Margaret M. Griffen

The effect of early spine fixation on non-neurologic outcome.

INTRODUCTION It has been shown that spinal fracture fixation within 3 days can reduce the incidence of pneumonia, length of stay, number of ventilator days, and hospital charges. Our institutional protocol calls for surgical stabilization of spinal fractures within 3 days of admission. We hypothesized that compliance with an early spinal fracture fixation protocol (within 3 days of admission) would improve non-neurologic outcome in patients with spinal fractures. METHODS The trauma registry was queried for the period January 1988 through October 2001 to identify patients with spinal fractures requiring surgical stabilization. Patients were analyzed to determine the compliance with our protocol and to determine whether early spinal fixation can reduce the incidence of pneumonia, reduce length of stay, and reduce mortality. RESULTS 1,741 patients with spinal fractures were identified. 299 (17.2%) required surgical stabilization. 174 (58.2%) had surgical stabilization within 3 days while 125 (41.8%) had surgical stabilization greater than 3 days from admission. There were no significant differences between the two groups with regards to age (37.9 versus 42.5), admission GCS (14.1 versus 13.9), or ISS (22 versus 20.8). The incidence of pneumonia was similar in both groups (21.8 versus 25.6%). The mortality was higher in the early group as compared with the late group (6.9 versus 2.5%), although it did not reach statistical significance. The hospital length of stay was significantly shorter (14.3 versus 21.1) for patients who had early spine fixation, however there was no statistically significant difference between the two groups with regards to intensive care unit length of stay (7.2 versus 7.9) or number of ventilator days (5.02 versus 1.9). Patients who were severely injured (ISS > 25) also had a significantly shorter hospital length of stay (19.6 versus 29.1) if they underwent early spinal fixation. Patients with thoracic spine injury and associated spinal cord injury had a significantly shorter HLOS (10.1 versus 30.5), ICULOS (2.3 versus 13.1), and lower incidence of pneumonia (6.5 versus 33.3%). CONCLUSIONS Reasonable compliance with an early spinal fracture fixation protocol produced some outcome improvements in non-neurologic outcome. Early spine stabilization reduced hospital length of stay in all patients. Patients with thoracic spine trauma and a spinal cord injury had the greatest benefit in reduction of morbidity, HLOS and ICULOS from early stabilization. There was a trend toward poorer outcome in some groups with early spine stabilization. A rigid protocol requiring early surgical spine stabilization in all patients does not appear justified. Although early spine stabilization should be performed whenever possible to reduce hospital length of stay, the timing of this procedure should be individualized to allow patients with the most severe physiologic derangements to be optimized preoperatively.

Guidelines for Management of Small Bowel Obstruction

STATEMENT OF THE PROBLEMThe description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management o

Definitive Establishment of Airway Control is Critical for Optimal Outcome in Lower Cervical Spinal Cord Injury

BACKGROUND Respiratory complications can undermine outcome from low cervical spinal cord injury (SCI) (C5-T1). Most devastating of these is catastrophic loss of airway control. This study sought to determine the incidence and effect of catastrophic airway loss (CLA) and to define the need for elective intubation with subsequent tracheostomy to prevent potentially fatal outcomes. METHODS A database of 54,838 consecutive patients treated in a level I trauma center between January 1988 and December 2004 was queried to identify patients with low cervical SCI, without traumatic brain injury. Patients were then stratified into complete or incomplete SCI groups, based on clinical assessment of their SCI. Mortality, age, injury severity, need for intubation, and tracheostomy were analyzed for each group using Fishers exact test or Students t test, as appropriate, accepting p < 0.05 as significant. RESULTS One hundred eighty-six patients met inclusion criteria. The majority of low cervical spinal cord injuries were complete (58%). Overall, 127 (68%) patients required intubation, 88 (69%) required tracheostomy, and 27 died (15% of study population). Between each group there were significant differences in age and Injury Severity Score, however, within each group there were no significant differences in either. Eleven CSCI patients were not intubated; four of whom were at family request. Six of the remaining seven patients encountered fatal catastrophic airway loss. One patient was discharged to rehabilitation. Patients with incomplete SCI required intubation less frequently (38%); however, 50% of those required tracheostomy for intractable pulmonary failure. CONCLUSIONS These data indicate that regardless of severity of low cervical SCI, immediate, thorough evaluation for respiratory failure is necessary. Early intubation is mandatory for CSCI patients. For incomplete patients evidence of respiratory failure should prompt immediate airway intervention, half of whom will require tracheostomy.

Practice management guidelines for timing of tracheostomy: The EAST practice management guidelines work group

STATEMENT OF THE PROBLEM The ideal time for performing a tracheostomy has not been clearly established. Periods ranging from 3 days to 3 weeks have been suggested in the literature. With current operative methods, it has been established that tracheostomy can be performed with a low rate of complications. In a review of 281 tracheostomies, as well as another 2,862 cases in the literature, Zeitouni and Kost1 reported 0% mortality in their series and 0.3% mortality in the other series since 1973. The risks of prolonged endotracheal intubation—such as patient discomfort, necessitating increased sedation; sinusitis; inadvertent extubation; and laryngeal injury—have become increasingly apparent. Selection of patients who might benefit from conversion of a translaryngeal tube to a tracheostomy tube is a complex medical decision. Furthermore, different subgroups may benefit from tracheostomy at different times in their hospital course. Management of patients with a single organ failure (head injury or respiratory failure) may differ from that of the multiple injury trauma patient. With the lack of clear guidelines for selecting patients for tracheostomy, considerable variability exists in the timing of the procedure, with local practice preferences guiding care, rather than patient considerations. We initiated our review by converting the need for information about optimal timing of tracheostomy into several answerable questions: 1. Does performance of an “early” tracheostomy provide a survival benefit for the recipients? 2. What patient populations benefit from an “early” tracheostomy? 3. Does “early” tracheostomy reduce the number of days on mechanical ventilation and intensive care unit length of stay (ICU LOS)? 4. Does “early” tracheostomy influence the rate of ventilatorassociated pneumonia?

The effect of early surgical treatment of traumatic spine injuries on patient mortality.

INTRODUCTION The ideal timing of spinal fixation is controversial. A recent study showed that early spine fixation reduced morbidity and resource utilization. We previously noted a trend toward higher mortality in patients undergoing early spinal fixation. This study was done to analyze whether the timing of spinal fixation had a significant effect on mortality. METHODS The registry of our Level I trauma program was queried for all patients with at least one spinal vertebral injury. Anatomic and physiologic variables included age, initial Glasgow Coma Scale score, systolic blood pressure, heart rate, and Injury Severity Score. Outcome was evaluated in terms of ventilator days, intensive care unit length of stay, hospital length of stay (HLOS), and mortality. Patients were stratified by day of spinal operative fixation as early when done within 48 hours and late when done after 48 hours. Data were analyzed using chi and an unpaired t test, accepting p < 0.05 as significant. RESULTS Three hundred sixty-one patients between January 1988 and February 2003 required operative spinal fixation (158 early, within 48 hours vs. 203 late, beyond 48 hours). There was no significant difference between the two groups except mortality, which was significantly higher in the early group (7.6 vs. 2.5%; p = 0.0257), and HLOS, which was significantly shorter in the early group (14.42 vs. 17.64 days; p = 0.025). CONCLUSION Spinal fixation within 48 hours after vertebral fractures and dislocations appears to increase mortality despite similar anatomic and physiologic parameters in the later operative group. Incomplete resuscitation of patients before surgery may have contributed to this result. The shorter HLOS may have been because of the higher number of early deaths. Prospective studies to identify the optimal timing of spinal fixation and the reason for these outcome differences are warranted.

Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank

BACKGROUND To examine the efficacy of early versus late spinal fracture fixation, we reviewed National Trauma Data Bank (NTDB) records to identify the breakpoint in reported timing of operative fixation. Using this breakpoint we then analyzed outcome for those treated early versus late, hypothesizing that the early group would experience better outcome as reflected by resource utilization and complications. METHODS The NTDB was queried for patients with any level spinal fracture that required surgical stabilization. Histogram analysis of the postinjury day of initial operative fixation was used to determine the point at which the majority of operative procedures had been performed, thereby defining early (E) and late (L) groups. Patients in E were matched to a cohort from L with similar age, Injury Severity Score, and Glasgow Coma Scale. Outcome data included hospital length of stay, intensive care unit length of stay, ventilator days, charges, incidence of complications, and mortality. The groups were compared using Students t test for continuous variables and Fishers exact test for categorical variables, accepting p < or = 0.05 as significant. RESULTS Of 16,812 patients who underwent operative fixation, 59% were completed within 3 days of injury and formed E. The 374 L patients whose dataset was complete enough to allow analysis were matched to 497 E patients. There was no significant difference in the presence of spinal cord injury between E and L (51 vs. 48%; p = 0.3735). Complications were significantly higher in L (30% vs. 17.5%; p < 0.0001) yet mortality was similar in both groups (2.0% vs.1.9%; p > 0.05). CONCLUSIONS NTDB records indicate that the majority of patients with spinal fractures undergo operative fixation within 3 days, and that these patients had less complications and required less resources. Use of a national data bank to compare groups with similar injury severity and presenting physiology can validate best practice and define opportunities for improvement in care.

Age: Is It All in the Head? Factors Influencing Mortality in Elderly Patients With Head Injuries

BACKGROUND Elderly patients, an increasing segment of the population, who sustain traumatic brain injury (TBI) are known to have worse outcomes, including higher mortality. This objective of this study was to examine the Crash Injury Research Engineering Network and to determine at what age motor vehicle crash fatalities from head injuries increased. METHODS The Crash Injury Research Engineering Network database was queried from 1996 to 2009. Study inclusion criteria were adult vehicle occupants with TBI, with an Abbreviated Injury Scale score ≥2. The age at which mortality increased was calculated. Patients younger and older than this cutoff age were compared to determine differences in crash characteristics. The determined cutoff age was compared with one found in a larger, population-based database. RESULTS There were 915 patients who met the study criteria. An increase in mortality was seen at age 60 years despite no difference in Injury Severity Score and a decrease in crash severity. Patients ≤60 years were more likely to have alcohol involved, to be in a rollover crash, and had higher crash speeds. Comparing the element of the crash attributed to the head injury, the patients >60 years were more likely to have struck the airbag, door, and seat. An analysis of the larger database revealed an increase in mortality at age 70 years. CONCLUSIONS There was a higher mortality secondary to head injuries in those older than 60 years involved in motor vehicle crashes. Improved safety measures in vehicle design may decrease the number of head injuries seen in the older population.

Are pediatric concussion patients compliant with discharge instructions

BACKGROUND Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management. METHODS A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit. RESULTS A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance. CONCLUSION Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance. LEVEL OF EVIDENCE Care management, level IV. Epidemiologic study, level III.

Two careers in one: an analysis of the earning power of certification in surgical critical care.

BACKGROUND The core of general surgery supports multiple disciplines, each of which entails similar operative care for different diseases. The purpose of this study was to compare variations of practice patterns of four general surgeons to define the general surgical core that each shared in common, and to determine the effect of subspecialization in surgical critical care on the scope of practice and efficiency of revenue production. METHODS The charges and collections of four members of the same surgical faculty were analyzed for the 6 months beginning July 1, 2000. Three members practiced general surgery with additional specialization in surgical oncology, surgical endoscopy, and trauma/critical care. The fourth covered all aspects of general surgery, including in-house trauma call, but not surgical critical care. Data were stratified by Current Procedural Terminology code and categorized as operative, bedside care (which included minor procedures), and evaluation/consultation care. Scope of practice was defined as the proportion of operative cases represented by the 10 most frequently performed procedures. General surgical core was defined as those cases that were preformed by all four surgeons at the same frequency. Efficiency of revenue generation was defined as collection rate for these procedures divided by the established, budgeted collection rate for each practitioner. All results were compared using chi(2) with significance accepted at p < 0.05. RESULTS Fifteen operative procedures were performed with equal frequency by each surgeon and represented a broad spectrum of surgical disease. These procedures constituted a similar proportion of operative practice for all specialists (mean, 45.2%; 90% confidence limit, 3.5%), yet occupied 70% of the trauma surgeons 10 most frequent surgical procedures versus 36% for the surgical oncology and surgical endoscopy. Charges generated by the provision of surgical critical care, especially in bedside procedures commonly performed in the intensive care unit, exceeded all of the other three surgeons and equaled the revenue generated by operative care. Although overall revenue-generating efficiency was less for the trauma surgeons (57% of eventual collections vs. 67%, chi(2) p = 0.1), immediate reimbursement for critical care was higher than for any other clinical services. CONCLUSION These data demonstrate that subspecialization in surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional operative care, and fees generated can actually exceed revenue from operative care. With impending decreases in global reimbursement, and attempts to unbundle operative fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs.

Experience with 161 cases of anterior exposure of the thoracic and lumbar spine in an acute care surgery model: impact of exposure level and underlying pathology on morbidity.

Study Design. Retrospective chart review. Objective. To evaluate the outcomes of anterior exposure of the thoracic and lumbar spine by an acute care surgery service. Summary of Background Data. Spine surgeons typically require an “approach surgeon” to provide anterior exposure of the thoracic and lumbar spine. We hypothesized that a dedicated acute care surgery service can perform those operations with acceptable morbidity and mortality. Methods. A retrospective review of 161 trauma and nontrauma patients was performed. All cases were performed at a level I trauma center with a dedicated acute care surgery service. In-hospital morbidity and mortality were evaluated. A brief description of the operative techniques used by our group is also provided. Results. Of the 161 patients, 59 (37%) were trauma patients. Ninety-three patients (58%) had anterolateral retroperitoneal exposure of the thoracic and lumbar spine. Sixty-eight patients (42%) had anterior retroperitoneal midline exposure of the lumbar and lumbosacral spine. Total morbidity was 9.3% (7.4% for trauma patients and 1.8% for non trauma patients). Morbidity was highest in patients who had anterolateral exposure of the thoracic and lumbar spine (6.8%). Morbidity in patients who had midline exposure of L4 to S1 was 0%. Total mortality was 1.2% (3.3% for trauma patients and 0% for nontrauma patients). The acute care surgery service gained 3141 physician work relative value units (RVU) by performing those operations. Conclusion. Anterior exposure of the thoracic and lumbar spine both for trauma and nontrauma related indications can be performed with acceptable morbidity and mortality by a dedicated acute care surgery service. Morbidity and mortality were higher in trauma patients and in those who underwent thoracolumbar procedures. Patients who had midline exposure of L4 to S1 for degenerative disc disease had the lowest morbidity. Level of Evidence: 4