A CASE OF SUCCESSFUL COMPLEX TREATMENT OF A PATIENT WITH SPINE AND SPINAL CORD INJURY AT CERVICAL LEVEL
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Spine and spinal cord injury is one of the problematic and important issues of modern traumatology and orthopedics. Currently, one can observe the increasing amount of such injuries. It is conditioned by the increasing rate of industrial and road traffic injuries.
According to the literature data, the rate of spine and spinal cord injuries varies significantly and constitutes 0.7-8 % of all locomotor injuries [1, 2, 3]. Spine and spinal cord injuries are up to 20 % of injuries [2].
Injuries to the cervical spine and the spinal cord are 30-60 % of all spinal injuries [3, 4]. About 75 % of injuries at the cervical level relate to C3-C7. 45-60 % of injuries to the cervical spine are associated with some neurologic events [3]. The rate of spine and spinal cord injuries demonstrate the wavy pattern, with significant increase during summer time because of swimmers [5].
The rate of disability is 57-100 % [6]. Despite of high level of assistance and good opportunities for treatment in intensive care units, the mortality achieves 15 % after cervical spinal injuries [3].
Outcomes of injuries and increasing quality of life are improved by complex treatment of spine and spinal cord injury which includes extensive examination, timely administration of high tech operations and early initiation of restorative treatment [7].
Objective – to demonstrate a successful case of complex surgical treatment and reconstructive treatment of a patient with spine and spinal cord injury at the cervical level.
The patient K., age of 21, was admitted to the neurosurgery center, Regional Clinical Center of Miners’ Health Protection, on June 18, 2012. He was transferred by the emergency aid team 22 hours after the injury. The patient had complaints about absent active motions in his lower extremities, intense limitation of active motions in his upper extremities and decreasing sensitivity in his lower extremities.
The history of the injury: a civilian injury, 2 hours before application for aid. During swimming in the river he suffered from his head hitting against the bottom. He felt absent movements in his lower extremities, limitation of active motions in his hands and disordered sensitivity. His friends pulled him out of water. The emergency team transferred him to the admission department of the center. The patient was examined by the neurosurgeon and the intensivist on duty.
The objective status: severe general condition as result of rough neurologic symptoms and severity of the injury. The position was passive, lying on the stretcher, on his back. The cervical spine was fixed with the rigid collar (Philadelphia type). Alcohol smell was from his mouth. Normosthenic body composition, satisfactory nutrition. The skin surface was of body color, sooty and clean. Peripheral lymph nodes were not increased. Body temperature was normal. Breathing was spontaneous, adequate, through natural airways. Auscultation showed vesicular breathing over all regions of the lungs, without stertor. RR – 18 per min. Hemodynamics with tendency towards hypotension. AP = 90/50 mm Hg, HR = 90 per min. The regular shape of the abdomen, which was soft during palpation. Depressed intestinal motility. Urinary excretion through catheter. Urine was light.
The local examination: a visible graze in the right parietal region. Neck muscles were tense during palpation, with evident pain in the plane of spinous processes at level of C5-C6.
Neurologic status: the patient was in clear consciousness, adequate, critical, with good space and time orientation and ability to direct contact. The face was innervated symmetrically, the tongue was along the middle line. The pupils were in the median position, anisocoria – D > S. Right-side photoreaction was depressed. Increased tone in the extremities, D = S. Active tendon reflexes in the extremities, stronger reflexes in the lower extremities. Strength of flexors and extensors of the forearm and the hand decreased to 1 point. Muscular strength in the lower extremities – 0 points. Hypesthesia from level of L3. Persistent sensitivity in anogenital zone. Persistent deep articular and muscular sensitivity in the lower extremities. Disordered functioning of pelvic organs in view of delay.
The patient received the examination:
1. Cervical spine X-ray examination: a compression fracture of C5.
2. Cervical spine MSCT: a transverse-longitudinal fracture of C5 with displaced fragments towards the spinal canal up to 6 mm. Spinal canal stenosis up to ¼ of section. Wedge-shaped deformation of C5 vertebral body of degree 2. Kyphotic deformation at level of C5 – 162 degrees. A fracture of C5 arc to the left, with displacement of fragments across the width. Posterior subluxation of C5 vertebra (Fig. 1).
3. Chest X-ray examination: pulmonary fields with symmetrical transparency without visible infiltrative and focal changes. No bone traumatic changes, pneumo- and hydrothorax.
According to the results of the objective examination and the additional techniques the diagnosis was made: “Closed spine and spinal cord injury. An unstable compression and splintered fracture of C5 vertebral body with spinal cord compression, a fracture of C5 arc to the left. Disorder of nerve conductance through spinal cord from C5: ASIA A. Lower paraplegia. Upper deep paraparesis. Disordered functioning of pelvic organs by type of delay. A graze in the region of soft tissues of parietal region to the left. Alcohol intoxication”.
The general clinical analyzes were made in the admission department. AS-0.5, s/c was placed. Fast presurgical assessment and preparation of the graze in the parietal region were made. The patient was transferred to the emergency surgery room after consideration of the complaints, the data of the examination, presence of the signs of anterior compression of the spinal cord at the level of C5 vertebra, rough neurologic symptoms.
The emergency surgery was performed on June 18, 2006, 40 minutes after admission: removal of C5 vertebral body; anterior decompression of the spinal cord; interbody fusion for C4-C6 with porous NiTi implant, with additional fixation with a metal plate. The operation lasted for 2 hours and 30 minutes, anesthesia – 3 hours.
During the operation we noted the following moments: the paravertebral muscles were imbibed with the blood; a defect and deformation of C5; hypermobility in the spinal motional segment C5-C6. The body and the fragments of C5 compressing the spinal cord were removed. After spinal cord decompression the revision of epidural space was made. The anterior longitudinal ligament was of florid color. The spinal cord was free along the entire length, with weak pulsation. After hemostasis, anterior interbody fusion was made with porous NiTi implant with a metal plate (Fig. 2). The wound was irrigated with aseptic solutions. The control X-ray examination was conducted. The position of the metal construct was satisfactory. The wound was sutured layer by layer. The skin was sutured by means of intracutaneous cosmetic suture.
The patient was transferred to the intensive care unit in the early postsurgical period. Intensive care was conducted: antibacterial, infusion, disaggregation and neurotropic therapy. Artificial lung ventilation with the intubation tube lasted for 6 days. The rehabilitation measures were initiated in the intensive care unit on the 2nd day after surgery and lasted for 7 days. The rehabilitation program was developed with consideration of the functional status and the objectives. Also intensive passive motional therapy for the joints of the upper and lower extremities, electrostimulation of breathing muscles, vibration massage of the chest and physiological positioning of the extremities were performed. Intensive care lasted for 8 days.
On June 26, 2012, after stabilizing the general condition, the patient was transferred to the neurosurgery department No.1. After initiation of the hospital stage one could observe partial restoration of muscular tone in the upper and lower extremities, appearance of minimal active motions in the knee and hip joints, “floating” motions in the ulnar and radiocarpal joints, restoration of reflectory breathing and absence of active motions in the hands.
Infusion, disaggregation and neurotropic therapy was prolonged in the neurosurgery department. At the hospital stage the rehabilitation was conducted with the individual program of motion-restorative therapy with 2 stages.
The first stage – preliminary: the objective – to restore motional functions of musculoskeletal system, primary staged vertical orientation.
The tools:
– passive motions in the joints of the extremities and the body;
– multi-channel electric stimulation of the muscles of the back and the lower extremities;
– manual massage of the upper extremities;
– active and passive motions of the body and the extremities in the mode of forced movement: initiation of sitting position, training of supporting with hands, changing position of the body, knee-hand position, kneeling stand near the support, stance gymnastics.
The duration of the stage was 7 days.
The results of the first stage of restorative treatment: increasing strength and muscular tone in the extremities and the back; increasing volume of active and organized movements in the big joints of the extremities; evident improvement in movement patterns; clear motor paths of movements; partial restoration of the organs of the small pelvis.
The second stage – restorative (8 days) – the period of special movement therapy. The period included isotonic and isometric mode with divided load with 25-30 min 2 times per day.
The tools:
– active movements in horizontal and vertical planes;
– more active movements of the extremities, with muscle force;
– vertical standing with external aid and without it;
– independent walking.
The results of the second stage of restorative treatment: independent sitting and standing position; independent walking; good restoration of motion functions of the right hand; stepping movements; good balancing state; improving movement patterns; higher level of motion synthesis.
The patient’s state was compensated. He was discharged for outpatient treatment. The total length of hospital treatment was 23 bed-days.
The short term functional results of treatment were estimated in 4 months after the injury. The positive time trends were noted at the background of the complex surgical and restorative treatment. Active movements in the upper and lower extremities restored (Fig. 3). Functioning of the pelvic organs restored. There were some signs of mild tetraparesis (ASIA D). Muscular strength restored to 4 points. The patient could move independently, without supporting devices. He could perform self-care.
The short term functional results were estimated as good.
CONCLUSION
Complex treatment of patients with spine and spinal cord injuries, including timely surgical treatment and early initiation of neurorehabilitation with individual programs, significantly improves outcomes of injuries and quality of life.