Early Versus Late Stabilization of the Spine in the Polytrauma Patient

Abstract

Systematic review. To determine whether early spinal stabilization in the multiple trauma patient is safe and does not increase morbidity or mortality. There is no consensus regarding the timing of surgical stabilization of the injured spine, especially in patients with multiple trauma. Designing and performing randomized clinical trials to evaluate early versus late surgery is difficult. Between January 1990 and July 2009, a computer-aided search using the keywords Spine or Spinal, Trauma, Spinal Cord Injury, and Surgery was done that included MEDLINE, EMBASE, HealthSTAR, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, PsycINFO, and PsychLit. Articles dealing only with neurologic improvement that did not mention other non-neurologic factors that were affected by early surgery were excluded. The authors selected and assessed the studies to be included in the analysis. An unblinded assessment of the quality of the study was done using the Gradeing of Recommendation, Assessment, Development and Evaluation approach to rank each article for its relevance to the topic. Eleven articles directly comparing 2 cohorts that had early or late surgery were identified. All of the studies evaluated consistently demonstrated shorter hospital and intensive care unit length of stays, fewer days on mechanical ventilation, and lower pulmonary complications in patients who are treated with early spine decompression and stabilization. These advantages are more marked in patients with polytrauma. Data regarding morbidity and mortality rates are more variable. There is strong evidence within the literature that early surgical stabilization consistently leads to shorter hospital stays, shorter intensive care unit stays, less days on mechanical ventilation, and lower pulmonary complications. This effect is more evident in patients who have more severe injuries as measured by Injury Severity Score. This benefit is seen in both, spinal cord injured and noncord-injured patients. There is also some evidence that early stabilization does not increase the complication rates compared to late surgery.