TACTICS OF STAGED SURGICAL TREATMENT OF SPINE AND SPINAL CORD INJURY IN POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
During 20 years the injury rates have been increasing significantly and without a trend to decreasing. The increasing mortality after polytrauma has acquired patterns of disaster and has become a real threat to the national safety in many countries including Russian Federation [1, 2].
In time of piece the frequency of injuries to the spine, the spinal cord and its meninges is about 0.7-7.8 % of all locomotor injuries [3], and 14-20 % in polytrauma [4, 5]. Among all polytrauma cases thoracic injuries consist 23-56.9 %, and according to some authors – more than 60 % [6, 7, 8]. In most cases patients with polytrauma demonstrate the following dominating combinations of injuries: thoracic injuries and spine-spinal cord injury (SSCI) or traumatic brain injury (24.6 %), thoracic injuries and extremity injuries (21.2 %), thoracic and abdominal injuries (9.3 %) [9].
Among fatal cases, 25-50 % of cases are associated with closed thoracic injuries. The causes of lethal outcomes are disorders of functions and systems as result of an injury (31 %), posttraumatic complications in various time intervals of responses to injuries (25 %) [10].
Mutual burdening syndrome, which results in development of multiple organ dysfunction, develops in patients with polytrauma and concurrent injuries such as closed thoracic injury and spine-spinal cord injury. Early surgical treatment of SSCI is sometimes impossible in early period, because of thoracic injuries resulting in disorders of its protective structural function. The earliest respiratory complications of thoracic injuries in polytrauma are pneumonia (59.7 %), exudative pleuritis (50 %), clotted hemothorax (9.6 %) and pleural empyema (16 %) [9].
Surgical tactics for treating patients with spine and spinal cord injuries in polytrauma has its own features and is realized on the basis of damage control approach [11]. The combination of spinal column (with its contents) injury and multiple injuries to the skeleton, internal organs and severe traumatic brain injury, which are life-threatening, results in necessity for multi-staged surgical treatment. First of all, some interventions for removing life-threatening injuries, correction of traumatic shock, stabilizing general state are carried out, after that – reconstructive interventions for the spine and the spinal cord.
Objective – to optimize tactics of staged surgical treatment of spine and spinal cord injuries in polytrauma.
MATERIALS AND METHODS
During 2008-2014 the treatment was carried out for 63 patients with polytrauma, with spine and spinal cord injury as a dominating or concurrent injury. The greatest proportion of the victims included the persons of working age (21-50 years, 46 patients, 73 %). The mean age of the patients was 35.9 ± 13.2. Two-thirds of the patients (74.6 %) were men. Within time intervals from 30 minutes to three hours after injuries 23 (36.5 %) patients were transferred to the clinical center by the emergency aid teams. 40 patients were transported by the reanimobile from other medical facilities (within 6 hours – 4 and more days, 63.5 %).
After the complex examination for all patients the following combinations of injuries were found: spine and spinal cord injury (SSCI) and traumatic brain injury (TBI) – 13 (20.6 %); SSCI and thoracic injury – 13 (20.6 %); SSCI, TBI and skeletal injuries – 7 (11.2 %); SSCI and abdominal injury – 1 (1.6 %); SSCI, TBI, skeletal, thoracic and abdominal injuries – 29 (46 %). The highest amount of injuries was related to the thoracic spine – 42.9 %, the cervical spine – 31.7 % and the lumbar spine – 25.4 % correspondingly. The prevailing injury mechanisms were road traffic accidents – 29 (46 %) and industrial accidents – 18 (28.6 %).
Spinal injuries were found in 58 patients: Type A (A1-3) in 17 cases, type B (B1-3) – 39 cases, type C (C1) – one case. The fracture of C1 odontoid process with subluxation was found in one patient. Severe spinal cord injuries without spinal column damages were identified in 5 cases. Neurologic disorders were estimated with ASIA/ISCSCI. The examination with ASIA/ISCSCI identified the most severe spinal cord disorders (types A, B) in 43 (68.2 %) patients.
Surgical tactics for patients with spine and spinal cord injuries in polytrauma is oriented to multi-staged surgical treatment and consist in strict adherence to diagnostic algorithm, appropriate sequence of surgical interventions and intensive care.
We believe that it is appropriate to use the following approach to realizing surgical interventions in patients with polytrauma, when two groups of operations in acute period of polytrauma are distinguished:
1. Emergent operations, i.e. obligatory. They include surgical interventions for abdominal injuries, ongoing bleeding in the chest cavity, for cerebral and spinal cord compression. The emergent operations include some procedures for femoral fractures, unstable pelvic injuries, fractures of the shoulder and the clavicle, open fractures of long bones, ruptures and crushing injuries in extremity segments.
2. Delayed operations include some procedures, which are necessary, but allow time delays. Such procedures are osteosynthesis for closed shaft fractures of the humerus, the forearm, the leg, intraarticular fractures, fractures of small long bones and the foot with displaced fragments. According to our concept of assistance, 61 patients with polytrauma were treated with use of surgical techniques. They received 150 surgical interventions for various anatomic regions depending on the identified combinations of the injuries.
RESULTS AND DISCUSSION
The short term outcomes of treatment of the patients with spine and spinal cord injuries with polytrauma were evaluated on the basis of 100-point scale by Karnovsky.
As result of performed complex treatment, the short term outcomes were examined in 49 patients (within 3 months – 1 year). The mean period of hospital treatment was 60.5 ± 31.5 days.
The patients with spine and spinal cord injuries in polytrauma showed unsatisfactory outcomes of treatment in 34.7 % of the cases (0-40 points), the mean points of Karnovsky scale were 32.1 ± 6.1: full absence of dynamics in neurologic status and progressing disease (increasing spastic low paraparesis in one patient). 28 (57.1 %) patients demonstrated satisfactory (50-80 points) outcomes, the mean points – 75.5 ± 7.8. The estimation criteria were improving sensitivity below the injury level, appearance of minimally active movements, increasing muscular strength, restoring function of pelvic organs, patient’s activation, improvement in self-care. However, despite of lost working capability in such patients, they are independent and can live at home conditions. 8.2 % of the patients demonstrated good (90-100 points) outcomes, Karvovsky scale – 96.7 ± 1.9. The patients demonstrated normal daily activity without need for medical assistance.
11 patients died in acute period of spine and spinal cord injury. The diagnosis was: “Polytrauma, spine and spinal cord injury in combination with severe traumatic brain injury, skeletal, thoracic and abdominal injuries”. The mean age was 38.3 ± 13.7 years. The state of the patients was extremely severe at the moment of their admission. The mean duration of stay in the intensive care unit was 12.4 ± 8.5 days. The main cause of death was multiple organ insufficiency (respiratory, cardiovascular, renal) – 9 patients; in 4 cases – after pulmonary arterial embolia; in 1 case – after cardiac tamponade.
The example of multi-staged surgical treatment of patients with SSCI in polytrauma is the case of a patient with spine and spinal cord injury in combination with severe chest injury.
The patient R., age of 31, history case #15866/14, was admitted to the admission department of Clinical Center of Miners’ Health Protection on November, 21, 2014. There were no complaints at admission. The patient was on artificial lung ventilation.
The patient suffered from the road traffic accident, 21.11.2014, about 11 a.m. He was driving his car, when he lost control, drove to the road ditch. As result, the car flipped over. The emergency aid team transferred him to the admission department of Myski City Hospital. The patient was examined by the traumatologist on duty, the surgeon and the anesthesiologist. The X-ray examination was made. He was admitted to the intensive care unit with the diagnosis: “Severe concomitant injury. Spine and spinal cord injury. Unstable multi-fragment compression fracture of L1 vertebra with spinal cord compression. Unstable compression splintered fracture of L5 vertebral body. Fracture of Th9-11 transverse processes to the left. Fracture of Th12 spinous process, L2-L3 vertebrae. Fracture of L2-L3-L4 transverse processes. Right lower monoplegia. Posttraumatic bilateral lung contusion, bilateral pneumothorax, minimal hemothorax to the left. Closed displaced fracture of the ribs 3-8 to the right. Closed fracture of the ribs 5-7 to the left with displaced fragments. Brain concussion. Contused scalp abrasion. Traumatic shock of 3rd degree. Spinal shock. The traumatologist on duty performed draining for both pleural cavities according to Bulau”.
By the agreement with the administration of the clinical center, the team of instant readiness transported the patient to the admission department. After admission the patient was examined by the attendant neurosurgeon, the traumatologist and the surgeon. According to the emergent indications the patient was admitted to the intensive care unit.
At admission the general state of the patient was severe. The severity of the state was conditioned by polytrauma (spine and spinal cord injury, severe thoracic injury, non-precise neurologic symptoms, respiratory insufficiency). The body composition was normosthenic, with satisfactory nutrition. The skin surfaces and the visible mucosa were clean, pale and cold during palpation. ALV was realized by means of the intubation tube. The breathing was impaired in all pulmonary fields, without stertor. Cardiac tones were obscure and rhythmical. The hemodynamics was stable. AP = 130/80 mm Hg, HR – 86 per min. The abdomen was of normal shape and soft when palpated. Intestinal peristalsis was auscultated. Urine output was through the catheter.
Local examination: in the chest region the pleural drains were placed on both sides in 2nd and 7th intercostal spaces. There were no signs of exhaust air out of the drains. The visual examination showed the intense deformation in the thoracolumbar spine.
Neurologic status: consciousness was depressed at the background of drug sedation. The patient was not able to contact. The face was innervated symmetrically. The palpebral fissures were equal. The pupils were of middle size, in the middle position, OD = OS, the photoreactions were clear. The tone in the upper extremities was sufficient. The strength in the muscles of the upper extremities was impossible for measuring. Tendon reflexes from the upper extremities were brisk and without differences on opposite sides. The tone in the lower extremities was low, tendon reflexes were depressed, D = S. The muscle strength was not measured. The degree of sensitivity disorders was impossible to measure. There were no pathologic and meningeal symptoms.
The examination was made:
1. Chest radiology with frontal view, and chest HCT: multiple fractures of the ribs on both sides: 4-8 to the right along posterior and middle axillary line. Floating fractures of ribs 4-5, additionally along the middle clavicular line with displacement of fragments across the width up to 1/2-2/3; ribs 3-9 to the left along the scapular line without displacement of fragments. Bilateral pneumothorax, with collapse of up to 1/3-1/2 of both lungs, more in lower anterior departments. Bilateral hemothorax with its minimal volume. Massive bleeding in lower lobe of the left lung with signs of rupture in segmental (S6, S10) and subsegmental bronchi. Small inferior basal infiltration in the right lung. The mediastinum is located in middle position. There were no signs of exudation in the pericardial cavity (Fig. 1a).
2. Lumbar HCT: multi-fragmental fracture of L1 vertebral body, explosive type, decreasing height to 2/3 from Th12, with displacement of fragments towards the spinal canal and its stenosis up to 2/3, fracture of arches, left transverse and spinous process L1. Anteriolateral (to the right) dislocation of Th12, up to 1/4-1/3 of cranial region L1, with fracture of inferior articular processes Th12 to the left, superior articular processes L2-L3 on both sides and L4 to the right, with displacement of fragments. Longitudinal compression fracture of L5 vertebral body, with fragmentation of superior anterior region, wedge-like deformation of degree 1, without narrowing in the spinal canal. Posterior medial traumatic hernia of L4-L5 intervertebral disk, up to 0.8 cm, with compression of dural sac (Fig. 1b).
3. Cranial radiography: no injuries to the cranial vault on the cranial images (two views).
Figure 1
The patient R., age of 31: a – chest MSCT with 3D reconstruction at admission; b – lumbar MSCT at admission
a 
b
On the basis of the data of general examination and radiologic techniques the diagnosis was confirmed: “Polytrauma: closed spine and spinal cord injury. Compression comminuted non-stable fracture, burst fracture of L1 vertebral body (type A3), subluxation of Th12. Compression longitudinal non-stable fracture of L5 vertebral body. Fracture of inferior vertebral processes Th12 to the left, of superior L2-L3 articular processes on both sides and L4 to the right, with displacement of fragments. Disorders of spinal cord conductance from Th12 in ASIA-A segment. Lower paraplegia. Disorder of pelvic organ function in view of delay. Brain concussion. Severe thoracic injury: closed complicated fracture of ribs 4-8 to the right (floating ribs 4-5), ribs 3-9 to the left without displacement of fragments. Bilateral pneumothorax with collapse (1/3-1/2 of both lungs). Bilateral hemothorax, minimal volume. Massive bleeding in lower lobe of the left lung, disruption of segmental (S6, S10) and subsegmental bronchi. Heart contusion. Traumatic shock”.
For estimation of management tactics the concilium including the physicians of the duty team was realized. Considering the severity of the state, increasing respiratory insufficiency after the thoracic injury, multiple fractures of the ribs on both sides, increasing pneumothorax, failure of previous Bulau draining for both pleural cavities, clinical signs of ongoing bleeding from injured tissues of the left lung, the concilium defined the following tactics of staged surgical treatment:
- To conduct recurrent draining for both pleural cavities under thoracoscopy. To conduct osteosynthesis for the ribs on both sides for support function of the chest.
- To perform diagnostic laparoscopy for identification of abdominal injuries.
- To conduct fiber-optic bronchoscopy after surgery.
- To conduct chest HCT on November, 22, 2014.
- To conduct reposition stabilizing surgical intervention for injured spinal segments in case of absent signs of ongoing bleeding, correction of bilateral pneumothorax, spreading tissue in both lungs and stabilizing general state.
On November, 21, 2014 the emergent surgery was carried out: 1. Diagnostic laparoscopy did not find any abdominal injuries. 2. Endovideothoracoscopy, revision, sanation, recurrent draining for both pleural cavities. Osteosynthesis of the ribs 4, 5 to the right, and the rib 4 to the left (Fig. 2a). We found some regions of the most severe chest injury resulting in its structural breakdown. Such injuries included the fractures of the ribs 4 and 5 to the right along anterior axillary line, because they resulted in floatation of the segment. Osteosynthesis for the rib 4 to the left was performed, because of significant displacement of fragments resulting in an injury to the left lung tissues. The regions of the chosen fractures were marked, and the skin incisions of 6 cm were made. Open reposition and osteosynthesis of fractures with the original fixator (angle stability plate; the patent # 126260. Russian IPC A61B. The utility model – the osteosynthesis plate for multiple floating fractures of ribs. The statement from August, 2, 2012, published on March, 3, 2013) were made.
Inferior tracheostomy was made on November, 25, 2015.
After removal of bilateral pneumothorax, spreading tissues in both lungs and stabilizing general state the surgery was made on November, 28, 2014: L1 laminectomy, removal of bone fragments out from the spinal canal, posterior decompression for the spinal cord, spinal cord revision, microsurgical plastics for dural sac, transpedicular fixation of Th12-L2 (Fig. 2b). After performing posterior and partial anterior decompression of the spinal canal at L1 level we found absent epidural fiber, intense deformation of dural sac, and, along the lateral surface to the right, a defect in dura mater (3×0.4 cm) with spinal root prolapse into the defect region of the spinal roots. Under the optical magnification with the surgical microscope OPMI Pentero (Carl Zeiss) a bone fragment (L1) of 2×1 cm was removed. Dural sac plastic surgery was realized with artificial dura mater. The graft was fixed with twisted vascular suture with prolene 6/0 (Fig. 2b). Dural sac showed its free position and was filled with spinal fluid. The total surgery time was 2 hours.
Figure 2
The patient R., age of 31: a – chest X-ray – after 1st stage of surgical treatment (internal osteosynthesis of ribs IV-VI to the right and the rib IV to the left); b – lumbar MSCT – after 2nd stage of surgical treatment (decompressive laminectomy for L1, revision of spinal cord, dural sac plastics, posterior transpedicular fixation for Th12-L2)
a 
b
The period of treatment in the intensive care unit was 31 bed-days. The patient received artificial lung ventilation during 18 days. The tracheostomy tube was removed 26 days after admission. Postsurgical period was without any abnormalities. Healing was with primary tension. The sutures were removed on 12th day. Intensive care was continued in the neurosurgery department #2. Restorative management was according to the individual program. The conducted treatment was associated with positive dynamics. Appearance of sensitivity in the lower extremities was in view of burning, unpleasant feelings, minimal motions in the left lower extremity with the spastic component. The patient was discharged for after-care in the neurologist and the rehabilitation physician in the health resort Topaz at his place of residence.
90 days later the patient was admitted to the neurosurgery department #2 for the second stage of surgical management.
There were some complaints after admission: absence of active motions in the right lower extremity, limited motions in the left lower extremity, decreasing sensitivity in the lower extremities.
The neurology status at admission: clear consciousness, adequate state, good space and time orientation. The patient is able to contact. The position is active. He can sit on the bed. Movement is by means of a wheel chair. The face is symmetrically innervated. The interpalpebral fissures are equal. The pupils are of middle size and in the medial position. OD = OS. The photoreactions are clear. Muscular strength and tone are sufficient in the upper extremities, D = S. SHR are normal and without differences on opposite sides. There is hypotrophy. Tendon reflexes in the muscles of the lower extremities (more intense on the right side). The tone is decreased in the lower extremities, S > D. The muscular strength in the right lower extremity is 0-1 point, in the left lower extremity – 2 points. Tendon reflexes are weak to the right, and of middle intensity to the left. Hypesthesia and hyperesthesia are from the omphalus level. There are no abnormal pathologic and meningeal symptoms.
The surgery was performed under endotracheal anesthesia on May, 21, 2015: decompressive stabilizing intervention with spinal fixation with dorsal or ventral implants: thoracotomy to the right with resection of 10th rib. Removal of L1 vertebral body, anterior decompression of the spinal cord. Anterior interbody fusion for Th12-L2 with the interbody cage (Fig. 3).
Figure 3
The patient R., age of 31. Lumbar MSCT – after 3rd stage of surgical treatment (removal of L1 vertebral body, anterior decompression of spinal cord, anterior interbody fusion for Th12-L2 with expansible interbody cage)
The treatment in the intensive care unit was 1 bed-day. The pleural drain was removed on the second day. The postsurgical period was without complications. Healing was accompanied by primary tension. The sutures were removed on the 10th day. The individual rehabilitation program was initiated from the third day after the surgery.
At the background of the treatment one could observe the regressing reflex disorders in view of appearance and gradual increase in volume of motions in the proximal departments of the lower extremities and the concurrent improvement in sensitivity. There is restoration of pelvic organ function, contractility in the muscles of both thighs and legs (Fig. 4). The general period of treatment including two periods of hospital stay was 78 bed-days. The short term results are satisfactory (87 points according to Karnovsky scale).
Figure 4
The patient R., age of 31. The short term functional results
The given clinical case shows that positive results were possible with the offered scheme of multi-stage surgical treatment with microsurgical techniques for severe spine and spinal cord injuries as part of polytrauma.
CONCLUSION
1. Treatment of patients with spine and spinal cord injuries in polytrauma are realized in conditions of a specialized medical facility with possibilities for complex high tech surgical, traumatological and neurosurgical aid.
2. Conduction of emergent surgical interventions for removal of life threatening states within 6 hours and delayed operations within 3 days in patients with spine and spinal cord injuries in polytrauma allowed reducing period of artificial lung ventilation and hospital stay, with satisfactory and good functional outcomes in 65.3 %.