A CLINICAL CASE OF COMPLETE FUNCTIONAL RECOVERY AFTER SURGICAL TREATMENT OF A PATIENT WITH COMPLICATED CERVICAL SPINE INJURY Yakushin O.A., Novokshonov A.V., Krashennikov L.P.
Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
Tsyvyan Novosibirsk Research Institute of Traumatology and Orthopedics, Novosibirsk, Russia
Treatment of patients with spine and spinal cord injuries, which are determined by rough neurological disorders, high amount of complications and high mortality and disability, is one of the significant problems in traumatology and neurosurgery [1, 2, 3].
Cervical spine injuries are registered in about 60 % of cases. Approximately 75 % of cases are presented by injuries at C3-C7 level. Neurological symptoms present in 40-60 % of cases [4, 5].
Despite of significant progress in arrangement of urgent care, active surgical management and modern principles of critical and intensive care, high level of mortality (70-88 % depending on injury level) is observed in complicated cervical spine injuries [6, 7]. The main causes of mortality are respiratory and cardiac complications, and neurotrophic complications leading to sepsis [4, 7].
The improvement in functional outcomes of treatment, the decrease in number of complications and the increase in life quality in patients with complicated cervical spine injury are possible by means of early surgical treatment and complex rehabilitation [8, 9].
Objective – to show a case of complete functional recovery of a patient with a complicated cervical spine injury after previous surgical treatment in a specialized neurosurgery center.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation (the order of Russian Health Ministry, 19 June 2003, No.266), with the written consent for participation in the study and the approval from the local ethical committee of Regional Clinical Center of Miners’ Health Protection (the protocol No.7, 5 March 2018).
A CLINICAL CASE
The patient D., age of 54, was admitted to the admission unit of Regional Clinical Center of Miners' Health Protection. She was transported by the specialized transfer team 6.5 hours after the injury with complaints on pain in cervical spine, limitation of active movements in hands, sense of numbness in fingers of both hands and urination delay.
Circumstances of injury: a home injury on 10 December, 2018, about 6:30 p.m. The patient was riding on the air pillow down the hill. She fell and hit her head. After that, she complained of pain and limited motions in the cervical spine, weakness in the head and urination delay. She was conscious. The emergency care team delivered her to the admission unit of the nearest medical facility. After the examination, the patient was admitted to the intensive care unit. The diagnosis was: “A closed traumatic brain injury. Brain concussion. A compression fracture of C3-C5 vertebral bodies with spinal cord compression. Spinal shock”.
Intensive care was conducted. For further treatment, the patient was transported with the reanimobile to the admission unit of the center. On admission, the patient was examined by the neurosurgeon. Computer imaging of the cervical spine was conducted. The patient was admitted to the intensive care unit.
Objective status on admission: the general condition was severe and stable. The condition severity was determined by the injury, pain syndrome and neurological symptoms. The body temperature was 36.5 °C. The breathing was independent and adequate. AP = 16 per min. Breathing in all lung fields, without stertor. Heart tones were rhythmical, the pulse was 82 per min. on the radial arteries. AP = 140/70 mm Hg. The abdomen was soft and painless in all regions. Peristaltic sounds were auscultated and were low. Urination through the catheter. The urine was clear. The diuresis was sufficient.
Neurological picture. The patient was conscious, adequate, critical, space-oriented and available for productive contact. No features from 12 pairs of cranial nerves. The cervical spine was fixed with Philadelphia rigid collar. Cervical lordosis increased visually. Neck muscles were tensioned and painful during palpation. Painful percussion of spinous processes at C4-C7 level. Muscular tone in the upper extremities was moderately decreased, without differences on both sides. Active motions in the hand joints and fingers of both extremities were limited. The muscular strength of forearm extensors, flexors and extensors of the hand and the fingers was low (2-3 points), D = S. Hypesthesia of fingers of both hands. Motional and sensory disorders in the lower extremities were not found. The Romberg stance and finger-nose tests were not tested. Abnormal or meningeal symptoms were not identified at the moment of the examination.
The examination was conducted:
- SCT of the cervical spine: a fracture of the anterior and posterior arc C1 to the right without displacement. A linked dislocation of C5 vertebra. A fracture of superior spinous process C6 to the left (Fig. 1).
Figure 1
The patient D., female, age of 54: SCT of cervical spine at admission: a fracture of anterior and posterior C1 arc without displacement to the right. Joined dislocation of C5 vertebra.
- X-ray examination of the chest: no pneumohemothorax. No fractures of rib fragments. The lungs were without focal and infiltrative changes.
The diagnosis was confirmed according to the results of the examination: “A closed spine and spinal cord injury. Bilateral sliding and linked dislocation of C5 vertebra, a fracture of superior spinous process C6 to the left. A fracture of anterior and posterior arc C1 to the right without displacement. A disordered conduction through the spinal cord, a segmentary type from C5, ASIA-C. Superior paraparesis. Disordered function of pelvic organs of delay type”.
Owing to the modern ideas about pathogenesis of traumatic disease of the spinal cord, the patient received a surgical intervention 8.5 hours after the injury: a removal of an intervertebral disk C5-C6, an opened reduction of C5, correction of anterior compression of the spinal cord and its roots. Anterior interbody fusion of C5-C6 with the interbody cage and fixation with the cervical plate and screws. From the surgery protocol: “Revision of the surgical approach shows an intense blood imbibition of soft tissues and paravertebral muscles, an injury to the intervertebral disk with formation of step-shaped deformation at C5-C6 level of the spinal-motional segment. The intervertebral disk C5-C6 was removed up to endplates of adjacent vertebrae. An opened manual reduction of C5 dislocation was performed. Anterior decompression of the spinal cord and its roots was achieved. The interbody metal cage (6 × 12 mm) was placed into the intervertebral space in traction position along the axis and flexion of the cervical spine. The position of the implant was appropriate. Additional fixation of the spinal-motional segment C5-C6 with the cervical plate and screws was conducted”. The control X-ray images showed satisfactory position of the implants (Fig. 2). The surgery lasted for one hour, anesthesia – one and a half an hour.
Figure 2
The patient D., age of 54: X-ray examination of cervical spine after surgical treatment: reduced dislocation of C5 vertebra. Anterior interbody fusion of C5-C6 with the interbody cage, with fixation with cervical plate and screws in C5-C6 vertebral bodies.
After completion of the surgery, the patient was treated in the intensive care unit. At the background of high level of consciousness, 3 hours after surgery, the patient was switched to independent breathing. The intubation tube was removed. The general time of treatment in in the intensive care unit was 1 bed-day. Intensive therapy was continued in the profile neurosurgery unit. Rehabilitation treatment with the individual program was initiated on the second day after surgical treatment and was directed to recovery of general activity, muscular tone in the extremities and active motions, preparation for vertical positioning. The postsurgical period was without complications. The sutures were removed on the 14th day after the surgery. The healing was with primary tension. Fixation with Philadelphia rigid collar was continued. The patient could take vertical position on the 7th day. She could move independently, without foreign objects.
The neurological status showed the positive time trends at the background of the treatment. Function of the pelvic organs restored on the fourth day after the surgery. Gradual regression of neurological symptoms (increasing volume of active motions and muscular strength in the upper extremities). At the moment of discharge for outpatient treatment, the full volume of active movements in the joints of the upper extremities was achieved. The muscular tone in the upper extremities was moderately low, without side differences. Recovery of muscular strength of flexors and extensors of the hand and fingers – 4-5 points, D = S. Mild hypesthesia of fingers of both hands was persistent. The figure 3 shows the functional result of the treatment one month after the injury. The general period of inhospital treatment was 31 bed-days. Complex restorative treatment was continued at the outpatient stage.
Figure 3
The patient D., age of 54: functional outcome 1 month after injury.
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The patient was examined 7 months after the surgery. Neurological symptoms regressed. The functional recovery was full. Working ability restored within the full range. The general period of treatment was 182 days. The functional outcome of complex treatment of the patient was estimated as good.
CONCLUSION
Therefore, the demonstrated clinical case confirms the necessity for early transfer of patients with complicated spinal injuries to specialized centers. Active surgical management and complex restorative treatment for patients with spine and spinal cord injuries result in good functional recovery of lost functions.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.