Abstract
Purpose
Cervical traumatic spinal cord–injured patients often way require both anterior cervical spine stabilization and tracheostomy in the first few days after the injury. The infectious complication of tracheostomy can interfere with the evolution of the fixation surgery. The aim of our study was to evaluate the safety of tracheostomy performed early after anterior cervical spine stabilization.
Materials and methods
We reviewed the clinical records of 28 patients admitted to our hospital intensive care unit. In all cases, percutaneous tracheostomy was performed using the percutaneous dilation technique.
Results
The average time interval between the fixation surgery and tracheostomy was 8.25 ± 5.57 days. We had complications in tracheostomy in only 3 cases: minor bleeding occurred in 1 patient and stomal infection, not propagated to the fixation surgery wound, was observed in 2 patients. Two patients died without causal relation to these interventions.
Conclusions
The early performance of tracheostomy after cervical spinal fixation surgery is safe, still realized early and nearly this, at least if the tracheostomy is performed by percutaneous method.
1
Introduction
It is estimated that 40 new traumatic spinal cord injuries (SCIs) are produced annually per million inhabitants. Approximately half of these patients have cervical SCI . Respiratory insufficiency is the primary cause of death both in the short-term and long-term phases of recovery from SCI. Patients with traumatic cervical SCI often need spinal fixation in the first few days after injury . A significant number of such patients experience respiratory insufficiency, requiring intubation and mechanical ventilation (MV), due to respiratory muscles paralysis, difficulties in tracheobronchial secretions clearance, other traumatic associated injuries , and even as a result of the fixation surgery itself .
In these cases, if MV is expected to be prolonged, a tracheostomy is recommended to prevent complications and facilitate weaning as soon as possible because this procedure has been demonstrated to have beneficial effects, such as to optimize the artificial ventilatory support through a drop of dead space, avoid complications of prolonged orotracheal intubation, promote weaning from MV, facilitate bronchial secretions clearance, support phonation and swallowing, and reduce length of sedation .
When tracheostomy has been indicated soon after cervical osteosynthesis, there is a tendency to postpone placement of the tracheostomy until the osteosynthetic wound has fully healed, resulting in a loss of the advantages of early tracheostomy. In recent years, the development of percutaneous dilation tracheostomy has permitted this technique to be performed shortly after anterolateral cervical fixation surgery . Stabilization of the cervical spine is often accomplished by anterior approach by a transverse incision at the anterior neck on patients receiving MV through an endotracheal tube. These patients have been experiencing postsurgical changes that have yet to heal and have 2 incisions that are very close together in the same region of the neck in which the tracheostomy must be performed. This raises concerns about possible contamination and subsequent infection resulting from manipulations in the immediate vicinity of the recent surgical wound or the development of other complications (dehiscence, bleeding, granuloma, stenosis, etc) .
The aim of this study was to determine whether it is safe to perform a tracheostomy after cervical spine fixation; and therefore, we have attempted to specify the complications associated with a tracheostomy after anterolateral cervical spine fixation surgery. We hypothesize that a tracheostomy shortly after anterolateral cervical spine fixation is safe and correct.
2
Methods
We conducted a prospective cohort study for which we have recollected the clinical data of all patients who underwent tracheostomy during their stay in the intensive care unit (ICU) of the National Hospital of Paraplegics in Toledo, Spain, a 7-bed medical/surgical ICU, over a period of 3 years, from June 2006 to May 2009.
For the study, we included all patients with traumatic cervical spinal injury treated with anterolateral cervical spine fixation surgery in whom tracheostomy was subsequently performed because of needed prolonged MV. All tracheotomies were performed by percutaneous dilational technique by skilled practitioners.
The following data were recorded: demographic data (age, sex); severity of trauma, estimated using the description of associated lesions; the level and severity of their injuries, vertebra-spinal and neurologic (based on the classification system used by the American Spinal Injury Association [ASIA] scale ); the surgical technique used; timing of the tracheostomy performed; and early and late complications of tracheostomy, with particular regard to the major or minor bleeding and wound or stomal infection. We have not considered the appearance of dysphagia, a very frequent complication of both cervical spinal stabilization surgery and tracheostomy, although usually immediately reversible. The time from cervical fixation to tracheostomy, from tracheostomy to weaning, and the length of stay in the ICU were also calculated as well as the duration of prior translaryngeal intubation and the duration of MV.
“Early” tracheostomy was defined as that performed within the first 6 days after spinal stabilization surgery, and the late period was after the first postoperative week. Other definitions used are the following: duration of MV, number of days wherein artificial respiration was practiced; successful weaning from MV, breathing without assistance for at least 48 hours; ventilation free days, number of days without any need for ventilatory support.
2.1
Statistical analysis
The continuous variables are presented as means ± SD. The categorical variables are presented as number and percentage values. The Fisher exact test was used to compare qualitative data, given that the number of patients was small and did not follow a normal distribution. Statistical analyses were performed by using the SPSS program for Windows, version 15.0 (SPSS Inc, Chicago, IL). The results were regarded as statistically significant when P value was less than .05.
2
Methods
We conducted a prospective cohort study for which we have recollected the clinical data of all patients who underwent tracheostomy during their stay in the intensive care unit (ICU) of the National Hospital of Paraplegics in Toledo, Spain, a 7-bed medical/surgical ICU, over a period of 3 years, from June 2006 to May 2009.
For the study, we included all patients with traumatic cervical spinal injury treated with anterolateral cervical spine fixation surgery in whom tracheostomy was subsequently performed because of needed prolonged MV. All tracheotomies were performed by percutaneous dilational technique by skilled practitioners.
The following data were recorded: demographic data (age, sex); severity of trauma, estimated using the description of associated lesions; the level and severity of their injuries, vertebra-spinal and neurologic (based on the classification system used by the American Spinal Injury Association [ASIA] scale ); the surgical technique used; timing of the tracheostomy performed; and early and late complications of tracheostomy, with particular regard to the major or minor bleeding and wound or stomal infection. We have not considered the appearance of dysphagia, a very frequent complication of both cervical spinal stabilization surgery and tracheostomy, although usually immediately reversible. The time from cervical fixation to tracheostomy, from tracheostomy to weaning, and the length of stay in the ICU were also calculated as well as the duration of prior translaryngeal intubation and the duration of MV.
“Early” tracheostomy was defined as that performed within the first 6 days after spinal stabilization surgery, and the late period was after the first postoperative week. Other definitions used are the following: duration of MV, number of days wherein artificial respiration was practiced; successful weaning from MV, breathing without assistance for at least 48 hours; ventilation free days, number of days without any need for ventilatory support.
2.1
Statistical analysis
The continuous variables are presented as means ± SD. The categorical variables are presented as number and percentage values. The Fisher exact test was used to compare qualitative data, given that the number of patients was small and did not follow a normal distribution. Statistical analyses were performed by using the SPSS program for Windows, version 15.0 (SPSS Inc, Chicago, IL). The results were regarded as statistically significant when P value was less than .05.
3
Results
During this 3-year period, 152 patients were treated with tracheostomy. There were 28 patients with whom the tracheostomy was performed after anterior or anterolateral cervical spine stabilization surgery. We reviewed the data from of these 28 patients who complied with the inclusion criteria. Of these patients, 23 (82.1%) were men, whereas the remaining 5 (17.9%) were women. Their ages ranged from 21 to 74 years and the mean age was 39.6 ± 13.7 years. The cause of spinal fracture was a driving accident in 17 cases (60.7%), fall in 9 (32.1%), and diving accident in 2 (7.2%). All patients have traumatic cervical SCI.
In all cases, percutaneous tracheostomy was performed using the percutaneous dilation technique, by a specialist in intensive care medicine at the ICU of our hospital. The tracheostomy was performed early within the first 7 days after intubation in 14 cases (50%) and after the eighth day after intubation (late) in the remaining 50%. All our patients had SCI together with vertebra-spinal fracture. The level of the vertebrae fracture was as follows: C1 to C3, 3 cases (10.7%); C4 to C5, 15 cases (53.6%); and C6 to C7, 10 cases (35.7%). The severities of the underlying neurologic injuries, based on the ASIA classification system, were classified as ASIA A, 21 cases (75%); ASIA B, 4 cases (14.3%); and ASIA C, 3 cases (10.7%). Of these 28 patients, 15 (53.6%) presented other traumatic lesions in addition to SCI, some of which were present in more than 1 body region, and which were distributed as follows: traumatic brain injury, 11 patients (39.3%); craniomaxillofacial trauma, 1 patient (3.6%); blunt thoracic trauma, 4 patients (14.3%); abdominal trauma, 1 patient (3.6%); and fracture of pelvis or large bones of the limbs, 2 patients (7.1%). Other clinical data are shown in Table 1 .
