SIGNIFICANCE OF EARLY INTERHOSPITAL TRANSPORTATION IN COMPLEX TREATMENT OF PATIENTS WITH ACUTE SPINE AND SPINAL CORD INJURY
Federal Scientific Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The spinal cord injury presents one of the most complicated problems of public health. This problem is important for the developed countries and the developing ones without appropriate medical assistance.
Injuries to the spine and the spinal cord constitute up to 20 % from all skeletal injuries. Among all injuries to the spine and the spinal cord the concomitant spine and spinal cord injury takes 13-63 % without decreasing tendency [3, 4, 10].
Despite some improvements in rendering assistance for patients with spine and spinal cord injuries, the implementation of new techniques for surgical treatment and the modern methods for resuscitation and intensive care, one can observe the high rates of mortality: 27.9 % for isolated injuries to the spine and the spinal cord [7, 8], and 23-40 % [1, 5, 11] for combinations in other anatomic regions.
At the present time for patients with spine and spinal cord injury (SSCI) the surgeons aspire to perform surgical interventions in early period after injuries [9]. However, according to the literature data, the authors have not any uniform opinion about timing of surgical management, and they vary time intervals within 6-72 hours after trauma [2]. Many authors accent that treatment of patients with spine and spinal cord injuries should be realized in the specialized centers [4, 6, 12, 13].
Considering severity of state and ongoing bleeding, more than a half of patients are admitted from accident site to the nearest medical prophylactic facilities having surgical departments.
Investigation of causes of appearance, frequency and clinical manifestations of SSCI is necessary for timely realization of the first medical assistance, correct timely transfer and further planning the curative and rehabilitative measures.
Objective – to estimate efficiency of early interhospital transportation in complex treatment of patients with injuries to the spine and the spinal cord.
MATERIALS AND METHODS
During 2008-2011 the teams of instant readiness of the clinical center realized transfer for 73 patients with spine and spinal cord injuries (SSCI) from the medical facilities of Kemerovo region. There were 33 (45.2 %) patients with isolated injuries to the spine and spinal cord and 40 (54.8 %) patients with polytrauma with SSCI as the dominating or concurrent injury. Injury Severity Score (ISS) was used for estimating the severity of traumatic injuries, the mean score was 32.6 ± 0.4.
The timing of transfer was different despite the fact that we adhere to the earliest possible transfer to our clinic and the earliest surgical treatment for injuries to the spine and the spinal cord. The main cause of late transfer was absence of objective criterions for making decisions about patient’s transportability at the accident sites [12].
Only 60.3 % of the patients were transferred to Clinical Center of Miners’ Health Protection within 24 hours. 6 patients (8.2 %) were transferred on the second day. 31.5 % of the patients were transferred on the third day and later. Only 23 patients with spine and spinal cord injuries were transferred within two days, as well as 27 patients with polytrauma; it impacted the timing of surgical management and further functional outcomes.
For the questions of interhospital transportation the clinical center includes the single dispatcher service, which receives all information about the patient. On the basis of received data about diagnosis and severity of patient’s state the transport team is prepared, and the choice of measures for specialized medical assistance is made. On the obligatory basis the team included anesthesiologist-intensivist, nurse-anesthetist and ambulance driver. The composition of remaining specialists depended on the dominating injury defining severity of patient’s state: traumatologist-orthopedist, neurosurgeon, surgeon.
During primary examination for patients with injuries to the spine and the spinal cord it is essential to estimate the level of spinal cord injury, because further tactics of intensive care depends on it. The preparation for transportation was made after primary examination and estimation of the level of spinal cord injury and the degree of disorder in the spinal cord. Besides correction of respiratory disorders, the therapy for prevention and treatment of ascending edema of the spinal cord was the hallmark of intensive care in the patients with polytrauma with spinal cord injuries in the upper departments (cervical and upper thoracic). The antiedemic therapy included saluretics (furosemide), medications for improving hemorheology and microcirculation (trental, rheopolyglucinum). Bronchial sanitation was obligatory for the patients with respiration disturbance after tracheal intubation.
During transportation all patients received monitoring of AP, HR, ICP, SpO2, ECG, diuresis control. The examination of hemostasis values was made before transportation and after its completion.
Cervical spinal injuries were fixed with the transport collar of Philadelphia type, with transportation in the vacuum mattress. Transportation of patients with thoracic spinal injuries was realized only with the vacuum mattress. The injuries to the lumbosacral region were immobilized with Kashtan anti-shock suit with pneumocompression over injured regions up to 30-40 mm Hg, and 15-20 mm Hg for remaining regions of the body. There were no lethal outcomes at the stage of interhospital transfer.
Most transported patients were of working age of 21-50 (53 patients, 72.6 %). The mean age of the patients was 36.9 ± 12.5. The men were in 80 % (table 1).
| Table 1 | ||||||||
| Age and gender distribution of patients with SSCI who were transported from other facilities | ||||||||
Most injuries were in the cervical spine – 32 (43.8 %), followed by thoracic (31.5 %) and lumbar spine (24.7 %). Home injury (34.2 %) and road traffic accident were the leading mechanisms of injury.
The patients with polytrauma had the following combinations of injuries: spine and spinal cord injury (SSCI) and traumatic brain injury (TBI) – 8 (20 %), SSCI and thoracic injury – 7 (17.5 %), SSCI, thoracic and skeletal injury – 11 (27.5 %), SSCI and abdominal injury – 1 (2.5 %), SSCI, TBI, skeletal, thoracic and abdominal injury – 13 (32.5 %).
At admission all patients received complex clinical examination performed by the physicians of the duty team. X-ray examination included: 1) computer tomography for an injured segment of the spine; 2) head CT was made in case of available clinical data about traumatic brain injury; 3) chest X-ray, and CT in some cases for confirmation of injury severity; 4) skeletal X-ray examination.
Spinal injuries were found in 69 patients: type A in 23 cases (31.5 %), type B – 46 (61.6 %), type C (C1) – 1.4 %. X-ray examination did not find bone traumatic injuries of the spine in 5.5 %. Magnetic resonance imaging showed traumatic rupture of the intervertebral disk in one patient and severe contusion of the spinal cord at the level of cervical thickness in three patients. Neurologic examination was realized with ASIA/ISCSCI [6] (table 2).
| Table 2 | ||||||||||
| Distribution of patients with SSCI according to types of fractures and degrees of disorders of spinal cord functioning | ||||||||||
The examination with ASIA/ISCSCI found the most severe disorders in functions of the spinal cord (type A, B).
Surgical treatment was performed in 89 % of the patients with acute spine and spinal cord injuries who were transported to the specialized center.
Tactics of treatment was chosen on the basis of estimating severity of state and the data of clinical and radiologic examination.
The short term results of treatment of injuries to the spinal cord and its meninges were evaluated with 100-point scale by Karnovsky [15].
RESULTS AND DISCUSSION
14 patients with spine and spinal cord injuries died during hospital treatment (19.1 %). Among them 8 patients had isolated SSCI, 6 patients – polytrauma. The mean age of the patients was 43.8 ± 9.1. The greatest amount of lethal outcomes was noted in the patients with the injuries in the cervical and upper cervical regions of the spine – 11 (78.5 %) cases. The hospital mortality in these patients was directly related to the level of spinal cord injury and timing of transfer from the non-specialized medical facilities (table 3).
| Table 3 | ||||||||||
| Relationship between mortality in patients with spine and spinal cord injuries and time of transfer from other facilities | ||||||||||
The maximal mortality (50 %) was observed in the patients with dominating or concurrent injuries at the cervical level and with polytrauma who were transported on the second day; it was conditioned by increasing edema in the spinal cord and developing acute cardiovascular and respiratory failure.
One of the criterions for estimation of efficiency of treatment is postsurgical mortality. According to our data this rate was 15.3 % of all operated patients transported to the center. Within postsurgical period 10 patients died; 4 patients did not receive surgical treatment because severity of their state and short period of hospital stay.
The main causes of death after spine and spinal cord injuries were multiple organ dysfunction (cardiovascular, respiratory, renal) in 9 cases, pulmonary embolism – 3, purulent septic complications – 2.
The short term results of treatment were observed in 59 (80.8 %) patients within the intervals from 3 months till 1 year. The mean terms of hospital treatment for the patients with SSCI were 59.6 ± 28.1 days. The patients with isolated injuries to the spine and the spinal cord had longer hospital period in comparison with the medicosocial standards (54.5 ± 21.1 days). It was conditioned by late terms of transfer to the clinic and already advanced complications (bed sores, pneumonia, lower venous thrombosis) which required longer treatment.
The mean period of hospital treatment in the patients with dominating spine and spinal cord injury with polytrauma was 60.2 ± 28.7 days. Early transfer and active surgical tactics allowed 1.5 time reducing terms of hospital treatment for the patients with dominating SSCI in comparison with the medicosocial standards.
The unsatisfactory results of treatment were in 27.1 % (0-40 points): absent dynamics in neurologic status, need for constant nursing care; transfer and operation within 3 or more days. The satisfactory results were observed in 50.8 % (50-80 points). The estimation criterions were improving sensitivity below injury level, appearance of minimally active motions, increasing muscular strength in the extremities, restoration of function of pelvic organs, activation of patient, improvement in self-care. However despite of the fact that such patients demonstrate lost working ability, they can perform self-care and live at home. The good results were observed in 22.1 % of the patients (90-100 points). They demonstrated normal daily activity and did not require medical assistance. The good and satisfactory results of treatment were in the patients who were transported from other medical facilities and operated within 2 days from injury.
Purulent complications were in 30.5 % of the cases. Postsurgical period showed superficial purulence in the sutures in 3 patients; the inflammatory events were corrected with conservative therapy. 15 cases were characterized with sacral bedsores at the background of neurotrophic disorders. Secondary tension was achieved after surgical and conservative treatment.
The example of early interhospital transport and timely active surgical tactics is the case of the patient with severe injury to the spine and the spinal cord.
The patient Ch., age of 20, was admitted to the admission department of Clinical Center of Miners’ Health Protection on 29.07.2008. The patient had complaints concerning the pain in the cervical spine, weakness in the upper extremities, sense numbness along the interior surface of the upper arm and the forearm on the both sides, absence of active motions in the lower extremities, dysfunction in pelvic organs by type of delay.
The history: the road traffic accident, 28.07.2005. There was a collision of a car and a truck. The patient was in the car and she was a passenger on the back seat. From the accident site an emergency team transported her to the admission department of the nearest medical facility (in prone position with the fixed cervical spine with use of rigid head holder). Treatment in the intensive care unit lasted for 24 hours. Infusion therapy was made. On July, 29, 2008 for further treatment the patient was transported to the admission department of Clinical Center of Miners’ Health Protection.
Objective estimation: severe general state conditioned by severity of the injury and significant neurologic symptoms. The position was passive, on the back. The cervical spine was fixed with the rigid collar of the type Philadelphia. The skin was flesh-coloured. The breathing was independent, rhythmical, through the natural airways, with auscultatory weakness in the lower departments on both sides, without rattling. Hemodynamics was stable. The arterial pressure was 110/70 mm Hg, pulse – 82 per min. Cardiac sounds were clear and rhythmical. The abdomen had its usual shape, without participation in breathing act; soft during palpation; weak vermicular movement. Disordered functions of the pelvic organs of delay type. Urine was removed through the permanent catheter.
Local examination: the left hand and the forearm were fixed with plaster splint.
Neurologic status: clear consciousness, adequate behavior, spatial orientation. No pathology in cranial nerves. Limited active motions in the upper extremities; full range of motions in shoulder joints. The strength in the shoulder decreased to 3-4 points, in the hands – to 2 points. No active motions in the lower extremities. Decreased tone in the extremities, more expression in the legs. Decreased tendon reflexes from the upper extremities, but appearing on both sides; no reflexes from the lower extremities. Hypoesthesia of conductive type from the level of C7. Proprioceptive sensitivity in the lower extremities.
Cervical MSCT showed a compression splinted fracture of C6 vertebral body with separation and displacement of bone fragments into the spinal canal, with compression of the spinal cord, a bilateral fracture of C6 vertebral arch and a compression fracture of C7 vertebral body (Fig. 1).
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Figure 1 Patient Ch., age of 20. Cervical spine MSCT at admission. |
Figure 2 Patient Ch., age of 20. Cervical spine X-ray examination after surgery. |
The diagnosis was made on the basis of the clinical radiologic data: “Polytrauma. Closed spine and spinal cord injury in acute period. Compression comminuted non-stable fracture of C6 vertebral body with spinal cord compression, fracture of arches and inferior articular process to the right. Compression fracture of C7 vertebral body (type B2.2). Syndrome of full disarrangement in conductivity from C7 in the spinal cord (ASIA – A). Upper paraparesis, lower paraplegia. Disordered pelvic organ functions of delay type. Spinal shock. Closed fracture of radial bone in distal one-third of left forearm without displaced fragments. Chest contusion”.
After examination and short presurgical preparation the patient received emergent surgery: removal of C6 vertebral body, anterior decompression of the spinal cord. Anterior interbody fusion for C5-C7 with titanium endofixator. C5-C7 fixation with the cervical plate (Fig. 2).
Postsurgical period was without complications. The wound healed with primary tension. The sutures were removed on 10th day. Vascular and neurostimulating drugs were used. On the third day after surgery the remedial gymnastics, massage, electric stimulation and initiation of vertical positioning were initiated. After 43 days the patient was discharged for outpatient treatment. The patient received recurrent examination in 6 months after surgery. There were improvements in neurologic symptoms in view of increasing volume of range of motions, strength in extremities and restoration of function of pelvic organs. The patient moved independently (Fig. 3-4). The short term results were good.
Figures 3-4
Patient Ch., age of 20. Functional outcomes 6 months after trauma.
The described clinical case shows that early interhospital transfer for patients with spine and spinal cord injuries, and timely surgical treatment allows achieving good results.
CONCLUSION
1. The optimal time for transfer of patients with spine and spinal cord injuries to the specialized center is 24 hours after an accident. Late transfer (after 3 days) increases amount of unsatisfactory surgical results (up to 27.1 %).
2. Time of transfer, gender, age of patients and worsening somatic pathology are the main factors determining mortality in patients with spine and spinal cord injury who are transported from other medical facilities.