Early Spinal Stabilization Research Articles

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.

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

Background: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured patients both in general and in respect to spinal injury severity. Methods: A retrospective analysis of multiple-injured patients with an associated spinal trauma within the thoracic or lumbar spine (injury severity score (ISS) >16, age >16 years) was performed from January 2012 to December 2016 in two Level I trauma centres. Demographic data, circumstances of the accident, and ISS, as well as time to spinal surgery were documented. The evaluated outcome parameters were length of stay in the intensive care unit (ICU) (iLOS) and length of stay (LOS) in the hospital, duration of mechanical ventilation, onset of sepsis, and multiple organ dysfunction syndrome (MODS), as well as mortality. Statistical analysis was performed using SPSS. Results: A total of 113 multiple-injured patients with spinal stabilization and a complete dataset were included in the study. Of these, 71 multiple-injured patients (63%) presented with an AOSpine A-type spinal injury, whereas 42 (37%) had an AOSpine B-/C-type spinal injury. Forty-nine multiple-injured patients (43.4%) were surgically treated for their spinal injury within 24 h after trauma, and showed a significantly reduced length of stay in the ICU (7.31 vs. 14.56 days; p < 0.001) and hospital stay (23.85 vs. 33.95 days; p = 0.048), as well as a significantly reduced prevalence of sepsis compared to those surgically treated later than 24 h (3 vs. 7; p = 0.023). These adverse effects were even more pronounced in the case where cutoffs were increased to either 72 h or 96 h. Independent risk factors for a delay in spinal surgery were a higher ISS (p = 0.036), a thoracic spine injury (p = 0.001), an AOSpine A-type spinal injury (p = 0.048), and an intact neurological status (p < 0.001). In multiple-injured patients with AOSpine A-type spinal injuries, an increased time to spinal surgery was only an independent risk factor for an increased LOS; however, in multiple-injured patients with B-/C-type spinal injuries, an increased time to spinal surgery was an independent risk factor for increased iLOS, LOS, and the development of sepsis. Conclusion: Our data support the concept of early spinal stabilization in multiple-injured patients with AOSpine B-/C-type injuries, especially of the thoracic spine. However, in multiple-injured patients with AOSpine A-type injuries, the beneficial impact of early spinal stabilization has been overemphasized in former studies, and the benefit should be weighed out against the risk of patients’ deterioration during early spinal stabilization.

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

OBJECTIVE Few studies have investigated the advantages of early spinal stabilization in the patient with polytrauma in terms of reduction of morbidity and mortality. Previous analyses have shown that early stabilization may reduce ICU stay, with no effect on complication rates. METHODS The authors prospectively observed 340 polytrauma patients with an Injury Severity Score (ISS) of greater than 16 at a single Level 1 trauma center who were treated in accordance with a protocol termed "early appropriate care," which emphasizes operative treatment of various fractures within 36 hours of injury. Of these patients, 46 had upper thoracic and/or cervical spine injuries. The authors retrospectively compared patients treated according to protocol versus those who were not. Continuous variables were compared using independent t-tests and categorical variables using Fisher's exact test. Logistic regression analysis was performed to account for baseline confounding factors. RESULTS Fourteen of 46 patients (30%) did not undergo surgery within 36 hours. These patients were significantly more likely to be older than those in the protocol group (53 vs 38 years, p = 0.008) and have greater body mass index (BMI; 33 vs 27, p = 0.02), and they were less likely to have a spinal cord injury (SCI) (82% did not have an SCI vs 44% in the protocol group, p = 0.04). In terms of outcomes, patients in the protocol-breach group had significantly more total ventilator days (13 vs 6 days, p = 0.02) and total ICU days (16 vs 9 days, p = 0.03). Infection rates were 14% in the protocol-breach group and 3% in the protocol group (p = 0.2) Total complications trended toward being statistically significantly more common in the protocol-breach group (57% vs 31%). After controlling for potential confounding variables by logistic regression (including age, sex, BMI, race, and SCI), total complications were significantly (p < 0.05) greater in the protocol-breach group (OR 29, 95% CI 1.9-1828). This indicates that the odds of developing "any complication" were 29 times greater if treatment was delayed more than 36 hours. CONCLUSIONS Early surgical stabilization in the polytrauma patient with a cervical or upper thoracic spine injury is associated with fewer complications and improved outcomes. Hospitals may consider the benefit of protocols that promote early stabilization in this patient population.

Congenital subaxial cervical subluxation presenting as a bilateral Erb’s palsy: surgical management, rehabilitation, and outcome

Subaxial spine injuries during infancy are uncommon. We present the case of an infant referred to our brachial plexus clinic with proximal weakness of both arms noted immediately following a complicated breech delivery. Nerve conduction studies were consistent with bilateral proximal upper plexus injury; however, radiological evaluation revealed a C4-C5 subluxation and MRI features of bilateral C5 root avulsions. He was immobilized in a cervical-body orthosis and underwent open reduction and posterior C4-C5-C6 fixation at 10weeks age using luque rods, sublaminar wires, and rib graft. The spine was immobilized in a custom molded cervicothoracic brace for a total of 3months, and a home exercise program prescribed. Follow-up radiographic evaluation showed good posterior bony fusion by 2months but persistent bilateral proximal upper limb weakness with reduced compound motor action potential (CMAP) amplitudes of the axillary and musculocutaneous nerves. Bilateral supraclavicular exploration and C5 root neurotization using the ipsilateral C7 nerve roots were performed at 7months of age. Voluntary biceps activity followed by voluntary external rotation with gravity eliminated was noted within the next 2-3months. He progressed to develop near normal motor control of bilateral upper limbs within 1year. We wish to report this rare entity and our favorable outcome using a strategy of early spinal stabilization and neurotization repair to restore function following proximal nerve root injury.

Early Versus Late Stabilization of the Spine in the Polytrauma Patient

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.

Does Early Fracture Fixation of Thoracolumbar Spine Fractures Decrease Morbidity or Mortality?

Systematic Review. To determine whether early spinal stabilization in thoracolumbar spine trauma decreases morbidity and mortality. The role of early spinal stabilization through surgical means may have a number of benefits. These include reduced morbidity and mortality because of more rapid mobilization afforded by spinal column stabilization and a reduction in the incidence and severity of sepsis and respiratory failure. There are several potential disadvantages of early surgery. The most strongly debated is the potential that the additional physiologic injury may result in an unintended increase in morbidity and mortality caused by worsening of existing injuries, such as with pulmonary or intracranial trauma. This problem may be compounded by increased hemorrhage and resulting hypotension. Operating in the presence of missed or underestimated associated injuries or under less-than-ideal conditions relative to the complexity of the surgery and resources required is also a potential disadvantage. A systematic review of the English-language literature was undertaken for articles published between January 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining the timing of thoracolumbar fracture fixation. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria, assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. A total of 68 articles were initially screened, and 9 ultimately met the predetermined inclusion criteria. These studies demonstrated that early stabilization of thoracic fractures reduced the mean number of days on a ventilator, the number of days in intensive care unit and in hospital, and reduced respiratory morbidity compared with late stabilization. This effect, other than the length of hospital stay, was not seen with stabilization of lumbar fractures. There is not enough evidence to determine the effect of the timing of stabilization on mortality in thoracolumbar fractures. Ideally, patients with unstable thoracic fractures should undergo early (<72 hours) stabilization of their injury to reduce morbidity and, possibly, mortality.

The Initial Assessment and Management of the Multiple-Trauma Patient With an Associated Spine Injury

Review and summary of the relevant literature from multiple disciplines. Provide the readership with evidence-based guidelines on the initial assessment and treatment of the multiple-trauma patient with an associated spinal column injury. Early operative stabilization of the isolated spinal column injury has decreased hospital and intensive care unit length of stay. Early intervention has not provided consistently improved neurologic outcomes. The timing of spinal column stabilization in the multiple-trauma patient continues to be a source of discussion. Review of published English literature from 1990 to present using key words: spinal trauma, multiple-trauma with spinal injury; timing of spinal injury treatment; spinal fracture management; and Advanced Trauma Life Support. The treatment of the poly-trauma patient with an associated spinal column injury requires strict adherence to Advanced Trauma Life Support principles. Once life and limb-threatening injuries have been identified and addressed, spinal column assessment and neurologic protection must be maintained at the highest priority. Early spinal stabilization can be performed safely in the multiple-trauma patient in medical centers, in which medical and ancillary staff is available on a 24-hour basis and is familiar with these procedures.

Gorham Disease of the Spine

This is a case report of Gorham disease of the spine with review of the literature. To review the diagnosis, therapy, clinical course, and prognosis of Gorham disease of the spine. This is the 17th reported case of spinal involvement by this rare type of idiopathic osteolysis. The patient was studied with radiographs, nuclear bone scans, computed tomography scans, magnetic resonance scans, and biopsies. His spine was stabilized by posterior and anterior rods, corpectomies, and bone grafts. The patient's spine had remained stable for 22 months after surgery, but intractable chylothoraces and spreading bone destruction were present. Spinal Gorham disease has high morbidity and mortality, but the course in an individual patient is difficult to predict. Early spinal stabilization should be considered before irreversible neurologic complications occur.

Prognosis and treatment of cervical spine injuries with associated head trauma.

Pathological and biomechanical studies indicate that many injuries of the head and neck are to be considered as an entity, because cervical spinal fractures and head injuries are frequently combined. Depending on the localization and severity of the injury to the cervical spine, the incidence of an associated head trauma is reported in the literature as being between 6% and 63%. In 59 patients with cervical spinal fractures hospitalized in our department since 1980, we have examined the influence of head trauma on the prognosis and the management. Forty-three patients had fractures and/or dislocations in the lower cervical spine, and 16 had injuries in the upper region; head injuries were present in 33 (56 percent); minor injuries in 15, moderate and severe injuries in 10. Lesions requiring operation were a depressed skull fracture, extracerebral haematomas and scalp lacerations. Six out of 59 patients died; of these, four had suffered a severe head trauma. As a rule, surgery of the head and immobilization of the spine fracture were carried out as the first step followed by realignment of the spine with possible decompression and stabilization of the affected segment as a second step. Fractures and/or dislocations of the cervical spine are frequently accompanied by head injuries. The severity of associated brain lesions has a marked influence on the prognosis. The correct identification of cervical lesions was delayed in about every second patient with minor head injury but rarely in comatose patients. In patients with altered consciousness an early spinal stabilization may be useful.