| ATLS (R) y control del daño en trauma espinal |
ATLS(R) and damage control in spine trauma. Schmidt OI, Gahr RH, Gosse A, Heyde CE. Leipzig University, Department of Orthopaedic Surgery, Spine Unit, Liebigstrasse 20, 04103 Leipzig, Germany. christoph-eckhard.heyde@medizin.uni-leipzig.de. World J Emerg Surg. 2009 Mar 3;4:9.Abstract Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660300/pdf/1749-7922-4-9.pdf
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| Abogando por "control de daños columna vertebral", como una modalidad de tratamiento segura y eficaz para las fracturas inestables toracolumbares en pacientes politraumatizados: una hipótesis |
Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. Stahel PF, Flierl MA, Moore EE, Smith WR, Beauchamp KM, Dwyer A. Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, Colorado 80204, USA. philip.stahel@dhha.org. J Trauma Manag Outcomes. 2009 May 11;3:6.Abstract BACKGROUND: The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome. PRESENTATION OF HYPOTHESIS: We hypothesize that the concept of "spine damage control" - consisting of immediate posterior fracture reduction and instrumentation, followed by scheduled 360 degrees completion fusion during a physiological "time-window of opportunity" - will be associated with less complications and improved outcomes of polytrauma patients with unstable thoracolumbar fractures, compared to conventional treatment strategies. TESTING OF HYPOTHESIS: We propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360 degrees completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery. IMPLICATIONS OF HYPOTHESIS: A "spine damage control" protocol may save lives and improve outcomes in severely injured patients with associated spine injuries. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686673/pdf/1752-2897-3-6.pdf |
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