Review Article
Damage Control Orthopaedics in Spinal Trauma
Colby Oitment, MD, MSc(c),
FRCSC
Patrick Thornley, MD, FRCSC
Thorsten Jentzsch, DrMed,
MSc
Mark Pahuta, MD, PhD, FRCSC
From the Department of Orthopedic Surgery,
McMaster University, Hamilton General Hospital,
Hamilton, Ontario (Oitment, Thornley, and
Pahuta), the Division of Orthopaedic Surgery,
Toronto Western Hospital, University Health
Network (Jentzsch) and Department of Surgery,
University of Toronto (Jentzsch), Toronto,
Ontario, Canada, and the Department of
Orthopaedics, Balgrist University Hospital,
University of Zurich, Zurich, Switzerland
(Jentzsch).
None of the following authors or any immediate
family member has received anything of value
from or has stock or stock options held in a
commercial company or institution related
directly or indirectly to the subject of this article:
Oitment, Thornley, Jentzsch, and Pahuta.
J Am Acad Orthop Surg 2021;29:e1291-e1302
DOI: 10.5435/JAAOS-D-21-00312
Copyright 2021 by the American Academy of
Orthopaedic Surgeons.
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JAAOS® December 15, 2021, Vol 29, No 24
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ABSTRACT
There has been a shift in the management of the polytrauma patients
from early total care to damage control orthopaedics (DCO), whereby
patients with borderline hemodynamic stability may be temporized with
the use of external fixators, traction, or splinting with delayed
osteosynthesis of fractures. Recently, there has been an increasing
trend toward a middle ground approach of Early Appropriate Care for
polytrauma patients. The concepts of DCO for the spine are less clear,
and the management of trauma patients with combined pelvic ring and
spinal fractures or patients with noncontiguous spinal injuries present
unique challenges to the surgeon in prioritization of patient needs. This
review outlines the concept of DCO and Early Appropriate Care in the
spine, prioritizing patient needs from the emergency department to the
operating room. Concepts include the timing of surgery, minimally
invasive versus open techniques, and the prioritization of spinal injuries
in the setting of other orthopaedic and nonorthopaedic injuries.
Contiguous and noncontiguous spinal injuries are considered in
construct planning, and the principles are discussed.
T
he term polytrauma primarily describes blunt trauma patients with
multiple injuries, which compromise a patient’s physiology by a high
degree of inflammation (eg, systemic inflammatory response syn-
drome), potentially affecting even uninjured end organs.1 The optimal timing
for surgical stabilization of extremity and spinal fractures in the polytrauma
patient has been the subject of much investigation and debate for over 4
decades.2 The initial trauma is understood as the so-called “first hit.” Pa-
tients are predisposed to potential catastrophic decline if deemed inappro-
priately stable for surgery, whereby definitive surgery may provide a “second
hit,” taxing a patient’s biological reserve.
The term damage control subject was originally coined by the US Navy,
referring to the steps required to keep a badly damaged ship afloat and avoid
the spread of catastrophic damage throughout the entire vessel.1 Damage
control subject as it relates to surgery was initially explored in general
surgery, working to control subject catastrophic bleeding with abbreviated
resuscitative laparotomy, restore compromised blood flow, and control
subject contamination.1 Secondarily, damage control subject focuses on
intensive care treatment, targeting rewarming, acid-base imbalance
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Damage Control Orthopaedics in Spinal Trauma

correction, and optimization of coagulopathy and
hemodynamic status.3 Regarding orthopaedics, damage
control orthopaedics (DCO) was first introduced by
Scalea et al,4 in which relevant fractures were treated
with external fixators, primarily with delayed osteo-
synthesis on patient stabilization. With an increased
understanding of the physiology of trauma, the work of
Scalea et al has become better understood and led to the
shift in orthopaedics from early total care (ETC) to
DCO. The work of Pape et al5 described four patient
conditions in polytrauma to inform stability for defin-
itive orthopaedic management: stable, borderline,
unstable, and in extremis (Table 1). Through this
algorithmic approach, patients can be stratified into
their appropriate injury category based on their degree
of shock, coagulation, temperature, and soft-tissue
injury (Table 2). Most importantly, borderline pa-
tients require constant reassessment during surgery if
attempting ETC to ensure resuscitation parameters
remain unchanged.
The so-called “window of opportunity” for definitive
osteosynthesis is often pursued during postoperative day
5 to 10 because days 2 to 4 have been reported to be
unsuitable for definitive osteosynthesis, given sustained
inflammatory and fluid-shift changes at this stage.1
Such DCO parameters, as it relates to combined
extremity and spinal trauma, are less understood, and
clinical equipoise remains despite the frequency of this
clinical entity. Damage control subject, as it relates to the
spine, encompasses multiple concepts including the tim-
ing of surgery, minimally invasive compared with open
techniques, and the concept of limiting the extent of
surgery during periods of hemodynamic instability with
the goal of providing a stable construct that is least
traumatic to the patient—now better understood to refer
to Early Appropriate Care (EAC). Trauma patients with

Table 1. Assessment of the Four Different Clinical Grades and Ranges of Clinical Parameters Determining the
Different Grades of Hemodynamic Stability

Stable Borderline Unstable In Extremis

Parameter (Grade 1) (Grade II) (Grade III) (Grade IV)
Blood pressure (mmHg) 100 or more 80-100 60-90 ,50-60
Blood units (2 hr) 0-2 2-8 5-15 .15
Lactate levels Normal range Approximately 2.5 .2.5 Severe acidosis
Shock
Base deficit (mmol/L) Normal range No data No data .6-18
ATLS classification I II-III III-IV IV
Urine output (mL/hr) .150 50-150 ,100 ,50
Platelet count (mg/mL) .110,000 90,000-110,000 ,70,000-90,000 ,70,000
Factor II and V (%) 90-100 70-80 50-70 ,50
Coagulation
Fibrinogen (g/dL) .1 Approximately 1 ,1 DIC
D-Dimer Normal range Abnormal Abnormal DIC
Temperature — .34°C 33°C-35°C 30°C-32°C 30°C or less
Lung function; PaO2/FiO2 .350 300 200-300 ,200
Chest trauma scores; AIS AIS I or II AIS 2 or more AIS 2 or more AIS 3 or more
TTS 0 I-II II-III IV
Soft-tissue Abdominal trauma (Moore) #II #III III III or . III
injuries
Pelvic trauma (AO class) A type (AO) B Or C C C (crush, rollover
abd.)
Extremities AIS I-II AIS II-III AIS III-IV Crush, rollover ext
rem.
Surgical Damage control subject (DCO) ETC DCO if uncertain DCO DCO
strategy or definitive surgery (ETC) ETC if stable

AIS = abbreviated injury scale, ATLS = advanced trauma life support, DCO = damage control orthopaedics, DIC = disseminated intravascular,
ETC = early total care, TTS, thoracic trauma score
Reproduced with permission from Pape et al: Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical
decision making. J Orthop Trauma 2005;19[8]:551-562.

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 Colby Oitment, MD, MSc(c), FRCSC, et al

Review Article
Table 2. Time Sequence of Parameters Indicative of the Four Pathophysiologic Cascades in Polytrauma
Parameter Indicative of Time to Normalization
High-Risk Patients in Case of an Parameter Indicative of High-Risk Patients
Pathophysiology Admission (day 1) Uneventful Course Clinical Course (.day 2) Comment
Shock BP , 90 mm ,1 d Catecholamine Irrelevant after
HG . 5 blood Units/2 hr dependency .2 d resuscitation
Lactate . 2.5 mmol/L
Base excess . 8 mmol/L
Coagulation Platelet count ,90,000 1-2 d .3 d below 100,000 or Simple parameter,
failure to increase good indicator
Core temperature ,33°C Hours Irrelevant after rewarming Irrelevant after
rewarming
Soft-tissue injuries PaO2/FiO2 ,300 ,2-4 d PaO2/FiO2 ,300 for .2 d Lung function often
Lung contusions, AIS . 2 pathologic extravascular close to normal for
Chest trauma score; lung water (.10 mL/kg 2-3 d (PaO2/FiO2
TTS . II BW) .300)
Abdominal trauma (Moore .
II)
Complex pelvic trauma

AIS = abbreviated injury scale, BP = blood pressure, BW, body weight, HG = hemoglobin, TTS = thoracic trauma score
Reproduced with permission from Pape et al: Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical
decision making. J Orthop Trauma 2005;19[8]:551-562.
Arbitrary threshold values are documented that indicate a high-risk situation on admission and during further course in regard to the
development of organ dysfunction.

combined pelvic ring and spinal fractures or patients
with noncontiguous spinal injuries present unique
challenges to the surgeon in prioritization of patient
needs. The following review will discuss the concepts
related to DCO/EAC of the spine, offering triaging and
management strategies to safely address concurrent
spine injuries in the polytraumatized patient.
The Emergency Department
Prehospital emergency medical services triage should aim
to identify patients with potential spinal cord injury for
expeditious immobilization of the cervical spine and
transfer to a level one trauma centre.6 Any patient with
altered mental status, evidence of intoxication, dis-
tracting injuries, focal neurological deficits, or spinal
pain/tenderness may be presumed to have a potential
spinal injury.6
On arrival to the emergency department, standard
advanced trauma life support (ATLS) should be under-
taken with primary and secondary survey using appro-
priate cervical immobilization and logroll precautions.7
Any patient who is unable to lay flat on the spine board
with fixed positive sagittal balance or excessive thoracic
kyphosis (Figure 1) should be presumed to have pre-
existing spinal deformity and padded in a position of
comfort.8 Although patients often already have rigid
cervical orthoses placed on their neck by emergency
medical services, it should be recognized that their
application in these patients can worsen fracture
displacement.8
High tetraplegic cervical injuries require prompt air-
way support, and the treating team must identify com-
ponents of neurogenic shock and treat following the
published guidelines with a combination of fluids, blood
products, and vasopressors.6 Initial cord perfusion
should be optimized with the use of supplemental
oxygen, volume resuscitation, and mean arterial pres-
sure targets . 85 mmHg, avoiding systolic hypotension
below 90 mmHg.9 Although no high-quality evidence is
available to support hemoglobin thresholds in acute
spinal cord injury, the authors generally seek to main-
tain a minimum hemoglobin over 80 g/L.
As a routine aspect of the ATLS protocol, a pan-CT
scan including the spine is completed. Patients with “stiff
spines” from known or newly diagnosed ankylosing
spondylitis or diffuse idiopathic skeletal hyperostosis
should also have full spine magnetic resonance imaging
(MRI) to identify spinal fractures, given noncontiguous
vertebral injury rates up to 20% and an 11.4 times
increased risk of spinal cord injury in the setting of
fracture in this patient cohort.6

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Damage Control Orthopaedics in Spinal Trauma
Figure 1
Photograph showing elderly patients with fixed sagittal deformity, whose head does not lay flat on the spine board should be presumed
to have ankylosing spondylitis or another potentially stiff spine at risk for fracture and should be padded with the head taped in a
position of patient-directed comfort.
The Congress of Neurological Surgeons recom-
mendations regarding closed reduction for fracture dis-
locations of the cervical spine indicate level 3 evidence for
early closed reduction in awake cooperative patients,
avoiding reductions in patients with altered mental status
and additional ventral pathology (eg, disk herniation and
epidural hematoma).9 Prereduction MRI in these pa-
tients will demonstrate disrupted or herniated inter-
vertebral discs in up to 50% of patients with facet
subluxation injuries; however, these findings do not
Figure 2
Radiograph showing C4 flexion teardrop and fracture-
dislocation with active cord compression. This is an example
of a fracture-dislocation with active cord compression in the
cervical spine, which may benefit from immediate inline
traction to reduce cord compression.
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seem to affect the outcome of closed reduction, drawing
into question the utility of prereduction MRI in
appropriately selected patients.9 Furthermore, the tim-
ing of preoperative MRI remains widely variable and
controversial among clinicians, although it is the au-
thor’s preference to obtain preoperative MRI when
timing to operating room access will not be delayed in
acquiring such advanced imaging. Although the role of
closed reduction is controversial,10 a small series of 17
patients from 2018 showed favorable neurologic out-
comes with immediate closed reduction.11 It is the
opinion of the authors that fracture dislocations (eg,
flexion teardrop in Figure 2) or comminuted cervical
burst fractures may benefit from gentle inline traction
with Gardner-Well’s tongs. All patients on admission to
hospital require a detailed American Spinal Injury
Association Impairment examination.12 These princi-
ples are listed in table 3.
The Concept of Damage Control in the
Spine
Anesthetic Considerations
The airway should be secured without mobilization of
the cervical spine in the setting of spinal cord injury,13
which may be accomplished with awake or asleep fi-
beroptic intubation13 with manual inline stabilization.
Laryngoscopy may induce extension in the subaxial
spine and flexion at the cervicothoracic junction.14 The
blade of the laryngoscope may displace occipitocervical
injuries anteriorly.15 Gentle cricoid pressure is contro-
versial but not believed to markedly affect fracture
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Review Article
Table 3. Summary of Concepts of Acute Emergency Management of Spinal Cord Injuries
Principles of acute emergency management of spinal cord injuries
Prehospital
EMS may suspect SCI in patients with
1. Altered mental status
2. Intoxication
3. Distracting injuries
4. Neurological deficits
5. Spinal pain/tenderness
ATLS
Primary and secondary survey completed with
1. Apply rigid cervical orthosis
If preexisting deformity or at extremes of age, position of comfort without collar
2. Airway support for high cervical injuries
3. Identify neurogenic shock and treat with a combination of fluids, blood products, and vasopressors following the ATLS protocols
4. Imaging: Pan-CT as part of the ATLS protocol
Additional full spine MRI for ankylosing spondylitis/DISH spine to rule out noncontiguous fractures and epidural hematoma
5. Detailed ASIA examination on admission to hospital for all SCIs
Reperfuse the spinal cord
1. Supplemental oxygen
2. Reperfuse to hemoglobin target . 80 g/L
3. MAP targets . 85 mmHg, avoid SBP , 90 mmHg
4. Consider inline traction/closed reduction

ASIA = American Spinal Injury Association, ATLS = advanced trauma life support, DISH = Diffuse Idiopathic Skeletal Hyperostosis, EMS =
Emergency Medical Services, MAP = mean arterial pressure, MRI = magnetic resonance imaging, SBP = systolic blood pressure

displacement in most cases.16 Chin lift and jaw trust
should be avoided in the setting of cervical fracture.17
Awake intubation allows for neurological examination
after the airway is secured and the patient is positioned;
however, this requires an awake, alert, and cooperative
patient.18 Succinylcholine should be avoided for
induction around the time of spinal cord injury because
of a theoretical risk of succinylcholine-induced hyper-
kalemia from denervation hypersensitivity.19
Blood pressure should be maintained to optimize
spinal cord perfusion. Although evidence on long-term
outcomes are controversial, grade 3 recommendations
from the American Association of Neurological Sur-
geons recommend avoidance of systolic blood pressure
below 90 mmHg and the mean arterial pressure main-
tenance between 85 and 90 mmHg during surgery and
for the first 5 to 7 postoperative days.20 Injuries above T6
typically require inotropic, chronotropic, and vasoactive
agents with both alpha-1 and beta-1 effects, such as
dopamine, epinephrine, and/or norepinephrine.20
Phenylephrine has alpha-1 dominant effects and is
preferred for low thoracic and conus level injuries to
support peripheral vasoconstriction.20
In fluid management, blood loss should be minimized
with appropriate positioning on the Jackson table,14 al-
lowing the abdomen to drift between the chest and hip
pads, limiting intra-abdominal pressure. Tranexamic
acid preoperatively or continuous infusion may be
used.14 It is the authors preference to start colloids or
blood transfusion early to avoid dilutional coagulop-
athy, which could lead to difficulties in intraoperative
hemostasis and postoperative hematoma. Principles of
anesthetic management are summarized in Table 4.
Timing of Surgery
Nearly all recently published data support early decom-
pression for acute spinal cord injuries. The original sur-
gical timing in acute spinal cord injury study trial
demonstrated 20% of patients undergoing early (,24
hours) surgical decompression showed a greater than

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Damage Control Orthopaedics in Spinal Trauma
Table 4. Summary of Anesthetic Considerations
Anesthetic Considerations
Induction
Airway/Breathing
Awake or asleep fiberoptic intubation
Circulation
Preoperative tranexamic acid
MAP target 85-90 mmHg
Injuries above T6: Alpha-1 and Beta-1 agonists
(norepinephrine, epinephrine, dopamine)
Injuries below T6: Alpha-1 agonist (phenylephrine)
Hemoglobin .80 g/L
MAP = mean arterial pressure, SBP = systolic blood pressure
two abbreviated injury scale grade improvement in
motor function at 6 months (compared with 9% in the
late [$24 hours] decompression group).21 More recent
studies have pooled prospective multicenter databases
examining 1,031 patients and showed improved
recovery in motor and sensory (light touch and pin
prick) function in patients receiving decompressive
surgery within 24 hours compared with patients
receiving decompression after 24 hours.22 In this study,
after 36 hours, the potential for recovery plateaued.
The literature regarding the exact timing of surgical
decompression remains controversial. Meta-analyses
have supported improved motor function with surgery
occurring within 8 hours compared with greater than 8
hours from surgery.23 Most data included in this meta-
analysis are prospective and retrospective cohort data
with a lack of overall high-quality evidence.23 In a meta-
analysis conducted by Ma et al,24 the effects of early
decompression were particularly favorable for complete
American Spinal Injury Association spinal cord injuries.
Table 5. Advantages of Open Posterior Versus Percutaneous Screw Placement
Technique
Open posterior approach
Percutaneous screw placement
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Avoid
Avoid succinylcholine in the setting of acute SCI
Manipulation of the cervical spine
Direct laryngoscopy
Chin lift/Jaw thrust
Succinylcholine
Hemodilution with excessive crystalloid transfusion
SBP , 90 mmHg
Two randomized controlled trials have examined the
effect of urgent (,8 hour) timing of surgical decom-
pression. Cengiz et al compared less than 8 hour to 3 to
15 days delays, and Chen et al compared less than 8
hour to greater than 8 hour decompression for acute
traumatic spinal cord injury (SCI) with both studies
demonstrating benefit of early decompression for motor
and sensory recovery.25,26 Unless the patient is in
hemodynamic extremis and unable to tolerate surgery,
we recommend urgent decompression and stabilization.
Minimally Invasive Versus Open Surgery
In acute trauma patients, fixation may be placed
through a traditional open posterior approach or screws
may be placed percutaneously. Percutaneous pedicle
screw fixation is associated with shorter surgical time,
hospital stay, lower rates of infections, and improved
pain scores.27 Two randomized controlled trials have
been conducted on this matter,28,29 both supporting
percutaneous screw fixation for these reasons. They are
Advantages
1. Allows the surgeon to correct traumatic deformity directly; more
appropriate for AO type B2 and C type injuries
2. Permits fusion techniques
3. Permits simultaneous open decompression; more appropriate
for patients with neurological deficit
4. May reduce long-term pseudarthrosis and hardware failure
with appropriate fusion
1. Recommended for patients with AO type A2-4 axial loading (if
surgery is indicated) and B1 type flexion-distraction injuries
2. Reduced operative time
3. Reduced blood loss
4. Reduced surgical site infections
5. Safer in patients with borderline hemodynamic instability
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Figure 3
Chart showing the prioritization of spine procedures among other injuries. ATLS = advanced trauma life support, I & D = irrigation and
débridement
particularly attractive in the setting of polytrauma to
reduce surgical morbidity and provide stability to spinal
fractures in patients with borderline hemodynamic
stability. Of note, percutaneous facet fusion techniques
described for degenerative lumbar spine conditions have
not currently been investigated in depth for the spine
trauma patient but may emerge as a potential technique
adjunct in future.
Disadvantages of percutaneous fixation include
increased radiation exposure, technical difficulties in
placing screws in traumatic deformity, and correcting
traumatic deformity.30 Percutaneously placing screws
does not allow for posterior fusion, which may lead to
pseudarthrosis, hardware failure, and chronic back
pain. Although research has demonstrated no differ-
ences in kyphosis correction between open and percu-
taneous techniques,30 if notable correction is required
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Colby Oitment, MD, MSc(c), FRCSC, et al
Review Article
that cannot be accomplished through positioning on the
table, or decompression is required, then an open
approach is likely preferable. A treatment algorithm
proposed by Sebaaly et al recommends open decom-
pression and fusion for any patient requiring a
decompression, AO type B2 (mixed bony/soft tissue
flexion-distraction injuries) and AO type C fracture
dislocations.30 The authors recommend percutaneous
fixation for AO type A2-4 axial loading injuries (if
surgery is indicated) and B1 (osseous flexion-
distraction) fractures.30 Advantages of each fixation
type are provided in Table 5.
Prioritizing the Surgical Plan
Life-threatening injuries should be treated before nonlife-
threatening injuries. As such, cranial pathology; thoracic
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Damage Control Orthopaedics in Spinal Trauma

injuries including hemo/pneumothorax, cardiac injuries, reduced, and ETC for orthopaedic injuries may be con-
and aortic injuries requiring intervention, vascular in- sidered. Generally, we endorse the treatment of long
juries including visceral bleeding; and pelvic ring injuries bones and pelvis, followed by the spine and reassessing
should be prioritized above a spinal fracture.31 This the patient’s hemodynamic status for upper extremity/foot
general approach is provided in Figure 3. and ankle procedures. In the setting of neurologic def-
Hemodynamic status should be assessed after the icits, the spine again should be prioritized. These prin-
management of life-threatening injuries. Patients in ex- ciples are summarized in Figure 3.
tremis are too unstable for prone spine surgery. Femur,
tibia, and pelvic injuries may be placed under traction or
externally fixated, and the pelvis may be packed if nec- Contiguous and Noncontiguous Spinal
essary. The surgeon may consider closed reduction or Fractures
inline traction of cervical fracture dislocations, the use of
Contiguous injuries of the spine are generally incorpo-
rigid cervical orthoses, and ongoing use of logroll pre-
rated into the same construct.32 Noncontiguous injuries
cautions during ICU care and further management of life-
of the spine are fractures occurring at least three ver-
threatening injuries. Morbidity reducing orthopaedic
tebral levels apart. It is critical these injuries are rec-
procedures may be performed at bedside if appropriate,
ognized for appropriate surgical planning.33 Based on a
including irrigation and débridement of open wounds,
small series of 32 fractures in 15 patients, Secer et al32
compartment releases, reduction of joint dislocations,
recommended that when .5 intact vertebral levels
and splinting of upper extremity and foot and ankle
separate injured segments, two separate constructs
injuries.
should be used, and in cases where four or less segments
In borderline and stable patients suitable for prone
separate the fractured segments, then they should be
surgery, the neurologic status of the patient must be con-
treated in the same construct. In our experience, if the
sidered. Borderline patients who are neurologically intact
two separate surgical constructs leave ,3 vertebral
should have the orthopaedic morbidity reduced through
levels between them, then they are incorporated into the
external fixation or traction of pelvic and long bone in-
same construct. Using a single construct in the thoracic
juries, release of compartments, irrigation and débride-
spine has likely less clinical relevance because this part of
ment of open injuries, reduction of dislocations, and
the spine is relatively immobile. In the cervical and
other injuries splinted. Complex acetabular fractures and
lumbar spine, sparing segments is more important to
periarticular fracture dislocations around the femoral
preserve motion. Figure 3 demonstrates noncontiguous
head may be managed in a case-by-case basis with dis-
fractures, whereby the cervical spine injuries were
cussion between the spine and trauma teams. Borderline
managed nonsurgically, whereas the noncontiguous
patients with progressive or notable neurologic injury
thoracic extension fractures were incorporated into the
should have the spine prioritized to reduce morbidity,
same construct with a long posterior thoracic fusion
and the surgeon should consider percutaneous fixation.
(Figure 4). In the setting of multiple constructs, the
Generally, at the authors institution, a level 1 trauma
surgeon should triage the importance of each
center, all procedures that can be performed supine are
construct/injury based on the patient’s ability to
performed at once and preferably simultaneously with a
potentially not tolerate the entire procedure.
dual surgeon approach to maximize surgical efficiency.
This may include femoral or tibial ex-fix of lower
extremity long bones, percutaneous SI screws, and
anterior pelvic plating. These procedures may proceed in Managing Intraoperative Hemodynamic
conjunction with anterior cervical plating and/or Instability
closed/open cervical reductions and fusions to reduce Preoperatively, as part of the standard ATLS protocol,
the overall surgical time length of anesthesia. Posterior the patient should have accurate crossmatch or blood
spinal procedures may occur in conjunction and with typing. It is important to have an accurate preoperative
some foot and ankle procedures. A collaborative and estimate of blood loss and communicate frequently with
multidisciplinary approach is required to develop the the anesthesiologist during the procedure.34 If resources
most efficient and least morbid approach to stabilization permit, intraoperative cell-saver may be considered.34
of the patient.31 Long constructs and contiguous fractures should esti-
Hemodynamically stable patients without neurologic mate a minimum of 1 L of blood loss and have blood in
compromise should have orthopaedic morbidity the room before starting the procedure.35 Tranexamic

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 Colby Oitment, MD, MSc(c), FRCSC, et al

Review Article
Figure 4

Radiograph showing an example of a patient with ankylosing spondylitis and noncontiguous spinal injuries. A and B, Sagittal
thoracolumbar CT cuts demonstrating noncontiguous extension fractures at T9/10 and T6, along with (C), a parasagittal CT of the
cervical spine demonstrating a unilateral superior facet of C7, and unilateral C2 pars injury. The patient’s thoracic injuries were treated in
a single construct (D), whereas the cervical spine was managed in a collar.

acid transfusion with a 10 mg/kg loading dose and
10 mg/kg/hr continuous infusion should be considered.
Hypotensive anesthesia should be avoided in the setting
of spinal cord injury. Surgical positioning in reverse
Trendelenburg with proper positioning of the hip bol-
sters to reduce intra-abdominal pressure, thereby
reducing intraoperative blood loss should be used.36
Intraoperatively, the surgeon must take meticulous
care to differentiate bleeding from muscle, bone, and
epidural vessels. Soft-tissue bleeding may be treated with
monopolar or bipolar cautery, whereas bone bleeding
may be treated with bone wax, and epidural bleeding
may be managed with bipolar cautery. Multiple topical
synthetic agents are available, which promote clot for-
mation using thrombin, collagen, gelatin, and/or cellu-
lose such as commercially available topical tranexamic
acid, Gelfoam, FLOSEAL, and SURGIFLO.34
Postoperative Considerations
A paucity of high-level evidence is available to guide the
postoperative management of the polytrauma patient with
associated spinal injuries after definitive osteosynthesis and
spinal fixation. The use of perioperative high-dose steroids
in the polytrauma patient with a spinal cord injury remains
highly controversial, stemming back to 1984, and the
ensuing National Acute Spinal Cord Injury Studies and the
issues of improperly reported subgroup analyses that
overestimated the effects of steroid use in these patients in
this highly scrutinized three-study series.37 It remains the
author’s institutional practice of the authors to not use
high-dose steroids in this patient cohort. Of notable
concern in the polytrauma patient is the appropriate
timing of thromboprophylaxis, given the elevated pro-
pensity for venous thromboembolism weighed against
increased bleeding risk in this cohort.6 The European
clinical practice guideline on managing major bleeding
and coagulopathy after trauma recently released their fifth
edition evidence-based recommendation as part of the
“STOP the Bleeding Campaign.”6 Grade 1B recom-
mendations highlight the emphasis of a restricted volume
replacement strategy to allow target blood pressure
maintenance until bleeding can be controlled and
targeting a hemoglobin level of 70 to 90 g/L (grade 1C).6
The guidelines further recommend early mechanical
thromboprophylaxis with intermittent pneumatic com-
pression while the patient is immobile and has a bleeding
risk and combined pharmacological and intermittent
pneumatic compression thromboprophylaxis within 24
hours after bleeding has been controlled or the patient is
mobile. In addition, they recommend against the routing
use of vena cava filters as thromboprophylaxis.6

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Damage Control Orthopaedics in Spinal Trauma

Importantly, early chemical thromboprophylaxis
has been shown to not markedly increase the rates
of bleeding complications in polytrauma patients,
demonstrating a safe profile for early administration
within 24 hours of bleeding control subject.38 No direct
comparisons are available for early versus delayed
thromboprophylaxis protocols in the polytrauma
patient with associated spine trauma. Zeeshan et al39
reported a propensity-matched analysis on the optimal
timing of thromboprophylaxis in postoperative spine
trauma patients. Matching 3,554 patients, patients
receiving early thromboprophylaxis (within 48 hours)
were less likely to develop deep vein thromboses (2.1%
versus 10.8%, P , 0.01) with no difference in post-
prophylaxis autologous blood transfusion requirements
nor postprophylaxis decompressive procedures (P =
0.27) nor mortality (P = 0.53).38 Importantly, early
thromboprophylaxis can be expected to mitigate the
associated risks of morbidity and mortality with venous
thromboembolism while likely imparting no increased
surgical complication risk profile for patients, although
further investigations are ongoing.
Polytrauma patients requiring intensive care unit ad-
missions are at an increased risk for immobility and
associated joint contracture, ventilator-associated
pneumonias, and thromboembolism.2 Early mobiliza-
tion in polytrauma patients has been shown to be a safe
and effective strategy in minimizing the rates of deep
vein thrombosis and ventilator-associated pneumo-
nias.40 In addition, the time on ventilator and overall
length of hospital stay has been shown to be decreased
in early mobilizing patients with associated decreased
rates of delirium and improved functional status at the
time of discharge.40 A lack of consensus exists on the
most appropriate modality for mobilization and timing
of such modalities in the polytrauma patient. Currently,
there is much more focus being given to specific injury
rehabilitation within the literature in the critical care
setting.41 Surgical stabilization of unstable spine frac-
tures can allow for earlier mobilization, and delayed
clearance of spinal precautions is a barrier to patient
mobilization and can cause notable morbidity.41 Part of
the role of a comprehensive DCO approach to the
polytrauma patient’s spine care must ensure early sta-
bilization and clearance of spinal precautions when
appropriate in addition to close consultation with the
intensivist team to ensure these parameters are conveyed
in a clear and timely manner.40
Summary
Damage control subject orthopaedics in the spine trauma
patient is a critical element for the orthopaedic surgeon to
be aware of and gain comfort with implementing in the
polytrauma setting. More importantly, DCO as it per-
tains to the spine must follow a clinical pathway towards
EAC. Table 6 provides the summary and take home
points from the principles of DCO for spinal trauma.
Given the potential for a neurologic outcome,
improvement with early recognition and management
throughout the entirety of the trauma resuscitation,

Table 6. Summary of Principles of DCO for Spine Trauma

Principles of DCO for Spine Trauma
1. Perform ATLS including primary and secondary survey with appropriate spinal precautions, identifying neurologic injuries.
2. Resuscitate patients with SCI to maintain cord perfusion using MAP targets, O2 saturation, and avoiding anemia, and these
should be continued for 5-7 d postoperatively.
3. Patients in hemodynamic extremis may receive either closed reduction or in-line traction of cervical fracture dislocations, with
frequent communications between ICU and spine teams, until patient is suitable for surgery.
4. Engage in multidisciplinary discussion to triage spinal injuries among the patient’s other injuries, given their hemodynamic and
neurologic status.
5. The surgeon should consider percutaneous fixation options, if appropriate fracture morphology, in patients with borderline
hemodynamic status.
6. Anesthetic induction must avoid cervical manipulation in the setting of cervical fractures.
7. Obtain stable spinal fixation with early decompression for all patients with spinal cord injury.
8. Contiguous spinal fractures should be incorporated in the same construct.
9. Noncontiguous injuries should be incorporated in the same construct if , 5 levels apart.

ATLS = advanced trauma life support, DCO = damage control orthopedics, MAP = mean arterial pressure

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spinal trauma in the polytrauma patient must be iden-
tified early. It is vital to create a system-wide, organized
and algorithmic approach to the polytraumatized spine
patient from the time of hospital presentation until a
coordinated definitive management with early stabili-
zation and neural element decompression can be safely
performed in these patients.
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