Therapeutic-and-Diagnostic Algorithms in Traumas of the Upper Cervical Spine

Yu.A. Shulev, V.V. Stepanenko, V.N. Bikmullin, V.V, Remenets, A.V. Vorobyev

Municipal Multi-Field Hospital N 2,
Medical Academy of Postgraduate Education, Saint Petersburg, Russia

 

Injuries of the upper cervical spine (UCS) account for 1-1.5% of all traumas of the cervical spine as a whole. The rate of mortality in UCS injuries is almost 45%. High cost of diagnostic procedures, materials for operation and implants is a forcible argument, conditioning choice of optimum therapeutic-and-diagnostic algorithms, which will allow to render effective care to a casualty on the one hand and to avoid excessive and unjustified instrumentalization.

Materials and Methods. We analyzed data of multimodality examination and treatment of 71 cases with different types of UCS trauma. All the patients were divided into 3 groups in compliance with a dominating clinical-and-morphologic syndrome.

Group I. Patients with neurologic complications, i.e. clinical syndrome of spinal cord compression (12). Group II. Patients with orthopedic complications, i.e. instable injuries and a high risk of development of secondary neuroorthopedic disorders (43). Group III. Patients with minor injuries, i.e. biomechanically stable injuries with minimum neurologic disorders (16).

Estimation of a neurologic status (the ASIA scale, 1998), myelopathic syndrome (the JOA scale, 1994), pain syndrome (Ranowat's scale, 1993) was a compulsory element of a diagnostic program. Rentgenography with determining standard indices and distances (White, Panjabi, Klaus, Spence, Powers), CT with reconstruction, MRI were used for assessment of a critical point of orthopedic inconsistency and compression factors. UCS injuries were evaluated on the basis of classifications, elaborated by Martin G. J. et al. (1981), Fielding J.W. and Hawkins R.J. (1977), Andersen and D'Alonzo (1974), Levine and Edwards (1985).

Results. Spinal cord compression and instability were absolute indications for using neuroorthopedic correction in all cases of Group I. Presence of anterior compression of the spinal cord demanded transoral decompression as the first stage and fixation as the second stage of intervention. We used cable and hook fixation. Cable fixation was performed in accordance with Brook-Gallie's method; the CCD-cervical system (Sofamor-Danek) was used for hook fixation. Treatment resulted in adequate decompression of the spinal cord in all cases.

Dynamics of dominating clinical syndrome (myelopathy) and final functional adaptation of a patient were considered to be a criterion of treatment efficacy in this group. Efficacy of surgical treatment was estimated on the basis of Fujimura-Hirabajashi's index. Excellent and good results were watched in 10 (83%) and 4 (17%) cases.

As for Group II, interventions were performed in 17 patients; conservative treatment was carried out in 26 cases. We used such methods as axis fixation with a cannulated screw according to Nakanishi-Apfelbaum (1982, 1993), removal of C2-C3 disc and plate fixation, posterior occipitocervical fixation, interarch spondylodesis with C1-C2 fixation.

Efficacy of treatment in Group II was estimated on the basis of dynamics of dominating clinical syndrome (pain syndrome, Ranowat's scale) and functional adaptation. Surgical tactics allowed to achieve better results during a shorter period of time in comparison with conservative treatment.

Conservative treatment was carried out in all 16 cases of Group III. Different devices for external mobilization were used. We managed to achieve regression of pain in the neck and restoration of functional independence. There was a two-fold decrease of pain intensity in a month; it disappeared completely in 3 months.

Conclusion. A rational algorithm of a casualty examination, objectifying a character of traumatic changes in UCS, includes estimation of a neurologic status with the help of the ASIA, JOA scales, as well as Ranowat's scale, and an orthopedic status with an analysis of injury biomechanics. It is expedient to use diagnostic-and-therapeutic algorithms and to estimate treatment results in homogenous groups of casualties, selected on the basis of dominating clinical syndrome.