Early versus late stabilization of spine injuries: a systematic review

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

BACKGROUND

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.

METHODS

This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.

RESULTS

A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).

CONCLUSION

A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.

LEVEL OF EVIDENCE

Systematic Review/Meta-Analysis; Level IV.

A novel online calculator based on inflammation-related endotypes and clinical features to predict postoperative pulmonary infection in patients with cervical spinal cord injury

BACKGROUND

Postoperative pulmonary infection (POI) of patients with cervical spinal cord injury (CSCI) is highly heterogeneous, while the potential endotypes and related risk factors remain unclear.

METHODS

A retrospective collection of 290 CSCI patients was conducted from January 2010 to July 2024 using 1:1 propensity score matching to compare POI (n = 145) and non-POI (n = 145) groups. We generated laboratory examination data from admission patients and identified endotypes using unsupervised consensus clustering and machine learning. CSCI patients were randomly assigned to the training set (n = 203) and internal validation set (n = 87). A separate cohort comprising 245 CSCI patients were used for external validation. Independent predictors for POI were identified using univariate and multivariate logistic regression. A nomogram and an online calculator were developed and validated, both internally and externally.

RESULTS

Two inflammation-related endotypes were identified: high inflammation endotype (endotype C1) and low inflammation endotype (endotype C2). Eight predictors for POI were identified (including age, operation duration, number of surgical segments, time between injury and surgery, preoperative steroid pulse, American Spinal Injury Association (ASIA) grade, smoking history, and inflammation-related endotype). A nomogram integrating the risk factors showed excellent discrimination in the training set (AUC, 0.976; 95% CI 0.956-0.996), internal validation set (AUC, 0.993; 95% CI 0.981-1.000), and external validation set (AUC, 0.799; 95%CI 0.744-0.854). Calibration curves demonstrated excellent fit, and decision curves highlighted its favorable clinical value. An online calculator (https://tjspine.shinyapps.io/dynnomapp/) was constructed to improve the convenience and efficiency of our prediction model.

CONCLUSIONS

We identified inflammation-related endotype and constructed a web-based calculator for predicting POI in patients with CSCI, exhibiting excellent clinical utility.

Traumatic spinal cord injury: acute phase treatment in critical care

PURPOSE OF REVIEW

Surgical timing in traumatic spinal cord injury (t-SCI) remains a point of debate. Current guidelines recommend surgery within 24 h after trauma; however, earlier timeframes are currently intensively being investigated. The aim of this review is to provide an insight on the acute care of patients with t-SCI.

RECENT FINDINGS

Multiple studies show that there appears to be a beneficial effect on neurological recovery of early surgical decompression within 24 h after trauma. Currently, the impact of ultra-early surgery is less clear as well as lacking evidence for the most optimal surgical technique. Nevertheless, early surgery to decompress the spinal cord by whatever method can impact the occurrence for perioperative complications and potentially expedite rehabilitation. There are clinical and socioeconomic barriers in achieving timely and adequate surgical interventions for t-SCI.

SUMMARY

In this review, we provide an overview of the recent insights of surgical timing in t-SCI and the current barriers in acute t-SCI treatment.

OCT4 protein and gene expression analysis in the differentiation of spermatogonia stem cells into neurons by immunohistochemistry, immunocytochemistry, and bioinformatics analysis

BACKGROUND

Spermatogonia Stem Cells (SSCs) are potential candidates for reprogramming and regeneration. Recent studies have revealed that differentiated cells can be reverted to pluripotent by overexpressing a set of pluripotent transcription factors. OCT4 (encoded by pou5f1), a POU transcription factor family member, is essential to the potential that controls pluripotency, and it is widely expressed in pluripotent stem cells, although it decreased or suppressed after differentiation.

METHODS

In this investigated research, we examined the OCT4 expression during the differentiation of SSCs into neurons (involving four stages in the following order: SSCs in vivo and in-vitro, embryonic Stem Cell-like (ES-like), Embryonic Bodies (EBs), and finally Neurons) by Immunocytochemistry (ICC), Immunohistochemistry (IMH), and Fluidigm Real-Time polymerase chain reaction. In addition, we use some databases like STRING to predict protein-protein interaction and enrichment analysis.

RESULTS

We evaluated the expression of OCT4 in this process, and we observed that it is expressed in SSCs, ES-like, and EBs during the differentiation of spermatogonia stem cells into adult neurons. We show that by adding RA to EBs, the expression of OCT4 is reduced and is not expressed in the neuron cells. We observed that the expression of OCT4 is linked and interacts with the differentiation of spermatogonia stem cells into neuron cells, and it has been shown to be biologically functional, like stem cell maintenance and somatic cell reprogramming.

CONCLUSION

Our findings can help us better understand the process of differentiation of spermatogonia stem cells into neurons, and it can be effective in finding new and more efficient treatments for neurogenesis and repair of neurons. We examined the OCT4 expression during the differentiation of SSCs into neurons (involving four stages in the following order: SSCs in vivo and in-vitro, embryonic Stem Cell-like (ES-like), Embryonic Bodies (EBs), and finally Neurons) by Immunocytochemistry (ICC), Immunohistochemistry (IMH), and Fluidigm Real-Time polymerase chain reaction. In addition, we use some databases like STRING to predict protein-protein interaction and enrichment analysis. We evaluated the expression of OCT4 in this process, and we observed that it is expressed in SSCs, ES-like, and EBs during the differentiation of spermatogonia stem cells into adult neurons. We show that by adding RA to EBs, the expression of OCT4 is reduced and is not expressed in the neuron cells. We observed that the expression of OCT4 is linked and interacts with the differentiation of spermatogonia stem cells into neuron cells, and it has been shown to be biologically functional, like stem cell maintenance and somatic cell reprogramming.

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.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

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, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 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 (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 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 (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 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 (AIS_TS ≥ 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 (AIS_Thorax ≥ 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.

Sonic Hedgehog Effectively Improves Oct4-Mediated Reprogramming of Astrocytes into Neural Stem Cells

Irreversible neuron loss following spinal cord injury (SCI) usually results in persistent neurological dysfunction. The generation of autologous neural stem cells (NSCs) holds great potential for neural replenishment therapies and drug screening in SCI. Our recent studies demonstrated that mature astrocytes from the spinal cord can directly revert back to a pluripotent state under appropriate signals. However, in previous attempts, the reprogramming of astrocytes into induced NSCs (iNSCs) was unstable, inefficient, and frequently accompanied by generation of intermediate precursors. It remained unknown how to further increase the efficiency of astrocyte reprogramming into iNSCs. Here, we show that mature astrocytes could be directly converted into iNSCs by a single transcription factor, Oct4, and that the iNSCs displayed typical neurosphere morphology, authentic NSC gene expression, self-renewal capacity, and multipotency. Strikingly, Oct4-driven reprogramming of astrocytes into iNSCs was potentiated with continuous sonic hedgehog (Shh) stimulation, as demonstrated by a sped-up reprogramming and increased conversion efficiency. Moreover, the iNSC-derived neurons possessed functionality as neurons. Importantly, crosstalk between Sox2/Shh-targeted downstream signals and phosphatidylinositol 3-kinase/cyclin-dependent kinase 2/Smad ubiquitin regulatory factor 2 (PI3K/Cdk2/Smurf2) signaling is likely involved in the mechanisms underlying this cellular event. The highly efficient reprogramming of astrocytes to generate iNSCs will provide an alternative therapeutic approach for SCI using autologous cells.

The Importance of Early Surgical Decompression for Acute Traumatic Spinal Cord Injury

Background

Traumatic spinal cord injury (SCI) is a tragic event that has a major impact on individuals and society as well as the healthcare system. The purpose of this study was to investigate the strength of association between surgical treatment timing and neurological improvement.

Methods

Fifty-six patients with neurological impairment due to traumatic SCI were included in this study. From January 2013 to June 2017, all their medical records were reviewed. Initially, to identify the factors affecting the recovery of neurological deficit after an acute SCI, we performed univariate logistic regression analyses for various variables. Then, we performed a multivariate logistic regression analysis for variables that showed a p-value of < 0.2 in the univariate analyses. The Hosmer-Lemeshow test was used to determine the goodness of fit for the multivariate logistic regression model.

Results

In the univariate analysis on the strength of associations between various factors and neurological improvement, the following factors had a p-value of < 0.2: surgical timing (early, < 8 hours; late, 8–24 hours; p = 0.033), completeness of SCI (complete/incomplete; p = 0.033), and smoking (p = 0.095). In the multivariate analysis, only two variables were significant: surgical timing (odds ratio [OR], 0.128; p = 0.004) and completeness of SCI (OR, 9.611; p = 0.009).

Conclusions

Early surgical decompression within 8 hours after traumatic SCI appeared to improve neurological recovery. Furthermore, incomplete SCI was more closely related to favorable neurological improvement than complete SCI. Therefore, we recommend early decompression as an effective treatment for traumatic SCI.

Update on critical care for acute spinal cord injury in the setting of polytrauma

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

The impact of urgent intervention on the neurologic recovery in patients with thoracolumbar fractures

Background

We carried out an observational longitudinal retrospective study between 2000 and 2009 in 28 patients who underwent surgery for unstable vertebral fractures with neurologic deficits.

Methods

For the statistical analysis, we used the Chi²-test to compare proportions in independent groups and the exact Fisher test and the Wilcoxon test for repeated measures, and we compared the mean values using the Mann-Whitney U test at a significance level of P<0.05. Timing to surgical intervention (urgent ≤8 vs. >8 h), and neurologic status using the American Spinal Injury Association (ASIA) Impairment Scale at baseline and at the end of follow-up were assessed. We tested the ASIA score improvement at the end of follow-up using multiple regression analysis, adjusted by variables such as ISS, timing of intervention, location, approach and type of fracture.

Results

Twenty-eight patients were included in the analysis. Of the total, 11 (39.2%) underwent surgery urgently (≤8 h) and 17 (60.8%) in >8 h. The mean difference in the neurologic improvement in all patients was 0.97 (95% CI, 0.51-1.42) and was statistically significant (P=0.001). The mean difference in the neurologic improvement in patients with incomplete lesions was 1.59 (95% CI, 1.01-2.17, P=0.001). In these patients, the mean improvement for those intervened in less than 8 h was 1.73 compared to those operated on after more than 8 h (mean improve 0.47) with a difference statistically significant (P=0.007).

Conclusions

Urgent surgery was associated with neurologic improvement in patients with spinal cord injury (SCI). This improvement was mainly observed in patients with an incomplete lesion.

Early surgical decompression within 8 hours for traumatic spinal cord injury: Is it beneficial? A meta-analysis

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.

Spine Trauma-What Are the Current Controversies?

Although less common than other musculoskeletal injuries, spinal trauma may lead to significantly more disability and costs. During the last 2 decades there was substantial improvement in our understanding of the basic patterns of spinal fractures leading to more reliable classification and injury severity assessment systems but also rapid developments in surgical techniques. Despite these advancements, there remain unresolved issues concerning the management of these injuries. At this moment there is persistent controversy within the spinal trauma community, which can be grouped under 6 headings. First of all there is still no unanimity on the role and timing of medical and surgical interventions for patients with associated neurologic injury. The same is also true for type and timing of surgical intervention in multiply injured patients. In some common injury types like odontoid fractures and burst type (A3-A4) fractures in thoracolumbar spine, there is wide variation in practice between operative versus nonoperative management without clear reasons. Also, the role of different surgical approaches and techniques in certain injury types are not clarified yet. Methods of nonoperative management and care of elderly patients with concurrent complex disorders are also areas where there is no consensus. In this overview article the main reasons for these controversies are reviewed and the possible ways for resolutions are discussed.

Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI).

METHODS

A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of Recommendation Assessment, Development and Evaluation working group.

RESULTS

The search yielded 449 potentially relevant citations. Sixteen additional primary studies were identified through other sources. Six studies met inclusion criteria. All but 2 studies were considered to have moderately high risk of bias. Across studies and injury levels, the impact of early surgical decompression (≤24 hours) on clinically important improvement in neurological status was variable. Isolated studies reported statistically significant and clinically important improvements at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low strength of evidence) but not at other time points; another study observed a statistically significant 6 point improvement in ASIA Impairment Scale (AIS) among patients with AIS B, C, or D, but not for those with AIS A (very low strength of evidence). In one study of acute central cord syndrome without instability, a clinically and statistically meaningful improvement in total motor scores was reported at 6 and 12 months in patients treated early (versus late). There were, however, no significant differences in AIS improvement between early and late surgical groups at 6- or 12-months (very low strength of evidence). One of 3 studies found a shorter length of hospital stay associated with early surgical decompression. Of 3 studies reporting on safety, no significant differences in rates of complications (including mortality, neurologic deterioration, pneumonia or pressure ulcers) were noted between early and late decompression groups.

CONCLUSIONS

Results surrounding the efficacy of early versus late decompressive surgery, as well as the quality of evidence available, were variable depending on the level of SCI, timing of follow-up, and specific outcome considered. Existing evidence supports improved neurological recovery among cervical SCI patients undergoing early surgery; however, evidence regarding remaining SCI populations and clinical outcomes was inconsistent.

Current Options for Cell Therapy in Spinal Cord Injury

Spinal cord injury (SCI) is a complex pathology that evolves after primary acute mechanical injury, causing further damage to the spinal cord tissue that exacerbates clinical outcomes. Based on encouraging results from preclinical experiments, some cell treatments being translated into clinical practice demonstrate promising and effective improvement in sensory/motor function. Combinatorial treatments of cell and drug/biological factors have been demonstrated to be more effective than cell treatments alone. Recent advances have led to the development of biomaterials aiming to promote in situ cell delivery for SCI, together with combinatorial strategies using drugs/biomolecules to achieve a maximized multitarget approach. This review provides an overview of single and combinatorial regenerative cell treatments as well as potential delivery options to treat SCI.

Thoracolumbar fractures without neurological impairment: A review of diagnosis and treatment

An appropriate protocol and unified management of thoracolumbar fractures without neurological impairment has not been well defined.

This review attempts to elucidate some controversies regarding diagnostic tools, the ability to define the most appropriate treatment of classification systems and the evidence for conservative and surgical methods based on the recent literature.

Cite this article: Vilà-Canet G, García de Frutos A, Covaro A, Ubierna MT, Caceres E. Thoracolumbar fractures without neurological impairment: a review of diagnosis and treatment. EFORT Open Rev 2016;1:332-338. DOI: 10.1302/2058-5241.1.000029

Clinical outcomes of posterior spinal stabilization with rigid vertical strut and spinal process wires (the Adeolu's technique) in a developing country

Introduction

Conventional instrumentation for spinal stabilization is beyond the reach of many patients in developing countries. A low-cost and easily-available method of spinal stabilization using vertical struts and spinal process wires (Adeolu's technique) was recently introduced in Nigeria. We describe the clinical outcomes of a prospective series of patients managed using the technique.

Methods

From 2011 to 2012, we performed posterior spinal stabilization in eighteen patients using the technique. Primary outcomes were radiological evidence of rigid stabilization and mobilization without restrictions referable to the procedure in the immediate post-operative period. Implant rotation, migration, back-out, fracture, wound infection, worsening neurological status and need for implant removal were secondary measures. Overall patient satisfaction was assessed using a five-point Likert scale. The average follow-up period was 11.6 months.

Results

The average age of the patients was 45.8 years. Trauma with unstable spinal fractures (11), spondylosis (5), and thoracic extra-dural tumour (2) were the indications for surgery. The average number of spinal levels stabilized was 6. All patients had satisfactory primary outcomes. Implant rotation occurred in 3 patients (16.7%). There was no case of implant migration, back-out or fracture. Superficial surgical site infection occurred in one patient. There was no need to remove the implant in any subject and none had post-operative worsening of neurological status. The overall patient satisfaction was good with 17 patients (94.4%) reporting “highly satisfied” or “satisfied” with the surgical procedure.

Conclusion

The technique offers utility in a wide range of spinal pathologies and short-term clinical outcomes are good.

Polytrauma Patients With Associated Spine Fractures: An Assessment of Surgical Intervention on Patient Outcome

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.

The role of specialist units to provide focused care and complication avoidance following traumatic spinal cord injury: a systematic review

OBJECTIVE

Current recommendations for traumatic spinal cord injury treatment recommend immediate transfer to a spinal injury unit (SIU) where available following patient stabilisation. Although transfer is dependent on a variety of factors, the largest review was unable to justify implementation of such units on the basis of insufficient and lack of quality data in favour of care at the SIU as opposed to non-SIU centres. Our study sought to investigate: are subspecialty spinal injury units (SIUs) able to provide superior care compared with traditional trauma/rehab units? Is the standard of care of acute spinal cord injured patients to be managed in SIU's?

METHOD

A literature search was conducted across five major databases using the key terms: "spinal cord injury" AND "Spinal Injury Unit" OR "spinal rehabilitation" OR "spinal injury centre" OR "specialist care" OR "care requirements."

RESULTS

After review of over 500 studies, only 9 met inclusion criteria, 3 of which were past reviews. There were no relevant RCT's obtained. Standardised roles of global SIU units are needed to deliver equitable and high quality care as current evidence demonstrates variable standards of care and service (mean LOS range: 16-174 days). There is low quality evidence supporting earlier admission into SIU units being associated with improved neurological outcome, complication rates and reduced LOS, despite variations in the definition of "early admission" across studies.

CONCLUSIONS

Our review demonstrates a lack of standardisation within SIU on a global scale, with significantly different outcomes reported across published studies. New and higher quality evidence directly comparing SIU to non-SIU based care is required. Earlier transfer (<24 h) to SIU following initial injury and stabilisation is advised.

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>

A novel approach to patients with acute odontoid fractures: atlantoaxial instability as a prognostic variable

Liu S, Liu L. Re: Evaniew N, Yarascavitch B, Madden K, Ghert M, Drew B, Bhandari M, et al. Atlantoaxial instability in acute odontoid fractures is associated with nonunion and mortality. Spine J 2015;15:1160 (in this issue).

Timing of surgical decompression for traumatic cervical spinal cord injury

PURPOSE

Although there have been numerous studies aimed at determining the effects and safety of early vs. late surgical decompression for traumatic cervical spinal cord injury, controversies still exist regarding the optimal timing of surgery for this serious spinal trauma. This study was conducted to evaluate the effectiveness and safety of early vs. late surgical decompression for lower cervical spine trauma associated with spinal cord injury.

METHODS

A retrospective review of was performed on consecutive patients who underwent surgical decompression for lower cervical (C3-C7) spine trauma associated with spinal cord injury at six institutions across China from January 2007 to January 2012. These patients were analysed according to the timing of surgical intervention. The early group comprised patients who underwent surgery within the first 72 hours after being injured, whilst the late group comprised patients who underwent surgery after the first 72 hours. For analysis of neurologic improvement, patients who had completed a follow-up of at least six months were assessed. Other outcomes analysed were hospitalisation periods, complications and mortality.

RESULTS

A total of 595 patients were identified (456 men and 139 women at an average age of 41.4 years), with 212 in the early group and 383 in the late group. Patients in both groups had made a significant neurologic improvement in the final follow-up, but no statistically significant difference was noted between groups. Patients in the early group had a significantly shorter hospital stay (15.4 vs. 18.3 days, p <0.001) but realised no benefits in terms of intensive care unit length of stay and ventilator days. No significant differences were identified between groups with regards complications (pneumonia, pulmonary embolism, wound infection, sepsis and urinary tract infection). Compared with the late group, the early group had a significantly higher incidence of postoperative neurological deterioration (6.6 vs. 0.7 %, p <0.001) and mortality (7.1 vs. 2.1 %, p = 0.003).

CONCLUSION

The timing of surgery for patients sustaining traumatic lower cervical spine injury with neurological involvement did not affect neurological recovery. Early surgical intervention was associated with a higher incidence of mortality and neurological deterioration compared with late surgical intervention, indicating that surgery after the first 72 hours might be relatively safe.

The prehospital management of suspected spinal cord injury: an update

INTRODUCTION

Spinal cord injury (SCI) is a serious condition that may lead to long-term disabilities placing financial and social burden on patients and their families, as well as their communities. Spinal immobilization has been considered the standard prehospital care for suspected SCI patients. However, there is a lack of consensus on its beneficial impact on patients' outcome.

OBJECTIVE

This paper reviews the current literature on the epidemiology of traumatic SCI and the practice of prehospital spinal immobilization.

DESIGN

A search of literature was undertaken utilizing the online databases Ovid Medline, PubMed, CINAHL, and the Cochrane Library. The search included English language publications from January 2000 through November 2012.

RESULTS

The reported annual incidence of SCI ranges from 12.7 to 52.2 per 1 million and occurs more commonly among males than females. Motor vehicle collisions (MVCs) are the major reported causes of traumatic SCI among young and middle-aged patients, and falls are the major reported causes among patients older than 55. There is little evidence regarding the relationship between prehospital spinal immobilization and patient neurological outcomes. However, early patient transfer (8-24 hours) to spinal care units and effective resuscitation have been demonstrated to lead to better neurological outcomes.

CONCLUSION

This review reaffirms the need for further research to validate the advantages, disadvantages, and the effects of spinal immobilization on patients' neurological outcomes.

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.

Management strategies for acute spinal cord injury: current options and future perspectives

PURPOSE OF REVIEW

Spinal cord injury is a devastating acute neurological condition with loss of function and poor long-term prognosis. This review summarizes current management strategies and innovative concepts on the horizon.

RECENT FINDINGS

The routine use of steroids in patients with spinal cord injuries has been largely abandoned and considered a 'harmful standard of care'. Prospective trials have shown that early spine stabilization within 24  h results in decreased secondary complication rates. Neuronal plasticity and axonal regeneration in the adult spinal cord are limited due to myelin-associated inhibitory molecules, such as Nogo-A. The experimental inhibition of Nogo-A ameliorates axonal sprouting and functional recovery in animal models.

SUMMARY

General management strategies for acute spinal cord injury consist of protection of airway, breathing, oxygenation and control of blood loss with maintenance of blood pressure. Unstable spine fractures should be stabilized early to allow unrestricted mobilization of patients with spinal cord injuries and to decrease preventable complications. Steroids are largely considered obsolete and have been abandoned in clinical guidelines. Nogo-A represents a promising new pharmacological target to promote sprouting of injured axons and restore function. Prospective clinical trials of Nogo-A inhibition in patients with spinal cord injuries are currently under way.

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.

Percutaneous pedicle screw for unstable spine fractures in polytraumatized patients: A report of two cases

Unstable spine fractures commonly occur in the setting of a polytraumatized patient. The aim of management is to balance the need for early operative stabilization and prevent additional trauma due to the surgery. Recent published literature has demonstrated the benefits of early stabilization of an unstable spine fracture particularly in patients with higher injury severity score (ISS). We report two cases of polytrauma with unstable spine fractures stabilized with a minimally invasive percutaneous pedicle screw instrumentation system as a form of damage control surgery. The patients had good recovery from the polytrauma injuries. These two cases illustrate the role of minimally invasive stabilization, its limitations and technical pitfalls in the management of unstable spine fractures in the polytrauma setting as a form of damage control surgery.