By Jeffrey R. Carlson, MD
One of the more commonly-observed orthopaedic issues is fracture of the vertebrae due to a sports injury, car accident, fall or other high-energy trauma. Traumatic injuries of the spine and spinal cord are one of the leading causes of death and permanent disability. In less severe cases, spinal stabilization can be achieved through the use of external bracing or traction. In cases involving more extensive spinal injury or polytrauma, surgery will be required. The type of surgical fixation depends on a variety of factors, including the type of fracture(s), the overall condition of the patient, and any concomitant injuries.
There are several schools of thought about the timing of surgical fixation for traumatic spine fractures and whether surgery should be undertaken in the first few days after traumatic injury or if it should be delayed to allow for the patient’s condition to stabilize. This topic remains controversial as findings have not been conclusive for either side of the argument.
Several studies indicate that early intervention may actually be beneficial, especially for fractures of the thoracic spine. In a study by the Presley Regional Trauma Center in 2001, patients with early surgically-fixated thoracic fractures were shown to have less incidence of pneumonia, less intensive-care bed days, less ventilator days, less incidence of embolic issues and lower overall costs for care. Most high-risk patients had lower hospital resource utilization and a reduced incidence of pneumonia, regardless of the level of spinal fracture.
Another study released in the Journal of Trauma – Injury, Infection & Critical Care, December 2007, studied a cohort of 361 traumatic spine fracture and vertebral dislocation patients. Of those, 158 patients underwent early surgical fixation. The study found that surgical fixation within 48 hours of the traumatic event showed an increased mortality rate for those patients.
This controversy ultimately revolves around the condition of the patient. Spinal cord injuries can be improved (not the reversal of paralysis, but returning use of the triceps for patient transfer) up to several months from the time of injury. Spinal nerve injuries generally improve with earlier surgery. The longer the nerve (outside of the spinal cord) is compressed, the more likely there will be a permanent injury. Those multi-trauma patients that have long bone or abdominal injuries will need to have lifesaving treatment prior to performing spinal stabilization. This may dictate a delay in the decompression of the neurologic elements and may decrease the potential for their recovery. The evaluation of these studies then concludes that the surgical timing is dependent on the status of the patient; operations for spinal stabilization are done when the patient is stabilized sufficiently from the initial injury to successfully recover from the surgery.
Jeffrey R. Carlson, MD is a Harvard Spine Trauma/Neurosurgical Fellow who practices at Orthopaedic & Spine Center in Newport News, VA. Voted a “Top Doc” for 2012, 2013, 2014, Dr. Carlson is a pioneer in the development of outpatient spine surgeries and minimally-invasive surgical techniques.
