Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis

Clinical risk factors associated with the need for tracheostomy in traumatic cervical and high thoracic spinal cord injury

BACKGROUND

Our objective was to assess the association of completeness and level of spinal cord injury (SCI) with the need for tracheostomy and identify additional risk factors predictive of tracheostomy.

METHODS

This was a retrospective review of patients with SCI between January 2017 and December 2022.

RESULTS

Patients with complete SCI were roughly thirty-three times more likely to have a tracheostomy when compared to incomplete injury (82 ​% vs 12 ​%, p ​< ​0.001, OR ​= ​32.9). The rate of tracheostomy did not differ between spinal cord levels for complete (p ​= ​0.68) or incomplete (p ​= ​0.08) injuries. Penetrating injury, low GCS, high ISS, and polytrauma were associated with tracheostomy need in incomplete SCI.

CONCLUSION

Complete injury was statistically significantly associated with the need for tracheostomy while level of injury failed to reach significance. Patients with incomplete SCI that have certain clinical risk factors should be considered for early tracheostomy.

Epidemiology, timing, technique, and outcomes of tracheostomy in patients with trauma: a multi-centre retrospective study

BACKGROUND

Tracheostomy is performed in patients with trauma who need prolonged ventilation for respiratory failure or airway management. Although it has benefits, such as reduced sedation and easier care, it also has risks. This study explored the unclear timing, technique, and patient selection criteria for tracheostomy in patients with trauma.

METHODS

We included 220 adult patients with trauma who underwent tracheostomy after endotracheal intubation between January 2019 and December 2022. We compared clinical outcomes between patients who underwent early (within 10 days) and late (after 10 days) tracheostomy and between patients who underwent percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST). Factors associated with hospital and intensive care unit (ICU) length of stay (LOS), ICU-free days, duration of mechanical ventilation, and ventilator-free days (VFDs) were identified using multiple linear regression analysis.

RESULTS

The patients' mean age was 61.5 years; 75.9% were men. Most tracheostomies were performed after 10 days (n = 135, 61.4%), with PDT serving as the more common approach during this period. Contrastingly, early tracheostomies (n = 85, 38.6%) were predominantly performed using ST. Early tracheostomy was significantly associated with reduced hospital (P = 0.038) and ICU LOS (P = 0.047), decreased duration of mechanical ventilation (P = 0.001), and increased VFDs (P < 0.001). However, no significant association was found with ICU-free days (P = 0.072) or in-hospital mortality (P = 0.917).

CONCLUSION

Early tracheostomy was associated with reduced hospital and ICU LOS, decreased duration of mechanical ventilation, and increased VFDs.

The influencing factors for tracheostomy decannulation after traumatic cervical spinal cord injury: a retrospective study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the outcomes and influencing factors of tracheostomy decannulation (TD) in persons with traumatic cervical spinal cord injury (SCI).

SETTING

China Rehabilitation Research Center (CRRC) in Beijing, China.

METHODS

From January 2017 to December 2021, 365 persons with traumatic cervical SCI were admitted to the China Rehabilitation Research Center. During hospitalization, tracheostomy patients were enrolled and divided into the TD group and non-TD group. Demographic and clinical data, as well as functional assessments, were collected and recorded for all persons. The factors influencing TD were analyzed using both univariate and multivariate logistic regression.

RESULTS

A total of 78 persons with traumatic cervical SCI from CRRC were enrolled in this study. Of these, 48 persons (61.5%) underwent successful decannulation, with a median time of 93.5 days (IQR: 62.0-143.8 days). Multivariate logistic regression revealed that AIS A (P = 0.021, OR: 5.378, 95% CI, 1.287-22.474) and Charlson comorbidity index (CCI) (P = 0.003, OR: 1.836, 95% CI, 1.230-2.740) were significant risk factors of reduced success in TD. PEF in the TD group was 145.44 ± 50.56 L/min. Middle-aged and young persons with traumatic cervical SCI at C3 to C5 neurological level did not satisfy the criterion of PEF (over 160 L/min), but they can still attempt tracheostomy decannulation.

CONCLUSION

AIS A and a high CCI will reduce the success rate of tracheostomy decannulation in persons suffering from traumatic cervical SCI.

Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI.

METHODS

This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation.

RESULTS

The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest.

CONCLUSION

Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Long-term trends and risk factors of tracheostomy and decannulation in patients with cervical spinal cord Injury

STUDY DESIGN

Retrospective study.

OBJECTIVES

To investigate the risk factors of tracheostomy and decannulation after cervical spinal cord injury (CSCI) and their epidemiological changes over the past 8 years in Beijing Bo'ai Hospital, China Rehabilitation Research Center (CRRC), China.

SETTING

Beijing Bo'ai Hospital, CRRC.

METHODS

We reviewed 8 years of patient data (2013.1.1 to 2020.12.31) at CRRC, focusing on those hospitalized and diagnosed with CSCI. We analyzed changes in demographic and clinical data's trends. Logistic regression analysis was used to determine factors impacting tracheostomy and decannulation.

RESULTS

Finally, 1641 CSCI patients met the inclusion criteria. Over the past 8 years, the proportion of tracheostomized patients with CSCI was 16.3%, and the proportion of successfully decannulated of tracheostomized patients with TCSCI was 77.9%. We found that Traumatic (OR = 1.8, 95% CI = 1.06, 3.22; p = 0.046), Motor level of injury (C5-C8) (OR = 0.32, 95% CI = -1.91,-0.34; p = 0.005), AIS = A/B/C (OR = 22.7/11.1/4.2, 95% CI = 12.16,42.26/5.74,21.56/2.23,7.89; p < 0.001/p < 0.001/p < 0.001), age > 56 (OR = 1.6, 95% CI = 1.04, 2.32; p = 0.031) were the risk factors for tracheostomy. By analyzing the risk factors of decannulation failure in tracheostomized patients with TCSCI through multivariable logistic regression, statistically significant differences were found in age > 45 (OR = 4.1, 95% CI = 1.44, 11.81; p = 0.008), complete injury (OR = 2.7, 95% CI = 1.26, 5.95; p = 0.011), facet dislocation (OR = 2.8, 95% CI = 1.13,7.07; p = 0.027).

CONCLUSIONS

Recent years have witnessed shifts in the epidemiological characteristics of CSCI. Identifying the factors influencing tracheostomy and decannulation in CSCI can aid in improving patient prognosis.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

Analysis of Risk Factors for Postoperative Deep Vein Thrombosis in Traumatic Spinal Fracture Complicated with Spinal Cord Injury

The purpose of this study is to investigate the risk factors for postoperative deep vein thrombosis (DVT) in patients with traumatic spinal fractures complicated with Spinal Cord Injury(SCI). We conducted a retrospective analysis of 110 patients with traumatic spinal fractures and SCI admitted to our hospital from March 2021 to April 2024. DVT was diagnosed using ultrasound. Patient history, general data, surgical data, laboratory tests, and thromboelastogram (TEG) results were collected. The patients were divided into a DVT group and a non-DVT group according to the results of ultrasound one week after surgery. The risk factors and diagnostic value were analyzed using binary logistic regression and receiver operating characteristic (ROC) curves in both univariate and multivariate analyses. Multivariate and ROC analysis results showed that D-dimer, lower extremity, duration of bedrest, and MA values of TEG were independent risk factors for DVT in SCI, with D-dimer having the highest diagnostic value (AUC = 0.883). The AUC values for lower extremity, duration of bedrest, and MA were 0.731, 0.750, and 0.625. In conclusion, Postoperative D-dimer > 5.065 mg/l, lower extremity < 3, duration of bedrest, and MA value of TEG are independent risk factors for postoperative DVT in SCI patients, D-dimer having the highest diagnostic value. When the above risk factors occur, clinicians need to be vigilant and take appropriate prevention and treatment measures.

Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver

BACKGROUND

The unsuccessful extubation in patients with traumatic cervical spinal cord injuries (CSCI) may result from impairment diaphragm function and monitoring of diaphragm electrical activity (EAdi) can be informative in guiding extubation. We aimed to evaluate whether the change of EAdi during a single maximal maneuver can predict extubation outcomes in CSCI patients.

METHODS

This is a retrospective study of CSCI patients requiring mechanical ventilation in the ICU of a tertiary hospital. A single maximal maneuver was performed by asking each patient to inhale with maximum strength during the first spontaneous breathing trial (SBT). The baseline (during SBT before maximal maneuver), maximum (during the single maximal maneuver), and the increase of EAdi (ΔEAdi, equal to the difference between baseline and maximal) were measured. The primary outcome was extubation success, defined as no reintubation after the first extubation and no tracheostomy before any extubation during the ICU stay.

RESULTS

Among 107 patients enrolled, 50 (46.7%) were extubated successfully at the first SBT. Baseline EAdi, maximum EAdi, and ΔEAdi were significantly higher, and the rapid shallow breathing index was lower in patients who were extubated successfully than in those who failed. By multivariable logistic analysis, ΔEAdi was independently associated with successful extubation (OR 2.03, 95% CI 1.52-3.17). ΔEAdi demonstrated high diagnostic accuracy in predicting extubation success with an AUROC 0.978 (95% CI 0.941-0.995), and the cut-off value was 7.0 μV.

CONCLUSIONS

The increase of EAdi from baseline SBT during a single maximal maneuver is associated with successful extubation and can help guide extubation in CSCI patients.

Spinal cord injury: global burden from 1990 to 2019 and projections up to 2030 using Bayesian age-period-cohort analysis

Background

Spinal cord injuries, often resulting from spine fractures, can lead to severe lifelong symptoms such as paraplegia and even mortality. Over the past few decades, there has been a concerning increase in the annual incidence and mortality rates of spinal cord injuries, which has also placed a growing financial strain on healthcare systems. This review aims to offer a comprehensive overview of spinal cord injuries by estimating their global incidence, prevalence, and the impact in terms of years lived with disability, using data obtained from the 2019 Global Burden of Disease Study.

Method

In this study, we utilized data from the 2019 Global Burden of Disease Study, a widely recognized source for global health data. Our methodology involved estimating the global incidence and prevalence of spinal cord injuries while also assessing the impact on years lived with a disability. We analyzed this data comprehensively to identify patterns and trends and made predictions.

Finding

This research delved into the evolving trends in the global burden of spinal cord injuries, identified key risk factors, and examined variations in incidence and disability across different Socio-demographic Index (SDI) levels and age groups. Briefly, in 2019, the global incidence and burden of YLDs of SCI significantly increased compared to 1990. While males had higher incidence rates compared to females. Falls were identified as the primary cause of SCI. Trend projections up to 2030 revealed a slight decrease in ASIR for males, an upward trend in age-specific incidence rates for both sexes and a similar pattern in age-standardized YLD rates. Additionally, our findings provided crucial groundwork for shaping future policies and healthcare initiatives, with the goal of mitigating the burden of spinal cord injuries, enhancing patient outcomes, and fortifying prevention efforts.

Interpretation

Understanding the global burden of spinal cord injuries is essential for designing effective healthcare policies and prevention strategies. With the alarming increase in prevalence rates and their significant impact on individuals and healthcare systems, this research contributes vital insights to guide future efforts in reducing the incidence of spinal cord injuries, improving the quality of life for affected individuals, and reducing the economic burden on healthcare systems worldwide.

Earlier Tracheostomy Reduces Complications in Complete Cervical Spinal Cord Injury in Real-World Practice: Analysis of a Multicenter Cohort of 2001 Patients

BACKGROUND AND OBJECTIVES

It is believed that early tracheostomy in patients with traumatic cervical spinal cord injury (SCI) may lessen the risk of developing complications and reduce the duration of mechanical ventilation and critical care stay. This study aims to assess whether early tracheostomy is beneficial in patients with traumatic cervical SCI.

METHODS

We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program database from 2010 to 2018. Adult patients with a diagnosis of acute complete (ASIA A) traumatic cervical SCI who underwent surgery and tracheostomy were included. Patients were stratified into those receiving early (at or before 7 days) and delayed tracheostomy. Propensity score matching was used to assess the association between delayed tracheostomy and the risk of in-hospital adverse events. Risk-adjusted variability in tracheostomy timing across trauma centers was investigated using mixed-effects regression.

RESULTS

The study included 2001 patients from 374 North American trauma centers. The median time to tracheostomy was 9.2 days (IQR: 6.1-13.1 days), with 654 patients (32.7%) undergoing early tracheostomy. After matching, the odds of a major complication were significantly lower for early tracheostomy patients (OR: .90; 95% CI: .88-.98). Patients were also significantly less likely to experience an immobility-related complication (OR: .90; 95% CI: .88-.98). Patients in the early group spent 8.2 fewer days in the critical care unit (95% CI: -10.2 to -6.61) and 6.7 fewer days ventilated (95% CI: -9.44 to -5.23). There was significant variability in tracheostomy timeliness between trauma centers with a median odds ratio of 12.2 (95% CI: 9.7-13.7), which was not explained by case-mix and hospital-level characteristics.

CONCLUSION

A 7-day threshold to implement tracheostomy seems to be associated with reduced in-hospital complications, time in the critical care unit, and time on mechanical ventilation.

A Fast-Track Respiratory Protocol for High Cervical Spine Injury: A Case Report

BACKGROUND

Cervical spinal cord injury can greatly affect pulmonary function, resulting in complications, including respiratory failure with prolonged mechanical ventilation, ultimately leading to increased mortality and high health care costs. Weaning from mechanical ventilation is particularly challenging in patients with complete high spinal cord injury.

CASE PRESENTATION

We present the case of a 42-year-old man who suffered a complete cervical 5-6 spinal cord injury following a rollover motor vehicle crash and subsequently developed postoperative pneumonia and severe hypoxemic respiratory failure. He received a novel approach to fast-track respiratory care, including early and aggressive secretion clearance management, moderate pressure level of airway pressure release ventilation, timely transition to spontaneous mode, early tracheostomy and humane care, and high-flow oxygenation via tracheotomy after weaning off the ventilator. As a result, the patient experienced significant improvement in pulmonary function and was successfully liberated from the ventilator within a 2-week period.

CONCLUSION

This case highlights the potential effectiveness of fast-track respiratory care in promoting lung function restoration and expediting liberation from mechanical ventilation in patients with severe hypoxemic respiratory failure following a complete cervical spinal cord injury. However, further research is warranted to validate these findings and expand our understanding in this area.

[Perioperative management after traumatic paraplegia : Avoiding complications]

This article describes the current status of modern treatment options for traumatic spinal cord injuries with a particular focus on the perioperative phase. Along with a recognition of age-related specific features that can impact successful treatment of spinal injuries, prompt interdisciplinary treatment while adhering to the "time is spine" principle is of high importance. By considering this approach and using modern diagnostic and surgical techniques, successful surgical treatment can be achieved while taking into account individual characteristics, such as reduced bone quality, accompanying injuries as well as oncological and inflammatory rheumatic comorbidities. The preventive and treatment strategies for frequently occurring complications in the management of traumatic spinal cord injuries are presented. By considering case-specific factors, utilizing modern surgical techniques, avoiding or promptly treating typical complications and initiating interdisciplinary treatment, crucial groundwork for a successful long-term treatment of this highly debilitating and life-altering injury can be established in the perioperative phase.

Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates

Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.

Effect of tracheostomy timing in pediatric patients with traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established.

OBJECTIVE

This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes.

DESIGN/METHODS

The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days).

RESULTS

Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence.

CONCLUSIONS

Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.

Respiratory Complications and Weaning Considerations for Patients with Spinal Cord Injuries: A Narrative Review

Respiratory complications following traumatic spinal cord injury are common and are associated with high morbidity and mortality. The inability to cough and clear secretions coupled with weakened respiratory and abdominal muscles commonly leads to respiratory failure, pulmonary edema, and pneumonia. Higher level and severity of the spinal cord injury, history of underlying lung pathology, history of smoking, and poor baseline health status are potential predictors for patients that will experience respiratory complications. For patients who may require prolonged intubation, early tracheostomy has been shown to lead to improved outcomes. Prediction models to aid clinicians with the decision and timing of tracheostomy have been shown to be successful but require larger validation studies in the future. Mechanical ventilation weaning strategies also require further investigation but should focus on a combination of optimizing ventilator setting, pulmonary toilet techniques, psychosocial well-being, and an aggressive bowel regimen.

Tracheostomy in traumatic cervical spinal cord injury: Early versus late tracheostomy

OBJECTIVE

The purpose of this study was to characterize the relationship between predictors and the time of tracheostomy after traumatic cervical spinal cord injury (TCSCI).

METHODS

Five hundred twenty-six patients with TCSCI treated between January,2012 and December, 2021 were retrospectively reviewed. Patients were subdivided into two groups: early tracheostomy (≤7 days from initiation of endotracheal intubation) and late tracheostomy. Comparisons between early tracheostomy and late tracheostomy were statistically analyzed. Logistic regression analysis was applied to identify independent predictors of tracheostomy and calculate probability for different grades of combining predictors to predict tracheostomy. Spearman's correlation coefficient was used to evaluate the association between the grade of combining predictors and the time to tracheostomy.

RESULTS

Among 526 eligible patients, 63(12.0%) had a tracheostomy performed. Compared with late tracheostomy group, patients in early tracheostomy group had higher ISS, more severe neurological status while fewer In-hospital LOS days and ICU LOS days. By Logistic regression analysis, severe American Spinal Injury Association Impairment Scale (AIS A), the neurological level of injury (NLI>C5), higher Injury Severity Score (ISS>16) and advanced age (over 50 years old) were identified as independent predictors for tracheostomy. Depending on the likelihood of tracheostomy, the combining predictors were graded into five categories. As the value of probability was higher than 50%, Grade I-III made optimistic predictions about tracheostomy. According to Spearman's correlation analysis, early tracheostomy had a strong association with Grade I, while late tracheostomy was closely correlated with Grade III.

CONCLUSIONS

Factors related to the decision of tracheostomy were ASIA impairment scale, neurological level of injury, injury severity score and age. The grades of combining predictors could support indication for predicting the time of tracheostomy.

A Nomogram Model for Prediction of Tracheostomy in Patients With Traumatic Cervical Spinal Cord Injury

OBJECTIVE

To develop a nomogram for the prediction of tracheostomy in patients with traumatic cervical spinal cord injury (TCSCI).

METHODS

A total of 689 TCSCI patients were included in our study. First, the variable selection was performed using between-group comparisons and LASSO regression analysis. Second, a multivariate logistic regression analysis (MLRA) with a step-by-step method was performed. A nomogram model was developed based on the MLRA. Finally, the model was validated on the training set and validation set.

RESULTS

The nomogram prediction model incorporated 5 predictors, including smoking history, dislocation, thoracic injury, American Spinal Injury Association (ASIA) grade, and neurological level of injury (NLI). The area under curve in the training group and in the validation group were 0.883 and 0.909, respectively. The Hosmer-Lemeshow test result was p = 0.153. From the decision curve analysis curve, the model performed well and was feasible to make beneficial clinical decisions.

CONCLUSION

The nomogram combining dislocation, thoracic injury, ASIA grade A, NLI, and smoking history was validated as a reliable model for the prediction of tracheostomy.

Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury

How to cite this article: Govil D, Pachisia AV. Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury. Indian J Crit Care Med 2022;26(10):1067-1068.

Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children

Purpose of Review

This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available.

Recent Findings

Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment.

Summary

Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.

Perioperative management in complex spine surgery: a narrative review

The last two decades have seen a significant increase in the number of spine surgical procedures performed worldwide. This type of surgery includes a wide variety of procedures, from mini-invasive discectomies to multi-level spinal arthrodesis and osteotomies. Moreover, different surgical approaches are described at different spine levels: the anesthesiologist should be aware of the potential benefits and risks for the patients and be prepared for their management. In this narrative review we seek to describe basic concepts of perioperative spine care and address evolving areas in which care is changing. We will discuss preoperative concerns, intraoperative management including airway management, choice of maintenance, intraoperative neuromonitoring and anesthetic effect, blood management and the dynamic topic of anesthetic and analgesic techniques. Finally, we will briefly address the issue of perioperative complications as they relate specifically to spine surgery.