Timing of thoracic and lumbar fracture fixation in spinal injuries: a systematic review of neurological and clinical outcome

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1 Eur Spine J (2007) 16: DOI /s REVIEW Timing of thorcic nd lumbr frcture fixtion in spinl injuries: systemtic review of neurologicl nd clinicl outcome Jozef Pulus Henricus Johnnes Rutges Æ F. Cumhur Oner Æ Luke Peter Hendrik Leenen Received: 9 Jnury 2006 / Revised: 9 August 2006 / Accepted: 5 September 2006 / Published online: 16 November 2006 Ó Springer-Verlg 2006 Abstrcts A systemtic review of ll vilble evidence on the timing of surgicl fixtion for thorcic nd lumbr frctures with respect to clinicl nd neurologicl outcome ws designed. The purpose of this review is to clrify some of the controversy bout the timing of surgicl frcture fixtion in spinl trum. Better neurologicl outcome, shorter hospitl sty nd fewer complictions hve been reported fter erly frcture fixtion. But there re lso studies showing no difference in neurologicl outcome when compred to lte tretment. Mortlity is nother controversil point since recent report of higher mortlity in erly treted ptients. A systemtic review of the literture ws preformed. Ten rticles were included. Erly frcture fixtion is ssocited with less complictions, shorter hospitl nd ICU sty. The effect of erly tretment on the neurologicl outcome remins uncler due to the contrdictory results of the included studies. Erly thorcic nd lumbr frcture fixtion results in improvement of clinicl outcome, but the effect on neurologicl outcome remins controversil. Keywords Review Spinl frctures Timing Surgicl fixtion Outcome nd trum J. P. H. J. Rutges (&) F. C. Oner Deprtment of Orthopedic Surgery, University Medicl Centre Utrecht, Heidelbergln 100, Utrecht 3584 CX, The Netherlnds e-mil: j.rutges@umcutrecht.nl L. P. H. Leenen Deprtment of Surgery, University Medicl Centre Utrecht, Utrecht, The Netherlnds Introduction Trumtic injuries of the spinl column re less common thn extremity frctures nd hve low functionl outcome [23]. Spinl frctures hve n nnul incidence of 64 per 100,000 [23] nd neurologicl deficit is seen in 10 30%, resulting in n estimted 12,000 new spinl cord injuries in the United Sttes every yer [23, 50, 53]. Only 54% of ll ptients with spinl frctures return to their previous level of employment [31]. Spinl stbiliztion with internl fixtion is indicted in unstble spinl frctures, spinl cord compression nd progressive neurologicl deficit [31, 38, 53]. Although erly spinl stbiliztion in thorcic nd lumbr frctures is ssocited with shorter hospitl sty, less complictions nd more neurologicl recovery, timing of surgicl fixtion of unstble frctures remins controversil [11, 21, 30, 32, 49, 53]. The rguments for erly fixtion of unstble thorcic nd lumbr spine frctures re minly bsed on the results of niml spinl cord decompression studies nd clinicl studies on timing of femur frcture fixtion. Improved neurologicl outcome is reported fter erly decompression in niml experiments [7, 14, 17, 18, 52]. Advntges of erly femur frcture fixtion re well known nd reported by severl studies [5, 6, 10, 20, 24, 40, 47]. Clinicl reserch in the pst decde suggests tht erly stbiliztion of spinl frctures my improve neurologicl outcome, reduce complictions, ICU nd hospitl sty [8, 10, 11, 19, 26, 30, 32, 36, 41, 45, 49]. Erly stbiliztion is considered sfe but recent study by Kerwin et l. [26] reports trend to higher mortlity in erly-operted ptients. Neurologicl outcome is subject of debte; while some rticles report no difference in neurologicl outcome in erly nd lte

2 580 Eur Spine J (2007) 16: stbilized spinl frctures [22, 42, 54], other studies report significntly better neurologicl outcome in erly operted ptients [19, 45]. In order to clrify some of the controversy on the timing of surgicl stbiliztion systemtic review ws conducted. An electronic literture serch ws preformed, the retrieved rticles were criticlly pprised nd levels of evidence (LOE) were determined. The ims of this review re to report ll the vilble evidence for the timing of stbiliztion of trumtic thorcic nd lumbr frctures nd to identify ptient relted fcts (e.g., trum severity nd frcture level) in which the outcome ws obtined. Methods The electronic dtbses of MEDLINE ( EMBASE ( nd Cochrne Collbortion ( were serched. Detils bout the serch strtegy re stted in Tble 1. There were 181 hits in MEDLINE nd 236 in EMBASE, no rticles were found in the Cochrne librry. All rticles were screened for relevncy by reding titles nd bstrcts. Inclusion criteri were cler comprison of outcome between different time points nd trumtic frctures tht required surgicl stbiliztion of the thorcic or lumbr spine. Trum severity ws not selection criteri nd ptients rnging from polytrum to single level frctures were included in this study. Articles concerning children, the cervicl spine, conservtive tretment, pthologic frctures nd decompression surgery without fixtion or stbiliztion were excluded. In Medline ten rticles [8, 10 12, 26, 29, 30, 32, 43, 45, 49] were found nd one rticle [19] ws found fter reference trcking. In EMBASE two dditionl rticles [29, 48] were found resulting in totl of 13 rticles (Tble 2). Full text copies were obtined nd nlyzed. Men ge, frcture chrcteristics, trum severity, neurologicl impirment, surgicl tretment, use of corticosteroids nd rehbilittion protocols were ssessed. The rticles by Prsd et l. [43], De Lun et l. [12] nd Mgerl [29] were excluded. The resons for exclusion were no cler comprison between different time points nd full text of the rticle by De Lun et l. [12] ws not vilble. The remining ten rticles were criticlly pprised (Tble 3). Qulity ssessment ws bsed on the Cochrne Hndbook for Systemtic Reviews of Interventions [51]. In order to determine the possibility of selection bis the selection procedure nd the homogeneity of the ptient popultions were exmined. The studies were lso ssessed on stndrdiztion of opertive procedure nd peri- nd postopertive cre in order to determine the risk on performnce bis. Attrition bis ws scored on the bsis of percentge follow-up nd exclusion criteri. The risk on detection bis ws bsed on the description of how the dt ws cquired nd how sttisticl nlysis ws performed. Levels of evidence (LOE) of the included rticles were determined ccording to the center for evidence bsed medicine (CEBM) instructions ( Results Ptient nd study chrcteristics (Tbles 2, 3) The ge of the 1,427 ptients in the included studies re comprble, most ptients re in the fourth decde of life t the time of injury, with men ge of 35.3 yers. Trum severity scores were similr in the studies tht included ll trum levels nd higher in the studies by McLin [32] nd Di et l. [11] which focus on polytrum ptients. McKinley et l. [30], Di et l. [11] nd Rth et l. [45] only included ptients with neurologicl impirment; in the other studies the percentge of neurologicl impirment rnges between 47 nd 76%. Phrmceuticl tretment with corticosteroids is mentioned by McLin [32], Rth et l. [45] nd Schlegel et l. [49]. McLin [32] initites tretment with corticosteroids s soon s possible t the emergency room. Corticosteroid therpy ws not dminis- Tble 1 Serch strtegy (results: ) Dtbse Serch Limits Hits MEDLINE EMBASE (surgicl OR surgery) AND (tretment OR stbiliztion OR frcture repir OR fixtion) AND (spinl OR spine OR vertebrl) AND (trum OR injury OR frcture OR polytrum) AND (timing OR erly OR urgent) AND (outcome OR complictions OR sty) [surgicl OR ( surgery /exp OR surgery )] AND [tretment OR stbiliztion OR ( frcture /exp OR frcture ) AND repir OR fixtion)] AND [(spinl OR ( spine /exp OR spine ) OR vertebrl] AND [( trum /exp OR trum ) OR ( injury /exp OR injury ) OR ( frcture /exp OR frcture ) OR ( polytrum /exp OR polytrum )] AND (timing OR erly OR urgent) AND (outcome OR complictions OR sty) Title/bstrct 181 None 236

3 Eur Spine J (2007) 16: Tble 2 Ptient chrcteristics Authors No. of ptients Age Frcture level Trum severity Neurologicl impirment Schinkel et l. [48] 72 h: h: 15 Kerwin et l. [26] 72 h: h: 85 Rth et l. [45] 24 h: h: 7 48 h: 24 Chipmn et l. [8] 72 h: h: 77 Di et l. [11] 72 h: h: 50 McKinley et l. [30] 72 h: h: 296 Croce et l. [10] 72 h: h: 68 Gebler et l. [19] 8h: h: h: 12 McLin [32] 24 h: h: 13 Schlegel et l. [49] 72 h: h: (14 78) Thorcic 27 ISS % 39.5 Thorcic 90 ISS 21.8 ND Lumbr Thorcolumbr (T12-L2) 31 ND 100% (15 84) Other Thorcolumbr 146 ISS % 34.8 Thorcolumbr (T12-L2) 91 ISS % (17 64) (13 66) 36.2 ND ND 100% 32.1 Thorcic 79 Lumbr Thorcic 34 Lumbr Thorcic 9 Lumbr Thrcic 28 (2 83) Thorco-lumbr (T11-L2) 53 Lumbr 17 Cervicl 19 ISS % 15.9% Polytrum 76% ISS % ISS % Prsd et l. [43] 29 ND Thorcic 25 ND ND Lumbr 26 De Lun et l. [12] b 24 Mgerl [29] 45 ND ND ND ND ND Not described Only in ptients with ISS 15, none of the 58 ptients with ISS 15 hd neurologicl impirment b Full text not vilble tered to ptients tht were operted 1 week or more fter initil trum in Rth et l. s [45] study. Schlegel et l. [49] describe tht corticosteroids were not dministered during his study since the beneficil effect of steroid derivtes ws not mde public t the time of study. Rehbilittion fter frcture stbiliztion is described by only three rticles [19, 32, 49]. An orthosis nd erly mobiliztion were included in the rehbilittion protocol of these studies. Qulity (Tble 4) Since ll studies were prognostic outcome studies they were scored LOE IIc. They were ssessed on the risk of selection, performnce, ttrition nd detection bis. Gebler et l. [19] nd McLin [32] disply dequte selection nd stndrdiztion. Doubt exists on the selection procedure in the rticle by Schlegel et l. [49], which included ptients rnging from 2 to 83 yers of ge t the time of injury. In the study popultion described by Schinkel et l. [48] there is much difference in ge nd neurologicl impirment between the study groups. The studies by Mckinley et l. [30] nd Chipmn et l. [8] do not describe frcture chrcteristics. The studies by Mckinley et l. [30], Croce et l. [10], Chipmn et l. [8] nd Kerwin et l. [26] lck stndrdiztion, they do not clerly describe the used opertive technique nd peri- nd postopertive cre ws not stndrdized. Di et l. [11], Schinkel et l. [48] nd Rth et l. [45] dequtely describe the stndrd opertive procedure, but postopertive tretment or rehbilittion is not mentioned. Loss of follow-up ws 33% in the lte follow-up group of Schlegel et l. [49] nd 15% in the study of Gebler et l. [19]. Mckinley et l. [30] describe 1-yer follow-up but does not mention for which percentge of the ptients this follow-up ws obtined nd could only report time to surgery in dys nd not in hours. Results nd conclusions of the included rticles Results nd conclusions of these rticles were ssessed nd compred with ech other. A summry of the re-

4 582 Eur Spine J (2007) 16: Tble 3 Study chrcteristics Authors nd recruitment Tretment Corticosteroids Rehbilittion Follow up Outcome Schinkel ( ) Kerwin ( ) Rth ( ) Chipmn ( ) Di ( ) McKinley ( ) Croce ( ) Gebler ( ) McLin ( ) Schlegel ( ) Prsd recruitment period unknown De Lun ( ) Mgerl ( ) ND Not described Ventrodorsl pproch, posterior trnspediculr stbiliztion nd scopic nterior fusion ND ND Hospitl ND ND ND Hospitl Posterior trnspediculr stbiliztion nd decompression if necessry Administered in frctures less thn 1 week old ND 8 36 months (men 14.2) Anterior or posterior repir ND ND Hospitl Segmentl instrumenttion, nterior nd posterior pproch Lminectomies, spinl decompression, spinl fusions nd internl fixtions ND ND 3 12 yers (men 5.2 yers) Lung function, ventiltor dys, hospitl nd ICU sty Mortlity, pneumoni, ICU sty, hospitl sty nd ventiltor dys Neurologicl outcome (Frnkel) Complictions, ICU sty, hospitl sty nd neurologicl outcome Mortlity, complictions nd neurologicl outcome (ASIA) ND ND 1 yer Hospitl sty, rehbilittion length, chrges nd neurologicl outcome (ASIA) ND ND ND Hospitl Posterior pedicle instrumenttion nd decompression if necessry Posterior spinl stbiliztion nd combined with nterior procedure for decompression or stbiliztion if necessry Anterior or posterior pproch 26 trnspediculr screw plte fixtion, 2 interlminr wire fixtion nd 1 lminectomy ND Initited in the emergency room Not dministered Light orthosis for 3 months Molded orthosis nd erly mobiliztion Orthosis nd rehbilittion protocol yers (men 5.6) Mortlity, pneumoni, ventiltor dys, ICU sty, hospitl sty nd chrges Complictions, revisions, rdiogrphic mesurements nd neurologicl outcome (Frnkel) 2 yers Mortlity nd neurologicl outcome (Frnkel) Hospitl (neurologicl impirment 3.6 yers) ND ND Hospitl Complictions, ventiltor dys, ICU sty, hospitl sty nd chrges Neurologicl outcome (Frnkel) Segmentl spinl instrumenttion with bent rods Complictions ND ND ND Men 4.7 yers Complictions nd neurologicl outcome (Frnkel) sults is shown in Tble 4. McLin [32] nd Croce et l. [10] report tht stbiliztion within 72 h is sfe in polytrum ptients nd does not result in higher mortlity. Kerwin et l. [26] suggest individulized preopertive optimiztion. Di et l. [11] gree with Kerwin et l. [26] nd stte tht thorcolumbr frcture fixtion should not be dependent on rigid protocol. When ptients re hemodynmiclly unstble nd poorly resuscitted lte stbiliztion is preferred. McLin [32] concludes tht erly stbiliztion is pproprite in progressive neurologicl deficit nd unstble frctures (Tbles 5, 6). Rth et l. [45] nd Gebler et l. [19] found significntly more neurologicl improvement in erlyoperted ptients. Chipmn et l. [8], Di et l. [11] nd McKinley et l. [30] report no difference in neurologicl outcome. Fewer complictions fter erly surgery re reported by Chipmn et l. [8]. The incidence of pneumoni nd pulmonry complictions like cute respirtory distress

5 Eur Spine J (2007) 16: Tble 4 Study qulity Authors nd yer Study design Selection bis Performnce bis Attrition bis Detection bis LOE Schinkel et l. [48] RCS +/ +/ Kerwin et l. [26] RCS + Rth et l. [45] RCS + +/ + Chipmn et l. [8] RCS +/ Di et l. [11] RCS + +/ + McKinley et l. [30] PCS +/ +/ +/ IIc Croce et l. [10] RCS + Gebler et l. [19] RCS + + +/ McLin [32] PCS + + Schlegel et l. [49] RCS +/ + RCS Retrospective comprtive study, PCS prospective comprtive study, (+) low risk of bis, (+/ ) moderte risk of bis doubtful, ( ) high risk of bis Attrition bis not determined, follow up ws limited to hospitl Tble 5 Results of the studies tht combine thorcic nd lumbr frctures Authors nd yer Mortlity Complictions Hospitl sty (dys) Neurologicl outcome <72 h >72 h <72 h >72 h <72 h >72 h <72 h >72 h Rth et l. [45] Chipmn et l. [8] McKinley et l. [30] Gebler et l. [19] McLin [32] Improvement 1.64 Frnkel grdes,b * Improvement 0.61 Frnkel grdes b,c * All complictions All complictions 9.9* ICU 18.9* ICU Improvement 39.1% 54.6% 3.5* 8.5* Pulmonry Pulmonry 14.1* 19.3* ASIA motor 34.6%* 45.4%* index % d Wound inf. Wound inf e 3.8% e 4.0% f 7.1% 7.7% g ARDS b 0% ARDS 7.7% g 1.10 Frnkel grdes,b Schlegel Pulmonry et l. [49] 6.8%* Pulmonry 27.6%* 18.3 * ICU 3.0* 29.0* ICU 7.8* Pulmonry All pulmonry complictions, Wound inf. deep wound infection *P < 0.05 <24 h b Neurologicl outcome only described in ptients with neurologicl impirment t rrivl t the hospitl c >24 h d Dt not vilble for seprted groups e <8 h f h g h Improvement 1.20 Frnkel grdes b ASIA motor index Improvement 0.57 Frnkel grdes b,g Improvement 1.20 Frnkel grdes b Tble 6 Results of studies tht describe thorcolumbr frctures Authors nd yer Mortlity Complictions Hospitl sty (dys) Neurologicl outcome <72 h >72 h <72 h >72 h <72 h >72 h <72 h >72 h Di et l. [11] 3.3% Pulmonry 21% 18.2 Recovery rte 71.4% Chipmn et l. [8] All complictions 39.1%* All complictions 54.6%* 9.9* ICU 3.5* 18.9 * ICU 8.5* Dt not vilble for seprted groups *P < 0.05

6 584 Eur Spine J (2007) 16: syndrome (ARDS) is lower in the erly operted groups, reported by Kerwin et l. [26], McKinley et l. [30], Croce et l. [10] nd Schlegel et l. [49]. Kerwin et l. [26] nd Croce et l. [10] report this decrese in pneumoni especilly for thorcic frctures. Di hs found no sttisticl difference in compliction rte in erly nd lte operted ptients. Gebler et l. [19] nd Di report complictions relted to the internl fixtion such s implnt loosening or filure of fixtion. Di et l. [11] hd no implnt filure in his 91 ptients nd implnt loosening ws found in 4.5% by Gebler et l. [19] nd filure of fixtion in 6.8%. Decresed hospitl sty in erly operted ptients is found in the rticles by Kerwin et l. [26], Chipmn et l. [8], McKinley et l. [30], Croce et l. [10] nd Schlegel et l. [49]. Shorter ICU sty in erly-operted ptients is reported by Chipmn et l. [8], Croce et l. [10] nd Schlegel et l. [49]. Discussion The electronic literture serch resulted in ten rticles tht were relevnt for this systemtic review. All studies were grded LOE IIc since they re ll prognostic outcome studies. Criticl pprisl of the included studies showed importnt flws in severl of them. For exmple, surgicl techniques re poorly described in six of the ten rticles. On the bsis of LOE nd the qulity of the included studies we must conclude tht the vilble evidence is limited. Nevertheless, this does not men tht we cnnot drw some conclusions from those studies. Controversy exists on the sfety of surgery within 72 h. McLin [32], Kerwin et l. [26] nd Croce et l. [10] report similr mortlity in erly nd lte procedure for thorcic or lumbr frctures. Kerwin et l. [26] report trend to higher mortlity in his rticle, but only in erly tretment of cervicl spine frctures. Since none of the studies report higher mortlity in erly-operted ptients with thorcic or lumbr frctures we cn conclude tht erly surgery is sfe. Becuse periopertive mortlity is quite uncommon with reported incidences between 0 nd 7.7%, study size is n importnt fctor in the ccurcy of mortlity results. Mortlity results re often bsed on smll number of decesed ptients, nd therefore the precision of these results is often limited. For more ccurte mortlity results, lrger ptient popultions re needed. Hospitl nd ICU sty is decresed by erly tretment. In ll included rticles tht report hospitl sty reduced number of hospitl dys nd ICU dys re found in the erly-operted ptient groups. A much longer hospitl sty ws found in the study by Schinkel et l. [48] since the neurologiclly impired ptients styed in the treting hospitl during their rehbilittion insted of nother rehb institution. Differences in incidence of complictions re reported in lmost ll included studies. Only Di et l. [11] nd Gebler et l. [19] found no significnt difference in compliction rte. Decrese of pulmonry complictions, like ARDS nd pneumoni, re reported for erly-stbilized thorcic nd lumbr frctures. Compring the outcome of thorcic with the outcome of lumbr frctures (Tbles 7, 8), the effect of erly surgery is more profound in thorcic frctures. A possible explntion cn be found in the rticles by Chipmn et l. [8], Kerwin et l. [26] nd Croce et l. [10]. All three studies show trend to higher ISS in thorcic thn in lumbr frctures. Chipmn et l. [8] lso report significntly more complictions nd longer hospitl sty in ptients with ISS > 15 compred with ISS < 15. Bsed on this dt we cn conclude tht the clinicl outcome of trumtic spinl frctures is not only influenced by timing of surgery but lso by frcture level nd trum severity. These findings suggest tht erly surgery is especilly dvntgeous in ptients with high ISS nd thorcic frctures. The study by Gebler et l. [19] describes implnt loosening nd filure. There ws no difference in incidence between erly nd lte stbilized for this type of compliction. Hrdwre filure rnges from 0 to 17% [13, 19, 33, 34, 38]. Re-opertion is needed in hlf of the ptients with hrdwre filure [13]. To reduce the risk of hrdwre filure experienced spine surgeons should be vilble for 24 h dy to perform erly surgery s dvocted by severl studies discussed in this review. This could be problem for smll trum center becuse this my result in n increse in stff working hours nd expenses. Rth et l. [45] nd Gebler et l. [19] report more neurologicl improvement in erly-stbilized ptients. Erly tretment is defined s tretment within 24 h in the rticle by Rth et l. [45] nd within 8 h by Gebler et l. [19]. Chipmn et l. [8], Di et l. [11] nd McKinley et l. [30] report no difference in neurologicl outcome, but they define erly surgery within 72 h. Animl studies hve reported n improved neurologicl outcome in erly decompressive surgery in spinl cord injury [7, 14, 17, 18, 52]. The timing of decompression in niml studies rnges from minutes to hours rther thn dys. The erlier the decompression, the better is the neurologicl outcome; this is reported by severl niml studies [7, 14, 17, 18]. These results cnnot be simply compred with clinicl results,

7 Eur Spine J (2007) 16: Tble 7 Results of studies tht describe thorcic frctures Authors nd yer Mortlity Complictions Hospitl sty (dys) Neurologicl outcome <72 h >72 h <72 h >72 h <72 h >72 h <72 h >72 h Schinkel et l. [48] 0% 0% 113 ICU ICU 9 Kerwin et l. [26] 0.4% 4.1% Pneumoni 10.2%* Pneumoni 26.8%* 11.31* ICU 3.6* 22.4* ICU 9.2* Croce et l. [10] 0% 2% Pneumoni 3.0%* Pneumoni 37.0%* 13.0* ICU 7.0* 30.3* ICU 15.1* *P < 0.05 Tble 8 Results of studies tht describe lumbr frctures Authors nd yer Mortlity Complictions Hospitl sty (dys) Neurologicl outcome <72 h >72 h <72 h >72 h <72 h >72 h <72 h >72 h Kerwin et l. [26] 0% 0% Pneumoni 16.7% Pneumoni 6.8% 10.4* ICU * ICU 2.7 Croce et l. [10]1 0% 0% Pneumoni 3.0% Pneumoni 0% 11.2* ICU 4.1* 16.7*ICU 7.1* *P < 0.05 since these experiments re conducted under highly stndrdized conditions with short nd limited spinl cord compression. Therefore, extrpoltion of these results to the humn clinicl sitution is doubtful since in ptients surgicl decompression is rrely preformed within severl hours, the injury is never stndrdized nd there is no dignostic mens to determine the exct type nd severity of the neurologic injury. Nevertheless, severl LOE I nd II clinicl studies support these findings in ptients with spinl cord injury [17, 18, 28, 35, 39, 55] nd reviews recommend erly surgery in spinl cord injury [2, 16, 36, 41, 44]. But there re lso rticles tht report no difference in neurologicl outcome between erly nd lte decompression [22, 42, 54]. There re strong indictions tht the positive effects of clinicl outcome re obtined when ptient is treted within 72 h. However, the effect of timing of decompressive nd stbilizing surgery on the neurologicl outcome remins controversil. At this moment there is no cler definition for wht is erly nd wht is lte in spinl trum surgery. This results in differently strtified ptient popultions; in this review we hve found three different definitions of erly surgery within 8, 24 nd 72 h (Tble 2). These definitions re bsed on studies tht report improved outcome in erly femur frcture fixtion [5, 40]. It is questionble whether these cn be extrpolted to spinl injuries. Furthermore, we could not find evidence for these definitions in ny niml or clinicl study concerning spinl cord injury. The complex pthophysiology of spinl cord injury with primry nd secondry processes, immedite, cute, intermedite nd lte phses mke it difficult to cliniclly distinguish between erly nd lte intervention [15, 37]. Moreover, next to timing there re severl other fctors tht my influence the neurologicl outcome of spinl injuries like frcture level nd trum severity [1, 25], this mkes it difficult to determine which ptients my benefit from erly tretment nd which will not, or possibly in which ptient erly tretment might even be hrmful. More etiologicl nd clinicl reserch is needed to improve insight in the pthophysiology of spinl cord injury resulting in better interprettion of the effect of timing on neurologicl outcome. Rndomized controlled trils re difficult nd prtly unethicl to conduct in trum ptients [4, 27, 46]. But since the effect of timing on the outcome of trum ptients is prognostic question level I nswer cn be delivered by high qulity prospective study, with n dequte ptient selection, dequte stndrdiztion of surgicl, peri- nd postopertive tretment nd dequte follow-up. Erly tretment should be divided into subgroups, for exmple in ptients operted within 8, 12 nd 24 h. Strtifiction for frcture level, injury severity score [3, 9] nd initil neurologicl sttus is lso needed to more specificlly determine the effect of erly surgicl stbiliztion on the outcome of thorcic nd lumbr frctures. Conclusion The vilble dt strongly support tht erly intervention in thorcic nd lumbr spine frctures is sfe nd dvntgeous. Especilly ptients with thorcic

8 586 Eur Spine J (2007) 16: frctures nd high ISS my benefit most from erly fixtion. Neurologic injury ptterns re diverse nd prognosis is difficult to determine in cute setting. The vilble dt suggest tht some of these ptients my benefit from erly intervention. Lrge-scle multicenter prospective dt collection my provide some of the nswers to these questions. References 1. Ackery A, Ttor C, Krssioukov A (2004) A globl perspective on spinl cord injury epidemiology. J Neurotrum 21: Albert TJ, Kim DH (2005) Timing of surgicl stbiliztion fter cervicl nd thorcic trum. J Neurosurg Spine 3: Bker SP, O Nell B, Hddon WH, Long WB (1974) The injury severity score: method for describing ptients with multiple injuries nd evluting emergency cre. J Trum 14: Benson KBA, Hrtz AJ (2000) A comprison of observtionl studies nd rndomized controlled trils. N Engl J Med 342(25): Bone LB, Johnson KD, Weigelt J, Scheinberg R (1989) Erly versus delyed stbiliztion of femorl frctures. J Bone Joint Surg Am 71: Brundge SI, McGhn R, Jurkovich GJ, Mck CD, Mier RV (2002) Timing of femur fixtion: effect on outcome in ptients with thorcic nd hed injuries. J Trum 52(299): Crlson GD, Gordon CD, Oliff HS, Pilli JJ, LMnn JC (2003) Sustined spinl cord compression. J Bone Joint Surg Am 85: Chipmn JG, Deuser WE, Beilmn GJ (2004) Erly surgery for thorcolumbr spine injuries decreses complictions. J Trum 56(1): Civil JD, Schwb CW (1988) The bbrevited injury scle, 1985 revision: condensed chrt for clinicl use. J Trum 28: Croce MA, Bee TK, Pritchrd E, Miller PR, Fbin TC (2001) Does optiml timing for spine frcture fixtion exist? Ann Surg 233(6): Di LY, Yo WF, Cui YM, Zhou Q 2004 Thorcolumbr frctures in ptients with multiple injuries: dignosis nd tretment review of 147 cses. J Trum 56(2): De Lun ER, Kords M, Risko Z (1989) Segmentl spinl instrumenttion in the erly fixtion of the frcture-disloctions of the dorsl nd lumbr spine (S.S.1). 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9 Eur Spine J (2007) 16: No uthors listed (2002) Mngement of cute centrl cervicl spinl cord injuries. Neurosurgery 50:S166 S Norenberg MD, Smith J, Mrcillo A (2004) The pthology of humn spinl cord injury: defining the problems. J Neurotrum 21: Oertel J, Niendorf WR, Drwish N, Schroeder HWS, Gb MR (2004) Limittions of dorsl trnspediculr stbiliztion in unstble frctures of the lower thorcic nd lumbr spine: n nlysis of 133 ptients. Act Neurochir 146: Ppdopoulus SM, Selden NR, Quint DJ, Ptel N, Gillespie B, Grube S (2002) Immedite spinl cord decompression for cervicl spinl cord injury: fesibility nd outcome. J Trum 52(323): Ppe HC, Ginnoudis P, Krettek C (2002) The timing of frcture tretment in polytrum ptients: relevnce of dmge control orthopedic surgery. Am J Surg 183: Ptel RV, DeLong W, Vresilovic EJ (2004) Evlution nd tretment of spinl injuries in the ptient with polytrum. Clin Orthop Relt Res 422: Pollrd ME, Apple DF (2003) Fctors ssocited with improved neurologic outcomes in ptients with incomplete tetrplegi. Spine 28: Prsd VS, Vidysgr JV, Purohit AK, Dinkr I (1995) Erly surgery for thorcolumbr spinl cord injury: initil experience from developing spinl cord injury centre in Indi. Prplegi 33(6): Rpdo A (1996) Generl mngement of vertebrl frctures. Bone 18:191S 196S 45. Rth SA, Khmb JF, Kretschmer T, Neff U, Richter HP, Antonidis G (2005) Neurologicl recovery nd its influencing fctors in thorcic nd lumbr spine frctures fter surgicl decompression nd stbiliztion. Neurosurg Rev 28(1): Ruzek IR, Ztzick DF (2000) Ethicl considertions in reserch prticiption mong cutely injured trum survivors; n empiricl investigtion. Gen Hosp Psychitry 22: Scle TM, Boswel SA, Scott JD, Mitchel KA, Krmer ME, Pollk AN (2000) Externl fixtion s bridge to intrmedullry niling for ptients with multiple injuries nd with femur frctures: dmge control orthopedics. J Trum 48: Schinkel C, Greiner-Perth R, Schwienhorst-Pwlowsky G, Frngen TM, Muhr G, Bohm H (2006) Does timing of thorcic spine stbiliztion influence periopertive lung function fter trum? Orthopde 35: Schlegel J, Byley J, Yun H, Fredericksen B (1996) Timing of surgicl decompression nd fixtion of cute spinl frctures. Orthop Trum 10(5): Sekhon LHS, Fehlings MG (2001) Epidemiology, demogrphics, nd pthophysiology of cute spinl cord injury. Spine 26:S2 S Section 6 (no uthors listed): Assessment of study qulity. In: Higgins JPT, Green S (eds) Cochrne hnkbook for systemtic reviews of interventions [updted Mrch 2005] Shields CB, Zhng YP, Shields LBE, Hn Y, Burke DA, Myer NW (2005) The therpeutic window for spinl cord decompression in rt spinl cord injury model. J Neurosurg Spine 3: Trivedi JM (2002) Spinl trum: therpy options nd outcomes. Eur J Rdiol 42: Vccro AR, Dugherty RJ, Sheehn TP, Dnte SJ, Cotler JM, Blderston RA et l (1997) Neurologic outcome of erly versus lte surgery for cervicl spinl cord injury. Spine 22: Ymzki T, Ynk K, Fujit K, Kmezki T, Uemur K, Nose T (2005) Trumtic centrl cord syndrome: nlysis of fctors ffecting the outcome. Surg Neurol 63:95 100