Early fixation of traumatic spinal fractures and the reduction of complications in the absence of neurological injury: a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program

Matthew P. Guttman MD 1 , 2 , Jeremie Larouche MD, MSc, FRCSC 3 , Frank Lyons MD, PhD, FRCSI 3 and Avery B. Nathens MD, PhD, FRCSC 1 , 2 , 4 , 5
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  • 1 Institute of Health Policy, Management, and Evaluation, and
  • 2 Divisions of General Surgery and
  • 3 Orthopedic Surgery, University of Toronto;
  • 4 Sunnybrook Research Institute, Toronto, Ontario, Canada; and
  • 5 American College of Surgeons, Chicago, Illinois
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OBJECTIVE

The optimal timing of operative stabilization of patients with traumatic spinal fractures without spinal cord injury (SCI) has not been established. The challenges of early operative intervention, which may require prone positioning in a patient with multisystem injuries, must be balanced with the disadvantages of prolonged immobilization. The authors set out to define the optimal timing of surgical repair of traumatic spinal fractures in patients without SCI and the effect of delayed repair on the incidence of major complications.

METHODS

A retrospective cohort study was conducted using data derived from the American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients who underwent operative fixation of a spinal fracture within 7 days of admission were included. Patients with SCI were excluded. The primary outcome was the occurrence of a major complication. Secondary outcomes included death and length of stay. Restricted cubic splines were used to model the nonlinear effects of time to spinal fixation and determine a threshold beyond which stabilization was associated with a higher rate of major complications. Logistic regression and propensity score matching were then used to derive estimates for the association between delayed fixation and major complications.

RESULTS

The authors identified 19,310 patients treated at 389 centers who met the inclusion criteria. Modeling identified fixation beyond 24 hours as a risk for major complications. Adjusting for potential confounders using multivariable logistic regression showed that late fixation was associated with a 1.30 (95% CI 1.15–1.46) times increased odds of developing a major complication. After propensity score matching, late fixation remained associated with a 1.25 (95% CI 1.13–1.39) times increased risk of experiencing a major complication.

CONCLUSIONS

In the absence of clear contraindications, surgeons should strive to stabilize traumatic spinal fractures without SCI within 24 hours. Early fixation can be expected to reduce major complications by 25%–30%.

ABBREVIATIONS AIS = Abbreviated Injury Scale; ED = emergency department; GCS = Glasgow Coma Scale; GEE = generalized estimating equation; IRR = incidence rate ratio; ISS = Injury Severity Score; SCI = spinal cord injury; TQIP = Trauma Quality Improvement Program.

Supplementary Materials

    • Supplemental Table 1 and Fig. 1 (PDF 558 KB)

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Contributor Notes

Correspondence Matthew P. Guttman: Sunnybrook Health Sciences Centre, Toronto, ON, Canada. matthew.guttman@sunnybrook.ca.

INCLUDE WHEN CITING Published online August 28, 2020; DOI: 10.3171/2020.5.SPINE191440.

Disclosures Dr. Nathens: medical director of the Trauma Quality Program at the American College of Surgeons, which oversees the Trauma Quality Improvement Program from which the data are derived.

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