Does Optimal Timing for Spine Fracture Fixation Exist?

Abstract

ObjectiveTo evaluate the effect of timing of spine fracture fixation on outcome in multiply injured patients. Summary Background DataThere is little consensus regarding the optimal timing of spine fracture fixation after blunt trauma. Potential advantages of early fixation include earlier patient mobilization and fewer septic complications; disadvantages include compounded complications from associated injuries and inconvenience of surgical scheduling. MethodsPatients with spine fractures from blunt trauma admitted to an urban level 1 trauma center during a 42-month period who required surgical spine fracture fixation were identified from the registry. Patients were analyzed according to timing of fixation, level of spine injury, and impact of associated injuries (measured by injury severity score). Early fixation was defined as within 3 days of injury, and late fixation was after 3 days. Outcomes analyzed were intensive care unit and hospital stay, ventilator days, pneumonia, survival, and hospital charges. ResultsTwo hundred ninety-one patients had spine fracture fixation, 142 (49%) early and 149 (51%) late. Patients were clinically similar relative to age, admission blood pressure, injury severity score, and chest abbreviated injury scale score. The intensive care unit stay was shorter for patients with early fixation. The incidence of pneumonia was lower for patients with early fixation. Charges were lower for patients with early fixation. Patients were stratified by level of spine injury. There were 163 cervical (83 early, 80 late), 79 thoracic (30 early, 49 late), and 49 lumbar fractures (29 early, 20 late). There were no differences in injury severity between early and late groups for each fracture site. The most striking differences occurred in the thoracic fracture group. Early fixation was associated with a lower incidence of pneumonia, a shorter intensive care unit stay, fewer ventilator days, and lower charges. High-risk patients had lower pneumonia rates and less hospital resource utilization with early fixation.

Percutaneous pedicle screw fixation in polytrauma patients

“…These data were confirmed in Croce group study [5]. Croce data underline as an early spine fixation at every level, is associated to a lower incidence of venous thrombosis, distress respiratory syndrome and H-LOS [5]. Schlegel showed as a delayed treatment after 72 h from trauma is associated to an increased pneumonia incidence risk till to 12.2 time, 4.8 time pressure sores onset risk, 3.2 time urinary tract infection risk of this of early fixation patients [10].…”

“…The better outcome was seen in patients with thoracic trauma or in presence of a neurological involvement [11]. These data were confirmed in Croce group study [5]. Croce data underline as an early spine fixation at every level, is associated to a lower incidence of venous thrombosis, distress respiratory syndrome and H-LOS [5].…”

“…These, conditions make the decision about timing and type of surgical treatment very difficult. Several studies clearly questioning the prevalent philosophy according to which ''the patients is too sick to operate on'', and underline as an early spine fixation, especially in polytrauma patients presents great advantages in non neurologic outcome [5,11,13]. Kerwin et al [11] describes one of the major case series with 229 polytrauma patients, underwent early spine fixation within 72 h. The clinical outcome of these patients compared to this of patients underwent delayed treatment, showed a briefer ICU and H-LOS, a lower incidence of pneumonia and generally of respiratory complications.…”

“…At the beginning only the positive effect on neurologic outcome has been extensively demonstrated [3,4]. Despite this increasing interest, few studies have debated the positive role of early spine fixation in non neurologic outcome [5][6][7]. Schlegel was the first to identify 72 h as the turning point between early and delayed spine stabilization.…”

“…Later, several studies demonstrated that an early spinal fixation was associated with a significant reduction in intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), incidence of pneumonia, reduced pain induced by spinal column instability and hospital charges, also for patients with an injury severity score of (ISS) [25 [6][7][8][9][10]. The greater advantages were seen in patients with thoracic spine injuries and associated thoracic trauma, in which an early fixation results both in the reduction of ICU and H-LOS as in the reduction of ventilations days and incidence of respiratory complications [5]. Timing of spinal fixation is crucial for a faster mobilization of patients to provide appropriate critical care, physical therapy, pulmonary toilet, and rehabilitation [11].…”