already published.

RESULTS

Regardless of the location and type of fracture, early surgery resulted in a reduction of median hospital and intensive care unit (ICU) length of stay, as well as a reduction of nosocomial complications. Regardless of the type of fracture and preoperative ASIA score, thoracic fractures had the worst outcome. Early treatment seemed to have better results, depending on the preoperative ASIA score.

CONCLUSION

Early surgery in patients with thoracolumbar fractures with incomplete neurological damage could positively affect neurological recovery, functional restoration, length of hospital and ICU stay, and associated comorbidity. Thoracic fractures had the worst outcome. Early surgery seemed to have better results if the initial ASIA score was good. The better the ASIA score on admission, the better was the outcome. Surgical timing did not affect the outcome when the ASIA score was A or E.

Factors affecting outcome of acute cervical spine injury: A prospective study

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.

Cellular transplantation-based evolving treatment options in spinal cord injury

Spinal cord injury (SCI) often represents a condition of permanent neurologic deficit. It has been possible to understand and delineate the mechanisms contributing to loss of function following primary injury. The clinicians might hope to improve the outcome in SCI injury by designing treatment strategies that could target these secondary mechanisms of response to injury. However, the approaches like molecular targeting of the neurons or surgical interventions have yielded very limited success till date. In recent times, a great thrust is put on to the cellular transplantation mode of treatment strategies to combat SCI problems so as to gain maximum functional recovery. In this review, we discuss about the various cellular transplantation strategies that could be employed in the treatment of SCI. The success of such cellular approaches involving Schwann cells, olfactory ensheathing cells, peripheral nerve, embryonic CNS tissue and activated macrophage has been supported by a number of reports and has been detailed here. Many of these cell transplantation strategies have reached the clinical trial stages. Also, the evolving field of stem cell therapy has made it possible to contemplate the role of both embryonic stem cells and induced pluripotent stem cells to stimulate the differentiation of neurons when transplanted in SCI models. Moreover, the roles of tissue engineering techniques and synthetic biomaterials have also been explained with their beneficial and deleterious effects. Many of these cell-based therapeutic approaches have been able to cause only a little change in recovery and a combinatorial approach involving more than one strategy are now being tried out to successfully treat SCI and improve functional recovery.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BACKGROUND

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

METHODS

Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.

RESULTS

All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).

CONCLUSIONS

Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications

Background

Optimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36 h when either lactate <4.0 mmol/L, pH ≥ 7.25, or base excess (BE) ≥−5.5 mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC.

Methods

At an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.

Results

Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9 % vs. 22.1 %). ISS (p < 0.0005) and time to EAC resuscitation (p = 0.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS.

Conclusions

EAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research.

Level of evidence

Level 1: prognostic study.

Gunshot injuries of the spine

BACKGROUND CONTEXT

Spinal gunshot injuries (spinal GSIs) are a major cause of morbidity and mortality in both military and civilian populations. These injuries are likely to be encountered by spine care professionals in many treatment settings. A paucity of resources is available to summarize current knowledge of spinal GSI evaluation and management.

PURPOSE

The aim was to summarize the ballistics, epidemiology, evaluation, treatment, and outcomes of spinal GSI among civilian and military populations.

STUDY DESIGN

This was a review of the current literature reporting spinal GSI management.

METHODS

MEDLINE (PubMed) was queried for recent studies and case reports of spinal GSI evaluation and management.

RESULTS

Spinal GSI now comprise the third most common cause of spinal injury. Firearms that produce spinal GSI can be divided into categories of high- and low-energy depending on the initial velocity of the projectile. Neural and mechanical spinal damage varies with these types and results from several factors including direct impact, concussion waves, tissue cavitation, and thermal energy. Management of spinal GSI also depends on several factors including neurologic function and change over time, spinal stability, missile tract through the body, and concomitant injury. Surgical treatment is typically indicated for progressive neurologic changes, spinal instability, persistent cerebrospinal fluid leak, and infection. Surgical treatment for GSI affecting T12 and caudal often has a better outcome than for those cranial to T12. Surgical exploration and removal of missile fragments in the spinal canal are typically indicated for incomplete or worsening neurologic injury.

CONCLUSIONS

Treatment of spinal GSI requires a multidisciplinary approach with the goal of maintaining or restoring spinal stability and neurologic function and minimizing complications. Concomitant injuries and complications after spinal GSI can present immediate and ongoing challenges to the medical, surgical and rehabilitative care of the patient.

Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable?

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.

Damage control in thoracic and lumbar unstable fractures in polytrauma. Systematic review

<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>

Timing of surgery in thoracolumbar trauma: is early intervention safe?

The understanding of the optimal surgical timing for stabilization in thoracolumbar fractures is severely limited. Thoracolumbar spine fractures can be devastating injuries and are often associated with significant morbidity and mortality. The role of early surgical stabilization (within 48–72 hours of injury) as a vehicle to improve outcomes in these patients has generated significant interest. Goals of early stabilization include improved neurological recovery, faster pulmonary recovery, improved pain control, and decreased health care costs. Opponents cite the potential for increased bleeding, hypotension, and the risk of further cord injury as a few factors that weigh against early stabilization. The concept of spinal cord injury and its relationship to surgical timing remains in question. However, when neurological outcomes are eliminated from the equation, certain measures have shown positive influences from prompt surgical fixation.

Early fixation of thoracolumbar spine fractures can significantly decrease the duration of hospital stay and the number of days in the intensive care unit. Additionally, prompt stabilization can reduce rates of pulmonary complications. This includes decreased rates of pneumonia and fewer days on ventilator support. Cost analysis revealed as much as $80,000 in savings per patient with early stabilization. All of these benefits come without an increase in morbidity or evidence of increased mortality. In addition, there is no evidence that early stabilization has any ill effect on the injured or uninjured spinal cord. Based on the existing data, early fixation of thoracolumbar fractures has been linked with positive outcomes without clear evidence of negative impacts on the patient's neurological status, associated morbidities, or mortality. These procedures can be viewed as “damage control” and may consist of simple posterior instrumentation or open reductions with internal fixation as indicated. Based on the current literature it is advisable to proceed with early surgical stabilization of thoracolumbar fractures in a well-resuscitated patient, unless extenuating medical conditions would prevent it.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]

BACKGROUND

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

METHODS

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

RESULTS

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

CONCLUSIONS

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care

OBJECTIVES

The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications.

DESIGN

Statistical modeling based on retrospective database.

SETTING

Level 1 trauma center.

PATIENTS

A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures.

INTERVENTION

All fractures were treated surgically.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated.

RESULTS

Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis.

CONCLUSIONS

Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.

Percutaneous pedicle screw fixation in polytrauma patients

PURPOSE

The clinical outcome of polytrauma patients underwent spine fixation was analyzed and correlated both to surgical time (early versus delayed) and to fixation type (open versus percutaneous).

METHODS

Twenty-four polytrauma patients were retrospectively evaluated. Patients were evaluated according to age, accident dynamic, mechanical ventilation need, blood transfusion need, SAPS II score, type of vertebral injury, time of fixation (within or after 72 h) and type of fixation.

RESULTS

Nine patients underwent percutaneous pedicle screw fixation and 12 open fusion. An early fixation allows better clinical outcome considering ICU stay (13.7 versus 21.71 days), H-LOS (25.8 versus 69.5 days), mechanical ventilation need (7 versus 16.2), blood transfusion need (250 versus 592 cc).

CONCLUSIONS

In polytrauma patients an early spine fixation improves clinical outcome. Patients underwent percutaneous screw fixation showed a better outcome compared to open surgery group obtained despite worst clinical conditions.

Meta-analysis of pre-clinical studies of early decompression in acute spinal cord injury: a battle of time and pressure

Background

The use of early decompression in the management of acute spinal cord injury (SCI) remains contentious despite many pre-clinical studies demonstrating benefits and a small number of supportive clinical studies. Although the pre-clinical literature favours the concept of early decompression, translation is hindered by uncertainties regarding overall treatment efficacy and timing of decompression.

Methods

We performed meta-analysis to examine the pre-clinical literature on acute decompression of the injured spinal cord. Three databases were utilised; PubMed, ISI Web of Science and Embase. Our inclusion criteria consisted of (i) the reporting of efficacy of decompression at various time intervals (ii) number of animals and (iii) the mean outcome and variance in each group. Random effects meta-analysis was used and the impact of study design characteristics assessed with meta-regression.

Results

Overall, decompression improved behavioural outcome by 35.1% (95%CI 27.4-42.8; I²=94%, p<0.001). Measures to minimise bias were not routinely reported with blinding associated with a smaller but still significant benefit. Publication bias likely also contributed to an overestimation of efficacy. Meta-regression demonstrated a number of factors affecting outcome, notably compressive pressure and duration (adjusted r²=0.204, p<0.002), with increased pressure and longer durations of compression associated with smaller treatment effects. Plotting the compressive pressure against the duration of compression resulting in paraplegia in individual studies revealed a power law relationship; high compressive forces quickly resulted in paraplegia, while low compressive forces accompanying canal narrowing resulted in paresis over many hours.

Conclusion

These data suggest early decompression improves neurobehavioural deficits in animal models of SCI. Although much of the literature had limited internal validity, benefit was maintained across high quality studies. The close relationship of compressive pressure to the rate of development of severe neurological injury suggests that pressure local to the site of injury might be a useful parameter determining the urgency of decompression.

Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course

OBJECTIVES

We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

1005 skeletally mature patients with Injury Severity Score (ISS) ≥18 with pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) fractures. Chest (n = 447), abdomen (n = 328), and head (n = 155) injuries were present.

INTERVENTION

Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433.

MAIN OUTCOME MEASUREMENTS

Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death.

RESULTS

Days in intensive care unit (ICU) and total hospital stay were lower with early fixation (5.1 ± 8.8 vs. 8.4 ± 11.1 ICU days (P = 0.006); 10.5 ± 9.8 versus 14.3 ± 11.4 total days (P = 0.001), after adjusting for ISS and age. Fewer complications (24.0% vs. 35.8%, P = 0.040), ARDS (1.7% vs. 5.3%, P = 0.048), pneumonia (8.6% vs. 15.2%, P = 0.070), and sepsis (1.7% vs. 5.3%, P = 0.054) occurred with early versus delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS.

CONCLUSIONS

Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The influence of procedure delay on resource use: a national study of patients with open tibial fracture

BACKGROUND

The purpose of this study was to (1) understand national variation in delay of emergency procedures in patients with open tibial fracture at the hospital level and (2) compare length of stay and cost in patients cared for at the best- and worst-performing hospitals for delay.

METHODS

The authors retrospectively analyzed the 2003 to 2009 Nationwide Inpatient Sample. Adult patients with open tibial fracture were included. Hospital probability of delay in performing emergency procedures beyond the day of admission was calculated. Multilevel linear regression random-effects models were created to evaluate the relationship between the treating hospital's tendency for delay (in quartiles) and the log-transformed outcomes of length of stay and cost.

RESULTS

The final sample included 7029 patients from 332 hospitals. Patients treated at hospitals in the fourth (worst) quartile for delay were estimated to have 12 percent (95 percent CI, 2 to 21 percent) higher cost compared with patients treated at hospitals in the first quartile. In addition, patients treated at hospitals in the fourth quartile had an estimated 11 percent (95 percent CI, 4 to 17 percent) longer length of stay compared with patients treated at hospitals in the first quartile.

CONCLUSIONS

Patients with open tibial fracture treated at hospitals with more timely initiation of surgical care had lower cost and shorter length of stay than patients treated at hospitals with less timely initiation of care. Policies directed toward mitigating variation in care may reduce unnecessary waste.

What do we currently know about thoracic spinal cord injury recovery and outcomes? A systematic review

OBJECT

The purpose of this paper was to systematically review and critically appraise the evidence for whether there are differences in outcomes or recovery after thoracic spinal cord injuries (SCIs) based on the spinal level, the timing of intervention, or cause of SCI.

METHODS

Systematic searches were conducted using PubMed/MEDLINE through January 5, 2012. From 486 articles identified, 10 included data on the population of interest. Included studies were assigned a level of evidence (LOE) rating based on study quality, and an overall strength of evidence was assessed. To estimate the effect of injury level on patient outcomes, the relative risk and risk difference were calculated when data were available.

RESULTS

From 486 citations identified, 3 registry studies and 7 retrospective cohort studies met the inclusion criteria. All were rated as being of poor quality (LOE III). Limited literature exists on the epidemiology of traumatic and nontraumatic SCI. Few studies evaluated outcomes based on SCI level within the thoracic spine. Pulmonary complications and thromboembolic events were less common in persons with lower thoracic SCI (T7-12) than in those with higher thoracic SCI (T1-6) in 2 large studies, but no differences were found in functional outcomes in 4 smaller studies. Patients undergoing earlier surgery (< 72 hours) may have fewer ventilator, ICU, and hospital days than those undergoing later surgery. One small study of SCI during repair of aortic aneurysm compared with traumatic SCI reported similar outcomes for both groups. There are substantial deficiencies in the scientific literature on thoracic SCI in regard to assessment, outcomes ratings, and effectiveness of therapy.

CONCLUSIONS

The overall strength of evidence for all outcomes reported is low. Definitive conclusions should not be drawn regarding the prognosis for outcome and recovery after thoracic SCI. From a physiological standpoint, additional methodologically rigorous studies that take into consideration various levels of injury in more anatomically and physiologically relevant form are needed. Use of validated, comprehensive outcomes tools are important to improve our understanding of the impact of thoracic SCI and aid in examining factors in recovery from thoracic SCI.

A methodological systematic review of early versus late stabilization of thoracolumbar spine fractures

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.

Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)

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.

Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures

BACKGROUND

Internal fixation of unstable thoracolumbar spine fractures requires correction of the lacking anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae above and two vertebrae below the fracture. Posterior short-segment pedicle instrumentation (SSPI)--one vertebra above and below--is suitable for approximately 40% of fractures, but not for all.

METHODS

A total of 52 patients with unstable thoracolumbar burst fractures meeting our inclusion criteria were instrumented using a novel approach, combining percutaneous SSPI, pedicle screw augmentation with polymethyl methacrylate (PMMA) and fractured vertebra kyphoplasty. We retrospectively reviewed patient and fracture data, operative results and 1 year radiographic follow-up postoperatively in 40 of the patients. We reviewed operative complications of all 52 patients.

RESULTS

Most fractures were AO/Magerl type A3.1, A3.2 and A3.3. They were instrumented within 72 h and ambulated without additional external bracing. Operative time averaged 2 h and blood loss was less than 50 cc in most cases. Complications were mostly related to PMMA leakage. On average, 3.3° (0-13) of correction was lost after 3 months, but remained constant afterward.

CONCLUSIONS

Percutaneous augmented short-segment pedicle instrumentation of unstable thoracolumbar fractures can be done with short operative times, minimal blood loss and a low complication rate. The radiographical results at 1 year are equal to anterior stabilization and are better than other posterior-only techniques.

Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes

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.

Current management review of thoracolumbar cord syndromes

BACKGROUND CONTEXT

Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES).

PURPOSE

To review the current management of thoracolumbar spinal cord injuries.

STUDY DESIGN

Literature review.

METHODS

Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options.

RESULTS/CONCLUSIONS

After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.

Early versus late stabilization of spine injuries: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

The objective of this study is to determine safety, benefits, outcomes, and costs of early versus late stabilization of spine injuries using data available in the current literature.

SUMMARY OF BACKGROUND DATA

There is currently a lack of consensus regarding the timing of surgical stabilization of the injured spine. This is limited by the reality that a randomized clinical trial to evaluate early versus late surgery is difficult to design and perform.

METHODS

A computer-aided search using the keywords Spine or Spinal, Trauma, Spinal Cord Injury, and Surgery 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, from January 1990 to July 2009 was done.

RESULTS

Eleven articles directly comparing two cohorts that had early or late surgery were identified. All of the studies 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 surgical spine decompression and stabilization. These advantages are more marked in patients with polytrauma. Consequently, costs associated with late surgery were higher compared with early surgery.

CONCLUSION

There is evidence in the current literature to show that early surgical stabilization 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 associated injuries as measured by ISS. This benefit is seen in patients who have cord injury as well as those who do not. There is some evidence that early stabilization does not increase the complication rates compared with late surgery.