A CASE OF SUCCESSFUL COMPLEX TREATMENT OF A PATIENT WITH THORACIC SPINE AND SPINAL CORD INJURY IN POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia,
Novosibirsk Research Institute of Traumatology and Orthopedics named after Ya.L. Tsivyan, Novosibirsk, Russia
Spinal trauma is a big medical and social problem. Despite of advancements in modern neurosurgery and critical care medicine, the rate and severity of spinal cord injuries does not decrease, but even increase. During 20th century one could observe more than 200-fold increasing rates of spinal injuries [1-4].
The modern epidemiological studies show that spine and spinal cord injury (SSCI) is 1-4 % of the total amount of different injuries, and their rate varies from 29.4 to 50 cases per 1 million residents in different geographic regions. The rate of spine and spinal cord injuries depends on availability of medical services and urbanization degree. As a rule, victims are active people at the age of 20-50. In the Russian Federation, about 50,000 cases of complicated spinal injury are registered annually, with disability in more than 8,000 cases and mortality of 6.3 % [5, 6].
Among patients with spine and spinal cord injuries, associated injuries are identified in more than 50 % of patients [7]. Lumbar spine injury is identified in 40-48 % of patients, cervical spine injury – in 28-38 %, thoracic spine injury – 12-24 %. The amount of patients with multiple and multi-level spinal injuries has been increasing during the recent years and reaches 14 %.
Patients need for timely surgical care with decompression of the spinal cord, its roots and vessels, spinal canal reconstruction and spine stabilization [8, 9, 10]. According to C.N. Tator et al (1993), admission of patients with SSCI to the specialized spinal centers reduced the mortality from 20 to 9 %, and the amount of patients with complete paralysis from 65 to 46 % [5].
Objective – to present the successful complex surgical and restorative treatment of the patient with thoracic spine and spinal cord injury in polytrauma.
The patient Z., age of 35, was admitted by the constant readiness team to Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, 24 hours after the injury. Her condition was severe at the moment of admission. Artificial lung ventilation was conducted.
From the anamnesis: catatrauma, falling from height of 8 meters. The first aid was realized in the intensive care unit in the nearest medical facility. Intensive anti-shock therapy was conducted, as well as left pleural cavity draining. Despite of the treatment, the patient’s condition was worsening, respiratory insufficiency was intensifying, and a trend to hypotonia was noted. Considering the condition severity, presence of neurological disorders and increasing respiratory insufficiency, the constant readiness team was called from Regional Clinical Center of Miners’ Health Protection. The primary examination was conducted by the specialists of the transport team and identified left-sided hemothorax and acute respiratory distress syndrome (ARDS) of the degree 2. Hemodynamics was stable, but with a trend to hypotonia, AP of 95-100/60-65 mm Hg, HR of 110-115 beats per min. The local examination showed the kyphotic deformation, pain during palpation at the level of Th7-Th8, bone crepitation to the right in the projection of the ribs 3-9, and the ribs 9-11 to the left. Crepitation and pathological mobility in the right clavicle were identified. The neurological status: low muscular tone and absent active movements in the lower extremities. Abdominal and tendon reflexes were suppressed. Hypesthesia from the level of Th7. Puncture and draining for the pleural cavity to the left were performed. About 1,000 ml of hemolysed blood discharged through the drains. Artificial lung ventilation (ALV) was initiated from the moment of hospital admission. The reason for ALV was increasing respiratory insufficiency as result of severe thoracic injury with pulmonary tissue damages.
Despite of some advancement in the treatment of acute respiratory distress syndrome, the mortality reaches 50-60 % [11, 12, 13]. The rate of pulmonary complications has the direct correlation with severity of traumatic injuries. Correction of life threatening hypoxia in respiratory insufficiency is one of the main tasks of intensive care during transportation of critically ill patients. Therefore, the mode of ALV was changed at the stage of preparation to transportation and during it. The ALV mode with low respiratory volumes (Vt – 6-7 ml/kg, Fr – 15, Pmax – 30–35 cm Н2О) was used in combination with positive end expiratory pressure (8 mbr). Only modes of controlled mechanical ventilation were used. The patient was transported by the reanimobile Mercedes-Benz equipped with the transport respirator Medumat Standard WM 22500 (Weinmann, Germany). The volume of infusion therapy was 1,400 ml (900 ml of crystalloids and 500 ml of hydroxyethylated starch 130/04). 600 ml of HES 130/04 were used during transportation. The fracture was immobilized with anti-shock suit Kashtan. The additional fixation of the cervical spine was performed with the transport collar of Philadelphia type. The patient received the narcotic analgetics (promedol 2 % - 1 ml i.m.) before use of Kashtan. Gamma-hydroxybutyric acid agents and relanium were used for sedation during transportation. The oxygenation values stabilized at the background of intensive care during transportation: increasing SpO2 with 89-90 % to 94-95, with decreasing FiO2 from 0.5 to 0.5. The hemodynamic values improved: decreasing tachycardia from 110 to 80 beats per min., increasing AP from 100/65 mm Hg to 120/80 mm Hg. Diuresis increased from 45 ml/h to 56 ml/h. Interhospital transportation lasted for 2 hours and 15 minutes, the distance – 200 km.
After admission to the clinical center, the patient was examined by the team of the physicians on duty. The additional examination was performed:
Thoracic spine MSCT – a fragmented fracture of Th7 vertebral body with compression of the dural sac. A fracture of the arc and the superior articular process to the right. A compression fracture of Th12 vertebra, a fracture of the arcs on both sides, a fracture of the transverse process of Th9 to the right (Fig. 1).
Figure 1. The patient Z, age of 35. MSCT of thoracic spine at admission
Chest MSCT – a fracture of the ribs 3-12 to the right, small hydrothorax to the right. A fracture of the ribs 9-11 to the left, pneumohydrothorax to the left. Left lung contusion (Fig. 2).
Figure 2. The patient Z, age of 35. MSCT of chest organs at admission
The patient was transported to the intensive care unit (ICU) after additional examinations. The patient was in the state of medicated sedation. Intermittent positive pressure ventilation was continued with FiO2 – 0.4 with the previous parameters, with EVITA 4 (Draiger, Germany).
The diagnosis was made on the basis of the conducted examination and the additional techniques: “Polytrauma. Spine and spinal cord injury, a compression splintered non-stable fracture of Th7 vertebra, a fracture of the arc and the superior articular process to the right. A fracture of the transverse spinous process of Th8 arc to the right. A fracture of the arc and the L1 spinous process. Disordered function of the spinal cord ASIA-B. Lower paraplegia. A complicated thoracic injury, a fracture of the ribs 3-12 to the right, small hemothorax to the right. A fracture of the ribs 9-11 to the left, pneumohemothorax to the left. A closed fracture of the right clavicle diaphysis. Left lung contusion. Blunt abdominal trauma with damage of the capsule of the right lobe of the liver. Pancreas contusion”.
Urgent diagnostic laparoscopy was performed by the surgeon on duty. A boundary damage of liver capsule was identified. Electrocoagulation of the liver wound, sanitation and abdominal cavity draining were carried out. Anemia presented within 24 hours after the injury (Hgb – 91 g/l, red blood cells – 2.96 * 109/l), thrombocytopenia (57 * 109/l). Surgical intervention for spine decompression and stabilization was delayed owing to severe condition of the patient. Plate osteosynthesis for the right clavicle was carried out on the second day. Tracheostomy was performed for tracheobronchial tree sanitation. Respiratory, infusion, hemostatic, vascular and antibacterial therapy, correction of anemia, thrombocytopenia, neuroprotective therapy and daily curative fiber-optic bronchoscopy were continued. The values of erythrocytes stabilized over time. The level of platelets increased, the intensity of ARDS decreased to 1st degree, diuresis increased to 85-90 ml per hour.
The patient received the surgery after stabilizing her condition on 9th day after the surgery: costotransversectomy. Removal of Th7 vertebral body, anterior decompression, spinal cord revision, dura matter plastics with use of microsurgical technique, Th6-Th8 interbody fusion with porous titanium nickelide, plate fixation. The dural sac was tensioned, with cyanotic color, without brain pulsation during revision. The dural sac was opened, and subdural space revision was performed. During revision, the anatomic integrity of the brain was preserved, the foci of cerebral tissue contusion were identified (Fig. 3), and dural sac plastics with artificial dura mater was conducted (Fig. 4). The fragments of Th7 vertebral body and adjacent disks were removed. The groove was created. The porous titanium nickelide with additional plate fixation was used (Fig. 5).
Figure 3. The patient Z, age of 35. The stage of surgery: revision of subarachnoidal space (optical magnification 1/6)
Figure 4. The patient Z, age of 35. The stage of surgery: plastic surgery of dural sac with use of the graft from artificial dura mater (optical magnification 1/6)
Figure 5. The patient Z, age of 35. MSCT of thoracic spine. Control of anterior interbody fusion
The positive trends were noted during treatment in the intensive care unit: pneumonia disappearance, respiratory insufficiency regression, partial regression of neurological symptoms. The wound healed with primary tension. The pleural drains were removed on 9th day. Artificial lung ventilation lasted for 18 days. The restorative treatment was initiated on 10th day after admission with use of the individual program, with consideration of severity of the injuries and the general condition. After 22 days, the patient was transported to the neurosurgery unit for continuing the disaggregation, neurostimulating and vascular therapy, and rehabilitation treatment.
At the background of the complex treatment, the patient demonstrated the positive trends including improving sensitivity, increasing strength in the lower extremities (up to 3 points to the right, up to 4 points to the left), recovery of pelvic organs functioning. The patient could move in the wheelchair (Fig. 6). The total period of the hospital treatment was 58 bed-days. The result of the treatment was satisfactory.
Figure 6. The patient Z., age of 35. The functional outcome of treatment on 58th day from admission
CONCLUSION
Early transportation of the patient with polytrauma to the specialized center and the medicodiagnostic procedures allowed stabilizing the general condition of the patient and carrying out the reconstructive plastic operation for the spine and the spinal cord. The complex approach to the treatment gave the satisfactory functional outcome of the treatment.
Information about financing and conflict of interests:
The study was carried out without sponsorship.
The authors declare the absence of clear and potential conflicts of interests relating to publication of this article.
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