Optimal Tracheostomy Timing After Traumatic Complete Spinal Cord Injury: A Comparative Analysis of Ultraearly, Early, and Delayed Practice

BACKGROUND AND OBJECTIVES: Tracheostomy is crucial for managing airway and respiratory complications in spinal cord injury (SCI) patients, with recent studies linking its timing to respiratory outcomes. The aim of this study was to determine the association between adverse events and tracheostomy timing in complete traumatic cervical SCI patients. METHODS: This multicenter retrospective observational cohort study used data from the Trauma Quality Improvement Program between 2010 and 2020 and included all complete traumatic cervical SCI patients who underwent spine surgery and tracheostomy. Tracheostomy timing was categorized into ultraearly (≤3 days), early (4-7 days), and delayed (>7 days) after surgery. The primary outcome was the occurrence of major in-hospital complications (HC). Secondary outcomes included immobility complications (IC), surgical site infections, hospital and intensive care unit (ICU) length of stay (LOS), and duration of mechanical ventilation. A secondary analysis directly compared the ultraearly and early tracheostomy groups. RESULTS: Among 2907 patients analyzed, 307 (10.6%) underwent ultraearly, 1034 (35.5%) early, and 1566 (53.9%) delayed tracheostomy. Adjusted multivariable analyses revealed significant reductions in HC and IC by 33% to 47% and 28% to 32%, respectively, for the ultraearly and early tracheostomy groups compared with the delayed group. In addition, both ultraearly and early groups experienced similar shorter hospital and ICU stays, and shorter ventilation durations compared with the delayed group. Secondary analysis with a direct comparison between the ultraearly and early groups showed a significant reduction of 3 days in ICU LOS in the ultraearly group. However, there were no significant differences in HC, IC, surgical site infections, hospital LOS, or ventilation duration between the ultraearly and early groups. CONCLUSION: Our findings indicate that ultraearly and early tracheostomy provide comparable benefits with delayed tracheostomy. If confirmed in prospective studies, this flexibility in tracheostomy timing would allow more thorough patient assessments, ensuing goal-concordant care and making informed decisions without compromising the advantages of early intervention.