Avoiding Complications in Spine Trauma Patients

Preoperative Evaluation and Decision Making

Patients who are injured, are in severe pain, or have an SCI are willing to undergo a procedure with a higher complication rate. It is therefore important that the spine surgeon provide the best estimation of the complication rate, numerical risk of most commonly encountered complications for a procedure, and a “likelihood of success.” Specific goals of surgery must be addressed and the patient's objectives must match those of the surgeon to ensure the greatest patient satisfaction. Bono et al., in a preoperative questionnaire, asked patients to score leg and back pain on a scale of 0–10. These same patients were then asked to list acceptable scenarios of complications that were presented. A multivariate analysis showed that patients with high-intensity low back pain (LBP), history of prior spinal injections, high educational status, white race, occupation, and a history of nonspinal surgery were indicators of patients with the greatest acceptance of a complication.

Complications With Preoperative Cervical Collar Management

The use of cervical collars is common in suspected spinal trauma patients. Also, cervical collars are used to further reduce pathologic motion of injured cervical vertebrae segments after the initial time of injury. Although the American Association of Neurologic Surgeons/Congress of Neurological Surgeons (AANS/CNS) cervical spine guidelines state that there is insufficient evidence for the use of cervical collars for the prevention of additional injury, when any spine trauma is suspected and there is a mechanism that could potentially have caused a cervical injury, cervical immobilization is reasonable. In spite of its importance in trauma, prolonged use of hard cervical collars can cause skin breakdown and ulceration. This is especially true in patients who are cognitively impaired, patients who are admitted to intensive care units (ICUs), or geriatric patients with type 2 odontoid fracture, where prolonged treatment with a hard collar may have inconsistent results. Additionally, cervical collars are associated with increased intracranial pressures (ICPs). One potential etiology of the increased ICPs is that the pressure on the neck caused compression of the inferior jugular veins and decreased venous outflow from the cranium. An effort to clear the spine is outlined in Chapter 11 with a goal to remove the collar as early as possible.

This holds true especially in the geriatric population, where prolonged collar use is needed and subsequent skin breakdown becomes a common finding due to pressure ulcers from long-term collar use. Many surgeons argue for early operative intervention in this population to encourage early mobilization and not require prolonged immobilization in a collar. The AOSpine North America Geriatric Odontoid Fracture Mortality Study, a retrospective review of operative versus nonoperative treatment for type 2 odontoid fractures, reported that treatment with rigid cervical collars resulted in a higher mortality rate than operative treatment.

Preoperative Timing

The timing of surgical intervention after a traumatic SCI has been controversial. Research into the timing of surgery has been complex due to the lack of standardized definition. Widely quoted studies have defined “early” as surgery performed “within 72 hours” as well as “after 5 days,” illustrating the variability in the term acute. In these studies, no statistical difference had been found with regard to hospital length of stay or neurologic improvement by American Spinal Injury Association (ASIA) grade between groups. Recent literature prospectively compared neurologic outcomes by the ASIA impairment scale (ASI) between patients with SCI treated earlier or later than 24 hours. This multicenter, international study group reported that early surgical stabilization for acute traumatic SCI resulted in a greater chance of improvement of ASIA score by 2 grades at 6 months with an odds ratio of 2.8. There was no statistically significant risk of complication or neurologic deterioration as a result of early surgery. However, before surgery in acute SCI it is recommended that the patient be hemodynamically stable and have a mean arterial pressure of 85 mm Hg.

One subset of patients for which it has been even more difficult to determine a benefit is those with central cord syndrome. Timing for surgery of central cord syndrome is more controversial. Because of the relatively older age group, higher frequency of spontaneous improvement, and lack of homogeneous pathologies of SCI, many studies have excluded central cord syndrome from timing studies.

Steroids in Spinal Cord Injury: Indications and Potential Complications

The use of methylprednisolone was recommended for acute traumatic SCI within 8 hours of onset per the NASCIS-2 study. Bracken et al., in the NASCIS-2 study, reported that there was a neurologic benefit at 6 and 12 months in the methylprednisolone groups who were at risk for pneumonia and sepsis. There is still much debate on this topic, but given the minimal benefit reported in this study and potential complications, numerous surgeons have stopped using these medications. The 2013 guidelines by the AANS/CNS Joint Section have for the first time discouraged the use of methylprednisolone in SCI. The justifications surrounding this discouragement are the complications that are associated with high-dose steroids, which include sepsis, pneumonia, pulmonary embolism, deep vein thrombosis, gastrointestinal bleeding, and inability for adequate wound healing. Last, Fehlings et al. recently published a systemic review that analyzed the results of three randomized controlled trials and one prospective study that compared the use of methylprednisolone sodium succinate (MPSS). Their analysis was similar to others and showed that administration of MPSS according to the dose and duration of the NASCIS-2 protocol offers no benefit in motor recovery, pinprick, or light touch when initiated at indiscriminate time periods. There was, however, moderate evidence of a small benefit in motor recovery when MPSS is given within 8 hours of injury compared with no intervention. There is no difference between groups in the complications associated with administration of MPSS; however, there may be a higher incidence of severe sepsis when the duration of MPSS infusion increases from 24 to 48 hours.

Blunt Cerebrovascular Injury

An international multicenter analysis of blunt cerebrovascular artery injury was recently published and showed a rate of approximately 1% (786 of 76,480 patients). Inclusion criteria were as follows: adult trauma patients (≥16 years) with severe injuries (Injury Severity Score [ISS] ≥16 points) with and without blunt cerebrovascular injury (BCVI). There were subgroups of BCVI: carotid artery injury (CAI) and vertebral artery injury (VAI). There were slightly more CAIs than VAIs, but the difference was not clinically significant. There was an increased risk of stroke in both subgroups. Additionally, cervical spine injuries were a major BCVI predictor. There were other predictors: high-energy mechanism, facial fractures, and general injury severity (via ISS). Drain et al. published a study that sought to identify factors that would warrant evaluation with computed tomography (CT) angiography of the VAIs; 144 BCVIs were identified among 1854 trauma patients. Four factors were found that would place a patient in a high-risk group that would necessitate imaging with CT angiography: female gender, decreased Glasgow Coma Scale score, cervical spine fracture, and concurrent BCVI. Sinnathamby et al. also prospectively compared the rate of detecting BCVI in the traumatic setting increase after using a diagnostic imaging pathway. Lebl et al. found a few characteristics associated with VAI, which include severely injured patients, high-risk patients with basilar skull fractures, occipitocervical dissociation, fractures in the transverse foramen greater than 1 mm, ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis, and facet subluxation/dislocation.

Preoperative Nutritional Status

Nutrition and metabolic requirements are much greater than baseline after acute traumatic injuries and surgery. Chen et al. published a systematic review of patients with cervical spine injury and showed that poorer nutritional status correlated with an increase in mortality; additionally, higher cervical level of injury and prolonged ventilation also were associated with increased mortality rate. Wong et al. found that patients with higher cervical injury and a more severe injury also had poorer nutritional status. Dvork et al. published a randomized controlled trial (RCT) that evaluated the difference in infection rates, nutritional status, feeding complications, number of ventilator hours, and length of stay among patients receiving early (<72 hours after injury) versus late (>120 hours after injury) initiation of enteral feeding. However, the biggest limitation to the study was the sample size (23 patients randomized; 17 analyzed). Despite the lack of evidence in the trauma literature to support early enteral feeding, Klein et al. retrospectively reviewed 27 patients who underwent lumbar spinal surgery for vertebral osteomyelitis and found that a significant proportion (24 of 26) of the chronically malnourished had postoperative complications. In the same study of 114 patients who underwent lumbar decompressive surgery, poor nutritional status was a factor in 11 of 13 (85%) postoperative infections encountered. It is therefore important to maximize nutrition and initiate enteral nutrition as soon as safely possible to enhance wound healing in patients with spine and spinal cord injuries.