Abstracts
The objective of this systematic review was to integrate the information from existing studies to determine the level of evidence and grade of recommendation of the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients. Eighteen papers were collected from different databases by keywords and Mesh terms; the level of evidence and grade of recommendation, the characteristics of the participants, the time of fracture fixation, the type of approach and technique used, the length of stay in the intensive care unit, the days of dependence on mechanical ventilator, and the incidence of complications in patients were assessed. The largest proportion of the studies were classified as level 4 evidence and grade C of recommendation which is favorable to the implementation of damage control in unstable thoracic and lumbar fractures in polytraumatized patients as a positive recommendation, although not conclusive. Most papers advocate fracture stabilization within 72 hours of the injury which is associated with a lower incidence of complications, hospital stay, stay in the intensive care unit and lower mortality.
Multiple Trauma; Spinal fractures/surgery; Fracture fixation; Lumbar vertebrae; Thoracic vertebra
O objetivo desta revisão sistemática foi integrar as informações dos estudos existentes para determinar o nível de evidência e grau de recomendação da aplicação do controle de danos em fraturas torácica e lombar instáveis em pacientes com politraumatismo. Foram incluídos 18 artigos encontrados em diferentes bancos de dados, usando-se palavras-chave e termos do MeSH; avaliaram-se: nível de evidência e grau de recomendação, características dos participantes, momento em que se realizou a fixação da fratura, tipo de acesso e a técnica utilizada, dias de permanência na unidade de terapia intensiva, os dias de dependência de ventilação mecânica e a incidência de complicações dos pacientes. A maior proporção de artigos foi classificada como nível 4 de evidência, com predomínio do grau C de recomendação, o que torna favorável à implementação do controle de danos em fraturas torácicas e lombares instáveis em pacientes com politraumatismo, não sendo, contudo, concludente. A maioria dos artigos preconiza a estabilização da fratura nas primeiras 72 horas da lesão, o que está associado a menor incidência de complicações, permanência hospitalar, permanência na unidade de terapia intensiva e a menor mortalidade.
Traumatismo múltiplo; Fraturas da coluna vertebral/cirurgia; Fixação de fratura; Vértebras lombares; Vértebras torácicas
El objetivo de esta revisión sistemática fue integrar la información de los estudios existentes para determinar el nivel de evidencia y grado de recomendación de la aplicación del control de daños en fracturas torácicas y lumbares inestables en pacientes politraumatizados. Se incluyeron 18 artículos localizados en diferentes bases de datos a través de palabras clave y términos del MeSH; se valoró el nivel de evidencia y grado de recomendación, las características de los participantes, el momento en que se realizó la fijación de la fractura, el tipo de abordaje y técnica utilizada, los días de estancia en la unidad de terapia intensiva, los días dependientes de ventilador mecánico y la incidencia de complicaciones de los pacientes. La mayor proporción de los estudios se catalogaron como nivel de evidencia 4 y se obtuvo un grado C de recomendación como predominante lo cual coloca la aplicación de control de daños a fracturas torácicas y lumbares inestables en pacientes politraumatizados como una recomendación favorable pero no concluyente. La mayoría de los artículos abogan por una estabilización de la fractura en las primeras 72 horas de la lesión lo cual se asocia a menor incidencia de complicaciones, estancia hospitalaria, estancia en la unidad de cuidados intensivos y menor mortalidad.
Traumatismo múltiple; Fracturas de la columna vertebral/cirugía; Fijación de fractura; Vértebras lumbares; Vértebras torácicas
INTRODUCTION
In the 1990s, treatment paradigms were aimed at reducing the number of emergency surgical procedures performed in patients polytraumatized by the deadly trio (coagulopathy, hypothermia, and hypotension),11 Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375-82. , 22 Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan GL Jr. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg. 1992;215(5):476-83. because it was observed that changes to the immune system and coagulation resulting from the "first hit", caused by the traumatic event put the patient at risk of suffering other injuries ("second hit") as a result of the surgical procedures to which they would be subjected.33 Stahel PF, Heyde CE, Ertel W. Current concepts of polytrauma management. Eur J Trauma. 2005:31(3);200-11. , 44 Gebhard F, Huber-Lang M. Polytrauma--pathophysiology and management principles. Langenbecks Arch Surg. 2008;393(6):825-31. From this emerged the philosophy of "damage control".55 Lichte P, Kobbe P, Dombroski D, Pape HC. Damage control orthopedics: current evidence. Curr Opin Crit Care. 2012 Dec;18(6):647-50.
Thus, the priority of surgical interventions, and the time to perform them, were dependent on the patient's physiological state.66 Rüedi TP, Buckley Richard E, Moran CG. AO Principles of fracture management. 2nd ed. New York: Thieme; 2007
In the field of orthopedics, these concepts have been well understood for the management of long bone and pelvic fractures in polytraumatized patients.77 Pape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26(11):1478-84.
In the case of isolated spinal fractures, the treatment regimen has been adequately defined and standardized; however, the optimum time, and the best type of fixation to use in unstable thoracolumbar fractures in polytraumatized patients, are still controversial.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6.
At present, the management of unstable thoracic and lumbar fractures consists mainly of: 1) deferred fixation after the associated lesions have been resolved or 2) a more aggressive approach called "early total care" via invasive anterior approaches, corpectomy, and anterior fusion based more on purely mechanical aspects than on the physiopathology of the traumatized patient.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6.
There is evidence to demonstrate a significant increase in mortality, from 2.5% to 7.6%, resulting from definitive early fixation of the spine within the first 48 hours following the trauma.99 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, et al. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308-13. On the other hand, bed rest, and insufficient mobility of the patient due to deferred stabilization of the fractures, have been associated with severe post-traumatic complications.1010 Banagan K, Ludwig SC. Thoracolumbar spine trauma: when damage control minimally invasive spine surgery is an option. Semin Spine Surg. 2012:24;221-5. , 1111 Stahel PF, Smith WR, Moore EE. Role of biological modifiers regulating the immune response after trauma. Injury. 2007;38(12):1409-22.
The concept of "spinal damage control" is defined as a procedure carried out in stages, consisting of the immediate reduction and posterior instrumentation of unstable thoracic and lumbar fractures in severely injured patients (ISS greater than 15) within the first 24 hours, followed by complete 360º fusion during the physiological "window of opportunity", if anterior decompression and fusion have been indicated for neurological or biomechanical reasons.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. , 1212 Stahel PF, Flierl MA, Moore EE, Smith WR, Beauchamp KM, Dwyer A. Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. J Trauma Manag Outcomes. 2009;3:6. The second procedure should be performed three days after the initial trauma, in order to avoid the acute hyperinflammation phase and ensure adequate recovery from bleeding and coagulopathy, reducing the risk of transoperative bleeding of the spongy bone and the epidural veins.33 Stahel PF, Heyde CE, Ertel W. Current concepts of polytrauma management. Eur J Trauma. 2005:31(3);200-11.
Thus, both the physiopathological state of the polytraumatized patient and the timing and nature of the surgical intervention are taken into account, avoiding "second hit" complications and reducing post-traumatic morbidity and mortality in patients in critical condition, resulting in reduced surgical and hospitalization times and fewer days of dependence on a ventilator. It also results in fewer early postoperative complications, such as wound complications, urinary tract infections, and pulmonary complications, including pneumonia and pulmonary embolism.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6.
Among the disadvantages are potential intraoperative complications, such as poor placement of the transpedicular screws, the risk of incomplete decompression of the spinal canal, and the need for a second surgery in more than 95% of patients.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6.
The objective of this systematic review was to integrate the information from the studies to determine the level of evidence and the grade of recommendation regarding the application of damage control in unstable thoracic and lumbar fractures in polytraumatized patients.
METHODS
This systematic review was conducted based on the PRISMA Declaration.13 The study was registered under protocol number R-2014-3401-7.
The criteria were articles related to the early surgical treatment of thoracic and lumbar fractures in polytraumatized patients with ISS >15, in English and Spanish, including clinical trials and observational studies.
The Medline, Ovid, EBSCO host, The Cochrane Library, The Cochrane Library plus, EMBASE, LILACS, ScieELO, Springer Link, MD Consult, and Science Direct databases were used to search for articles published from 1990 to 2014, with June 19, 2014 as the cut-off date for the search.
The title and the abstract of each article were examined to eliminate clearly irrelevant or duplicate articles. The complete text of potentially relevant articles was retrieved for evaluation, and to determine the level of compliance with the eligibility criteria, as shown in Figure 1.
The articles were sent to two independent reviewers (PAJM and MGEA) who applied the CONSORT guide14 to the only randomized clinical study15 encountered and the Oxford Centre for Evidence-Based Medicine (CEBM) scale to all of the articles, in order to classify the level of evidence and the grade of recommendation. Interobserver reliability was analyzed using the intraclass correlation coefficient and interobserver variability calculation (Kappa).
For each article, the participant characteristics were evaluated (age, severity of the trauma according to ISS, and the level of the fractures), the time the fixation of the fracture was performed, the type of approach and technique used, the number of days in the intensive care unit, the number of days of dependence on a ventilator, and the incidence of complications.
RESULTS
Twenty-eight potentially relevant articles were located. Once the complete text had been retrieved and the level of compliance with the inclusion criteria determined, two articles were rejected - one1616 Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases. J Trauma. 2004;56(2):348-55. because it did not specify the time the fixation of the fracture was performed, and the other1717 Kossmann T, Trease L, Freedman I, Malham G. Damage control surgery for spine trauma. Injury. 2004;35(7):661-70. because it did not offer specific conclusions regarding the theme of this review, as well as five systematic reviews1818 Bellabarba C, Fisher C, Chapman JR, Dettori JR, Norvell DC. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010;35(Suppl 9):138-45.
19 Carreon LY, Dimar JR. Early versus late stabilization of spine injuries: a systematic review. Spine (Phila Pa 1976). 2011;36(11):E727-33.
20 Dimar JR, Carreon LY, Riina J, Schwartz DG, Harris MB. Early versus late stabilization of the spine in the polytrauma patient. Spine (Phila Pa 1976). 2010;35(Suppl 21):S187-92.
21 Fehlings MG, Sekhon LH, Tator C. The role and timing of decompression in acute spinal cord injury: what do we know? What should we do? Spine (Phila Pa 1976). 2001;26(Suppl 24):S101-10. -2222 Rutges JP, Oner FC, Leenen LP. Timing of thoracic and lumbar fracture fixation in spinal injuries: a systematic review of neurological and clinical outcome. Eur Spine J. 2007;16(5):579-87. and three literature reviews1010 Banagan K, Ludwig SC. Thoracolumbar spine trauma: when damage control minimally invasive spine surgery is an option. Semin Spine Surg. 2012:24;221-5.,2323 Schinkel C, Anastasiadis AP. The timing of spinal stabilization in polytrauma and in patients with spinal cord injury. Curr Opin Crit Care. 2008;14(6):685-9.,2424 Eck JC, Hodges SD. Timing of surgery for thoracolumbar spine trauma. Curr Orthop Pract. 2014:25(1);14-6. leaving a total of 18 articles. (Figure 1)
The clinical trial1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. complied with 20 of the 22 CONSORT guide items.1414 Cobos-Carbó A; CONSORT group. Randomized clinical trials (CONSORT). Med Clin (Barc). 2005;125(Suppl 1):21-7. All the studies were evaluated using the Oxford Centre for Evidence-Based Medicine (CEBM) scale to classify the level of evidence and the degree of recommendation.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. ,99 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, et al. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308-13.,1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. ,2525 Kerwin AJ, Griffen MM, Tepas JJ 3rd, Schinco MA, Devin T, Frykberg ER. Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank. J Trauma. 2008;65(4):824-30.
26 Park KC, Park YS, Seo WS, Moon JK, Kim BH. Clinical results of early stabilization of spine fractures in polytrauma patients. J Crit Care. 2014;29(4):694.e7-9.
27 Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851-8.
28 Bliemel C, Lefering R, Buecking B, Frink M, Struewer J, Krueger A, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366-73.
29 Konieczny MR, Strüwer J, Jettkant B, Schinkel C, Kälicke T, Muhr G, et al. Early versus late surgery of thoracic spine fractures in multiple injure patients: is early stabilization always recommendable? Spine J. 2013:13;S1529-9430(13)01391-0.
30 Frangen TM, Ruppert S, Muhr G, Schinkel C. The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. J Trauma. 2010;68(5):1208-12.
31 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. J Trauma. 2005;58(1):15-21.
32 Schlegel J, Bayley J, Yuan H, Fredricksen B. Timing of surgical decompression and fixation of acute spinal fractures. J Orthop Trauma. 1996;10(5):323-30.
33 Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G; German Trauma Registry. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006;61(1):156-60
34 McHenry TP, Mirza SK, Wang J, Wade CE, O'Keefe GE, Dailey AT, et al. Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am. 2006;88(5):997-1005.
35 Hierholzer C, Bühren V, Woltmann A. Operative timing and management of spinal injuries in multiply injured patients. Eur J Trauma Emerg Surg. 2007:33;488-500.
36 Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27(7):405-12.
37 Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543-5.
38 McLain RF, Benson DR. Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine (Phila Pa 1976). 1999;24(16):1646-54-3939 Pakzad H, Roffey DM, Knight H, Dagenais S, Yelle JD, Wai EK. Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes. Can J Surg. 2011;54(4):270-6. (Table 1)
The interobserver reliability was analyzed using the intraclass correlation coefficient and interobserver variability calculation (Kappa), obtaining agreement of 100% and eliminating the need for a third reviewer for the articles.
The significant results for this review were those derived from thoracic and lumbar fractures, although some studies included patients with cervical fractures or those with spinal fractures in combination with fractures of the lower limbs.
The studies included divided the time of fixation of the spinal fracture according to the hours elapsed between the time of the trauma and the fixation. Most of them (nine articles)2525 Kerwin AJ, Griffen MM, Tepas JJ 3rd, Schinco MA, Devin T, Frykberg ER. Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank. J Trauma. 2008;65(4):824-30.
26 Park KC, Park YS, Seo WS, Moon JK, Kim BH. Clinical results of early stabilization of spine fractures in polytrauma patients. J Crit Care. 2014;29(4):694.e7-9.
27 Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851-8.
28 Bliemel C, Lefering R, Buecking B, Frink M, Struewer J, Krueger A, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366-73.
29 Konieczny MR, Strüwer J, Jettkant B, Schinkel C, Kälicke T, Muhr G, et al. Early versus late surgery of thoracic spine fractures in multiple injure patients: is early stabilization always recommendable? Spine J. 2013:13;S1529-9430(13)01391-0.
30 Frangen TM, Ruppert S, Muhr G, Schinkel C. The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. J Trauma. 2010;68(5):1208-12.
31 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. J Trauma. 2005;58(1):15-21.
32 Schlegel J, Bayley J, Yuan H, Fredricksen B. Timing of surgical decompression and fixation of acute spinal fractures. J Orthop Trauma. 1996;10(5):323-30.-3333 Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G; German Trauma Registry. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006;61(1):156-60 defined early stabilization as that performed within the first 72 hours and late stabilization as that performed more than 72 hours following the trauma.
Two studies99 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, et al. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308-13.,3434 McHenry TP, Mirza SK, Wang J, Wade CE, O'Keefe GE, Dailey AT, et al. Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am. 2006;88(5):997-1005. used 48 hours as the cutoff point for the definition of early and late stabilization.
Four studies88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. ,3535 Hierholzer C, Bühren V, Woltmann A. Operative timing and management of spinal injuries in multiply injured patients. Eur J Trauma Emerg Surg. 2007:33;488-500.
36 Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27(7):405-12.-3737 Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543-5. used 24 hours as the cutoff for early and late fixation, of which only Stahel et al88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. specified the application of a protocol for the early fixation groups of patients who, after the fixation within the 24 hours following the trauma, presented unstable anterior lesions of the spine and were scheduled for anterior 360º fusion three days after the trauma if there were biomechanical or neurological indications, in order to avoid the acute phase of hyperinflammation and ensure recovery.
Cengiz et al1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. were the only authors to randomly assign patients to one of the fracture stabilization groups. In all the other studies, the moment of stabilization as determined by the surgeon, depending on the availability of surgical time or determined by the patient's conditions.
Injury Severity Score
The average ISS was reported by to the stabilization group (early vs. late) in most cases. The average ISS for the early fixation groups ranged from 16-42 points with an average of 26.35, while in the late fixation group, the average ISS vs. 27.78, with a range from 13 to 42.5.
Cengiz et al55 Lichte P, Kobbe P, Dombroski D, Pape HC. Damage control orthopedics: current evidence. Curr Opin Crit Care. 2012 Dec;18(6):647-50. do not specify the ISS, but only refer to the exclusion of clinically unstable patients with spondyloptosis, a biochemical profile compatible with severe mulitsystem injuries, and patients not able to endure radical surgery.
Fracture fixation approach and technique
In ten studies, neither the type of approach for spinal fracture stabilization (anterior or posterior) nor the type of fixation performed (transpedicular fixation, 360º fusion) is reported. The other studies mention both anterior and posterior approaches performed in isolation, simultaneously, or consecutively, depending on the type of instability, without any systematized order for cases in which both are performed in the same patient, and without specifying the type of fixation system used, with the exception of the study by Stahel et al,88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. which establishes a standardized damage control protocol for unstable spinal fractures consisting of early posterior fixation via a transpedicular system during the first 24 hours following the trauma. In those patients with unstable injuries of the anterior spine, anterior 360º fusion was scheduled for three days after the trauma. All the patients, except for one case of a B2 Chance fracture handled by exclusive posterior fixation with posterolateral fusion, required a second procedure to stabilize the anterior spine (97.6%).
Schlegel et al3232 Schlegel J, Bayley J, Yuan H, Fredricksen B. Timing of surgical decompression and fixation of acute spinal fractures. J Orthop Trauma. 1996;10(5):323-30. used an anterior approach for lesions of the anterior and middle spine involving the bone canal with neurological compromise or a posterior approach for patterns of posterior instability (luxation fractures, Chance fractures, burst fractures without neurological involvement). The type of fixation was not reported according to the approach used.
Cengiz et al1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. reported only the use of the posterior approach with the insertion of transpedicular screws and rods.
In the study by McLain et al,3838 McLain RF, Benson DR. Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine (Phila Pa 1976). 1999;24(16):1646-54 all the patients underwent posterior instrumentation, and anterior decompression was used in 26% of the patients as part of the initial operation for neural decompression, mechanical stabilization, or both.
McHenry et al3434 McHenry TP, Mirza SK, Wang J, Wade CE, O'Keefe GE, Dailey AT, et al. Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am. 2006;88(5):997-1005. report a predominance of posterior approaches, representing 92% of cases versus the anterior approach, used in 8% of cases.
The results reported regarding the number of days in the ICU were described in 13 of the studies, with a maximum average of 16 days for the early spinal fracture stabilization group. For the late stabilization groups a maximum average of 21.3 days was found. Cengiz et al1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. reported a mean of zero days in the ICU, however, this should be viewed with caution, as clinically unstable patients with spondyloptosis, a biochemical profile compatible with severe multisystem injuries, and patients not able to endure radical surgery, were excluded, and the need for intensive care in these patients was unlikely.
The number of days of dependence on a ventilator was reported in 12 articles, with a maximum average of 9.9 days for the early stabilization group and a maximum average of 20 days for the late stabilization group.
The main complications reported were pulmonary (pneumonia, pulmonary embolism, acute respiratory stress syndrome), deep vein thrombosis, sepsis, bed sores, acute renal failure, and complications related to the surgical wound, with a larger number of studies reporting a lower incidence of complications in the early stabilization group.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. ,2727 Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851-8. ,2828 Bliemel C, Lefering R, Buecking B, Frink M, Struewer J, Krueger A, et al. Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients. J Trauma Acute Care Surg. 2014;76(2):366-73.,3333 Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G; German Trauma Registry. Timing of thoracic spine stabilization in trauma patients: impact on clinical course and outcome. J Trauma. 2006;61(1):156-60,3636 Vallier HA, Super DM, Moore TA, Wilber JH. Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course. J Orthop Trauma. 2013;27(7):405-12.,3737 Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543-5.
Mortality was reported in 16 studies, and was not taken into account in only two studies.88 Stahel PF, VanderHeiden T, Flierl MA, Matava B, Gerhardt D, et al. The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study. J Trauma Acute Care Surg. 2013;74(2):590-6. ,3939 Pakzad H, Roffey DM, Knight H, Dagenais S, Yelle JD, Wai EK. Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes. Can J Surg. 2011;54(4):270-6. In the majority of studies, it was reported by fracture stabilization group (early vs. late), with a maximum percentage of 7.6% among the early treatment groups and 17% for the late groups.
Croce et al,2727 Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does optimal timing for spine fracture fixation exist? Ann Surg. 2001;233(6):851-8. upon stratifying their results by ISS, found that in patients with ISS ≥ 25 points, early fixation (< 72 h) of the spinal fracture is associated with less time in the ICU, shorter hospitalization times, and less costly procedures, but with a significant increase in mortality (5.6% vs. 2.7%). The causes of death reported were sepsis, drain damage, transesophageal fistula, and multiple organ failure.
Frangen et al,3030 Frangen TM, Ruppert S, Muhr G, Schinkel C. The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. J Trauma. 2010;68(5):1208-12. upon stratifying the population by ISS, reported higher mortality in the early stabilization group for patients with ISS ≥ 38 points.
Kerwin et al99 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, et al. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma. 2007;63(6):1308-13.,3131 Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. J Trauma. 2005;58(1):15-21. do not report a significant difference between the stabilization groups. However, unlike the studies already mentioned, these authors report mortality of 6.3% in the early stabilization group (<72 h) and of 17% in the late group (>72 h), reporting this difference as significant.
In terms of the level of evidence, one article was found with level 1b, five articles with level 2b, one article with level 3b, and 11 articles with level 4. (Table 1).
The grades of recommendation found were grade A in one study, grade B in six studies, and grade C in eleven studies. (Table 1)
DISCUSSION
Table 1 summarizes the main conclusions of the articles included in this review, as well as the level of evidence and grade of recommendation, according to the methodology used in each study.
The main limitation is the quality of the existing studies in reference to damage control applied to spinal fractures in polytraumatized patients. Most of the articles are retrospective, using databases, so they contain no information that is not conditioned by the bias of the results or the inferences that could be drawn from them, or else they are based on cohort studies, but not randomized. Only two studies are relevant in terms of methodological quality. One of them1515 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959-66. is the only one randomized for the time of the fixation of the fracture, and for this reason, a level of evidence and grade of recommendation higher than the others is warranted. However, its possible application to the polytraumatized patient may be biased since it excludes unstable patients (spondyloptosis, biochemical profile compatible with severe multisystem injury, and patients not able to endure radical surgery). The other study8 is relevant because it is the only one that proposes a damage control protocol for thoracic and lumbar spines in patients with severe lesions and that follows the patients in a prospective manner. The rest of the studies only focus on establishing the definitive moment of stabilization, but neither prioritize nor stress which surgical procedures should be performed, in what order, at what time, or under what circumstances.
FINAL CONSIDERATIONS
Most of the studies were classified as level of evidence 4 with a predominance of grade of recommendation C, which led to the conclusion that the application of damage control to unstable thoracic and lumbar fractures in polytraumatized patients is a favorable, though inconclusive recommendation.
Most of the articles advocate stabilization of the spinal fracture in seriously injured patients in the first 72 hours following the injury, which is associated with less incidence of complication, shorter hospitalization time, shorter stay in intensive care, and lower mortality.
ACKNOWLEDGEMENTS
We thank Dr. Tania Marín Macías for her collaboration and for translating the abstract of this article into Portuguese.
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Study conducted at the "Dr. Victorio De La Fuente Narváez" High Specialty Medical Unit. Federal District, Mexico.
Publication Dates
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Publication in this collection
June 2015
History
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Received
03 Mar 2015 -
Accepted
27 Apr 2015