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Timing of tracheostomy after anterior cervical spine fixation

Babu, Ranjith MS; Owens, Timothy R. MD; Thomas, Steven MS; Karikari, Isaac O. MD; Grunch, Betsy H. MD; Moreno, Jessica R. RN, BSN; Lad, Shivanand P. MD, PhD; Bagley, Carlos A. MD

Journal of Trauma and Acute Care Surgery: April 2013 - Volume 74 - Issue 4 - p 961–966
doi: 10.1097/TA.0b013e3182826ea4
CME Articles
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BACKGROUND Patients with cervical spinal cord injury frequently undergo early anterior cervical spine fixation (ACSF) and tracheostomy procedures to reduce further deterioration, to reduce risk of pulmonary complications, and to improve patient mobilization. However, tracheostomy is often delayed because of the risk of cross contamination as a result of the proximity to the ACSF incision site. Currently, there is a paucity of studies evaluating this outcome to determine the safety of early tracheostomy after ACSF. In this study, we have evaluated the outcomes and complications associated with early tracheostomy placement.

METHODS We performed a retrospective review of all patients who underwent tracheostomy placement and ACSF during the same hospitalization between 2005 and 2010. A variety of patient and procedural data were collected, including demographics, timing of ACSF and tracheostomy, length of hospitalization, indication for surgery, American Spinal Injuries Association and Glasgow Coma Scale scores on admission, reason for tracheostomy, method of tracheostomy, and complications.

RESULTS Of the 1,184 patients who underwent an ACSF, 20 (1.7%) required a postfixation tracheostomy. Tracheostomy was performed at mean (SD) of 6.9 (4.2) days after ACSF, ranging from 0 to 17 days. Although nearly half of all patients underwent postfixation tracheostomy within 6 days, no wound or implant infection was seen to occur in any patient. Ten patients (50%) developed ventilator-associated pneumonia, with most cases occurring before tracheostomy (90% vs. 10%, p < 0.0001). Univariate analysis only revealed late tracheostomy to significantly increase the risk of complications (odds ratio, 9.33; 95% confidence interval, 1.19–73.0; p = 0.033). Analysis of all studies in the literature revealed a 1% cross-infection rate, with no cases involving implant contamination.

CONCLUSION Our findings suggest that early tracheostomy can be performed safely after cervical spine fixation surgery, with no patients developing incisional or implant infections. As the risk of cross contamination is only 1%, early tracheostomy should be strongly considered because of its potential benefits.

LEVEL OF EVIDENCE Therapeutic/care management, level IV.

From the Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.

Submitted: September 23, 2012; Revised: November 27, 2012; Accepted: December 3, 2012.

Address for reprints: Carlos A. Bagley, MD, Division of Neurosurgery, Department of Surgery, Duke University Medical Center, PO Box 3087, Durham, NC 27710; email:

© 2013 Lippincott Williams & Wilkins, Inc.