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Despite current science unequivocally demonstrating a lack of effectiveness of high-dose methylprednisolone in the acute management of patients with spinal cord injuries, the issue remains a topic of daily debate and uncertainty among the involved care providers in the trauma bay. From a historic perspective, the consideration of high-dose steroids originated from presumed benefits in patients with brain tumors and head injuries in the 1960s and 1970s. After publication of the second “National Acute Spinal Cord Injury Study” (NASCIS-2) in 1990, the application of high-dose methylprednisolone for patients with acute SCI became a globally accepted standard of care for more than a decade.28,29 A critical analysis of the NASCIS data, however, placed the use of high-dose steroids under scrutiny due to questionable benefits and the potential for inflicting unintentional harm, such as placing the patients at increased risk for pulmonary infections.30 The large-scale prospective randomized multicenter “CRASH” trial (Corticosteroid randomization after significant head injury) confirmed the notion of the unjustified experimental nature of high-dose steroids in the acute management of neurological injuries. The CRASH trial was unexpectedly aborted after enrollment of about 10,000 patients, based on the unexpected finding of a drastically increased mortality in patients treated with methylprednisolone, compared to the placebo control group.31 The extrapolation of the negative results from this large-scale trial implied that the uncritical administration of corticosteroids in the 1980s and earlier may have been the cause of preventable post-injury mortality.32 In absence of new prospective randomized trials on the role of steroids in spinal cord injury, current guidelines and clinical recommendations consider the routine use of steroids for patients with acute spinal cord injury obsolete.3,33 A few selected neurological entities, such as spinal contusions or traumatic central cord syndrome (CCS) may allow consideration for a short course of steroids at the individual treating spine surgeon’s discretion.
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Thromboembolic Prophylaxis
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Prophylaxis against venous thromboembolism (VTE) is a crucial consideration in patients with unstable spine fractures and spinal cord injuries. The published literature showed a generally low VTE rate in patients with stable spinal fractures and absence of neurological injuries (<2%). In contrast, a venography-controlled study in patients with acute spinal cord injuries reported deep vein clots in the calf around 80%, and symptomatic VTE has been reported in up to 10% of spinal cord-injured patients.34 All trauma patients with associated spinal injuries should have mechanical prophylaxis instituted as soon as possible with graduated compression stockings and/or sequential compression devices. Pharmacologic prophylaxis with unfractionated heparin or low-molecular-weight heparin (LMWH) should be initiated as soon as the acute risk for additional bleeding in the trauma patient is adequately controlled.35 LMWH appears to be more effective for the VTE prevention and associated with fewer bleeding complications than unfractionated heparin in patients with spine injuries.34 The duration of pharmacologic VTE prophylaxis is determined by the patient’s mobility status and should be typically continued for 2 weeks in patients without neurological injuries, and for 6–12 weeks in presence of spinal cord injury. If patients are poor candidates or have a contraindication to pharmacological VTE prophylaxis due to increased risk of bleeding complications, then the early placement of a removable inferior vena cava (IVC) filter should be strongly considered as an alternative option.35 Low-risk patients, such as an ambulatory patient with an isolated stable A1-type thoracolumbar compression fracture (Fig. 23-3), do not require pharmacologic prophylaxis.35
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Timing of Tracheostomy
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One of the unresolved challenges in the management of ventilator-dependent trauma patients with associated unstable spine fractures and spinal cord injuries consists in defining the ideal timing of conversion to a tracheostomy.36 The conundrum consists of coordinating the timing of early tracheostomy (the intent of which is to reduce the inherent risk of ventilator-associated pneumonia) and the timing of cervical spine fixation (if indicated for the management of unstable cervical injuries). Spine surgeons are generally worried that a preceding tracheostomy may increase the risk of a surgical site infection for a delayed anterior cervical spine fusion (ACDF). This concern appears unjustified based on the existing literature which demonstrates that ACDF surgery is safely performed in presence of a prior tracheostomy, without an increased risk of a postoperative infection. As the dual incisions are typically located several centimeters apart, the tracheostomy wound can be safely draped off during the preparation for the ACDF procedure and does not appear to pose a risk of cross-contamination. In fact, these two procedures can be safely performed during the same operating-room visit under the same anesthetic. At our own institution, the requirement for prolonged mechanical ventilation in patients is discussed as part of the overall surgical plan in the management of patients with spine fractures and spinal cord injuries. Our protocol attempts to coordinate the early timing of tracheostomy with the timing for the spinal fusion. This proactive approach, tailored at decreasing the risk of preventable pulmonary infections and adverse outcomes in a highly vulnerable patient population, requires close cooperation between spine surgeons and the general surgery trauma team.37
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Timing of Spinal Surgery
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Unstable spine fractures, dislocations and fracture-dislocations must be recognized early and treated in a timely fashion. This entails early closed-reduction and application of halo fixators for unstable cervical spine injuries, and the early open-reduction and spinal fixation/fusion for unstable thoracic and lumbar injuries and for irreducible cervical spine dislocations. The example of an institutional protocol for the surgical management of thoracic and lumbar fractures/fracture-dislocations is shown in Fig. 23-11.16
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The widely disseminated practice of internally fixating unstable thoracic and lumbar fractures in polytrauma patients consist of either (1) a conservative approach of “delayed spine fixation” (after full resuscitation), or (2) a more proactive approach of “early total care.” Early total care often includes invasive anterior approaches, vertebral corpectomy, spinal canal decompression, and anterior spinal column stabilization/fusion. Many spine surgeons are discouraged from early spinal surgery based on the notion that multiply injured patients are frequently “too sick” to safely undergo surgical procedures within the first few days after major trauma.38 The problem associated with this conservative philosophy is that these vulnerable patients remain bedridden on log-roll precautions, which precludes from a coherent and proactive management of severe associated injuries to the head, chest, abdomen, and pelvis. In a landmark article, Croce and colleagues performed a retrospective analysis of a prospective database on 291 consecutive patients with unstable spine fractures requiring surgical fixation. Patients were matched for injury severity and stratified by level of spine injury into two distinct cohorts, depending on the timing of fracture fixation: “early” fixation (within 3 days, n=142) versus “late” fixation (>3 days, n=149).39 The authors found that the early fixation of thoracic spine fractures resulted in a lower incidence of pneumonia, fewer ventilator-dependent days, a shorter ICU stay, and reduced hospital charges.39 This notion was confirmed by a systematic review of the published literature by Rutges et al. who provided a comparison between different time-points of surgical stabilization of thoracic or lumbar spine fractures.40 The authors concluded that the early intervention for fracture stabilization in the thoracolumbar spine is safe, advantageous, and associated with a significantly decreased incidence of postoperative complications.40
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However, due to the lack of unequivocal scientific evidence from prospective randomized trials, there is a lack of consensus regarding the “optimal” timing of spine fracture fixation in multiply injured patients.41 Intuitive advantages of early spine fixation relates to preventing complications associated with prolonged bed rest and the inability to adequately position and mobilize severely injured patients in the intensive care unit (ICU). Unequivocally, multiply injured patients require unrestricted options for mobilization and positioning in the ICU, including the upright seated position for treatment of head injuries and the prone position for respiratory therapy of pulmonary complications, such as the acute respiratory distress syndrome. Finally, unstable and unreduced spinal fractures contribute to the “antigenic load” of major trauma by contributing to stress, pain, ongoing bleeding, and systemic release of inflammatory mediators.42,43 This translates into an increased overall trauma burden within the organism and can turn the physiological “host defense response” into a pathological “host defense failure.” These reasons provide a strong argument for the early clearance of bed rest and log-roll precautions in multiply injured patients.10,42 Recent evidence suggest that any unstable thoracic or lumbar spine fracture or dislocation should be reduced and fixated within 24 hours of admission.44,45,46 This notion is particularly applicable in the care of multiply injured patients at risk of sustaining “second hit” insults and post-injury complications, including pressure sores, pulmonary infections and thromboembolic complications.47,48
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A proactive approach of “spine damage control” has been described and validated in the recent literature with the intent of mitigating the risk of adverse outcomes in polytrauma patients with associated unstable thoracic or lumbar spine fractures at risk of adverse outcomes.49,50,51 The concept of “spine damage control” entails a staged procedure of immediate posterior fracture reduction and instrumentation within 24 hours (“day 1 surgery”), followed by scheduled 360° completion corpectomy and fusion during a physiological “time-window of opportunity” (>3 days after trauma).38 Proceeding with the second stage is done if an adjunctive anterior decompression and fusion is indicated for neurological or biomechanical reasons. This concept differs from the more common elective strategy of staged spine fixation by initial posterior fixation and delayed anterior completion in two ways. First, by its timeliness (posterior fixation within 24 hours) and second, by its expanded applicability to all unstable thoracolumbar fractures, including exclusive anterior column burst fractures. The analogy of management strategies for femur shaft fractures and unstable thoracolumbar spine fractures in multiply injured patients is schematically depicted in Fig. 23-12.38
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Our group recently published the results from our early institutional experience of applying the “spine damage control” protocol at our trauma center at Denver Health.46 A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and injury severity score (ISS) >15 were prospectively enrolled during a 3-year time window. Early “spine damage control” within 24 hours was performed in 42 patients, whereas 70 matched patients in the control group underwent definitive operative spine fixation at a delayed time-point. The mean time to initial spine fixation was significantly decreased in the “spine damage control” group (8.9±1.7 hours vs 98.7±22.4 hours, P<0.01). The early spine fixation cohort also showed a reduced length of operative time (2.4±0.7 hours vs 3.9±1.3 hours), length of hospital stay (14.1±2.9 days vs 32.6±7.8 days), and number of ventilator-dependent days (2.2±1.5 days vs 9.1±2.4 days), compared to the delayed spine fixation control group. Most importantly, the post-injury and postoperative complication rate was significantly decreased after “spine damage control,” including a reduced incidence of wound complications and surgical site infections (2.4% vs 7.1%), urinary tract infections (4.8% vs 21.4%), pulmonary complications (14.3% vs 25.7%), and pressure sores (2.4% vs 8.6%). Our early experience implies that a proactive concept of early stabilization of unstable thoracic and lumbar fractures in multiply injured patients represents a safe and effective treatment strategy that should be considered for implementation in other trauma centers.46 A representative example of an early “spine damage control” procedure in a polytrauma patient with a severe multilevel segmental fracture-dislocation of the thoracolumbar spine is shown in Fig. 23-13 and Fig. 23-14.
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Surgical Considerations
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In general, surgery for unstable spinal injuries attempts to accomplish three main goals which the authors term the “Holy Trinity of the Spine.”22
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To provide and maintain anatomic alignment of spinal segments.
To provide an early and “rock-solid” stability to the unstable spine.
To decompress neurological structures (spinal cord, spinal nerve-roots, cauda equina, conus medullaris), if indicated.
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The preferred treatment modality for unstable cervical spine fractures consists of an anterior decompression (including corpectomy) and fusion with anterior plating (ACDF) in conjunction with a bone graft substitute or cage. Unstable three-column fractures and fracture-dislocations with posterior facet dislocations may require a posterior approach or combined posterior/anterior approach with 360° fusion. Posterior cervical spine fixation is typically accomplished by placement of multilevel lateral mass screws with or without adjunctive bone grafting for spinal fusion.
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Thoracic and lumbar injuries
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Unstable vertebral fractures with or without neurological injuries are generally managed through anterior approaches (transthoracic or retroperitoneal) by anterior decompression with corpectomy and fusion using expandable cages and graft constructs, with or without adjunctive anterior column instrumentation with plates/screws or rods/screws. As described earlier, a standardized “spine damage control” procedure should be considered in multiply injured patients by initial posterior fracture reduction, fixation, and decompression by laminectomy, if indicated. This modality allows early mobilization and positioning of multiply injured patients as needed for intensive care. Definitive treatment consists of a delayed, staged anterior corpectomy and anterior column fusion (360°), if indicated (Fig. 23-15).
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“Chance” fractures of the B2-type (Fig. 23-3) are managed exclusively by a posterior approach with definitive internal fixation using pedicle screws, with instrumentation two levels above and two levels below the fracture site. Three-column injuries frequently require a combined posterior/anterior 360° fusion, as outlined earlier.
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Of note, the placement of surgical drains is rarely indicated in the acute surgical management of spinal injuries. Exceptions where drains are beneficial include placement of retroperitoneal drains after extensive anterior approaches and chest tubes for transthoracic approaches. In contrast, the prophylactic placement of drains around the cervical spine for anterior or posterior approaches, and for posterior thoracic or lumbar approaches does not appear to convey any benefit. Perceived benefits include the theoretical decreased risk of postoperative hematoma formation. However, it can be argued that keeping drains increases the risk of surgical site infections. Furthermore, side-effects from prolonged antibiotic therapy can occur if the surgeon requests antibiotics be continued while surgical drains remain in place. This request does not appear to be justified from a quality of care or patient safety perspective.