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Risk Factors for Respiratory Failure Following Operative Stabilization of Thoracic and Lumbar Spine Fractures
Timothy P. McHenry, MD1; Sohail K. Mirza, MD, MPH2; JingJing Wang, MS3; Charles E. Wade, PhD3; Grant E. O'Keefe, MD, MPH2; Andrew T. Dailey, MD2; Martin A. Schreiber, MD3; Jens R. Chapman, MD2
1 Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234-6200. E-mail address: timothy.mchenry@us.army.mil
2 Harborview Medical Center/University of Washington School of Medicine, 325 Ninth Avenue, Seattle, WA 98104
3 United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received Grant K23 AR048979 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Harborview Medical Center, Seattle, Washington

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 May 01;88(5):997-1005. doi: 10.2106/JBJS.E.00560
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Background: Respiratory failure is a serious complication that can adversely affect the hospital course and survival of multiply injured patients. Some studies have suggested that delayed surgical stabilization of spine fractures may increase the incidence of respiratory complications. However, the authors of these studies analyzed small sets of patients and did not assess the independent effects of multiple risk factors.

Methods: A retrospective cohort study was conducted at a regional level-I trauma center to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures. Demographic, diagnostic, and procedural variables were identified. The incidence of respiratory failure was determined in an adult respiratory distress syndrome registry maintained concurrently at the same institution. Univariate and multivariate analyses were used to determine independent risk factors for respiratory failure. An algorithm was formulated to predict respiratory failure.

Results: Respiratory failure developed in 140 of the 1032 patients in the study cohort. Patients with respiratory failure were older; had a higher mean Injury Severity Score (ISS) and Charlson Comorbidity Index Score; had greater incidences of pneumothorax, pulmonary contusion, and thoracic level injury; had a lower mean Glasgow Coma Score (GCS); were more likely to have had a posterior surgical approach; and had a longer mean time from admission to surgical stabilization than the patients without respiratory failure (p < 0.05). Multivariate analysis identified five independent risk factors for respiratory failure: an age of more than thirty-five years, an ISS of >25 points, a GCS of =12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. An algorithm was created to determine, on the basis of the number of preoperative predictors present, the relative risk of respiratory failure when surgery was delayed for more than two days.

Conclusions: Independent risk factors for respiratory failure were identified in an analysis of a large cohort of patients who had undergone operative stabilization of thoracic and lumbar spine fractures. Early operative stabilization of these fractures, the only risk factor that can be controlled by the physician, may decrease the risk of respiratory failure in multiply injured patients.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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