Timing of intervention for spinal injury in patients with polytrauma

Abstract

Objective: The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.

Methods: A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995-2020) based on the keywords - polytrauma OR multiple trauma AND spine fracture AND timing, present in "All the fields" of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.

Results: Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, "damage control" internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.

Conclusion: Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Keywords: Damage control; Polytrauma; Spine fracture; Spine surgery.

Fig. 1

This 45-year-old male was involved in a road traffic accident when his bicycle was hit by a speeding car. He was brought to the hospital within 5 h after the accident. He had an unstable burst fracture of L1 vertebra (A,B) closed oblique fracture of the right distal femur (C,D), and a communited Grade 3 open ankle fracture (E,F). After resuscitation, he underwent debridement and stabilisation of the ankle fracture with an external fixation (I,J), and short segment fixation of the spine (G,H). After a week, the femur fracture was treated by an intramedullary nail (K,L).

Fig. 2

A 55-year-old male patient was brought to the emergency room following a road traffic accident (two-wheeler versus four-wheeler). Post-resuscitation, his CT of the whole body revealed bilateral haemothorax and a spinal injury at T6-7 (unstable burst fracture) with incomplete neurological deficit (A–C). An inter-costal chest drainage tube was inserted on the right side and he was operated within 24 h for the spinal fracture (long segment posterior stabilisation and decompression) (D,E). He was electively ventilated for 48 h and then gradually weaned. Early spinal fixation enabled better mobilisation, pulmonary support and neurological recovery and rehabilitation.