Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

Organization of medical process at hospital stage is an important moment in conditions of significant urbanization of population and tremendous increasing injury rates [1].  

Disordered functions of the spinal cord after partial or complete destruction of the anatomic structures as result of trauma are irreversible and lead to severe disability [2]. The rate of traumatic injuries to the dural sac in combination with spinal fractures is 7.5-19 % of the cases [15]. As for adult patients, spinal cord injury is 4.9-5.3 % [5, 9, 11] among all nervous system injuries [5, 9, 11]. Spinal fractures are accompanied by injuries to the spinal cord and its elements in 2.2-20.6 % of the cases [6, 12]. Owing to improvement in surgical techniques and implementation of modern methods for resuscitation and intensive care about 50 % of the patients with spinal cord injury live more than 25 years; however, most proportion is disabled persons [5, 10].

At the present time for patients with spine and spinal cord injury (SSCI) surgeons aspire to perform surgical interventions in early period after an injury [8]. According to the literature data the authors have no the uniform opinion about timing of surgical management, and the timeframe varies within 6-72 hours from the moment of injury [15]. Correction of spinal canal deformation and spinal cord compression favors improving the blood flow in the spinal cord, enhancement and restoration of cerebrospinal fluid circulation, correction of irritation in different parts of central nervous system, reduction of common and sometimes irreversible disorders of the blood flow in the spinal cord [8, 13].

Practical implementation of microsurgical technique and optical magnification significantly extends the possibilities of primary restorative and late reconstructive operations in treatment of injuries to the spinal cord and its mater. Some authors appeal to wider administration of the surgical microscope for spinal surgery owing to improving visualization of injuries without increasing surgical approach. The opponents state that optical magnification result in increasing time of surgery with promoting the risk of contamination [14].

The first experience with reconstructive microsurgical operations for patients with severe spinal cord injuries has shown persisting deficiency of medullary tissue. Therefore, one should create the conditions for correction of this deficiency and axonal genesis [7]. The recent studies and development of new reconstructive operations found that the main objective was reconstruction of the anatomic structures of the spinal cord and its mater, i.e creation of volumetric integrity of the spinal cord by means of combined vascular neural autografts and restoration of spinal fluid circulation by means of dura mater plastics with consideration of increasing volume of the spinal cord after transplantation. Absence of normal spinal fluid circulation disarranges the blood flow and spinal cord function as the uniform organ, and it completely arrests conduction in remaining pathways.

Normalization of spinal cord function without saving its volume and without restoration of spinal fluid circulation in the subdural space is frustrated.   

Objective – to estimate efficiency of primary restorative and late reconstructive operations with use of microsurgical technique for treatment of the patients with injuries to the spinal cord and its mater.

 

MATERIALS AND METHODS

The study included 233 patients with spine and spinal cord injuries. The mean age of the patients was 35.7 ± 13.2. The men were in more than 76 % (table 1).

Table 1
Gender and age distribution of patients with spine and spinal cord injury

154 (69.1 %) patients were admitted in acute period of trauma within the interval from several hours to 3 days. The remaining 30.9 % of the patients were admitted within remote period of 3 months and more. The greatest proportion of the injuries was related to the cervical spine – 85 (31.4 %), followed by thoracic spinal injuries in 31.4 % and lumbar spinal injuries in 30.5 % correspondingly. According to injury mechanism the greatest proportion was related to home (43.5 %) and road traffic (33.6 %) injuries. ASIA/ISCSCI was used for evaluation of neurologic disorders (table 2).       

Table 2
Disorders of spinal cord function according to ASIA/ISCSCI

The ASIA/ISCSCI examination in acute period of spine and spinal cord injuries found that 82.4 % of the patients had the disorders corresponding to the types A, C and D. As for late period, 79.8 % of the cases were associated with disordered spinal cord functions of types A, C and C.  

Among 223 patients with spine and spinal cord injuries surgical treatment for the spinal cord and its meninges was realized for 116 (52 %) patients, including 72 patients with primary restorative operations in acute period, and 44 patients with late reconstructive operations (table 3).

Table 3
Distribution of patients with spine and spinal cord injury according to types of surgical interventions

Surgical techniques were chosen on the basis of complex examination for the patients with spine and spinal cord injuries: objective examination, clinical radiologic data, laboratory examinations.

Operations with optical magnification and microsurgical techniques were used for 72 (46.8 %) of the patients in acute period of SSCI, including 37 patients with diagnosed polytrauma with dominating injuries to the spine and spinal cord. Depending on the spinal injury type more than 30 % of the patients received surgical interventions with two stages. The first stage included anterior decompression for the spinal cord and interbody fusion, followed by posterior decompression, primary restorative surgery for the spinal cord and its meninges, and posterior spondylodesis. Posterior decompression was supplemented by microsurgical technique and optical magnification with the surgical microscope.   

Primary restorative surgery included evaluation of severity of spinal cord and its meninges injury, and presence of disordered circulation. 37 cases included dural sac injuries, with multiple or circular characteristics in 14 patients, and 4 patients with full or partial spinal cord injury. 35 cases were related to spinal cord edema at the level of the injured spinal segment. 2 cases included suturing for the injured spinal cord roots in the cauda equine. 4 patients with full or partial spinal cord injury received plastics with the vascular neural autograft according to Stepanov G.A. [7] with insignificant modification. All 72 patients received dural sac plastics, including 7 cases with restoration of circular injury with use of autotissues (autovein, the graft from the fascia lata) or with artificial dura mater for restoring cerebrospinal fluid circulation [12] and creation of reserved space for prevention of recurrent spinal cord edema after surgery.     

63.7 % of the patients were operated in long term period after SSCI by means of microsurgical technique and optical magnification. The main objective of late surgical treatment was correction of scar adhesion of meninges and restoration of free spinal fluid circulation.

During late reconstructive operations all patients received plastics of dural sac, including one case of circular plastics for the patient with spinal cord defect. Restoration of CSF circulation with meningomyelolysis was performed for 31 patients with evident scar- adhesive process and blocked CSF circulation. Plastic surgery with vascular neural autograft was used for 13 cases with intramedullary cysts in the spinal cord.       

The surgical microscope OPMI Pentero (Carl Zeiss) with 1:6 ratio of optical magnification, the microsurgical techniques and atraumatic suturing material allowed precisely verifying the degree of injuries to the spinal cord and its meninges and realizing qualitative tight suture during dural sac plastics that prevented the complication in view of continuing liquorrhea in 100 % of the cases.

The short term outcomes of treatment of the patients with injuries to the spinal cord and its meninges were estimated with 100-point scale by Karnovsky [3].

RESULTS AND DISCUSSION

The short term outcomes of reconstructive operations were estimated in 96 (82.8 %) patients.     

The patients who were operated acutely demonstrated unsatisfactory outcomes in 26.3 % (0-40 points): no improvement in neurologic status and disease progression (increasing spastic paraparesis). 42 % of the patients demonstrated satisfactory results (50-80 points). The estimating criteria were improving sensitivity below the level of the injury, appearance of minimal active movements, increasing strength in the muscles of the extremities, restoration of functioning in the pelvic organs, patient’s activation, and improvement in self-care. However, despite the fact that such patients demonstrated lost working ability, they could perform self-care and live at home. 31.7 % of the patients demonstrated good outcomes (90-100 points). They showed normal daily activity without need for medical assistance.

In the patients with late surgery the rate of unsatisfactory outcomes was 39 %. The good outcomes of treatment were in 14 %. Satisfactory outcomes were in 47 %.           

Purulent complications were noted in 26.7 %. In postsurgical period 5 patients demonstrated superficial purulence in the sutures. These events were arrested during conservative therapy. 26 cases were associated with bed sores in the sacral region. Healing with secondary tension was achieved with surgical and conservative treatment.           

The postsurgical lethal outcomes were noted in 20 (27.7 %) of the patients with acute spinal cord injury. Among them 11 patients were admitted to the clinical center with diagnosis: “Polytrauma, spine and spinal cord injury in combination with severe brain, skeletal and thoracic injuries”. The state of the patients was extremely severe at the moment of admission. The main cause of death was multiple organ insufficiency (respiratory, cardiovascular, renal). 9 patients died after surgical treatment for isolated spine and spinal cord injury. The causes of death were pulmonary embolism in 2 cases, and multiple organ insufficiency at the background of increasing spinal cord edema in 7 patients.    

The case of treatment for the patient with severe spine and spinal cord injury presents the example of timely primary restorative surgery with use of stable fixation, the surgical microscope and microsurgical technique.

The patient Ch., female, age of 24. Case history #11353/09

The patient was in the clinic. The diagnosis was as follows: “Polytrauma, closed traumatic brain injury, brain contusion of mild severity. Closed spine and spinal cord injury. Closed dislocation fracture of L1 vertebral body, the fracture of transverse processes L1-L3 to the right, the displaced fracture of spinous processes Th11-L3 (type B1.2.1), compression by bone fragments, injuries to dural sac and the roots of cauda equine at L1 level, lower paraplegia. Disordered functions of pelvic organs in view of delay. ASIA – A. Closed fracture of left clavicle. Closed complicated fracture of the ribs 7-10 to the right. Right hemopneumothorax. Right lung contusion. Closed fracture of the neck of right scapula. Closed fracture of right scapula”.        

The state at admission: complaints about headache, pain in the thoracolumbar spine, in the region of left clavicle, pain and absence of  motion in legs and disordered sensitivity, inappropriate urination.

The description of the injury: the injury after the road traffic accident (19 hours before admission). The patient underwent medical treatment with the diagnosis: “Road traffic accident. Closed traumatic brain injury. Mild brain contusion. Spine and spinal cord injury. Dislocation of 12^th thoracic vertebra. Compression splintered fracture of L1 vertebral body. Spinal cord injury. Lower paraplegia. A contused wound in the left parietooccipital region. Closed fracture of left clavicle. Closed fracture of the ribs 7-10 to the right. Right pneumothorax. Fractured neck of right scapula. Kidney contusion”.       

At admission we carried out anti-shock procedures, analgesia, intravenous saline and polyglucin infusion, primary surgical processing for wounds, right pleural draining according to Bulau. The patient’s state stabilized after the realized measures. The patient was transported with reanimobile to the admission department of our center.      

The general status: severe general state, which is conditioned by trauma and neurologic deficit. The position is passive, lying flat on back, in the transport suit Kashtan. The body structure is normosthenic, with satisfactory nutrition. Skin and visible mucosa are clean and pinky. Stable hemodynamics, AP 110\70 mm Hg. Heart rate – 90 per min. Diuresis with catheter.  

Neurologic status: The patient is conscious. The face is innervated symmetrically. The tongue is along the middle line. The pupils are narrow, equal, with normal photoreactions and oculocephalic reflexes. The ocular movements are with full volume and painless. Small-swinging horizontal nystagmus is evident. Muscular tone in the extremities is persistent. Increased tendon reflexes from the hands, without rude difference between the sides. Areflexia in lower extremities. No active motions in the legs. Atonia, no tendon reflexes. There are non-significant hyperesthesia, hyperpathia along dermatomes L1 and lower. No meningeal and pathologic signs.           

The local status: the examination of the thoracolumbar region shows evident kyphotic deformation in the region of thoracolumbar spine, as well as sharp pain during palpation of spinous processes Th11-L3, the fracture of left clavicle with displaced fragments; the fracture of posterior processes of the ribs 7-10 to the right; displaced fragments across the width; right pneumothorax with right lung collapse by 1.2-1.5 cm; minimal hemothorax to the left; right lung contusion (predominantly in upper and middle departments), with massive traumatic infiltration (hemorrhage); infiltrative changes in lower basal region of the left pulmonary field; the mediastinum displacement to the left.

The computer tomography of the thoracolumbar region of the spine showed the dislocation-fracture of L1 with rude lateral displacement (Fig. 1).

Figure 1

Patient Ch., age of 24. MSCT of thoracolumbar spine at admission

Chest X-ray identified the fracture of left clavicle, the fracture of the ribs 7-10 to the right, right massive hemothorax, right pneumothorax, contusion and bleeding in the right lung.

The emergent surgery was performed: laminectomy for Th12, L1; open reduction of Th12-L1 fracture-dislocation; posterior transpedicular fixation for Th11-L1, L2-L3 with neuronavigation, microsurgical revision of the spinal cord, lineal injury to the dural sac, edema, focuses of contused spinal cord. Plastic surgery for the dural sac was realized with artificial dura mater (Fig. 2, 3). The surgery duration was 3 hours and 35 minutes.

Figure 2

Patient Ch., age of 24. The surgical microscope image, x10 magnification. The surgery stage: spinal cord revision.

 

Figure 3

Patient Ch., age of 24. The surgical microscope image, x10 magnification. The surgery stage: dural sac plastics with artificial dura mater

                   

After posterior transpedicular screw fixation the state of the screws was satisfactory, without transition behind the limits of the above-mentioned bodies. Displacement of Th12 body up to 6 mm forwards. Kyphotic deformation at the level of fracture. The fracture of transverse processes L1-L3 to the right (Fig. 4).

Figure 4

Patient Ch., age of 24. MSCT of thoracolumbar spine after surgical treatment

During complex treatment one could observe the positive dynamics in view of gradual regression of neurologic symptoms: appearance of active muscular contractions and sensitivity in lower extremities, disappearance of respiratory insufficiency and gastritis. There are persistent disorders in pelvic organ functioning (delay). Diuresis is through the catheter. There are no bed sores. The patient has been discharged in compensated state for outpatient treatment. The total period of hospital treatment was 75 days.       

The patient was examined 1.5 year after discharge. The patient showed restoration of contractive ability of the muscles in both thighs, better sensitivity up to the level of middle one-third in both legs, restoration of functioning in pelvic organs. The patient is partially independent and moves with a wheel chair.     

The given clinical example shows that microsurgical techniques result in positive outcomes after severe injuries to the spinal cord and its meninges.

 

CONCLUSION

1.      Microsurgical operations for reconstructing the spinal cord and its meninges provide volumetric integrity of the spinal cord at the level of injury.

2.      Normal CSF circulation after injuries to the spinal cord and its meninges can be restored only with microsurgical plastic procedures for dura mater. The method of choice for plastic surgery of the dural sac is venous autograft or artificial dura mater in both acute and late periods of spine and spinal cord injury.

3.      Approximation of the volume of primary and late restorative surgical operations for the spinal cord and its meninges resulted in improvement in disordered functions of the spinal cord, with satisfactory and good outcomes in 82.8 %.