Lubelski Daniel, Tharin Suzanne, Como John J, Steinmetz Michael P, Vallier Heather, Moore Timothy
1Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Center for Spine Health, and Department of Neurological Surgery, Cleveland Clinic, Cleveland.
5Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland; and.
J Neurosurg Spine. 2017 Dec;27(6):633-637. doi: 10.3171/2017.4.SPINE16933. Epub 2017 Oct 6.
OBJECTIVE Few studies have investigated the advantages of early spinal stabilization in the patient with polytrauma in terms of reduction of morbidity and mortality. Previous analyses have shown that early stabilization may reduce ICU stay, with no effect on complication rates. METHODS The authors prospectively observed 340 polytrauma patients with an Injury Severity Score (ISS) of greater than 16 at a single Level 1 trauma center who were treated in accordance with a protocol termed "early appropriate care," which emphasizes operative treatment of various fractures within 36 hours of injury. Of these patients, 46 had upper thoracic and/or cervical spine injuries. The authors retrospectively compared patients treated according to protocol versus those who were not. Continuous variables were compared using independent t-tests and categorical variables using Fisher's exact test. Logistic regression analysis was performed to account for baseline confounding factors. RESULTS Fourteen of 46 patients (30%) did not undergo surgery within 36 hours. These patients were significantly more likely to be older than those in the protocol group (53 vs 38 years, p = 0.008) and have greater body mass index (BMI; 33 vs 27, p = 0.02), and they were less likely to have a spinal cord injury (SCI) (82% did not have an SCI vs 44% in the protocol group, p = 0.04). In terms of outcomes, patients in the protocol-breach group had significantly more total ventilator days (13 vs 6 days, p = 0.02) and total ICU days (16 vs 9 days, p = 0.03). Infection rates were 14% in the protocol-breach group and 3% in the protocol group (p = 0.2) Total complications trended toward being statistically significantly more common in the protocol-breach group (57% vs 31%). After controlling for potential confounding variables by logistic regression (including age, sex, BMI, race, and SCI), total complications were significantly (p < 0.05) greater in the protocol-breach group (OR 29, 95% CI 1.9-1828). This indicates that the odds of developing "any complication" were 29 times greater if treatment was delayed more than 36 hours. CONCLUSIONS Early surgical stabilization in the polytrauma patient with a cervical or upper thoracic spine injury is associated with fewer complications and improved outcomes. Hospitals may consider the benefit of protocols that promote early stabilization in this patient population.
很少有研究探讨早期脊柱固定术对多发伤患者在降低发病率和死亡率方面的优势。既往分析表明，早期固定术可能会缩短重症监护病房（ICU）住院时间，且对并发症发生率无影响。方法：作者前瞻性观察了在一家一级创伤中心接受治疗的340例损伤严重程度评分（ISS）大于16分的多发伤患者，这些患者均按照一项名为“早期适当治疗”的方案进行治疗，该方案强调在受伤后36小时内对各种骨折进行手术治疗。其中，46例患者有上胸椎和/或颈椎损伤。作者回顾性比较了按方案治疗的患者与未按方案治疗的患者。连续变量采用独立t检验进行比较，分类变量采用Fisher精确检验进行比较。进行逻辑回归分析以考虑基线混杂因素。结果：46例患者中有14例（30%）在36小时内未接受手术。这些患者比方案组患者年龄更大（53岁对38岁，p = 0.008），体重指数（BMI）更高（33对27，p = 0.02），且发生脊髓损伤（SCI）的可能性更小（82%未发生SCI，而方案组为44%，p = 0.04）。在结局方面，未按方案治疗组患者的总机械通气天数（13天对6天，p = 0.02）和总ICU住院天数（16天对9天，p = 0.03）明显更多。未按方案治疗组的感染率为14%，方案组为3%（p = 0.2）。未按方案治疗组的总并发症发生率在统计学上有更高的趋势（57%对31%）。通过逻辑回归控制潜在混杂变量（包括年龄、性别、BMI、种族和SCI）后，未按方案治疗组的总并发症明显更多（p < 0.05）（比值比29，95%可信区间1.9 - 1828）。这表明，如果治疗延迟超过36小时，发生“任何并发症”的几率会增加29倍。结论：对于伴有颈椎或上胸椎损伤的多发伤患者，早期手术固定术可减少并发症并改善结局。医院可考虑制定相关方案，以促进对这类患者进行早期固定术。
