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Volker Bühren, Ingo Marzi |
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Treatment of spinal injuries and fractures of the vertebral bodies has changed substantially in recent years. In particular management of fractures of thoracic and lumbar spine has been improved as a consequence of the results of multicenter trials. One major issue has been the thorough classification of the fractures into the three main types with instability in compression, flexion-distraction, or rotation. In addition reconstruction of the anterior column and in particular of disrupted disks by dorsal fixation alone even with additional cancellous bone grafting has been foundinadequate. For compound unstable fractures it has been proven, that a combined dorsal/ventral approach with a so called 360_ stabilisation will lead to the best functional and radiological results. However, open thoracotomy or lumbotomy are associated with highsystemic and local morbidity, so that meanwhile minimal invasive approaches using endoscopic visualization have been established as routine procedure.
The planning of time course and the selection of operative techniques to treat severe spinal injuries is guided by neurological deficits, instability and deformation. The aiming of care for multiple trauma ist focussed on survival, prevention of severe functional deficits, avoidance of septic complications and securing unrestricted handling of the patient for intensive care management. Damage control protocols have been evolved for the majority of skeletal trauma. However, for spinal injuries only application of the halo vest and the dorsal internal fixator can met the criteria for a simple and nether the less save fixation. Operative reconstructions of the anterior column are more or less time consuming, all techniques are demanding and depending on advanced logistics. Therefore, spinal injuries in multiple trauma patients should be exactly diagnosed on admission, carefully classified regarding instability and treated using techniques and time course suitable for the overall injury severity, advanced reconstruction operations should be delayed whenever possible.
The current issue is focussed on the relationship of multiple trauma and spine injuries in respect to epidemiology, relevance and management. Laurer et al. [1] present original data of a 4-year period demonstrating the relevance of spine injuries in severely traumatized patients with an ISS of 16 and higher. They found an interesting distribution between cervical, thoracic and lumbal injuries with a higher percentage of cervical spine injuries than expected. Woltmann et al. [2] present further original work indicating the incidence of abdominal injuries in combination with thoracic and lumbal spine fractures and the consequences for the management in this competing situation. Hierholzer et al. [3] review the management and timing of interventions in multiple trauma patients in particular with respect to the combined spine injuries. Lastly, El Saman et al. [4] present a detailed evaluation of the diagnostics of cervical spine injuries in multiple traumatized patients and their clinical management and timing.
Today, spine trauma is present in about one third of severely injured blunt multiple trauma patients. This combination requires a clear diagnostic protocol and a well defined treatment plan. Early stabilization of the spine allows up to date standard protocols for intensive care treatment without limitations. The implementation of minimal-invasive definitive spine surgery can be delayed to the later reconstruction phases with a patient under optimal conditions. |
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