A.A. Grin, V.V. Krylov, N.N. Nikolaev, Yu.S, Ioffe, V.M. Kaznacheev, M.A. Nekrasov
Sklifosovsky Research Institute of Emergency Care,
State Medical-Stomatologic University, Moscow, Russia
The goal of the present study was determining an algorithm of treatment of complicated and uncomplicated spinal injuries in patients with associated trauma.
Materials and Methods. Associated injuries account for approximately 50% of spinal trauma. In 2002 there were 372 patients with associated trauma of the spine and spinal cord (ATSSC), treated in neurosurgical departments of Moscow hospitals. Interventions were performed in 146 (39%) of them. The rates of postoperative and total mortality were 25% and 27% respectively. A number of patients with ATSSC, treated in the Sklifosovsky Research Institute of Emergency Care during 01.01. 2000-31.06.2003, was 161. Operations were made in 114 of them. A diagnostic algorithm included general and neurologic examinations, sonography of abdominal and pleural cavities, X-ray of a skull, pelvis, ribs, damaged extremities and all segments of the spine, myelography and CT of the spine. The patients were examined by a neurosurgeon, traumatologist and surgeon. The majority of patients (127 cases or 82%) were admitted to a resuscitation department. Their examination allowed to determine severity of associated trauma on the basis of the ISS scale. Neurologic disorders were estimated according to the ASIA scale; evaluation of a character of spinal injuries was carried out with applying the Chicago Classification of Spinal Trauma (P. Mayer, 1996).
Urgent operations were performed in 82 patients; 32 cases were operated in an intermediate and delayed periods. Modern fixing devices were used in 101 patients.
Results. Surgical tactics was determined after estimation of a general condition of patients and a character of injuries. Indications for urgent operations included compression of the spinal cord and its roots, augmentation of neurologic symptoms and/or an instable fracture of the spine. Treatment tactics and an operation extent were dependent on a volume of associated trauma. Priority and urgency of interventions were estimated with taking into account a life-threatening character of this or that trauma (the first priority), possible loss of function of one or several organs (the second priority); operations of the third priority included interventions, whose delay had no effect on treatment outcome.
Patients with cavitary hemorrhage (injuries of the spleen, liver, vessels of abdominal and pleural cavities, intracranial hematoma, continuous bleeding from a damaged lung) were the first to be operated on.
Operations of the second priority were represented by interventions on the spine and spinal cord; osteosynthesis of a femur, pelvic and shin bones was performed. Planned interventions on skeletal bones, drainage of coagulated hemothorax were operations of the third priority. One-stage operations on the spine and skeletal bones were made in 9 cases. Intervention on the spine were performed at the second stage in 19 patients. Operation on the spine preceded another intervention in 32 cases. Operations on the spine only were made in 54 patients.
Contraindications for an operation were conditioned by an extremely severe state of a patient and included shock, hemodynamics instability, coma, multiple injuries of ribs with hemopneumothorax, anemia, renal and/or liver insufficiency, fat embolism, thromboembolism of the pulmonary artery, pneumonia, non-fixed fractures of extremities.
A state on discharge was estimated on the basis of Karnofsky's scale. A mean score in the total group, in survivors and operated and discharged patients was 49, 66 and 62 respectively.
Fatal outcomes (23%) were conditioned by severe extravertebral injuries and accompanying pyo-septic complications. Postoperative mortality was equal to 15%.
Conclusion. The analysis of results showed, that surgical tactics in patients with ATSSC depended on severity of associated injuries and a patient's state before operation and its dynamics during intervention. Preoperative risk factors were as follows: shock, unstable hemodynamics, ruptures of internal organs with hemopneumothorax and/or hemoperitoneum, severe craniocerebral trauma, Hb<90 g/l, injuries of pelvic bones and hip joint, heart contusion, SpO2<90%, K+<3 mMol/l. Intraoperative risk factors comprised Hb reduction of less than 70 g/l, blood pressure of less than 90 mmHg, SpO2<85%, arrhythmia, single-episode blood loss of more than 800 ml, total blood loss of more than 1500 ml. Use of modern transpeduncular-laminar fixing devices allowed to perform two-stage operations in a severe state of patients with complicated instable fractures of the spine. Active intervention, performed at an early stage, is one of the methods of preventing pyo-septic and thromboembolic complications.