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

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.

Developments in the understanding of staging a "major fracture" in polytrauma: results from an initiative by the polytrauma section of ESTES

PURPOSE

Although the term "major fracture" is commonly used in the management of trauma patients, it is defined insufficiently to date. The polytrauma section of ESTES is trying to develop a more standardized use and a definition of the term. In this process, a standardized literature search was undertaken. We test the hypothesis that the understanding of "major fractures" has changed and is modified by a better understanding of patient physiology.

METHODS

A systematic literature search of the Medline and EMBASE databases was conducted in March 2022. Original studies that investigated surgical treatment strategies in polytraumatized patients with fractures were included: This included timing, sequence and type of operative treatment. A qualitative synthesis regarding the prevalence of anatomic regions of interest and core factors determining decision-making was performed. Data were stratified by decades.

RESULTS

4278 articles were identified. Of these, 74 were included for qualitative evaluation: 50 articles focused on one anatomic region, 24 investigated the relevance of multiple anatomic regions. Femur fractures were investigated most frequently (62) followed by pelvic (22), spinal (15) and tibial (15) fractures. Only femur (40), pelvic (5) and spinal (5) fractures were investigated in articles with one anatomic region of interest. Before 2010, most articles focused on long bone injuries. After 2010, fractures of pelvis and spine were cited more frequently. Additional determining factors for decision-making were covered in 67 studies. These included chest injuries (42), TBI (26), hemorrhagic shock (25) and other injury-specific factors (23). Articles before 2000 almost exclusively focused on chest injury and TBI, while shock and injury-specific factors (e.g., soft tissues, spinal cord injury, and abdominal trauma) became more relevant after 2000.

CONCLUSION

Over time, the way "major fractures" influenced surgical treatment strategies has changed notably. While femur fractures have long been the only focus, fixation of pelvic and spinal fractures have become more important over the last decade. In addition to the fracture location, associated conditions and injuries (chest trauma and head injuries) influence surgical decision-making as well. Hemodynamic stability and injury-specific factors (soft tissue injuries) have increased in importance over time.

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

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.

Encrypted smartphone text messaging between spine surgeons may reduce after-hours surgery

PURPOSE

"After-hours" non-elective spine surgery is associated with increased morbidity. Decision-making may be enhanced by collaborative input from experienced local colleagues. At our center, we implemented routine use of a cross-platform messaging system (CPMS; WhatsApp Inc., Mountain View, California) to facilitate quality care discussions and collaborative surgical decision-making between spine surgeons prior to booking cases with the operating room. Our aim is to determine whether encrypted text messaging for shared decision-making between spine surgeons affects the number or type of after-hours spine procedures.

METHODS

We retrospectively compared the number, type and length of after-hours spine surgery over three time periods: (A) June 1, 2016-May 31, 2017 (baseline control); (B) June 1, 2017-May 31, 2018 (implementation of retrospective quality care spine rounds); and (C) June 1, 2018-May 31, 2019 (implementation of CPMS). A qualitative analysis of the CPMS transcripts was also performed to assess the rate of between-surgeon agreement for timing and type of procedure.

RESULTS

The mean number of after-hours spine surgeries/month over the three study periods (A, B, C) was 10.83, 9.75 and 7.58 (p = 0.014); length of surgery was 41.82, 33.14 and 25.37 h/month (p = 0.001). Group agreement with the attending spine surgeon plan was 74.3% overall and was highest for the most urgent and least urgent types of indications.

CONCLUSIONS

Prospective (i.e., prior to booking surgery) quality care discussion for joint decision-making among spine surgeons using CPMS may reduce both the number and complexity of after-hours procedures.

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.

Are orthopaedic providers willing to work overtime to address COVID-19-related patient backlogs and financial deficits?

Aims

COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic.

Methods

An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers.

Results

In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an ambulatory surgery centre (ASC). Of the strategies to address departmental financial deficits, 85% of providers (n = 72) were willing to work extra hours without a pay cut.

Conclusion

Most orthopaedic providers are willing to help with patient care backlogs and revenue recovery by working extended hours instead of having their pay reduced. These findings provide insights that can be incorporated into COVID-19 recovery strategies.

Level of Evidence: III

Cite this article: Bone Jt Open 2021;2(7):562–568.

Traumatic spinal cord injury in southern Saudi Arabia: Patterns, time to surgery and outcomes

Introduction:

Spinal cord injury (SCI) is an unbearable neurological disorder. which has a destructive socioeconomic effect of affected individual, their families and the healthcare systems. Stressful spinal cord damages are caused by road traffic misfortunes, violence, sports or falls.

Methods:

Retrospective study of 112 spinal cord injured patient admitted to Aseer Central hospital (ACH) between the years 2016 and 2018.

Results:

The present study includes 112 cases of TSCI patients who admitted to Asser Central Hospital and surgically treated, with mean age 32.1 ± 14.12 years. Males were the mostly affected by almost 90.2%. Lower level of education is seen in 69.6% of patients; while only 30.3% of patients had university education or higher. Motor vehicle accidents (MVA) and falls are the only two causes of spinal cord injuries in this study; however, MVA was the cause of SCI in (79.5%) and 20.5% for falls.

Conclusions:

MVAs are the most source of spinal cord injuries in Southern Saudi Arabia with high male predominance. Despite the lack of significance between shorter time to surgery, and improvement in ASIA score, it was found that shorter time to surgery plays an important role in reducing the post-operative intensive care unit and ward stay, potentially reducing possible long stay related complications and eventually reducing health care cost.

Timing of intervention for spinal injury in patients with polytrauma

OBJECTIVE

The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.

METHODS

A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995-2020) based on the keywords - polytrauma OR multiple trauma AND spine fracture AND timing, present in "All the fields" of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.

RESULTS

Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, "damage control" internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.

CONCLUSION

Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Timing of surgical fixation in traumatic spinal fractures: A systematic review

BACKGROUND

The optimal timing of fracture fixation following spinal injury is controversial. Many spinal fractures occur as part of polytrauma requiring a complex management strategy. Whilst the decision to stabilize unstable spinal column injuries is without debate, the duration between injury and definitive fixation can impact on the incidence of post-operative complications. This study was designed to systemically summarize and compare the complication profile of early vs late stabilization of spinal injuries, in an attempt to unveil an appropriate treatment protocol for traumatic spinal fractures.

METHODS

A comprehensive search strategy was performed on the PubMed, Cochrane, and Google Scholar databases using key words. The search strategy provided 1120 results. Forty-six articles were reviewed for full-text. Reference lists were analysed for potential additional texts.

RESULTS

Sixteen articles met the inclusion criteria and were included for systematic review. Studies were controversial and the overall result was inconclusive. Several studies favour early stabilisation to reduce post-surgical complication rates, especially in cases of patients with high Injury Severity Scale (ISS) scores. However, this is challenged by a small number of studies reporting a higher mortality rate in the early-stabilisation cohort.

CONCLUSION

Due to limited studies and a small overall cohort, the authors would cautiously recommend the early surgical fixation of unstable spine fractures in the stable trauma patient. For severely injured patients, the discordance among literature warrants the need for further investigation.

Does the Coexistence of Multiple Segmental Rib Fractures in Polytrauma Patients Presenting With "Major" Vertebral Fracture Affect Care and Acute Outcomes?

OBJECTIVE

To determine whether operating on "major" vertebral fractures leads to premature abortion of surgery and/or other acute cardiopulmonary complications.

DESIGN

Retrospective review.

CLINICAL SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS AND INTERVENTION

We retrospectively queried our institutional Trauma Rregistry for all cases presenting with concomitant rib fractures and surgically managed vertebral fractures.

MAIN OUTCOME MEASUREMENTS

The main outcomes included the surgical outcome (aborted vs. successfully performed), total and Intensive Care Unit length of stay (LOS), adverse discharge, mortality, and functional outcomes.

RESULTS

We found 57 cases with concomitant segmental rib fractures and surgically managed vertebral fractures. Seven patients (12%) received a rib fixation, of which 1 received before vertebral fixation and 6 after. Importantly, 4 vertebral fixation cases (7.02%) had to be aborted intraoperatively because of the inability to tolerate prone positioning for surgery. For case-control analysis, we performed propensity score matching to obtain matched controls, that is, cases of vertebral fixation but no rib fractures. On matched case-control analysis, patients with concomitant segmental rib fractures and vertebral fractures were found to have higher Intensive Care Unit LOS [median = 3 days (Inter-Quartile Range = 0-9) versus. 8.4 days, P = 0.003], whereas total LOS, frequency of complete, incomplete or functional spinal cord injury, discharge to rehab, and discharge to nursing home were found to be similar between the 2 groups.

CONCLUSION

Our findings demonstrate that segmental rib fractures with concomitant vertebral fractures undergoing surgical treatment represent a subset of patients that may be at increased risk of intraoperative cardio-pulmonary complications and rib fixation before prone spine surgery for cases in which the neurological status is stable is reasonable.

LEVEL OF EVIDENCE

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

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.

Operative Fixation for Clavicle Fractures-Socioeconomic Differences Persist Despite Overall Population Increases in Utilization

BACKGROUND

Clavicle fractures were traditionally treated conservatively, but recent evidence has shown improved outcomes with surgical management. The purpose of this study was to evaluate the recent trends in operative treatment of clavicle fractures, and to analyze for patient related factors that may affect treatment strategy.

METHODS

The Healthcare Cost and Utilization Project (HCUP) California and Florida inpatient, outpatient, and the Emergency Department databases were used to identify all patients with clavicle fractures between 2005 and 2010. We evaluated the overall number of procedures over the study period and calculated the rates of operative and nonoperative treatment by tracking a large cohort of emergency department patients with clavicle fractures. Poisson and multivariable regression were used to identify trends and patient factors associated with treatment.

RESULTS

There was a 290% increase in the annual number clavicle fracture procedures over the study period. The rate of fixation increased from 3.7% to 11.1% (P < 0.001). Significant increases were seen in all patient age groups less than 65 years. Comparatively, higher rates of fixation were found in patients who were white, privately insured, and of high-income status. Lower income status was also associated with delayed surgery.

CONCLUSIONS

The rates of clavicle fracture fixation have increased. However, there are differences associated with socioeconomic factors including race, insurance type, and income level. In part, this likely representing both underutilization and overutilization but may also show differential access to care. This differential utilization suggests both that further work is needed to more clearly define indications for operative versus nonoperative management and to further evaluate referral systems and access to care to ensure equal and quality treatment is available for all patients.

LEVEL OF EVIDENCE

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

Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients?

BACKGROUND

Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications.

METHODS

Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death.

RESULTS

Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046).

CONCLUSIONS

EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients.

LEVEL OF EVIDENCE

level II prospective, comparative study.

Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients

Background

Patient selection for surgical treatment of subaxial cervical spine fractures (S-CS-fx) may be challenging and is dependent on fracture morphology, the integrity of the discoligamentous complex, neurological status, comorbidity, risks of surgery and the expected long-term outcomes. The purpose of this study is to evaluate complications and long-term outcomes in a consecutive series of 303 patients with S-CS-fx treated with open surgical fixation.

Methods

Medical charts were retrospectively reviewed. The surviving patients participated in a prospective long-term follow-up, including clinical history, physical examination and updated cervical CT. Patients with ankylosing spondylitis were excluded from this study.

Results

The median patient age was 48 years (range 14.7–93.9), and 74 % were males. Preoperatively, 43 % had spinal cord injury (SCI), and 27 % exhibited isolated radiculopathy. The median time from injury to surgery was 2 days (range 0–136). The risks of SCI deterioration and new-onset radiculopathy after surgery were 2.0 % and 1.3 %, respectively. Surgical mortality (death within 30 days after surgery) was 2.3 %. The reoperation rate was 7.3 %. At the long-term follow-up conducted a median of 2.6 years after trauma (range 0.5–9.1), 256 (99.2 %) of the patients who had survived and were living in Norway participated. Of the patients with American Injury Severity Scale (AIS) A–D at presentation, 51 % had improved one or more AIS grades. At the time of follow-up, 89 % of the patients with preoperative radiculopathy were without symptoms. Furthermore, 11 % of the patients reported severe neck stiffness, 5 % reported severe neck pain (Visual Analog Scale (VAS) ≥7), 6 % reported hoarseness, and 9 % reported dysphagia at the follow-up. The stable fusion rate, as evaluated using cervical-CT, was 98 %.

Conclusions

In this large consecutive series of patients with S-CS-fx treated with open surgical fixation, the surgical mortality was 2.3 %, the risk of neurological deterioration was 3.3 % and the reoperation rate (any cause) was 7.3 %. The neurological long-term results were good, with 51 % improvement in AIS grade and resolution of radiculopathy in 89 % of the patients. Stable fusion was excellent and was achieved in 98 % of the follow-up group.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

Detecting severe injuries of the upper body in multiple trauma patients

BACKGROUND

The clavicle limits the upper thoracic cage and connects the body and upper extremities. The clavicle is easy to examine and is visible on standard emergency room radiographs. We hypothesized that clavicular fracture in polytrauma patients would indicate the presence of further injuries of the upper extremities, head, neck, and thorax.

METHODS

A population-based trauma registry was used. All patients were documented between 2002 and 2013. Inclusion criteria were age ≥16 y and injury severity score (ISS) ≥16. Patients were divided into two groups according to the presence or absence of a clavicular fracture (group C+ and group C-). Scoring was based on the abbreviated injury scale, ISS, and new injury severity score. Trauma mechanisms, demographics, and the posttraumatic clinical course were compared.

RESULTS

In total, 4790 patients with clavicular fracture (C+) and 41,775 without (C-) were included; the mean ISS was 30 ± 11 (C+) versus 28 ± 12 (C-). Patients with clavicular fracture had a longer stay on the intensive care unit with 12 ± 14 versus 10 ± 13 d. Injuries to the thoracic wall, severe lung injuries as well as injuries to the cervical spine were significantly increased in C+ patients. Thoracic injuries as well as injuries of the shoulder girdle and/or arm showed an increased abbreviated injury scale in the C+ group.

CONCLUSIONS

A clinically relevant coincidence of clavicular fractures with injuries of the chest and upper extremity was found. As clavicular fractures can be diagnosed easily, it might also help to reduce the incidence of missed injuries of the chest and upper extremity. Therefore, special attention should be paid on thoracic as well as upper extremity injures during the second and tertiary surveys in case of clavicular fractures.

Predicting In-Hospital Mortality in Elderly Patients With Cervical Spine Fractures: A Comparison of the Charlson and Elixhauser Comorbidity Measures

STUDY DESIGN

Retrospective analysis of nationally representative data collected for the National Hospital Discharge Survey.

OBJECTIVE

To compare the performance of the Charlson and Elixhauser comorbidity-based measures for predicting in-hospital mortality after cervical spine fractures.

SUMMARY OF BACKGROUND DATA

Mortality occurring as a consequence of cervical spine fractures is very high in the elderly. The Charlson comorbidity measure has been associated with an increased risk of mortality, but its predictive accuracy has yet to be compared with the more recent and increasingly used Elixhauser measure.

METHODS

Using the National Hospital Discharge Survey for the years 1990 through 2007, we identified all patients aged 65 years or older hospitalized with a diagnosis of cervical spine fracture. The association of each Charlson and Elixhauser comorbidity with mortality was assessed in bivariate analysis using χ tests. Two main multivariable logistic regression models were constructed, with in-hospital mortality as the dependent variable and 1 of the 2 comorbidity-based measures (as well as age, sex, and year of admission) as independent variables. A base model that included only age, sex, and year of admission was also evaluated. The discriminative ability of the models was quantified using the area under the receiver operating characteristic curve (AUC).

RESULTS

Among an estimated 111,564 patients admitted for cervical spine fractures, 7.6% died in the hospital. Elixhauser comorbidity adjustment provided better prediction of in-hospital case mortality (AUC = 0.852, 95% confidence interval: 0.848-0.856) than the Charlson model (AUC = 0.823, 95% confidence interval: 0.819-0.828) and the base model with no comorbidities (AUC = 0.785, 95% confidence interval: 0.781-0.790). In terms of relative improvement in predictive ability, the Elixhauser model performed 43% better than the Charlson model.

CONCLUSION

The Elixhauser comorbidity risk adjustment method performed numerically better than the widely used Charlson measure in predicting in-hospital mortality after cervical spine fractures.

LEVEL OF EVIDENCE

N/A.

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>

The intra- and postoperative management of accidental durotomy in lumbar spine surgery: results of a German survey

BACKGROUND

The intra- and postoperative management of accidental durotomy in operations of the lumbar spine is not standardized. It is the aim of our survey to obtain an overview on the current practice in neurosurgical departments in Germany.

METHODS

The used questionnaire consisted of three questions and could be answered within a few minutes by checking boxes. In September 2012, the questionnaire was sent to 149 German neurosurgical departments. In the following 4 weeks 109 replies (73.2 %) were received.

RESULTS

Seventy-one neurosurgical departments (65.1 %) treat dural tears by a combination of methods, 28 (25.7 %) with suture alone, 7 (6.4 %) with fibrin-coated fleeces alone, 2 (1.8 %) with muscle patch alone and 1 (0.9 %) with fibrin glue alone. Sixty-six neurosurgical departments (60.5 %) decide on postoperative bed rest depending on the quality of the dural closure. Forty-three (39.5 %) neurosurgical departments do not rely on the quality of the dural closure for their postoperative management. In total, 72.5 % of the neurosurgical departments prescribe bed rest for 1-3 days, 1.8 % for more than 3 days, whereas 25.7 % allow immediate mobilization.

CONCLUSIONS

Among German neurosurgeons, no consensus exists concerning the intra- and postoperative management of accidental durotomies in lumbar spine surgery. Despite not being proved to reduce the rate of cerebrospinal fluid fistulas, bed rest is frequently used. As bed rest prolongs the hospital stay with additional costs and has the potential of a higher rate of medical complications, a prospective multicenter trial is warranted.

Improving access to emergent spinal care through knowledge translation: an ethnographic study

Background

For patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery.

Methods

An ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario’s call centre.

Results

Several themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation.

Conclusions

Our findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts.

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients

BACKGROUND

Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization.

METHODS

Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures.

RESULTS

Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed.

CONCLUSION

A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes

Background:

Delay in surgical treatment is a source of distress to patients and an important reason for poor outcome. We studied the delay before carrying out scheduled operative orthopaedic procedures and the factors responsible for it.

Materials and Methods:

This prospective study was carried out between March 2011 and December 2012. Temporal details of the surgical procedures at our hospital were recorded in a proforma including the patients’ perception of the causes of the delay to surgery. Based on the urgency of the need for surgery, patients were classified into three groups using a modification of the method employed by Lankester et al. Data was analyzed using the Statistical Package for the Social Sciences, version 17.0. Predictors of surgical delay beyond 3 days were identified by logistic regression analysis.

Results:

Two hundred and forty-nine patients with a mean age 36.2 ± 19.2 years and M:F ratio 1.3 were recruited. 34.1% were modified Lankester group A, 45.4% group B and 20.5% group C. 47 patients (18.9%) had comorbidities, hypertension being the commonest (22 patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6 days). Fifty percent of emergency room admissions were operated on within 3 days, the figure was 13% for other admissions. Lack of theatre slot was the commonest cause of delay. There was full concordance between doctors and patients in only 70.7% regarding the causes of the delay. In 15.7%, there was complete discordance. Logistic regression analysis confirmed modified Lankester groups B and C (P = 0.003) and weekend admission (P = 0.016) as significant predictors of delay to surgery of >3 days.

Conclusion:

Promptness to operative surgical care falls short of the ideal. Theatre inefficiency is a major cause of delay in treating surgical patients in our environment. Theatre facilities should be expanded and made more efficient. There is a need for better communication between surgeons and patients about delays in surgical treatment.

Complications in acute phase hospitalization of traumatic spinal cord injury: does surgical timing matter?

BACKGROUND

Optimal timing of surgery after a traumatic spinal cord injury (SCI) is one of the most controversial subjects in spine surgery. We assessed the relationship between surgical timing and the occurrence of nonneurologic postoperative complications during acute hospital stay for patients with a traumatic SCI.

METHODS

A retrospective cohort study was performed in a single institution. Four hundred thirty-one cases of traumatic SCI were reviewed, and postoperative complications were recorded from the medical charts. Patients were compared using two different surgical timing cutoffs (24 hours and 72 hours). Logistic regression analyses were modeled for complication occurrence. The effect of surgical timing on complication rate was adjusted for potential confounding variables such as the level of injury, American Spinal Injury Association (ASIA) grade, Injury Severity Score (ISS), age, sex, Charlson Comorbidity Index, and Surgical Invasiveness Index.

RESULTS

Patients operated on earlier were younger, had less comorbidity, had a higher ISS, and were more likely to have a cervical lesion and a complete injury (ASIA A). A reduction in the global rate of complications as well as in the rate of pneumonias and pressure ulcers were predicted by surgery performed earlier than 72 hours and 24 hours. Increasing age, more severe ASIA grade, and cervical lesion as well as increased Charlson Comorbidity Index, ISS, and SII were also statistically related to the occurrence of complications.

CONCLUSION

This study showed that a shorter surgical delay after a traumatic SCI decreases the rate of complications during the acute phase hospitalization. We suggest that patients with traumatic SCI should be promptly operated on earlier than 24 hours following the injury to reduce complications while optimizing neurologic recovery. If medical or practical reasons preclude timing less than 24 hours, efforts should still be made to perform surgery earlier than 72 hours following the SCI.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic/care management study, level IV.

Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases

STUDY DESIGN

A retrospective study of intradural extramedullary schwannoma.

OBJECTIVE

The purpose of this study was to compare treatment results in the differential surgery of intradural extramedullary schwannoma.

BACKGROUND

A reference guide to the surgical procedures available to treat intradural extramedullary schwannoma has not yet been established.

METHODS

The study retrospectively reviewed 110 patients: Group A: laminectomy+microscopic excision; Group B: hemilaminectomy+microscopic excision; Group C: laminectomy+microscopic excision+pedicle screw fixation. Researchers selected patients for this retrospective review by applying the following criteria: 1) back pain spread out from the tumor level, sensory and motor loss; 2) treatment by surgery; 3) clinical diagnosis made by physical examination, magnetic resonance imaging (MRI), and pathology; 4) a minimum clinical and radiologic follow-up of 12 months. The clinical outcomes were assessed by comparing the Visual Analogue Pain Scores (VAS) and the Japanese Orthopedic Association Scores (JOA score). The study also performed a cost-effectiveness analysis.

RESULTS

Cervical vertebrae: The estimated blood loss in Group B was significantly less than in Group C (P<0.05) (Table 1). Thoracic vertebrae: The duration of hospital stay and estimated blood loss in Group A was significantly less than in Group C (P<0.05) (Table 2, 3). Lumbar vertebrae: The resection rate in Group C was significantly higher than in Group A and Group B (P<0.05) (Table 4). Treatment in Group B was the least expensive, and therefore, the most cost-effective.

CONCLUSION

In the case of appropriate surgical indications, the study suggests that hemilaminectomy+microscopic excision is advantageous in the removal of cervical schwannoma, and that laminectomy+microscopic excision is advantageous in the removal of thoracic schwannoma; lumbar intradural extramedullary schwannoma can be managed by laminectomy+microscopic excision+pedicle screw fixation.

The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study

BACKGROUND

In contrast to the established principles of "damage-control orthopedics" for temporary external fixation of long bone or pelvic fractures, the "ideal" timing and modality of fixation of unstable spine fractures in severely injured patients remains controversial.

METHODS

A prospective cohort study was designed to evaluate the safety and efficacy of a standardized "spine damage-control" (SDC) protocol for the acute management of unstable thoracic and lumbar spine fractures in severely injured patients. A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and Injury Severity Score (ISS) of greater than 15 were prospectively enrolled in this study from October 1, 2008, to December 31, 2011. Acute posterior spinal fixation within 24 hours was performed in 42 patients (SDC group), and 70 patients underwent definitive operative spine fixation in a delayed fashion ("delayed surgery"[DS] group). Both cohorts were prospectively analyzed for baseline demographics, length of operative time, amount of intraoperative blood loss, total hospital length of stay, number of ventilator-dependent days, and incidence of early postoperative complications.

RESULTS

The mean time to initial spine fixation was significantly decreased in the SDC group (8.9 [1.7] hours vs. 98.7 [22.4] hours, p < 0.01). The SDC cohort had a reduced mean length of operative time (2.4 [0.7] hours vs. 3.9 [1.3] hours), length of hospital stay (14.1 [2.9] days vs. 32.6 [7.8] days), and number of ventilator-dependent days (2.2 [1.5] days vs. 9.1 [2.4] days), compared with the DS group (p < 0.05). Furthermore, the complication rate was decreased in the SDC group with regard to wound complications (2.4% vs. 7.1%), urinary tract infections (4.8% vs. 21.4%), pulmonary complications (14.3% vs. 25.7%), and pressure sores (2.4% vs. 8.6%), compared with the DS cohort (p < 0.05).

CONCLUSION

A standardized SDC protocol represents a safe and efficient treatment strategy for severely injured patients with associated unstable thoracic or lumbar fractures.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Does timing of surgery affect hospitalization costs and length of stay for acute care following a traumatic spinal cord injury?

Although there is a trend toward performing early surgery for traumatic spinal cord injury (SCI), it remains unclear whether this tendency leads to decreased costs and length of stay (LOS) for acute care. This study determined the impact of surgical timing on costs and LOS after a traumatic SCI. A total of 477 consecutive patients sustaining an acute traumatic SCI and receiving surgery at a level I trauma center were included. A general linear model was used to assess the relationship among costs, LOS, and surgical delay, while accounting for various sociodemographic and clinical covariables. The analysis was also repeated with surgical delay dichotomized within 24 h or later after the trauma. Mean costs and LOS for all patients were respectively 24,156 ± 17,244 $CAD and 35.0 ± 39.4 days. The costs of acute care hospitalization were related to the surgical delay between the trauma and the surgery, in addition to age, injury severity score (ISS), American Spinal Injury Association (ASIA) grade, and neurological level. LOS was associated with the surgical delay dichotomized into two groups (<24 vs. ≥24 h), as well as with age, ISS, ASIA grade, and neurological level. This study suggests that resource utilization in terms of costs and LOS for the acute hospitalization is decreased with early surgery after an acute traumatic SCI, particularly if the procedure is performed within 24 h following the trauma. Performing the surgery as early as possible when the patient is cleared for surgery could lower the financial burden on the healthcare system, while optimizing the neurological recovery.

Prolonged bed rest as adjuvant therapy after complex reconstructive spine surgery

BACKGROUND

The benefits of postoperative mobilization include decreased incidence of pulmonary complications, pressure ulcers, and progression of deep vein thrombosis. However, the complexity of certain spinal reconstructions and the patient's physiologic condition may preclude the possibility of early mobilization. Prolonged bed rest after spine surgery is controversial.

QUESTIONS/PURPOSES

We evaluated the efficacy of prolonged bed rest after complex spine surgery to determine (1) patient characteristics that led to prescribing bed rest, (2) clinical and radiographic outcomes, (3) complications, and (4) estimated direct costs.

METHODS

We retrospectively reviewed all 11 patients (median age, 50 years) who underwent complex spine surgery followed by prolonged bed rest between 2005 and 2010. All patients were deemed at high risk for developing pseudarthrosis or instrumentation failure without postoperative bed rest. One patient died of complications related to pulmonary tuberculosis at 4 months. The patients averaged 3 months of bed rest. Minimum followup was 24 months (median, 30 months; range, 4-52 months).

RESULTS

All patients had (1) tenuous or limited fixation after correction of severe deformity, (2) previously failed spine reconstruction after early mobilization, or (3) limited treatment options if failure occurred again. No patient experienced pseudarthrosis, failure of instrumentation, thromboembolic disease, pressure ulcers, or pneumonia. One patient had a delayed union and one developed late urosepsis. The median cost of skilled nursing facilities during the period of bed rest was $16,702, while the median cost of home health nursing was $5712.

CONCLUSIONS

For patients with contraindications to early postoperative mobilization, prolonged bed rest may be useful to minimize the risk of complications that can occur with mobilization.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.