Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis

Abstract

BACKGROUND:Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS:Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS:Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%,p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION:In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures.

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis

“…Still, recent studies have challenged the role of TBI as a historical contraindication for SSRF, showing the potential benefit of chest wall stabilization in patients with TBI. 15,16,41 Namely, Prins et al reported that in patients with multiple rib fractures and TBI, SSRF was associated with decreased 30-day mortality and lower rates of pneumonia compared with nonoperative treatment. 15 However, while the timing of other surgical procedures in TBI patients has already been investigated-in patients with concurrent TBI and major orthopedic fractures Giannoudis et al 42 recommend early stabilization, as long as hypotension is avoided-no study has investigated the impact of timing to SSRF in this select patient population.…”

“…3 Patients with concomitant TBI and severe chest injury have prolonged lengths of stay in the ICU, an increased need for mechanical ventilation, 1,11 and a greater risk of pneumonia and mortality. 12,13 While flail chest remains the main indication for operative rib fixation, several recent studies have shown that SSRF could be beneficial in non-flail chest injury patterns, 10 in patients with associated pulmonary contusion, 14 and in patients with concomitant TBI, 15,16 expanding the indication of this surgical practice. Among all patients requiring SSRF, early operative fixation has been associated with decreased hospital LOS, ICU LOS, and duration of mechanical ventilation; [17][18][19][20][21] and current clinical guidelines [22][23][24] promote the operative management of chest wall injuries within the first 72 hours after admission.…”