Between 21% and 77% of patients with cervical SCI require a tracheostomy, with the variability of these numbers being due to the influence of at least 16 other factors (e.g., severity of the injury, presence of other injuries, admission Glasgow Coma Scale score, age, etc.) (Branco et al. 2011; Como et al., 2005). The interactions of these other parameters make it difficult to establish clear criteria for who should receive a tracheostomy. Identifying when a tracheostomy should be performed is also important to determine, as timing may impact a patient’s recovery with regards to developing complications and weaning from ventilation. In a systematic review of non-SCI patients who required tracheostomies, Griffiths et al. (2005) concluded that individuals who received an early tracheostomy did not experience fewer complications but did experience a shorter duration of mechanical ventilation. The timing of tracheostomy following spinal fixation should also be considered. Currently, the typical time is 1-2 weeks post-surgery, but this timing lacks conclusive evidence (Galeiras Vázquez et al. 2013). In addition to who should receive a tracheostomy and when it should be performed, there is also controversy surrounding whether tracheostomies are always beneficial, effective in ventilator weaning, and result in a reduced number of pulmonary complications. In fact, complications resulting from tracheostomies, such as tracheal stenosis, occur in up to 6% of patients (Lissauer, 2013), so the risks and benefits must be evaluated. Other complications have been reported to include tightness at the scar location, difficulty swallowing, and cosmetic inconveniences (Biering-Sorensen & Biering-Sorensen, 1992). Several studies have retrospectively examined the predictors for needing a tracheostomy and complications associated with the procedure; these are presented in Table 3.
There are two techniques for tracheostomy: surgical (open) and percutaneous. Surgical tracheostomy is the traditional technique that requires opening up the entire trachea to insert the tube. Percutaneous tracheostomy is an alternative procedure that was first developed in the late 1950s and can be performed at the patient’s bedside with fewer materials (Gysin et al. 1999). Percutaneous tracheostomy is less invasive and involves inserting a tracheostomy tube through the skin without directly visualizing the trachea. Due to its less invasive nature, this procedure was thought to be associated with fewer complications and infections, although this relationship is unclear (Gysin et al. 1999). Lastly, patients who required a tracheostomy had longer length of stay in hospitals as well as higher hospital costs (Winslow et al., 2002).
Several studies have investigated factors associated with needing a tracheostomy in acute SCI patients, such as higher injury severity and complete lesions (Leelapattana et al. 2012; McCully et al. 2014; Menaker et al. 2013; O’Keeffe et al. 2004; Yugue et al. 2012), as well as a cervical level of injury (Biering-Sorensen & Biering-Sorensen, 1992; McCully et al. 2014; Romero-Ganuza et al. 2011a; Seidl et al. 2010; Yugue et al. 2012). Other reported factors include older age (Harrop et al. 2004; Yugue et al. 2012) and a lower ASIA motor grade upon hospital admission (Menaker et al. 2013).