PERCUTANEOUS METHODS OF SPINAL STABILIZATION IN ELDERLY AND SENILE PATIENTS WITH ASSOCIATED INJURIES Slinyakov L.Yu., Chernyaev A.V., Lipina M.M., Kalinskiy E.B., Simonyan A.G.

Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia

According to WHO experts’ opinion, ageing of population is a global problem at the present time [1]. It is assumed that injuries to vertebral bodies in elderly and senile patients are caused by low-energy injuries owing to presence of osteopenia [1, 2, 3]. However increasing social activity in patients of this age group leads to increase in number of high-energy injuries and polytrauma [1].

Absolute indications for instrumental stabilization of uncomplicated spinal injuries are their unstable pattern [1, 2, 4, 5]. Currently, the issue of fixation of stable osteoporotic fractures of vertebral bodies has not any uniform solution [1, 2, 6, 7]. So, the use of transpedicular systems in osteoporosis causes the risk of unstable implants and their migration in the early postsurgical period [1, 2, 6, 8]. Currently, the wide-spread puncture methods of stabilization (vertebroplasty and kyphoplasty) are not related to standard treatment and are considered as an option [1, 2]. However it is necessary to note that the classic conservative treatment of compression fractures of vertebral bodies is not acceptable for patients with polytrauma. Long term bed rest and external fixators (braces, body posture correctors) can cause hypostatic complications (pneumonia, thromboembolic complications and others) and also decompensation of existent somatic pathology [1, 4, 6]. At the same time, early activation of patients and early axial load in the injury site causes a kyphotic deformation and development of persistent vertebrogenic pain syndrome [4]. Also one of unfavorable outcomes of incorrect treatment protocol for such injuries is development of mobile deformations and, as result, pain syndrome [8]. Therefore, treatment of patients with spinal injuries and multiple and associated injuries presents the difficult task, which requires strict adherence to management protocols and formation of indications for surgical treatment with consideration of polymorphism of injuries.

Objective – to substantiate the use of percutaneous methods of spinal stabilization in patients with polytrauma of elderly and old age.

MATERIALS AND METHODS

The study included 105 patients (40 men – 38.1 %, 65 women – 61.9 %) who were treated in the clinical basis of traumatology, orthopedics and disaster medicine department of Sechenov University in 2011-2017. The patients were distributed in compliance with the age and WHO classification: elderly age (60-74 years): men – 12 (11.4 %), women – 25 (23.8 %); senile age (75-90 years): men – 28 (26.7 %), women 40 (38.1 %). The mean age of patients was 77.4 ± 1.2.

The analysis of causes of injuries was conducted. The main cause was road traffic accidents – 85 (80.9 %) cases. Other causes were catatrauma – 15 (14.3 %) cases, and sport injuries – 5 (4.8 %). Considering the associated pattern of injury and presence of concurrent somatic pathology, all patients were in the intensive care unit immediately after hospital admission. The mean ICU stay was 9.2 ± 1.1 days.

The table 1 presents the structure of the injuries.

Table 1

Structure of associated injuries in the examined group of patients

Pattern of associated injury	Number of patients, abs. (%)
Chest injuries (uncomplicated fractures of ribs and sternum; hemo/pneumothorax without need for surgical treatment; lung contusion)	30 (28.6)
Closed traumatic brain injury (brain concussion, mid brain contusion)	23 (21.9)
Pelvic injuries (stable fractures)	10 (9)
Pelvic injuries (unstable)	5 (4.8)
Upper extremity fractures Clavicle fracture Humeral diaphysis fracture Proximal humeral fracture Forearm fracture	27 (25.7) 12 (11.4) 3 (2.85) 9 (8.6) 3 (2.85)
Lower extremity fractures Proximal femoral fracture Femoral diaphysis fracture Fractures of femoral or tibial condyles Leg diaphysis fracture Distal leg fracture	52 (49.5) 8 (7.6) 12 (11.4) 5 (4.8) 20 (19) 7 (6.7)

All complex of anti-shock measures was conducted at the critical care stage, including primary external stabilization for long bones and unstable pelvic injuries according to Damage Control.

According to results of radial examination (radiography, computer imaging – 100 % of cases), locations of spinal injuries and their patterns according to AO/ASIF-Magerl were estimated (the tables 2, 3). ASIA – Type E was used for estimation of neurological deficiency (100 %).

Table 2

Distribution of incidence of vertebral body injuries according to anatomic regions

Injury level	Number, abs. (%)
Th6-Th9	22 (21)
Th10-L1	52 (49.5)
L2-L5	18 (17.1)
Multiple injuries (2 and more vertebrae)	13 (12.4)

Table 3

Distribution of injuries to vertebral bodies in concordance with AO/ASIF-Magerl classification

Injury type	Number, abs. (%)
А1	65 (61.9)
А2	15 (14.3)
А3	17 (16.2)
В1	8 (7.6)

After transfer from ICU, the complex and dynamic estimation of somatic status was conducted. It included laboratory, instrumental and clinical methods. If somatic pathology in the decompensation stage was found, the corresponding therapy was conducted under supervision of profile specialists.

The estimation of risks of anesthesiology was conducted with ASA from American Association of Anesthesiologists. The patients of the examined group had the second (73 (69.5 %) patients) and third (32 (30.5 %) risk degrees.

Considering the characteristics of spinal injuries, the patients received puncture vertebroplasty of a broken vertebral body (Vertecem and Vertaplex vertebral bodies), multiple puncture vertebroplasty for multi-level injuries, percutaneous transpedicular fixation in combination with vertebral body plasty (if indicated), percutaneous transpedicular fixation with stabilizing system screw augmentation (Expedium LIS transpedicular fixators). In all cases, CT showed the absence of spinal canal stenosis (80 patients, 76.2 %) or stenosis was not more than 25 % (25 patients, 23.8 %) that did not require for opened decompression of the spinal canal, considering the absence of neurological complications. Puncture vertebroplasty was conducted for stable fractures of vertebral bodies without injuries to posterior wall of the body. The technique was used for 60 (57.1 %) cases. Multiple vertebroplasty (up to 3 levels) was performed for 13 (12.4 %) patients.

The indications for percutaneous transpedicular fixation were unstable injuries with kyphotic deformation of spinal column axis. Puncture cement plasty of vertebral body for stabilization of ventral column of the spine was conducted in absence of injuries to posterior wall of vertebral body. Percutaneous transpedicular fixation was performed for 15 (14.3 %) cases including 7 (6.7 %) in combination with puncture vertebroplasty.

In 10 (9.5 %) cases, the patients received percutaneous transpedicular fixation with augmentation of screws of the system. The indication for use of this stabilization type was unstable injuries to vertebral bodies with intense osteoporotic changes of bone tissue in vertebrae adjacent to injured bodies, with necessary conduction of intrasurgical reposition and reduction manipulations owing to risk of instability of screws of fixing system and their migration. Osteoporotic changes (haemangioma-similar changes in vertebral bodies, formation of cysts) were visualized with multispiral computer tomography.

The X-ray examination was conducted for all patients before surgical treatment.

During surgery, biplanar monitoring technique with use of two electronic optical converters in mutually perpendicular planes was used. This technique showed its efficiency in reduction of surgery time, decrease in radial load for patients and surgery team [9].

Before discharge for outpatient treatment all patients received standard X-ray examination of the spine.

For objectivation of treatment results, all patients received the questionnaire with the following scores [1]:

- Estimation of pain syndrome in the back with VAS (Visual Analogue Scale);

- Estimation of total life quality with SF-36 (The Medical Outcomes Study 36-Item Short Form Health Survey);

- Estimation of functional outcome of injury with FCI (the Functional Capacity Index).

Estimation of results was conducted with the following scheme:

1. Before surgical treatment – questionnaire with VAS, SF-36 and FCI.

2. Before discharge for outpatient treatment – control X-ray examination of the spine, questionnaire with VAS, SF-36, FCI.

3. 6 months from surgery – multispiral computer tomography of the spine, questionnaire with VAS, SF-36 and FCI.

4. After 12 months and then 1 time per year – spinal X-ray examination, questionnaire with VAS, SF-36 and FCI.

Maximal period of follow-up was 6 years (23 patients, 21.9 %). The mean time of follow-up was 3.4 ± 0.6 years.

The especially important issue was a possibility of simultaneous operations if several segments of the locomotor system were injured and surgical treatment was required. Owing to low invasive pattern of vetrebrologic surgeries, spinal stabilization was carried out simultaneously with fixation of fractures of extremities and the pelvis in 84 (80 %) cases, i.e. it showed simultaneous pattern. In 15 cases (14.3 %), stabilization of spinal injuries showed the isolated pattern in patients with thoracic injuries. 6 patients (5.7 %) refused from offered simultaneous vertebroplasty, but they were operated within 5-7 days owing to increasing pain in the back.

The statistical analysis was conducted with Statistica 8.0 for Windows (StatSoft Inc., USA). Parametrical statistical techniques (Student’s test) were used for calculation of probabilities of parametrical values relating to normal distribution. The mean values were presented as М ± σ. Qualitative variables were described with absolute and relative frequencies (percentage). Differences were statistically significant at p < 0.05.

The study corresponds to World Association Declare of Helsinki – Ethical Principles for Medical Research with Human Subjects, 2000, and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Russian Health Ministry on 19 June, 2003, No.266. All patients gave their written consent for participation in the study and publication of results.

RESULTS AND DISCUSSION

The mean VAS was 6.1 ± 0.8 before surgical treatment. It corresponds to pain of middle intensity. The patients with associated injuries to chest organs and the thoracic spine demonstrated the higher value, which corresponded to strong pain. It is explained by anatomic and functional relationship of injured structures. Estimation with SF-36 showed 43.17 ± 4.8 %. Presurgical FCI was 49.4 ± 1.7.

All patients received surgical stabilization of the spine with adherence to the standard protocol. Intrasurgical use of biplanar monitoring with electronic optical converter reduces the surgery time and presents the efficient preventive measure of such intrasurgical complications as malposition of screws of the fixing system, distribution of bone cement into the spinal canal and others. Strict adherence to the technique prevented the intrasurgical complications in 100 % of cases.

The X-ray control examination before discharge for outpatient treatment showed the correctness of performed surgical procedures and did not differ from intrasurgical one. The results of questionnaire with VAS, SF-36 and FCI are presented in the table 4.

Table 4

Results of questioning of patients

Score	After surgery n = 105	6 months n = 105	12 months n = 100	2 years n = 90	3 years n = 74	4 years n = 60	5 years n = 45	6 years n = 23
VAS	5.2 ± 0.8	4.9 ± 0.5*	3.2 ± 0.4*	3.8 ± 0.7*	4.0 ± 0.2*	3.2 ± 0.4	2.9 ± 0.5	3.1 ± 0.6
SF-36	54.2 ± 1.3	68.2 ± 2.1*	78.1 ± 2.3*	77.5 ± 1.7*	78.1 ± 1.0*	77.1 ± 2.4*	75.5 ± 1.3*	76.3 ± 2.4*
FCI	49.6 ± 2.1	67.8 ± 1.7*	80.4 ± 1.7*	89.2 ± 1.5*	92.3 ± 1.4*	90.4 ± 1.2*	95.1 ± 1.3	94.8 ± 1.8

Note: * – differences are statistically significant in comparison with basic data, p ≤ 0.05.

As the data shows, the results of the chosen treatment techniques were improvement in life quality with SF-36 and significant increase in FCI, indicating the good functional result of treatment. The statistically significant and reliable results were received within 4 years of the follow-up.

The number of observed patients decreased. 3 years after surgery, 14 (13.3 %) patients of senile age died. Death of the patients was not related to polytrauma. In 17 (16.2 %) cases, the patients were excluded from the study because of injuries in different locations. In other cases, the patients refused from live consultation and questionnaire.

The X-ray examination of the patients 6 months after surgical treatment showed the signs of bone tissue resorption around fixing screws without signs of migration in 5 (4.8 %) patients. There was not any correlation with clinical picture of vertebrogenic pain syndrome.

12 months after surgery, 10 (9.5 %) patients after puncture vertebroplasty showed stable compression fractures of adjacent vertebral bodies. All patients received conservative treatment with external fixators (braces, posture correctors). Further follow-up did not show any increasing deformation of a fractured vertebral body or increasing pain.

1 (0.95 %) patient showed the incomplete migration of augmented screws at the background of an abnormal fracture of vertebral body. The patient refused from revision intervention. The dynamic follow-up did not show any negative trends in the radial picture, but pain of middle intensity persisted.

The patients with previous bone tissue resorption around screws did not show any migration of implants.

The described changes can be explained by existence and progression of systemic osteoporosis and were not associated with errors in selection of treatment techniques. One should note all patients received the recommendations for diagnosis and pharmaceutical treatment of systemic osteoporosis after hospital discharge.

Also the study group was analyzed for early postsurgical complications. There were not any local purulent septic complications in the site of approach to the spinal column. Local purulent septic complication in osteosynthesis site of extremity bones and the pelvis were identified in 10 (9.5 %) cases. Hypostatic pneumonia was identified in 13 (12.4 %) patients. Thrombosis of lower extremity veins were diagnosed in 39 (37 %) cases and only in 9 (8.6 %) cases in early postsurgical period. The received results of incidence of complications correspond to available literature data [10, 11, 12].

Therefore, the used percutaneous techniques of spine stabilization showed their efficiency in the patients of older and senile age with multiple and associated injuries.

CONCLUSION

1. Percutaneous techniques for spine stabilization in patients with multiple and associated injuries present efficient surgical treatment.

2. Being low invasive techniques, the described spine stabilization techniques can be used as a part of the concept of simultaneous surgery.

3. Percutaneous techniques for spine stabilization do not increase the risk of purulent septic and thromboembolic complications in patients with polytrauma.

4. One should extend the list of indications for puncture vertebroplasty, considering the impossibility of adequate conservative treatment in patients of older age with uncomplicated stable spinal injuries.

Information on financing and conflict of interests

The study was conducted without sponsorship.

The authors declare the absence of clear and potential conflicts of interests relating to publication of this article.