M. Lee2, J. Miner2, C. Micallef2, A. Drury2, J. Whitis2, J. Bini1 1Wright State Physicians,Department Of Surgery,Dayton, OH, USA 2Wright State University,Department Of Surgery,Dayton, OH, USA
Introduction: Many soldiers in support of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn sustained unstable spinal injuries requiring placement of spinal hardware. It was most customary to defer fixations of unstable spine injuries to Role 4 and Role 5 military treatment facilities due to concerns for infection risk and related complications; though after an extensive literature search, it was found that there are no current clinical practice guidelines to direct surgeons in the decision to delay fixation. Our objective was to evaluate the practice of placing spinal instrumentation and examine the differences between those patients instrumented in theater versus those with delayed instrumentation.
Methods: Data was gathered from the beginning of Operation Iraqi Freedom/Operation Enduring Freedom with record review from the Armed Forces Health Longitudinal Health Joint Theater Trauma Registry (JTTR), Application (AHLTA), Patient Administration and Biostatisitics Activity (PASBA), and Joint Patient Tracking Application (JPTA). Soldiers with spinal injuries requiring fixation were selected and separated based on spinal instrumentation placed in theater or out of theater. Each group was assessed for development of complications and need for re-operation.
Results:344 soldiers were found to receive spinal fixation; 116 underwent instrumentation in theater while 235 were deferred for out of theater fixation. Those with fixations in theater had a lower overall complication rate in comparison to the out of theater population. In analysis of each individual complication, soldiers who underwent delayed fixation out of theater had higher incidence of PE, DVT, stage 3 and 4 ulcers along with increased rate of infectious processes. Early fixation in theater was related to greater incidence of loss of operative reduction/fixation in comparison to the out of theater counterparts. When comparing complication percentages between both groups, an overall p value for all accounting for all examined complications was found to be 0.9825.
Conclusion:In theater fixation was not associated with greater risk of infection as previously assumed along with lower rates of several other complications. Given these outcomes, early fixation may be favored while understanding these benefits are attenuated by the increase of loss of fixation. In the decision to proceed with early fixation, the instrumentation available along with the training and experience of the surgeon should be other considered factors.