Objectives: Patients with unstable cervical spine fractures are at significant risk of respiratory failure. Tracheostomy is often delayed for operative cervical fixation (OCF) due to concern for cross-contamination of the spinal surgical site by the tracheostomy. There is no consensus on the optimal timing of tracheostomy in the setting of recent OCF though the most recent Trauma Quality Improvement Project (TQIP) spine guidelines state early tracheostomy does not increase risk of infection or wound complications. This study evaluated the impact of tracheostomy timing on surgical site infections (SSI), length of stay (LOS), morbidity, and mortality for patients undergoing OCF and tracheostomy. We hypothesized delayed tracheostomy would increase LOS without improving outcomes.
Methods: Data from TQIP were used to identify patients with isolated cervical spine injuries, determined by an Abbreviated Injury Score < 3 in all regions other than spine, who underwent both OCF and tracheostomy between 2017-2019. Demographics, injury characteristics, procedures, and outcomes were abstracted. Univariate analysis compared patients who underwent early tracheostomy ( < 7days from OCF) to those who underwent delayed tracheostomy (≥7days from OCF). Bonferroni-corrected alphas of <.002 denoted statistical significance. Logistic regressions were performed for variables associated with SSI, morbidity, and mortality. Pearson correlations were used to evaluate the relationship between OCF to tracheostomy time interval with LOS and ventilator days.
Results: Of the 3,145,734 patients during the study period, 30,529 (1%) underwent concomitant OCF and tracheostomy. Among 1,438 patients who met inclusion criteria, 20 had SSI (1.4%). Median age was 58 years (interquartile range[IQR] 38-70 years), 78.6% male, median Injury Severity Score was 21[16-26].There was no difference in SSI incidence for patients who underwent early versus late tracheostomy (1.6% vs 1.2%,p=.5077). Late tracheostomy was associated with increased median ICU LOS (23.0 vs 17.0 days,p <.0001), ventilator days (19.0 vs 15.0,p <.0001), hospital LOS (29.0 vs 22.0 days,p <.0001), and overall morbidity (69.8% vs 58.8%,p <.0001). Only increased ICU LOS was associated with SSI (OR:1.017,95%CI:0.999–1.032,p=.0273; Figure 1A). Increased time from OCF to tracheostomy (OR:1.002/hour,95%CI:1.001–1.003,p <.0001) and increased ICU LOS (OR:1.023/day,95%CI:1.015–1.033; p<.0001) were associated with patient morbidity (Figure 1B), but not mortality (Figure 1C). Time from OCF to tracheostomy correlated with ICU LOS (r(1354)=.35,p <.0001), ventilator days (r(1312)=.25,p <.0001), and hospital LOS (r(1355)=.25,p <.0001).
Conclusion: Delayed tracheostomy after cervical fixation in patients with isolated cervical spine injuries is not associated with improved morbidity and is associated with longer LOS. Tracheostomy, when indicated, should not be delayed for theoretical concern of increased SSI risk.
