The timing of surgery (early vs. late) for spine fractures is controversial. However, there is general consensus regarding several absolute indications for urgent surgical intervention.

The most agreed upon reason for early intervention is any progressive neurological deficit caused by spinal cord or root compression. Spinal dislocations associated with a neurological deficit or spinal kyphosis that compromises the overlying skin or patient positioning for non-spine procedures are also strong indications for urgent surgical intervention.

Multiple studies have evaluated the effects that early (<24 h) versus intermediate (24–72 h) versus late (>72 h) surgical spine intervention have on mortality rates, neurological outcomes, and non-neurological outcomes.

Multiple studies have shown that timing of spine surgery has little to no affect on overall mortality rates [9–12]. However, a subgroup analysis of one of these studies demonstrated that patients with an ISS greater than 25 have a higher risk of death when they undergo spine surgery less than 72 h after injury (12 %) than when they undergo surgery 72 or more hours after injury (2 %) [13]. Contrary to this, Schinkel et al. [14] reported higher mortality rates in patients who undergo late surgical intervention (17 %) versus early intervention (6.3 %). Conversely, Kerwin et al. [15] showed a higher mortality rate in patients who underwent spine surgery less than 48 h after injury. The most frequent cause of death was from acute respiratory distress syndrome. Controversy exists on the timing of spine surgery and its affects on mortality rates; therefore, it is important to evaluate each patient individually with a team approach to determine the optimal time for surgical stabilization (Fig. 17.2).

The effect of early decompression on neurological improvement is also controversial. Studies have compared early (<24 h) to late (>72 h) decompression and showed no significant difference in neurological recovery [13, 16–18]. However, these studies were conducted in small cohorts. Other studies have reported that patients who underwent early surgery had greater neurological improvement, particularly those patients with incomplete spinal cord injuries [19, 20]. To better evaluate the effects of timing of surgery on neurological recovery, Fehlings et al. [21] conducted a large, international, multicenter, prospective study of 313 patients. They randomized patients to early or late surgery and showed that decompression within 24 h after injury was associated with neurological improvement of at least two American Spinal Injury Association (ASIA) grades at 6 months postoperatively. There was also a 2.8-fold higher chance of seeing an improvement of two ASIA grades in patients who underwent surgery early versus late. The mortality and complication rates were also similar between the early and late cohorts. Given these data, it appears that, when possible, early decompression (<24 h after injury) is safe and beneficial in regard to neurological recovery [21].

There are few data on the effects of early spine surgery (<24 h after injury) on the patient’s hospital course. However, studies have shown that spine surgery within 72 h after injury is associated with shorter hospital stays, shorter stays in the intensive care unit (ICU), and less time mechanically ventilated [13, 14, 19, 22]. Frangen et al. [23] demonstrated that severely injured patients (ISS > 38) benefited greatly from undergoing surgery within 72 h, with the average ICU stay decreasing by 6 days and the average hospital stay decreasing by 52 days compared with patients who underwent surgery more than 72 h after injury. Although the data are limited on the effects that early surgery (<24 h after injury) has on the hospital course, surgery within 72 h appears to be beneficial.

Optimal timing for surgical stabilization of spinal column injuries and long-bone fractures in polytrauma patients is controversial. Any injury that is life- or limb-threatening must be addressed first. As described previously, early spine decompression and stabilization can reduce morbidity, shorten ICU and hospital stays, and potentially improve neurological outcomes. Similarly, studies have shown that early stabilization of long-bone fractures, particularly femur fractures, in patients with polytrauma is associated with lower complication rates and shorter ICU and hospital stays [24–26]. Therefore, it is accepted that early stabilization of unstable spine fractures, pelvic fractures, acetabular fractures , and femur fractures enables early mobilization of patients and reduces complications [25, 27–32]. This has not only been demonstrated in patients with isolated injuries, but also in those with polytrauma. With that said, definitive care of fractures soon after injury can expose the patient to a “secondary hit,” which can cause a detrimental systemic inflammatory response. In severely injured patients, damage-control orthopaedics , with placement of provisional external fixation, is a viable option to limit operative time and blood loss [33, 34]. Unstable spine fractures, however, cannot be treated with temporary fixation. Therefore, when assessing the polytrauma patient, it is important to (1) determine which fractures can be provisionally stabilized with a splint or external fixator, (2) stabilize those fractures, and (3) then treat the unstable fractures that can be managed only with definitive stabilization. It is important for the general trauma surgeon, orthopaedic trauma surgeon, and spine surgeon to be in close communication to methodically plan the order of each procedure so the surgery can be completed in a timely fashion, and so that each procedure does not hinder the performance of subsequent procedures.