RECONSTRUCTIVE PROCEDURES IN TREATMENT OF PATIENTS WITH TRAUMATIC DISEASE OF THE SPINAL CORD
Novosibirsk Scientific Research Institute of Traumatology and Orthopedics named after Ya.L. Tsivyan,
Novosibirsk, Russia,
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The medical and social problems of treatment of spine and spinal cord injury preserve their actuality over the time. Over the last decade one can observe the steady increase in industrial and road traffic injuries, as well as gunshot wounds in local war conflicts.
According to the data from the World Health Organization (WHO), the number of victims with spinal cord injuries is about 30 persons per 100,000 of population [1, 2]. Spinal cord injury reaches 4.9-5.3 % among all injuries to the nervous system [3, 4]. Presence of traumatic injuries to the dural sac in combination with spinal fractures is found in 7.5-19 % of cases [5]. Disordered functions of the spinal cord after partial or full destruction of the anatomic structures as result of trauma are irreversible and lead to severe disability [6]. Improvement in the surgical, anesthetic and intensive care techniques resulted in decreasing mortality to 6 % in the late 80s of the last century [7] and caused the significant increase in lives of patients with spinal cord injuries. According to the literature data, at the present time 50 % of patients with paraplegia live more than 25 years after injuries [8, 9].
Traumatic disease of the spinal cord is characterized by presence of rough scar and cyst transformation of the spinal cord and its meninges with presence of deficiency of medullary tissue in the region of an injury that results in anatomic and functional disjunction of the ends of the spinal cord and liquor blocking at this level [8].
Therefore, the attempts of normalizing function of the spinal cord without preservation of its volumetric integrity and restoration of spinal fluid circulation in the subdural space are ill-starred.
Objective – to estimate the efficiency of the late reconstructive procedures using the microsurgical techniques in treatment of patients with traumatic disease of the spinal cord.
MATERIALS AND METHODS
The study included 69 patients with traumatic disease of the spinal cord as result of previous spine and spinal cord injury (SSCI). The mean age of the patients was 34.01 ± 12.7. More than 70 % of the patients were men of working age of 20-49. Most injuries related to the lumbar spine – 27 (39.1 %) of the cases. The thoracic spinal injuries were in 24 (34.8 %) cases, the cervical spine – in 18 (26.1 %) cases correspondingly. Home (40.5 %) and road traffic (47.8 %) injuries were the dominant injury mechanisms. ASIA/ISCSCI was used for estimation of neurologic disorders. In the patients with traumatic disease of the spinal cord 78.3 % of the cases of disordered functions of the spinal cord were associated with the types A, B and C.
The clinical examination for the patients with traumatic disease of the spinal cord identified the following states: pain syndrome in the region of previous injury in 31 (44.9 %) cases, increasing spasticity in the muscles of the extremities in 21.7 % of the patients, disorders of active movements and sensitivity below the injury level in 64 (92.5 %) patients, disordered functioning of the pelvic organs of various intensity in 60.8 %. More than 90 % of the patients showed some combinations of orthopedic and neurologic disorders.
The additional techniques of examination were used for confirmation of degrees of spinal cord lesions in the patients with spine and spinal cord injuries: magnetic resonance imaging (MRI), spiral computer tomography with myelography, electromyography (EMG).
The tactics of surgical treatment was determined on the basis of the clinical data and the results of instrumental examinations.
The additional techniques found the compression factor (displacement of bone fragments into the spinal canal, Urban wedge, non-reduced dislocations of the vertebral bodies) in 36.3 % of the patients with traumatic disease. These patients received decompressive and stabilizing operations for the ventral and posterior departments of the spine with fixation with use of various metal constructs. Closed hypothermia of the spinal cord was conducted in three cases of increasing spastic syndrome of the lower extremities.
63.7 % of the patients were operated in the remote period of SSCI with use of microsurgical technique and optical magnification. The main task of surgical treatment in the late period was elimination of scar adhesion and restoration of free circulation of spinal fluid.
During realization of late reconstructive operations all patients received dural sac plastic surgery including one case of circular plastics for the patient with the spinal cord defect. 31 patients with intense scar and adhesive process and presence of spinal fluid blocking received meningomyelolysis for restoration spinal fluid circulation. 13 patients with intramedullary cysts of the spinal cord received plastic surgery with the vascular and neural autograft according to the modified technique by Stepanov G.A. [8].
The technique by Stepanov G.A. consists in plastic surgery of a spinal cord defect with use of the autoneural graft, which is formed by means of a.ralialis and n.suralis. The neural autograft is placed to the lumen of the inverted vessel. The graft from v.saphena magna is used for the dural sac plastics.
We have found the number of the significant disadvantages during the more proper review of the technique by Stepanov G.A. Four surgical approaches are used for realization of surgery: one main and three additional approaches in various anatomic regions. It significantly increases time of surgery and anesthetic procedures. Use of a.ralialis as the graft leads to arresting blood flow in one of the paired arteries of the forearm and further development of ischemia in the hand. According to the literature data, 16-50 % of the cases are associated with disjunction of the superficial arterial arc, 4.5 % – with unclosed deep arterial arc of the hand [10]. In presence of unclosed arterial arches of the hand the use of a.ralialis as the graft can lead to necrosis of the first finger of the hand which carries out 50 % of hand functioning. Therefore, one can observe additional limitation of the functional activity in the patient with lower paraplegia.
Considering the literature data, we have concluded that this technique should be modified. During formation of the vascular-neural graft we use grafts from n.suralis and v. saphena parva in the same anatomic region. Afterwards, the vascular-neural graft is formed according to the technique by Stepanov G.A. Dural sac plastics is carried out with the graft from artificial dura mater with fixation with continuous blanket vascular suture with prolene 5/0.
Antibacterial, infusion, nootropic and neurostimulating therapy was conducted for all patients in the postsurgical period. Restorative treatment with the individually developed rehabilitation programs was initiated from 3rd day after surgical treatment.
RESULTS
The short term results of the complex treatment were examined in 69 patients. 100-point scale by Karnovsky was used for estimation of the results.
Use of the surgical microscope OPMI Pentero (Carl Zeiss) with optical magnification with 1:6 ratio, microsurgical tools and atraumatic suturing material allowed concise verifying the degree of the injury to the spinal cord and its meninges, realizing the qualitative and hermetic suture during dural sac plastics that excluded the postsurgical complication (ongoing liquorrhea) in 100 % of the cases.
In the patients with traumatic disease of the spinal cord the amount of unsatisfactory outcomes of treatment was 39 % (0-40 points): full absence of dynamics in neurologic status and progression of the disease. The good outcomes were in 14 % (90-100 points). The patients demonstrated normal daily activity without need for medical aid. The outcomes were satisfactory in 47 % of the patients (50-80 points). The estimation criteria were decreasing sensitivity below the level of an injury, appearance of minimally active motions, increasing muscular strength, restoring functions of the pelvic organs, activization of the patient, improving self-care. However despite lost working capability in such patients, they can perform self-care and live in home conditions.
There were no purulent septic complications in the patients with traumatic disease of the spinal cord in the postsurgical period in our study. The mean duration of hospital treatment was 36.05 ± 24.7 bed-days.
An example of microsurgical reconstructive operations in the patients with traumatic disease of the spinal cord is the case of treatment of the patient with spine and spinal cord injury in the late restorative period.
The patient B., age of 27, underwent treatment in the neurosurgery department during 26 bed-days. The diagnosis was: “Traumatic disease of the spinal cord. The consequences of the bilateral sliding fracture-dislocation of Th12 with spinal cord compression, disordered conduction from the level of the lumbar enlargement. ASIA B”.
The complaints upon admission: absent active motions in the feet, disordered sensitivity below the upper one-third of both legs, disordered function of the pelvic organs, pain in the lumbar region.
The circumstances of the injury: a road traffic injury, November 2, 2010. Emergency aid was delivered in one of the medical facilities of Kemerovo region. The instant readiness team transported the patient to Regional Clinical Center of Miners’ Health Protection. The diagnosis was: “Polytrauma. Closed spine and spinal cord injury. A fracture of the lower articular processes of Th12 on both sides, a fracture of the articular processes of L1 on both sides. Bilateral sliding dislocation of Th12 with compressed spinal cord, disordered conduction from the level of the lumbar enlargement. A compression fracture of the cranioventral angle of L1. A fracture of the spinous processes of Th12, L1, L2, a fracture of the transverse processes of L1-2. Severe spinal cord contusion at the level of the lumbar enlargement. Disordered conduction through the spinal cord (ASIA A). Lower paraplegia, disordered functioning of the pelvic organs by type of delay. A closed fracture of the left femoral bone in the proximal one-third with displaced fragments. A closed abdominal injury with injuries to the spleen and the left cupula of the diaphragm. The state after laparotomy, splenectomy and suturing of the wound of the left cupula of the diaphragm”.
The surgery was conducted on November 13, 2010: Th12 laminectomy. Spinal cord revision. Dural sac plastics with the graft from the broad fascia. Transpedicular fixation of Th10-L1.
At the background of the conducted treatment we observed the positive time trends in view of partial regression of neurological symptoms. The patient was discharged to outpatient treatment. The control examination showed the absence of dynamics of neurological disorders. The patient was admitted to the neurosurgery department for examination and determination of further treatment procedures.
The general status: general condition with middle severity conditioned by neurological symptoms. The position is passive, sitting in the wheelchair. The body composition is normal. Nutrition status is normal. Skin surfaces are body colored. The left leg is edematous. Breathing is independent, through natural airways. Breathing is vesicular, is auscultated over all pulmonary departments, without stertor. RR – 16 per min. Cardiac tones are clear and rhythmical. Hemodynamics is stable. AP = 120/80 mm Hg, HR – 72 beats per min. The abdomen is soft and painful when palpated. Vermicular movement is auscultated. Defecation is regular. Urination through epicystotoma. Urine is light with flocculus.
Local examination: there is a small kyphotic deformation at the thoracolumbar level. The postsurgical scar is normal at the lumbar level, without signs of inflammation. There is an indrawn scar about 6 cm diameter in the sacral spine.
Neurological status: clear consciousness. The patient is adequate, critical, with good space orientation and ability to productive contacting. Pain during percussion of Th11, L1 and L2 spinous processes. The long back muscles are moderately tensioned at the lumbar level, with pain during palpation. Muscular tone is available in the upper extremities, without differences in the sides. Upper limb muscular strength is 5 points. Muscular tone is decreased in the lower extremities, tendon reflexes are depressed, D = S. Motions in the knee joints are retained. Muscular strength in musculus quadriceps femoris – 4 points, strength in the muscles of the dorsal flexors and extensors of the feet is 0 points. Hypesthesia is from L4 level, anesthesia – from L5 level. There are no meningeal or pathological signs.
The examination was conducted: MSCT-myelography of the thoracolumbar spine with 3D reconstruction, April 24, 2012: arachnoidal space of the spinal cord and cauda equine is free, with smooth contrasting thorough the scanning region, with smooth extension along the interlaminectomic defect Th11-L1, with ovoid deformation by means of prolapse to the bone defects of the pedicles along Th12-L1 (Fig. 1).
Figure 1
The patient B., age of 27. MSCT myelography of the thoracolumbar spine: liquor blocking at the level of Th12
Considering the complaints, the data of the objective examination and additional techniques of the examination, the patient received the operation under endotracheal narcosis on May 4, 2012: relaminectomy for Th11-Th12. Microsurgical meningomyelolysis, opening and discharging of the tense arachnoidal liquor cyst, dural sac plastics with artificial dura mater. Spinal cord revision found the scar adhesion of the layers and dura mater with spinal cord compressed by the tense arachnoid liquor cyst (Fig. 2). Meningomyelolysis was conducted under optic magnification with the surgical microscope, as well as opening and discharging of the tense arachnoid cyst. Free moving of spinal fluid was achieved. Dural sac plastics was made with the graft from artificial dura mater (Fig. 3). The size of the graft is 4 × 1 cm.
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Figure 2 The patient B., age of 27. The surgical stage: meningomyelolysis, opening and discharge of the tense arachnoid liquor cyst of the spinal cord (1/6 optical magnification)
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Figure 3 The patient B., age of 27. The surgical stage: recurrent plastics of the dural sac with use of artificial dura mater (1/6 optical magnification)
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The postsurgical period included vascular, neurostimulating, analgetic and antibacterial therapy. From 3rd day after elimination of pain syndrome the restorative treatment with the individual program was initiated. The postsurgical period was without complications. The wound healed with primary intention. The sutures were removed on 10th day. On 26th day after the complex treatment we observed some positive time trends in view of increasing volume of active motions and improving sensitivity in the lower extremities. The patient could move in the wheelchair and independently stand with supporting (Fig. 4). The patient was discharged for outpatient treatment. His condition was compensated. The treatment outcome was determined as good.
Figure 4
The patient B., age of 27. The short term functional outcomes of the treatment (26th day after the operation)
The presented clinical case shows that use of microsurgical techniques gives positive results in severe injuries to the spinal cord and its layers.
CONCLUSION
1. Microsurgical operations with reconstruction of the spinal cord and its layers provide volumetric integrity of the spinal cord at the level of injury.
2. In case of injuries to the spinal cord and its layers the normal spinal fluid circulation is restored only after dural mater plastics. Artificial dura mater is considered as a method of choice for dural sac plastics.
3. If microsurgical reconstructive operations for the spinal cord and its layers are conducted in the late period of spin
e and spinal cord injury, improvement in disordered functions of the spinal cord is achieved, with 61 % of satisfactory and good outcomes of treatment.