Urgent surgical stabilization of spinal fractures in polytrauma patients.

STUDY
DESIGN: A prospective, longitudinal study of multiply injured patients treated with segmental instrumentation for spinal fractures with a minimum 2-year follow-up.
OBJECTIVES: To determine whether urgent stabilization of spinal fractures in severely injured patients increases the risk of surgery compared with early treatment and historical results. SUMMARY AND BACKGROUND DATA: Opinion in clinical studies is divided about whether operative treatment offers an advantage over nonoperative treatment in isolated spine fractures. Concomitant trauma is rarely discussed relative to decision making or surgical timing. Urgent stabilization of long-bone fractures improves survival and outcome in polytrauma patients. To date, urgent treatment of spine fractures in polytrauma patients has not been considered in the literature.
METHODS: Seventy-five consecutive patients treated with segmental instrumentation for spinal trauma were observed prospectively to assess perioperative and longterm outcome. Twenty-seven patients with severe polytrauma (injury severity score, > 26) were separately analyzed. Perioperative and postoperative results were analyzed relative to timing of surgery, injury severity score, and surgical approach. Urgent treatment was defined as that provided within 24 hours of the spinal injury, and early treatment was defined as that provided between 24 and 72 hours after injury.
RESULTS: Twenty-five patients (93%) sustained two or more major injuries in addition to the spine fracture, and 17 of 27 (63%) had neurologic injury. The mean injury severity score approached or exceeded the LD50 (50% expected mortality) in each group--36.0 for the early-treatment group and 42.0 for the urgent group--but only one patient in each group died. There were no deep venous thromboses, pulmonary emboli, neurologic injuries, decubiti, deep wound infections, or episodes of sepsis in either group. Blood loss for anterior procedures was significantly higher in the urgent group, but estimated blood loss for posterior procedures was similar for both groups. At 49 months' mean follow-up, no revisions were necessitated by the urgent spinal treatment.
CONCLUSIONS: Urgent spinal stabilization is safe and appropriate in polytrauma patients when progressive neurologic deficit, thoracoabdominal trauma, or fracture instability increase the risks of delayed treatment.