The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study.
BACKGROUND
In contrast to the established principles of "damage-control orthopedics" for temporary external fixation of long bone or pelvic fractures, the "ideal" timing and modality of fixation of unstable spine fractures in severely injured patients remains controversial.


METHODS
A prospective cohort study was designed to evaluate the safety and efficacy of a standardized "spine damage-control" (SDC) protocol for the acute management of unstable thoracic and lumbar spine fractures in severely injured patients. A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and Injury Severity Score (ISS) of greater than 15 were prospectively enrolled in this study from October 1, 2008, to December 31, 2011. Acute posterior spinal fixation within 24 hours was performed in 42 patients (SDC group), and 70 patients underwent definitive operative spine fixation in a delayed fashion ("delayed surgery"[DS] group). Both cohorts were prospectively analyzed for baseline demographics, length of operative time, amount of intraoperative blood loss, total hospital length of stay, number of ventilator-dependent days, and incidence of early postoperative complications.


RESULTS
The mean time to initial spine fixation was significantly decreased in the SDC group (8.9 [1.7] hours vs. 98.7 [22.4] hours, p < 0.01). The SDC cohort had a reduced mean length of operative time (2.4 [0.7] hours vs. 3.9 [1.3] hours), length of hospital stay (14.1 [2.9] days vs. 32.6 [7.8] days), and number of ventilator-dependent days (2.2 [1.5] days vs. 9.1 [2.4] days), compared with the DS group (p < 0.05). Furthermore, the complication rate was decreased in the SDC group with regard to wound complications (2.4% vs. 7.1%), urinary tract infections (4.8% vs. 21.4%), pulmonary complications (14.3% vs. 25.7%), and pressure sores (2.4% vs. 8.6%), compared with the DS cohort (p < 0.05).


CONCLUSIONS
A standardized SDC protocol represents a safe and efficient treatment strategy for severely injured patients with associated unstable thoracic or lumbar fractures.


METHODS
Therapeutic study, level III.
Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado 80204, USA. philip.stahel@dhha.org
Philip F
PF
Stahel
Todd
T
VanderHeiden
Michael A
MA
Flierl
Brittany
B
Matava
David
D
Gerhardt
Gene
G
Bolles
Kathryn
K
Beauchamp
Clay Cothren
CC
Burlew
Jeffrey L
JL
Johnson
Ernest E
EE
Moore
D000328:Adult; D002985:Clinical Protocols; D005592:Fracture Fixation / Q000379:methods / Q000592:standards; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay; D008159:Lumbar Vertebrae / Q000293:injuries*; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D013119:Spinal Cord Injuries / Q000517:prevention & control; D016103:Spinal Fractures / Q000601:surgery / Q000628:therapy*; D013904:Thoracic Vertebrae / Q000293:injuries*; D013997:Time Factors