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

To the Editor: We sincerely thank Dr Feng and Dr Jiang1 for their thoughtful commentary on our article, “Optimal Tracheostomy Timing After Traumatic Complete Spinal Cord Injury: A Comparative Analysis of Ultraearly, Early, and Delayed Practice.”2 We are encouraged that our findings have generated academic dialog and appreciate the opportunity to address the points raised. Regarding the definitions of tracheostomy timing, we agree that standardization across studies would improve consistency and comparability.1 In our study, we defined ultraearly tracheostomy as ≤3 days postsurgery, early as 4-7 days, and delayed as >7 days. The results showed that both ultraearly and early tracheostomy were associated with significantly lower in-hospital complications, shorter intensive care unit and hospital lengths of stay, and reduced mechanical ventilation duration compared with delayed tracheostomy. Moreover, outcomes were comparable between the ultraearly and early groups, suggesting flexibility in timing within the first postoperative week.2 We appreciate the concern raised about early tracheostomy after anterior cervical spine surgery due to the perceived risk of wound contamination or hardware infection.1 To address this, we conducted a secondary analysis adjusting for surgical approach using a similar multivariable model to the primary analysis. The findings remained consistent, indicating that early tracheostomy did not increase the risk of surgical site infection, even among patients undergoing anterior or combined approaches. These results align with a previous study performed by our group published in Neurosurgery,3 as well as other studies cited by Dr Feng and Dr Jiang4,5 These studies add to the growing body of evidence that early tracheostomy can be safely performed after anterior cervical spine surgery. We also acknowledge the limitation noted regarding tracheostomy technique.1 The data set we used did not distinguish whether tracheostomies were performed percutaneously or by open surgical approach. The Trauma Quality Improvement Program used International Classification of Disease-9 procedure codes through 2016-2017 and transitioned to International Classification of Disease-10 codes thereafter, limiting our ability to consistently differentiate tracheostomy technique across the full data set. However, in a separate study by our group evaluating the association between tracheostomy timing and spinal surgical approach, we were able to account for tracheostomy technique.3 In that analysis, which compared early (≤7 days) vs late (>7 days) tracheostomy while adjusting for both spine and tracheostomy approaches (percutaneous vs open), early tracheostomy remained associated with favorable outcomes. In summary, we appreciate the detailed appraisal of our work by Dr Feng and Dr Jiang and recognize their call for prospective, ideally randomized studies to better establish causality and refine optimal tracheostomy timing in this population. We share the authors' commitment to advancing care for patients with traumatic spinal cord injury and welcome ongoing dialog in this important area.