Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

 At the present time, high urban growth population, significant increase in road accidents and technogenic disasters create great difficulties for diagnostics and treatment of injuries to the spine and spinal cord in combinations with severe traumatic brain, thoracic and skeletal injuries.

Polytrauma is a combination of two or more injuries, one of which or their combination creates direct threat for patient’s life and is an immediate cause of traumatic disease [5].

Disordered spinal cord functions, as result of partial or complete destruction of anatomic structures after trauma, are irreversible and lead to severe disability [2]. In peace time the rate of injuries to the spine, spinal cord and dura mater is 0.7-7.8 % of all locomotor injuries [8, 11]. In case of polytrauma the number of injuries increases to 14-20 % [3, 6]. Among all nervous system injuries, the spinal cord injuries in adults are 4.9-5.3 %, in children ‒ 2.2-20.6 % [1, 8]. Traumatic injuries to dural sac in combination with spinal injuries are identified in 7.5-19 % of cases [13].

Despite of improvements in assistance for patients with spine and spinal cord injuries, implementation of new surgical and resuscitation techniques, one still observe high mortality rates, which  achieve 10.5 % of cases in isolated spine and spinal cord injuries [8], and 23-40 % for combinations with injuries to other regions [4, 5].

Diagnostics and treatment for spinal fractures and spinal cord injuries with polytrauma are associated with significant difficulties. Combination of injuries to several anatomic regions (traumatic brain injury, severe skeletal injuries, thoracic injuries, abdominal injuries, unstable pelvic injuries) averts surgeons’ attention from spinal injuries. Significant difficulties appear in identification of spine and spinal cord injuries in patients with disordered consciousness as result of severe traumatic brain injury or traumatic shock, which create difficulties for detailed examination of the spine and neurologic disorders.

Trauma outcome and quality of life are improved with complex treatment of spine and spinal cord injuries including complete examination, timely administration of high tech operations and early initiation of restorative treatment [10].At the present time, during treatment for isolated injuries to the spine and spinal cord surgeons aspire to perform surgical interventions in early terms after trauma [9]. However, according to the literature data, there is no uniform opinion about time for surgical intervention. According to some literature data, surgical treatment should be initiated within 6-12 hours [9], according to other opinions ‒ in case of polytrauma surgical treatment should be delayed by 12-72 hours [12]. Correction of spinal canal deformation and spinal cord compression promotes improvement in spinal cord blood supply, restores spinal fluid circulation, removes irritation in different parts of nervous system and decreases development of common, but sometimes irreversible circulation disorders in the spinal cord [9].

There are specific features of surgical tactics for treatment of spine and spinal cord injuries in polytrauma. Combination of life threatening injuries to the spinal column and its contents with injuries to bones, internal organs and traumatic brain injury results in necessary staged surgical treatment. Firstly, interventions for correcting life threatening injuries, traumatic shock correction and general state stabilizing are realized, later ‒ reconstructive interventions for the spine and the spinal cord.

Research objective ‒ to optimize surgical tactics for patients with spine and spinal cord injuries with polytrauma.

 

MATERIALS AND METHODS

63 patients with spine and spinal cord injuries with polytrauma received treatment in Clinical Center of Miners’ Health Protection in 2008-2014. The greatest amount of patients was of employable age (21-50 years, 46 persons, 73 %). The mean age of the patients was 35.9 ± 13.2. Two thirds of the patients (74.6 %) were men. The emergency aid teams (Clinical Center of Miners’ Health Protection) transported 23 (36.5 %) patients within time intervals from 30 minutes till 3 hours after trauma. 40 (63.5 %) patients were transported by the specialized teams which performed reanimobile transport from other medical facilities within 6 hours to 4 and more days.

The duty doctors (anesthesiologist-intensivist, neurosurgeon, traumatologist, surgeon) performed complex clinical examination for all patients after their admission. X-ray examination included: 1) computer tomography for injured spinal segment; 2) cerebral computer tomography was performed in presence of clinical data of traumatic brain injury; 3) chest radiologic examination, in some cases CT was performed for confirmation of severity degree; 4) skeletal radiologic examination.

After the complex examination the following variants of injuries combinations were found in all patients: 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 injury ‒ 7 (11.2 %); SSCI and abdominal trauma ‒ 1 (1.6 %); SSCI, TBI, skeletal, thoracic, abdominal injuries ‒ 29 (46 %). The greatest number of injuries was associated with thoracic department of the spine ‒ 42.9 %. Cervical spine injuries were 31.7 %, lumbar spine injuries 25.4 %. The prevailing injury mechanisms were road traffic accident ‒ 29 (46 %) and industrial injury ‒ 18 (28.6 %).                      

  Spinal injuries were found in 58 patients: type A (A1-3) ‒ 17 cases, type B (B1-3) ‒ 39, type C (C1) ‒ 1 case. A fracture of C1 odontoid process with subluxation was found in one patient. There were 5 cases of severe spinal cord contusions without spinal column injuries. Neurologic disorders were conducted with ASIA/ISCSCI (table).

Table
Spinal cord disorders according to ASIA/ISCSCI

The examination with ASIA/ISCSCI identified severe disorders in the spinal cord (A, B types) in 43 (68.2 %) patients.

11 patients died during acute period of spine and spinal cord trauma. The diagnosis was polytrauma, spine and spinal cord injury in combination with severe traumatic brain injury, skeletal, thoracic and abdominal injuries. The mean age of the dead patients was 38.3 ± 13.7. At admission moment the state of the patients was extremely severe. The mean period of stay in the hospital and ICU was 12.4 ± 8.5 days. The main cause of death was multiple organ insufficiency (respiratory, cardiovascular and renal insufficiency) in 9 patients. 4 lethal outcomes were caused by pulmonary thromboembolism, 1 lethal outcome ‒ with cardiac tamponade.

The short term outcomes of treatment of spine and spinal cord injuries with polytrauma were estimated with the hundred-point scale by Karnovsky.

The statistical analysis was performed with Statistica 6.0 software. The descriptive statistics was presented with mean arithmetic (M) and standard error in mean (m).

Surgical tactics was defined on the basis of complex examination for the patients with polytrauma (objective examination, clinical and radiologic data, laboratory examination).

 

RESULTS AND DISCUSSION

Surgical tactics for spine and spinal cord injury with polytrauma is oriented to multi-staged surgical treatment and consists in strict adherence to diagnostic algorithm, substantiated sequence of surgical interventions and intensive care.

We believe that it is appropriate to use the approach for surgical interventions in polytrauma, when two groups of operations for acute period of polytrauma are separated:

1. Emergent operations, i.e. obligatory. They include surgical interventions for abdominal injuries, for ongoing bleeding in chest cavity, for brain and spinal cord compression. Emergent interventions include operations for femoral fractures, unstable pelvic injuries, humerus and clavicle fractures in combination with severe thoracic injury, opened fractures of limb long bones, in ruptures and crushing injuries to limb segments.

2. Delayed operations, which are necessary for conduction, but are delayed. These are osteosynthesis for closed humeral shaft fractures, fractures of forearm, the leg, intraarticular fractures, fractures of small long bones of the hand and the foot with displaced fragments.

According to the concept accepted in our clinic we performed treatment for 61 patients with polytrauma including 150 indicated surgical interventions for different anatomic regions in dependence on identified combinations of injuries.

9 patients were not operated: 2 patients with spinal cord contusion at the cervical level were admitted to the neurosurgery center (positive results and regressing neurologic symptoms were observed). 7 patients were admitted to the clinic in extremely critical state with diagnosis: polytrauma with spine and spinal cord injuries in combination with severe traumatic brain, thoracic and abdominal injuries. There were 2 lethal outcomes during 3 hours after admission and 5 lethal outcomes in 2-3 weeks after admission.

Surgical interventions were performed interchangeably by two or more surgical teams. Uni- or bilateral pleural draining was emergently performed in 14 cases with closed complicated rib fractures with pneumo- and hemothorax. Diagnostic laparoscopy was performed in 25 cases. It found internal organ injuries in 11 patients. For them laparotomy was carried out. In these cases surgical management for the spine and the spinal cord was delayed and carried out on days 2-3, when state stabilizing was achieved. Decompressive cranial trepanation, evacuation of intracerebral hematoma and brain crushing injury focuses were performed in 3 patients with spinal injuries in combination with severe traumatic brain injury. Surgical management for the spine was delayed.

For the patients with spine and spinal cord injuries combined with multiple fractures of limb long bones the first stage included low invasive intramedullary femoral osteosynthesis with locking nails and plaster immobilization for other fracture regions. The second stage included decompressive stabilizing interventions for the spine. After general state compensation osteosynthesis was performed for fractures of the forearm and leg bones.

73 surgical interventions were performed for 54 patients with dominating spine and spinal cord injuries in 54 patients. It is conditioned by the fact that 26 % of the patients received operations in dependence on spinal injuries. The first stage included anterior spinal cord decompression and interbody fusion. Afterwards posterior spinal cord decompression, meningomyelolysis, dural sac plastics, transpedicular fixation or laminal hook fixation were conducted. Optical magnification and microsurgical techniques were used in 46 cases during posterior decompression, spinal cord revision and dural sac plastics. 

The case of treatment for the patient with severe spinal cord injury presents an example of complex treatment for patients with spine and spinal cord injury with polytrauma.

The patient D., age of 45, the case history #7947/11, received treatment in the neurosurgery center during 66 clinical days. The diagnosis was as indicated below: polytrauma; closed complicated spine and spinal cord injury; compression comminuted penetrating non-stable fracture of L4 vertebra, L3-4 articular processes, anterior-posterior left dislocation of L3 vertebral body with disrupted L3-4 disk, fractures of L1-L5 transverse processes to the right, L4 to the left (type B.2.2); disordered spinal cord functions ASIA-B; lower paraplegia, disordered functions of pelvic organs with delay type; closed non-complicated fracture of 9^th rib to the right; minimal hydrothorax to the right; closed fragmentary comminuted transsubtrochanteric fracture of the left femoral bone with displaced fragments; closed fragmentary comminuted displaced fracture of proximal one-third in both bones of the right leg.

There were complains about lumbar spine pain, absent active motions, absent sensitivity in the lower extremities and spontaneous urination.

The trauma circumstances: an industrial injury, May, 27, 2011, 2 a.m., as result of roof collapse in the underground mine. The victim suffered from a rock hit (in flexion position) to the lumbar region of the spine and lower extremities. The mine rescue brigade conducted transfer to the Beryozovsky city hospital. The examination was carried out. The patient was admitted to the intensive care unit. Anti-shock therapy and lower limb skeletal traction were performed. After reconciliation with the center management the specialized team carried out reanimobile transfer to Clinical Center of Miners’ Health Protection. The examination was performed by the duty team.

At admission moment the general state was middle severe, conditioned by polytrauma. The patient was in lying position in Kashtan anti-shock suit. The breathing was independent, adequate, thorough natural airways and was listened in all lung departments. Hemodynamics was stable, AP ‒ 130/90 mm Hg, pulse ‒ 86/min. The abdomen was symmetrical, soft in palpation, and painless in all parts. Diuresis was realized with a catheter.

The local examination. There was a moderate kyphotic deformation at the level of lower lumbar spinal department, as well as pain in palpation and load to the spinous processes at the lumbar level.

Neurologic status. The patient was consciousness, space-orienting and adequate for examination. Facial innervation was symmetrical, the tongue was along the middle line. The pupils were narrow and equal, with persistent photoreactions and oculocephalic reflexes. Eye movements were within the full range and painless. The muscular tone and strength in the upper extremities were equal and persistent.    Brisk tendon reflexes in the hands, D = S. Atony, areflexia from the lower extremities. Deep hypoaisthesis in the lower extremities with transition to anesthesia. Delayed pelvic disorders.                                

Lumbar MSCT: fragmented fracture of L4 vertebral body and L3-4 articular processes; boundary fracture of L3 inferior lateral angle to the right; anterior lateral left dislocation of L3 vertebral body to ½ of L4 cortical field; traumatic narrowing of L3-4 foraminal canal to the right, deformed dural sac at L3-L4 level as result of displaced bone fragments of L4 body, L3-4 articular processes and L3-4 ruptured disk; fractures of L1-5 transverse processes to the right, L4 to the left (Fig. 1).

X-ray examination of the left femoral bone: fragmentary comminuted, transsubtrochanteric fracture of the left femoral bone with displaced fragments (Fig. 2).

Figure 1 Patient D., age of 45. Lumbar spine MSCT with 3D reconstruction on admission

Figure 2 Patient D., age of 45. Left femur X-ray imaging on admission

                

X-ray examination of the right leg:  fragmentary comminuted fractures of both right leg bones in proximal one-third with displaced fragments (Fig. 3).

The emergent surgery was performed on May, 27, 2011: closed reposition, locking intramedullary fixation of the left femoral bone (Fig. 4).

Figure 3 Patient D., age of 45. Right leg X-ray imaging on admission

Figure 4 Patient D., age of 45. Left femur X-ray imaging after surgical treatment

                           

The patient was transferred to the ICU for further treatment. Infusion, anti-shock and antibacterial treatment was conducted.

The surgery was performed on May, 28, 2011: L4 laminectomy, open reposition for L3 dislocation, dural sac posterior decompression, revision for cauda equine roots, microsurgical plastics for dural sac, L2-5 transpedicular fixation under Medtronic neuronavigation system (Fig. 5). The revision showed a lineal injury to dural sac, edema of cauda equine roots with punctulated bleedings. After root decompression the dural sac plastics with artificial dura mater graft was conducted.

The surgery was performed on June, 6, 2011: open reposition, angle stability plate osteosynthesis for the right tibia (Fig. 6).

Figure 5 Patient D., age of 45. Lumbar spine MSCT after surgical treatment

Figure 6 Patient D., age of 45. Right leg X-ray imaging after surgical treatment

                            

Intensive care period was 11 days. Afterwards the patient was transferred to the neurosurgery department #1 for intensive care. Restorative treatment was made on individual basis. The postsurgical period was without complications. Healing by first intention was observed. The sutures were removed in 12 days. After realized treatment one could observe gradual regression in conduction disorders in view of appearance and gradual increase in the volume of motions in the proximal departments of the lower extremities and increasing sensitivity.

The patient was examined one year later. The examination showed improvement in pelvic organ functions, muscular contractility in both thighs and legs, increasing sensitivity in the lower extremities. The patient could stand with support to foreign objects. The movement was in the wheel chair.

The given clinical case shows that the offered algorithm of staged surgical treatment with microsurgical techniques for severe spine and spinal cord injuries with polytrauma allows achieving positive outcomes.

After complex treatment the short term outcomes were examined in 49 patients (3 months-1 year). The mean period of hospital treatment was 60.5 ± 31.5 days.

The unsatisfactory outcomes were observed in 34.7 % of cases (0-40 points) with spine and spinal cord injuries with polytrauma. The mean Karnovsky scale indices were 32.1 ± 6.1: full absence of dynamics in neurologic status and disease progression (worsening spastic lower paraparesis in one patient). For 28 (57.1 %) patients the results were estimated as satisfactory (50-80 points), the mean score ‒ 75.5 ± 7.8. The estimation criteria were improving sensitivity below the injury level, appearance of minimal active movements, increasing muscle strength in the extremities, restoring functions in the pelvic organs, patient activation, improving self-care. However despite of lost working capability in such patients, they can be independent and live in home conditions. The good outcomes were observed in 8.2 % of the patients (90-100 points). The mean Karnovsky score was 96.7 ± 1.9. They had normal daily activity without requirements for medical assistance.

 

CONCLUSION

1. Treatment for patients with spine and spinal cord injuries with polytrauma should be performed in specialized medical facilities with possibilities for complex high tech surgical, traumatologic and neurosurgical assistance.

The offered tactics of programmed multi-staged surgical treatment for patients with spine and spinal cord injuries with polytrauma allowed two times reducing mean period of hospital treatment compared to the medicoeconomic standards.

3. Using microsurgical reconstructive restorative techniques for the spinal cord and dura mater (during acute trauma period) resulted in improving disordered spinal cord functions, with satisfactory and good outcomes in 65.3 %.