Timing of surgery in thoracolumbar trauma: is early intervention safe?

Percutaneous Treatment of Traumatic A3 Burst Fractures of the Thoracolumbar Junction Without Neurological Impairment: The Role of Timing and Characteristics of Fragment Blocks on Ligamentotaxis Efficiency

Background: This study aims to evaluate how surgical timing and the radiological characteristics of fragment blocks can affect the effectiveness of ligamentotaxis, in restoring the spinal canal area, and local kyphosis in adults with traumatic thoracolumbar A3 burst fractures without neurological impairment treated with percutaneous short-segment fixation. Methods: A retrospective observational study was conducted between January 2016 and December 2022 on neurologically intact adult patients with a single A3 thoracolumbar fracture. Data collected included demographics, injury mechanism, fracture level, and clinical and surgical details. Radiological assessments included spinal canal area, local kyphotic angle, anterior and posterior vertebral heights, and fragment block measurements. Results: Out of 101 treated patients, 9 met the criteria with a mean age of 52.22 years. Most fractures were at L1 (88.89%). All patients had moderate-to-severe pain (NRS 6.22 ± 1.09) at baseline. Five patients (55.55%) underwent surgery within 72 h, with a mean surgical time of 109.22 min. SCA and LKA values improved significantly in all patients post-surgery. Early surgical intervention (<72 h) correlated with greater improvements in spinal canal area (p = 0.016) and local kyphotic angle (p = 0.004). A significant association was found between spinal canal area improvement and the percentage ratio of fragment height to "normal" vertebral height (rho = 0.682; p = 0.043). Conclusions: Early (<72 h) short-segment percutaneous fixation is recommended for adults with high functional demands and moderate-to-severe axial pain due to single traumatic A3N0M0 thoracolumbar fracture. This "upfront" approach is associated with enhanced indirect decompression and better local kyphotic angle restoration. Considering the fragment morphology could also be important in surgical planning.

Analysis of factors influencing the surgical treatment outcomes of spinal injuries in polytrauma patients

Background

This study aims to analyze the diagnosis and treatment conditions of polytrauma patients with spinal injuries, to clarify the site of the first surgical intervention, the timing of the surgery, and factors influencing prognosis.

Methods

This study collected and analyzed data on polytrauma patients with spinal injuries who were treated from January 2017 to January 2023. Data collected primarily included basic patient information, treatment strategy-related information, clinical scoring systems, imaging parameters, and prognosis. The impacts of relevant variables on postoperative survival outcomes were analyzed.

Results

This study included 60 patients. There was no significant change in the number of patients rated ASIA grade E after 90 days of admission, while there was a significant increase in those rated grade D (P<0.001). Among the groups, patients operated on within less than 12 h had the highest number of ASIA grade A, while those operated on after more than 48 h had the highest number of ASIA grade E (P=0.003). The survival rate of patients who underwent their first spinal surgery between 12 and 48 h was significantly better than those operated earlier than 12 h or later than 48 h (P=0.047). Patients who experienced hemorrhagic shock postsurgery had the lowest survival rate (P<0.001). Only age (P=0.004) and the number of surgeries outside the spine (P=0.033), as covariates, were significantly correlated with patient mortality (R2=0.519).

Conclusions

Performing spinal surgery too early or too late can adversely affect patient outcomes; the appropriate timing of surgery should be chosen based on the specific characteristics of the patient. In polytrauma patients under emergency conditions, the use of combined surgical treatments should be minimized to prevent the occurrence of a 'second hit'. Patients who experience hemorrhagic shock have the worst postsurgical survival; targeted treatment should be administered upon hospital admission.

Risk Factors for Postoperative Complications After Surgical Treatment of Type B and C Injuries of the Thoracolumbar Spine

BACKGROUND

Unstable thoracolumbar spinal injuries benefit from surgical fixation. However, perioperative complications significantly affect outcomes in surgicallytreated spine patients. We evaluated associations between risk factors and postoperative complications in patients surgically treated for thoracolumbar spine fractures.

METHODS

We conducted a retrospective multicenter study collating data from 21 spine centers across 9 countries on the treatment of AOSpine types B and C injuries of the thoracolumbar spine treated via a posterior approach. Comparative analysis was performed between patients with postoperative complications and those without. Univariate and multivariable analyses were performed.

RESULTS

Among 535 patients, at least 1 complication occurred in 43%. The most common surgical complication was surgical-site infection (6.9%), while the most common medical complication was urinary tract infection (13.8%). Among 136 patients with American Spinal Injury Association (ASIA) Impairment Scalelevel A disability, 77.9% experienced at least 1 complication. The rate of complications also rose sharply among patients waiting >3 days for surgery (P<0.001), peaking at 68.4% among patients waiting ≥30 days. On multivariable analysis, significant predictors of complications were surgery at a governmental hospital (odds ratio = 3.38, 95% confidence interval = 1.73-6.60), having ≥1 comorbid illness (2.44, 1.61-3.70), surgery delayed due to health instability (2.56, 1.50-4.37), and ASIA Impairment Scalelevel A (3.36, 1.78-6.35), while absence of impairment (0.39, 0.22-0.71), ASIAlevel E (0.39, 0.22-0.67) and, unexpectedly, delay caused by operating room unavailability (0.60, 0.36-0.99) were protective.

CONCLUSIONS

Types B and C thoracolumbar spine injuries are associated with a high risk of postoperative complications, especially common at governmental hospitals, and among patients with comorbidity, health instability, longer delays to surgery, and worse preoperative neurologic status.

Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania

OBJECTIVE

The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings.

METHODS

This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated.

RESULTS

Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively.

CONCLUSIONS

Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.

Risk factors for thirty-day morbidity and mortality after spinal trauma

BACKGROUND

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined.

METHODS

Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed.

RESULTS

The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay.

CONCLUSION

Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

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.

Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries

OBJECTIVE

We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs.

METHODS

A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages.

INCLUSION CRITERIA

published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods.

RESULTS

Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44-2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27-4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140).

CONCLUSIONS

Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.

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.

The Impact of the Affordable Care Act on Outpatient Spine Trauma Consult Follow-up

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to assess the impact of the Affordable Care Act (ACA) on spine trauma patient follow-up.

SUMMARY OF BACKGROUND DATA

Although damage to the spinal column accounts for a small proportion of all traumatic injuries, it results in a significant burden on the patient, provider, and health care system. Postoperative follow-up is essential to direct rehabilitation, prevent early deterioration, and manage complications early in the postoperative period. Previous studies have established the role of insurance coverage on follow-up compliance, however, the impact of the ACA on follow-up has been scant.

MATERIALS AND METHODS

A retrospective cohort study was performed upon institutional review board approval of spine trauma patients consulted by orthopedic spine or neurosurgery from January 2013 to December 2013 (pre-ACA) and January 2015 to December 2015 (post-ACA). Patient demographics, surgical case characteristics, and follow-up compliance were assessed via manual chart review. Multivariate regression analysis was used to identify predictors of follow-up in the overall cohort, as well as within nonoperative and operative patients.

RESULTS

A total of 827 patients were included in the final analysis after inclusion and exclusion criteria. Overall, patient follow-up significantly increased after implementation of the ACA (P<0.001), with pre-ACA follow-up at 35.0% (144/411) and post-ACA follow-up at 50.0% (208/516). Multivariate regression analysis further corroborated these findings, showing post-ACA status associated with a 1.66-fold higher likelihood of follow-up. Among nonoperative patients, the ACA failed to make a significant difference in follow-up (P=0.56), however, patients treated operatively showed a significantly higher likelihood of follow-up (odds ratio=2.92, P<0.001).

CONCLUSIONS

Postoperative follow-up is an essential part of patient care, aiding in improving clinical outcomes and limiting the economic burden on the health care system. This study suggests that passage of the ACA significantly improved patient follow-up for operatively managed patients but not for nonoperatively managed patients.

LEVEL OF EVIDENCE

Level III.

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients with TSCI can suffer further secondary damage and experience escalating disability and complications. It is important to quickly assess the patient to identify the location and severity of injury to make a decision to pursue a surgical and/or conservative management. However, there are many conditions that factor into the management of TSCI patients, ranging from the initial presentation of the patient to long-term care for optimal recovery. Here, we provide a comprehensive review of the etiologies of spinal cord injury and the complications that may arise, and present an algorithm to aid in the management of TSCI.

Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury

STUDY DESIGN

Large multicenter retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury.

SUMMARY OF BACKGROUND DATA

Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury.

MATERIALS AND METHODS

We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities.

RESULTS

Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001).

CONCLUSIONS

Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization.

LEVEL OF EVIDENCE

Level III.

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.

Instrumentation Removal following Minimally Invasive Posterior Percutaneous Pedicle Screw-Rod Stabilization (PercStab) of Thoracolumbar Fractures Is Not Always Required

BACKGROUND

Percutaneous stabilization for spinal trauma confers less blood loss, reduces postoperative pain, and is less invasive than open stabilization and fusion. The current standard of care includes instrumentation removal.

OBJECTIVE

1. Reporting patient outcomes following minimally invasive posterior percutaneous pedicle screw-rod stabilization (PercStab). 2. Evaluating the results of instrumentation retention.

METHODS

A prospective observational study of 32 consecutive patients receiving PercStab without direct decompression or fusion. Baseline data demographics were collected. Operative outcomes of interest were operative room (OR) time, blood loss, and length of hospital stay. Follow-up variables of interest included patient satisfaction, Numeric Rating Scales for Back and Leg (NRS-B/L) pain, Oswestry Disability Index (ODI), and return to work. Clinical outcome data (ODI and NRS-B/L) were collected at 3, 12, 24 months and continued at a 24-month interval up to a maximum of 8 years postoperatively.

RESULTS

81.25% of patients (n = 26) retained their instrumentation and reported minimal disability, mild pain, and satisfaction with their surgery and returned to work (mean = 6 months). Six patients required instrumentation removal due to prominence of the instrumentation or screw loosening, causing discomfort/pain. Instrumentation removal patients reported moderate back and leg pain until removal occurred; after removal, they reported minimal disability and mild pain. Neither instrumentation removal nor retention resulted in complications or further surgical intervention.

CONCLUSIONS

PercStab without instrumentation removal provided high patient satisfaction, mild pain, and minimal disability and relieved the patient from the burden of finances and resources allocation of a second surgery.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

Spinal Injury Without Neurological Symptoms in Severely Injured Patients: Impact on the Length of Stay?

BACKGROUND

The impact of spinal injuries on clinical outcome in most severely injured patients is currently being controversially discussed. At the same time, most of the studies examine patients with post-traumatic neurological disorders. The aim of this study was therefore to analyse severely injured patients with spinal injuries but without neurological symptoms with regard to their clinical outcome. Here the focus was then on the question, whether spinal injury is an independent risk factor increasing length of stay in the intensive care unit and in the hospital in total.

MATERIAL AND METHODS

Data of the TraumaRegister DGU^® were retrospectively analysed. Inclusion criteria were: Injury Severity Score ≥ 16, primary admission, age ≥ 16 years, time interval 2009 - 2016, and a full data set on length of stay in the hospital and the intensive care unit, respectively. Following a univariate analysis in the first step, independent risk factors for the length of stay in the intensive care unit and in the hospital in total were investigated using a multivariate regression analysis.

RESULTS

98,240 patients met the inclusion criteria. In this population, patients with Abbreviated Injury Scale (AIS) 2 and 3 spinal injuries were significantly younger (up to 60 years), and injuries were significantly more commonly caused by falls from a great height and traffic accidents (age ≤ 60 years: AIS_Spine 0: 58.4%, AIS_Spine 3: 65%; p < 0.001). Multivariate analysis showed that spinal injury without neurological symptoms is an independent risk factor for increased length of stay in the intensive care unit (odds ratio: + 1.1 d) and in the hospital in total (AIS 3 odds ratio: + 3.4 d).

CONCLUSION

It has been shown for the first time that spinal injury without initial neurological symptoms has a negative impact on the length of stay of most severely injured patients in the intensive care unit and in the hospital in total and thus represents an independent risk factor in this group of patients.

Surgical management of spine injuries in severe polytrauma patients: a retrospective study

Background: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

Precautions for Combined Anterior and Posterior Long-Level Fusion for Adult Spinal Deformity: Perioperative Surgical Complications Related to the Anterior Procedure (Oblique Lumbar Interbody Fusion)

Study Design

Retrospective, single-center study.

Purpose

We aimed to determine the perioperative complications of oblique lumbar interbody fusion (OLIF) as a first-stage procedure in combined anterior and posterior operation for adult spinal deformity (ASD) along with sagittal imbalance. Specifically, we aimed to identify the radiological and clinical types of perioperative surgical complications and the factors affecting these complications.

Overview of Literature

OLIF has recently gained popularity, and there are several reports of good outcomes and only a few of complications with OLIF; however, a few studies have focused on the perioperative surgical complications of ASD along with sagittal imbalance.

Methods

The perioperative period was a 1-week interval between the anterior and posterior procedures. All patients underwent simple radiography and magnetic resonance imaging preoperatively and postoperatively. Cage placement was evaluated for displacement (i.e., subsidence and migration) and vertebral body fracture. Clinical patient complaints were evaluated perioperatively. Student t-test was used for data analysis.

Results

A total of 46 patients were included, totaling 138 fusion segments. A week after OLIF, 14 patients/33 segments (30.4%/23.9%) demonstrated endplate injury-associated cage placement change. Subsidence was the most common cage placement-related complication. As compared with patients without endplate injury, those with endplate injuries showed significantly larger correction angles and a higher proportion of them had larger height cages than the disk height in the full-extension lateral view. Although 32.6% of the patients experienced perioperative clinical complications, they were relatively minor and transient. The most common complication was severe postoperative pain (Visual Analog Scale score of >7), and hip flexor weakness spontaneously resolved within 1 week.

Conclusions

OLIF yielded more than expected endplate injuries from treatment modalities for ASD along with sagittal imbalance. Therefore, surgeons should be cautious about endplate injury during OLIF procedures. It is difficult to accomplish lordosis correction via OLIF alone; therefore, surgeons should not attempt this impractical correction goal and insert an immoderate cage.

Activity of Daily Living After Long Level Fusion in Adult Spinal Deformity: Compared With Over 60-Year-Old Degenerative Spine Patients Without Adult Spinal Deformity

STUDY DESIGN

Prospective single center study.

OBJECTIVE

The aim of this study was to evaluate 1) the activity of daily living (ADL) of three categorized patients group; over 60-year-old degenerative spine patients without adult spinal deformity (ASD), nonoperative ASD patients, and operative ASD patients, 2) what kinds of activities would be impaired, and 3) how the ADL changes over time after long level fusion.

SUMMARY OF BACKGROUND DATA

There is still debate how surgeons could decide treatment methods for old-aged adult spinal deformity, operatively or not. There was lack of information how long level fusion impacts daily activities, especially sedentary Asian lifestyle. In Asia, impaired ADL is much more important issue because of different lifestyle.

METHODS

Patients were categorized into three groups; Group 1 was over 60-year old aged degenerative spine disease without deformity, Group 2 was ASD patients who did not have surgery, and Group 3 was ASD patients who had surgery for deformity correction. Patients were evaluated using answer Oswestry Low Back Pain Disability Questionnaire, and Assessment activities of daily living for sedentary Asian culture (ADL-SA) questionnaire.

RESULTS

Group 1 showed nearly full functions in every activity (ADL-SA: 41.4). ADL-SA scores of Group 2 were similar to Group 1 (P = 0.452). However, get up from bottom (P < 0.001), and pick up object (P < 0.001) were impaired. After long level fusion, ADL was impaired but gradually improved by time. From postoperative 1 year, total ADL score recovered to acceptable range. However, among ADL, activities associated sedentary lifestyle (get up from bottom, wipe floor, pick up object, and sit cross-legged) were still impaired after 2 years postoperatively.

CONCLUSION

ADL was impaired after long level fusion; however it would improve as time goes by. However, among ADL, activities associated sedentary lifestyle was still impaired. Hence give enough information to patients about limited activities before deciding operation.

LEVEL OF EVIDENCE

3.

Early (≤48 Hours) versus Late (>48 Hours) Surgery in Spinal Cord Injury: Treatment Outcomes and Risk Factors for Spinal Cord Injury

OBJECTIVES

Surgical management of spinal cord injury (SCI) is challenging. There is no standard guideline regarding the timing of surgery, although physicians have prioritized early surgery over the past decades. Although better outcomes have been observed from these studies, the definition of early surgery has been controversial, although mostly limited to 24-hours after injury. For some hospitals, this early surgery could be difficult to implement in practice. Hence, we re-evaluated the timing of early surgery as surgery within 48 hours and investigated the surgical outcomes of SCI depending on whether surgery was performed early (≤48 hours) or late (>48 hours). The primary outcomes were improvement in the American Spinal Injury Association Impairment Scale (AIS) grade in early and late surgery groups.

METHODS

This study was a retrospective cohort study in individuals aged 15-85 years, who underwent surgery for SCI between 2005 and 2016. The rate of AIS grade improvements was measured at 6 months after injury. Of the 86 enrolled patients, 31 (mean, 40.9 ± 12.64 hours) and 55 (mean, 168.25 ± 93.01 hours) patients were assigned to the early and late surgery groups, respectively.

RESULTS

AIS grade improvement was significantly greater in the early than in the late group (P = 0.039). In the early group, there was no significant difference in neurologic improvements among the AIS B, C, and D groups, but the AIS A group showed a significant improvement (P = 0.015). This finding was not observed in the late group (P = 0.060). AIS grade improvement was also significantly greater in the incomplete SCI group than in the complete SCI group, for all measurements (early, P = 0.007, late, P = 0.009). Other factors that significantly affected clinical outcomes were AIS grade on admission and the level of the injury.

Acute and Hyper-acute Thoracolumbar Corpectomy for Traumatic Burst Fractures Using a Mini-open Lateral Approach

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

The purpose of this study was to examine the feasibility of acute (<24 hours) and hyperacute (<8 hours) treatment of thoracolumbar burst fractures to maintain or improve spinal injury scores.

SUMMARY OF BACKGROUND DATA

Historically, treatment of spinal burst fractures within 24 hours from injury was considered an "acute" treatment timeframe. Patient polytrauma triage, multiple surgical specialty, and hospital resource coordination affect time to treatment. The mini-open lateral approach for thoracolumbar corpectomy obviates the need for an approach surgeon, which may allow for early surgical intervention.

METHODS

Sixteen patients treated within 24 hours with a mini-open lateral corpectomy for traumatic spinal pathology were reviewed for preoperative, perioperative, and postoperative data. Neurologic status was assessed using American Spinal Injury Association (ASIA) scores. Fractures occurred primarily from L1 to L3. Wide-footprint expandable titanium devices were used in 75% of patients. All patients received supplemental fixation.

RESULTS

Average time from injury to admission to the hospital (emergency room [ER]) was 1.8 hours, with an average time from the ER to operating room (OR) of 8.2 hours and an average OR time of 2.7 hours. Eight patients required ≤8 hours from injury event to surgical initiation, whereas seven patients required between 8 and 24 hours for surgery initiation (one patient with incomplete surgical timing record). Blood loss averaged 646 mL without intraoperative complication. One perioperative complication occurred and one patient developed an asymptomatic inferior vertebral body fracture. Length of hospital stay averaged 6 days. At last follow-up, nearly all patients experienced full or near-complete neurologic recovery with at least one ASIA grade improvement seen in 73% and 20% of patients improving two grades or more.

CONCLUSION

These results suggest that mini-open lateral approaches allow immediate decompression through hyperacute (<8 hours) treatment of spinal burst fractures in eligible patients. Additionally, low perioperative and postoperative morbidity allows for hastened recovery.

LEVEL OF EVIDENCE

4.

Assessment of variability in Turkish spine surgeons' trauma practices

OBJECTIVES

The aim of this study was to analyse the variability among Turkish spinal surgeons in the management of thoracolumbar fractures by carrying out a web survey.

METHODS

An invitation text and web-link of the survey were sent to the members of the Turkish Spine Society mail group. A fictitious spine trauma vignette, a 23 year-old male with a L1 burst fracture, was presented and 25 questions were asked to participants. Variability of answers in a given question was assessed with the Index of Qualitative Variation (IQV). Questions with high IQV values (>%80) were selected to evaluate the relation between participant factors (speciality, age, degree and experience level of the surgeon, type of the work centre and volume of the trauma patients).

RESULTS

Sixty-four (88%) among the 73 participating surgeons completed the survey. 45 (70%) of them were orthopaedic surgeons and 19 (30%) were neurosurgeons. 11 questions had very high variability (IQV ≥ 0.80), 5 had high variability (0.58-0.75) and 2 had low variability (IQV≤0.20). The question with the highest variability was related to the use of brace after surgery (IQV = 0.93). Following one was about the selection of fixation levels (IQV = 0.91). Neurosurgeons were more likely to use brace postoperatively and professors were less likely to perform decompression.

CONCLUSION

This survey shows that thoracolumbar spine trauma practice significantly varies among Turkish spine surgeons. Surgeons' characteristics affected some specific answers. Lack of enough knowledge about spine trauma care, fracture classifications and surgical techniques and/or ethical factors may be other reasons for this variability.

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.

Risk factors for pulmonary complication following fixation of spine fractures

BACKGROUND CONTEXT

Previous studies have suggested pulmonary complications are common among patients undergoing fixation for traumatic spine fractures. This leads to prolonged hospital stay, worse functional outcomes, and increased economic burden. However, only limited prognostic information exists regarding which patients are at greatest risk for pulmonary complications.

PURPOSE

This study aimed to identify factors predictive of perioperative pulmonary complications in patients undergoing fixation of spine fractures.

STUDY DESIGN/SETTING

A retrospective review in a level 1 trauma center was carried out.

PATIENT SAMPLE

The patient sample comprised 302 patients with spinal fractures who underwent operative fixation.

OUTCOME MEASURES

The outcome measures were postoperative pulmonary complications (physiological and functional measures).

MATERIALS AND METHODS

Demographic and injury features were recorded, including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, mechanism of injury, injury characteristics, and neurologic status. Treatment details, including surgery length, timing, and approach were reviewed. Postoperative pulmonary complications were recorded after a minimum of 6 months' follow-up.

RESULTS

Forty-seven pulmonary complications occurred in 42 patients (14%), including pneumonia (35), adult respiratory distress syndrome (ARDS) (10), and pulmonary embolism (2). Logistic regression found spinal cord injury (SCI) to be most predictive of pulmonary complications (odds ratio [OR]=4.4, 95% confidence interval [CI] 1.9-10.1), followed by severe chest injury (OR 2.7, 95% CI 1.1-6.9), male gender (OR 2.7, 95% CI 1.1-6.8), and ASA classification (OR 2.3, 95% CI 1.4-4.0). Pulmonary complications were associated with significantly longer hospital stays (23.9 vs. 7.7 days, p<.01), stays in the intensive care unit (ICU) (19.9 vs. 3.4 days, p<.01), and increased ventilator times (13.8 days vs. 1.9 days, p<.01).

CONCLUSIONS

Several factors predicted development of pulmonary complications after operative spinal fracture, including SCI, severe chest injury, male gender, and higher ASA classification. Practitioners should be especially vigilant for of postoperative complications and associated injuries following upper-thoracic spine fractures. Future study must focus on appropriate interventions necessary for reducing complications in these high-risk patients.

Outcome Instruments in Spinal Trauma Surgery: A Bibliometric Analysis

Study Design Literature review. Objective To identify outcomes instruments used in spinal trauma surgery over the past decade, their frequency of use, and usage trends. Methods Five top orthopedic journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in spinal trauma that reported patient-reported outcome instruments use or neurologic function scale use. Publication year, level of evidence (LOE), and outcome instruments were collected for each article and analyzed. Results A total of 58 studies were identified. Among them, 26 named outcome instruments and 7 improvised questionnaires were utilized. The visual analog scale (VAS) for pain was used most frequently (43.1%), followed by the Short Form 36 (34.5%), Frankel grade scale (25.9%), Oswestry Disability Index (20.7%) and American Spinal Injury Association Impairment Scale (15.5%). LOE 4 was most common (37.9%), and eight LOE 1 studies were identified (10.3%). Conclusions The VAS pain scale is the most common outcome instrument used in spinal trauma. The scope of this outcome instrument is limited, and it may not be sufficient for discriminating between more and less effective treatments. A wide variety of functional measures are used, reflecting the need for a disease-specific instrument that accurately measures functional limitation in spinal trauma.

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.

Effects of Lumbar Stiffness After Lumbar Fusion Surgery on Activities of Daily Living

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to assess the effects of lumbar stiffness after lumbar fusion surgery on functional limitations, health-related quality of life, and activities of daily living (ADL).

SUMMARY OF BACKGROUND DATA

Postoperative outcomes after fusion surgery are usually assessed using patient-reported instruments to describe disability related to pain and health status. There are few studies on the effects of lumbar stiffness on ADL after lumbar fusion surgery.

METHODS

This study included 93 patients who underwent lumbar fusion surgery for degenerative lumbar disease. Their mean age was 69 years (range 51-79), and the mean follow-up was 34 months (24-46). The patients were categorized into 5 groups according to the number of segments involved: 0 level (decompression), 1 level, 2 levels, 3 levels, and 4 levels. They completed a 21-item questionnaire about their ADL and the Short Form Health Survey 36 (SF-36) to evaluate the effects of lumbar stiffness on ADL after surgery.

RESULTS

There was a linear trend toward a decreased rating in all items in our questionnaire and in the physical component summary in the SF-36 related to postoperative lumbar stiffness. These trends were significantly related to the number of fused segments (P < 0.05 and P < 0.001, respectively). Patient satisfaction did not differ between the groups (P = 0.381). Patients who received a 1- or 2-level fusion reported no serious limitations in most ADL. Patients who received a 3- or 4-level fusion, especially 4-level fusion, reported more limitations because of postoperative lumbar stiffness.

CONCLUSION

This study investigated in detail the effects of lumbar stiffness after fusion surgery on ADL. Spine surgeons should consider the patient's occupation and lifestyle in preoperative planning. These results will help the surgeon explain the possible outcomes to patients planning to undergo fusion surgery.

LEVEL OF EVIDENCE

2.