Patients with Injuries of the Spine and Spinal Cord: Treatment Tactics in Associated Trauma

Krylov V.V., Grin A.A., Ioffe Yu.S., Nikolaev N.N., Nekrasov M.A., Bublievsky D.V.

Sklifosovsky Research Institute of Emergency Care, Moscow, Russia

The study goal was to determine tactics of treatment of patients with injuries of the spine and spinal cord in associated trauma.

Materials and Methods

A rate of associated injuries in spinal trauma is equal to approximately 50% (Table 1).

Table 1

A Structure of Spinal Trauma in Moscow
(Data of Neurosurgical Units of Hospitals, Attached to the Moscow Department of Public Health)

Years

A Number of Patients with Spinal Trauma

 

Complicated

Uncomplicated

Total

A Rate of Associated Injuries

1997

226

63

289

-

1998

304

126

430

-

1999

491

205

696

146 (21%)

2000

628

138

766

220 (29%)

2001

473

310

783

397 (51%)

In 2001 there were 397 patients with associated spinal trauma, treated in neurosurgical units of hospitals of the above Department. Operations were performed in 148 (37.3%) of them. Rates of postoperative and total mortality were 25.7% and 28.0% respectively (Fig.1).

A number of patients with associated spinal trauma, who underwent treatment in the Sklifosovsky Research Institute of Emergency Care during 01.01.2000-31.12.2002, was equal to 127; 113 of them needed operation on the spine and spinal cord. Surgical interventions were made in 98 patients. A diagnostic algorithm included general and neurologic examination; ultrasonic examination of abdominal and pleural cavities; X-ray examination of the skull, pelvis, ribs, all segments of the spine; myelography and CT of the spine. A patient was subject to additional X-ray, depending on results of examination. All cases were examined by a neurosurgeon, traumatologist and surgeon; 104 patients (82%) were admitted directly to a resuscitation unit, where monitoring of blood pressure, pulse rate, ECG, hemoglobin, K+, SpO2, total protein, creatinine and urea was carried out. Conclusion on severity of associated trauma was made on the basis of ISS (Injury Severity Score) after examination. Neurologic disorders were estimated with the help of the ASIA score (American Spine Injury Association). A character of injury of the vertebral column was assessed with applying the Chicago Classification of Backbone Trauma (P. Mayer, 1996).

Urgent operations (during the first day) and delayed (on the 2nd-3rd day) and intermediate interventions were performed in 71 and 27 cases respectively. Modern fixing devices were used in all 98 patients; 61 of them were treated with cervical plates, screws, tightening devices, transpedicular and hook systems, manufactured by Medtronic Sofamor Danek, Stryker, Conmet. Transpedicular fixation according to Roy-Camill was made in 37 patients.

Results

Surgical tactics in cases with associated spinal trauma was chosen after estimating a general condition of a patient and a character of injuries. Indications for urgent operation included presence of compression of the spinal cord and its roots, augmentation of neurologic symptoms and (or) a diagnosed unstable fracture of the vertebral column. When the latter was not accompanied by neurologic disorders, an operation was made after complete stabilization of a patient's state. Tactics of treatment and a volume of operation on the vertebral column were determined with taking into account associated pathology (injuries of thoracic and abdominal organs, bone fractures, shock development). Priority and urgency of operations were conditioned by presence of this or that life-threatening trauma (the first priority), possible loss of function of an organ or system of organs (the second priority). Operations, whose delay did not effect treatment outcome, were considered to be of the third priority.

Intervention for intracavitary bleeding (injuries of the spleen, liver, vessels of the abdominal and pleural cavity, intracranial hematoma, continuous bleeding from a damaged lung) were performed in the first instance.

Operations on the spine and spinal cord, osteosynthesis of the femur, pelvic and shin bones were made in the second instance. Non-urgent operations on skeletal bones, endoscopic drainage of coagulated hemothorax were interventions of the third priority. One-stage operations on the spine and skeletal bones were performed in 7 patients. Interventions on the spine, as the second stage of surgical treatment, were made in 16 cases. Operations on the spine preceded other interventions in 29 patients. Operations on the spine only were performed in 46 patients.

Operation on the spine was contraindicated in an extremely severe state of a patient, characterized by shock, hemodynamics instability, coma (consciousness level of less than 10 according to the Glasgow Coma Scale), multiple injuries of ribs with hemopneumothorax and manifestations of respiratory insufficiency (SpO2 of less than 90% in oxygen insufflation), anemia (hemoglobin of less than 90 g/l), heart contusion with signs of cardiac insufficiency, renal (anuria, oligouria, urea >10 mmol/l, creatinine > 80 mmol/l) and/or hepatic (total protein < 45 g/l, more than twofold increase of enzymes) insufficiency, fat embolism, pulmonary embolism, pneumonia, non-fixed fractures of extremities (in operations, using a posterior approach).

Pyo-septic complications and presence of polyorgan insufficiency were contraindications for operation on the spine in an intermediate period.

Surgical tactics in injuries of the cervical spine (levels of C3-7) was as follows: anterior decompression, reposition and fixation with a plate (Fig.2). In case of injury of more than 2 vertebrae, presence of posterior compression and considerable damage of posterior structures, one-stage posterior decompression and fixation with a tightening device or transpedicular system were performed (if a patient's state allowed) or it was done at the second stage of intervention.

Surgical tactics in injuries of the upper cervical spine (C1-2) depended on a patient's state and a damage character and consisted in performance of a full-volume operation, including reposition and stabilization in Halo-apparatus, posterior spondylodesis and internal fixation with a tightening device, cervical-cranial fixation, anterior spondylodesis with a screw (in trauma of C2 vertebra, Fig.3) or an autobone and plate. When a patient's state was severe, Halo-fixation was used; operation of a required volume was performed after a state stabilization.

Anterior spondylodesis with an autobone and plate was made in uncomplicated unstable injuries of anterior structures of the thoracic and lumbar spine. If a state was severe, posterior transpedicular spondylodesis with subsequent (in 2-3 weeks) anterior spondylodesis were performed (Fig.4).

Laminectomy, decompession, revision of the spinal cord and posterior transpedicular fixation were used in a complicated stable fracture of the thoracic and lumbar spine. Laminectomy, decompession, reclination, revision of the spinal cord, trasnpedicular (laminar) fixation (Fig.5) were made in complicated unstable fractures of the spine. If a patient's state permitted, anterior spondylodesis was performed simultaneously; if not it was done in 2-3 weeks (Fig.6).

A state on admission was estimated on the basis of Karnofsky's scale. Average scores in the whole group, survivors, operated and dismissed patients were 48.5, 64.5 and 62.1 respectively.

Fatal outcomes (23.6%) were conditioned by severe trauma of the thorax with contusion of the heart and lung, fractures of the pelvis and femur, craniocerebral trauma and developed pyo-septic complications. Postoperative mortality was 18.3%.

Conclusion

The results of treatment of patients with associated spinal trauma were analyzed. The analysis showed, that surgical tactic should be determined by severity of associated injuries, a patient's state before operation and its dynamics during it. As for risk factors, they are as follows: shock, unstable hemodynamics, ruptures of internal organs with hemopneumothorax and/or hemoperitoneum, severe craniocerebral trauma, Hb < 90 g/l, injuries of the pelvis and femur, heart contusion, SpO2 < 90%, K+ < 3 mmol/l. Intraoperative risk factors include reduction of Hb (< 70 g/l), blood pressure of less than 90 mm Hg, SpO2 < 85%, arrhythmia, single-moment blood loss of more than 800 ml, total blood loss of more than 1500 ml.

Use of modern transpedicular-laminar fixing devices allows to perform double-stage operations in a severe state of patients with complicated unstable fractures of the spine. Active surgical tactics at an early stage is one of the methods of preventing pyo-septic and thromboembolic complications.