Pathomechanisms of injuries of the spinal cord and spinal nerve roots in trauma of the thoracic and lumbar segments of the spine

Apart from clinical examination, X-ray pictures after administration of contrastive medium to the subarachnoid space and axial computerized tomography were performed in 95 patients with traumatic damage of the spinal cord and the nervous roots. It was found that spinal cord lesion in 46.3 per cent of the patients was caused by the injury acting according to the shearing mechanism with the components of the torsional forces leading to dislocation of the vertebra. As a consequence of the crushing mechanism in the injuries of all three spinal columns, the spinal cord and the nervous roots were injured in 30.5 per cent of the patients. The neurological changes were caused by injury of the anterior and the medial spinal columns in 15.8 per cent of the patients, fracture according to the extension mechanism--4.2 per cent, compression of the spinal cord by the mass of nucleus pulposus--3.2 per cent of the patients. The risk of spinal cord injury increases in the patients with accompanying degenerative changes of the spine, growth disorders, the symptoms of local stenosis of the spinal canal.     

Injuries to the spinal cord in elderly patients.

There are certain differences between the mechanism of injury and the course and results of treatment of post-traumatic spinal cord injuries in younger and older victims. Between 1965 and 1990 there were 564 patients over 60 years of age with spinal cord or cauda equina injuries treated at the Spinal Cord Centre in Konstancin, Poland. This article presents the level and degree of the nervous system injury, the methods of treatment and early mortality in the series. Of the patients, 43 per cent were aged between 60 and 65 years, but 31 per cent were patients over 70 years of age. More patients sustained injury to the cervical spine (72 per cent), and 42 per cent of lesions to the spinal cord were neurologically assessed as complete transverse cases. This paper stresses the high mortality rate, amounting to 26 per cent overall and 48 per cent in the groups with complete spinal cord lesions.     

Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring

We retrospectively analyzed the postoperative neurological complications in 137 patients who underwent a posterior spine fusion for scoliosis and had concomitant somatosensory cortical evoked-potential spinal-cord monitoring. The patients were divided into three specific operative groups: group 1, forty-nine patients who had a Harrington rod with segmental wiring (segmental spinal instrumentation); group 2, twenty patients who had Luque segmental spinal instrumentation; and group 3, sixty-eight patients who had a Harrington rod without segmental spinal instrumentation. There were neurological complications in twelve (17 per cent) of the sixty-nine patients in groups 1 and 2. Three patients (4 per cent) had a major injury to the spinal cord and nine patients (13 per cent) had only transient sensory changes. No difference was apparent between group 1 and group 2 in the degree of operative correction of curves or in the incidence of neurological complications. The one neurological complication (1.5 per cent) that occurred in the sixty-eight patients in group 3 was a Brown-Séquard syndrome. The factors related to increased risk for spinal cord injury in groups 1 and 2 included: (1) the passage of sublaminar wires in the thoracic and thoracolumbar spine, (2) intraoperative correction exceeding the preoperative bending correction, and (3) the surgeon's lack of adequate experience with the technique. With spinal cord monitoring we were able to predict the impending major neurological deficits, but the transient (sensory) changes that may be associated with segmental wiring were less reliably predicted.     

Blunt trauma of the diaphragm: a 15-county, private hospital experience.

During a 6-year period, 52 patients with nonpenetrating trauma to the diaphragm were treated in eight acute care hospitals, serving a 15-county area of Michigan. Charts were reviewed to identify patterns of injury, treatment, and outcome. Preoperative diagnosis was made in 50 per cent of cases based on chest x-ray findings; the remainder were diagnosed intraoperatively. Clinical examination revealed respiratory distress, decreased breath sounds, or elevated hemidiaphragm in 81 per cent of patients. Forty-two per cent of patients sustained significant head injuries. Fractures were present in 75 per cent of patients. Major chest injury was found in 92 per cent. Intra-abdominal organs were herniated in 67 per cent of cases with the stomach being most common (54%). The spleen was the most commonly injured abdominal organ (60%). The left diaphragm was injured in 75 per cent of cases; 2 per cent were bilateral. The most common postoperative complication was pneumonia. Mortality in this series was 13 per cent, with no case being related to the diaphragmatic injury. The authors conclude that blunt injuries to the diaphragm in the multiply-injured patient present a clinical diagnostic challenge requiring a high index of suspicion. Optimal care requires a multi-disciplinary critical care team to manage the high incidence of associated central nervous system, orthopedic, and chest injuries and associated high mortality rates.     

Venous thromboembolic events in hospitalized trauma patients

Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolus and is a significant cause of morbidity and mortality in injured patients. Absolute risk factors for VTE development are poorly defined. This study aimed to elucidate and evaluate risk factors in a large, population-based trauma registry. The trauma registry for a 10-year period of a single county was examined. VTE risk factors in 10,150 adult patients treated in the county's five trauma centers and seven nontrauma centers were identified. Chi2 and Student's t tests were used for statistical analysis. The incidence of VTE was low at 0.493 per cent. The rate was 0.096 per cent at nontrauma centers. Injury severity score (ISS), operative intervention, spinal cord injury, lower extremity fracture, and certain thoracic injuries were significant in VTE development. There were no differences in VTE rate by age, gender, injury mechanism, or admitting service. Hospital length of stay was doubled by VTE. The VTE rate at trauma centers was higher, which was expected, given the complexity of patients treated and higher ISS. Patients with ISS greater than 15, need for operation, spinal cord injuries, lower extremity fractures, and certain thoracic injuries are at risk for VTE.     

Spinal injuries caused by the flexion mechanism

The clinical documentation of 1,302 patients treated for spine injury from the flexing mechanism in 1965-1987 was analyzed. The relation between the degree of nervous system damage, the obtained neurological results and the character of injury (fracture or dislocation) as well as the level of spine injury was taken into account. It has been found that incidence of flexing injury of various parts of the spine oscillates slightly (39-44 per cent of all injuries). On the other hand, there is a significant predisposition to more frequent occurring of dislocations at flexing injury of the cervical spine and flexing fractures at thoracic spine injuries. The authors previous observations that young persons have more often fracture of the vertebra and older person--dislocation have been confirmed. Deep damage of the spinal cord is present more often at dislocation than fracture. The most serious damage of the spinal cord occurs at thoracic spine injury, in which the authors have found a very high percentage of patients with palsy (83 per cent at fracture, 98 per cent at dislocation).     

Management of athletic injuries of the cervical spine and spinal cord

Injuries to the cervical spine among athletes present inherent difficulties, especially in advising for return to contact sports. Experience with the acute care of 63 patients who sustained cervical spine injuries while participating in organized sporting events is analyzed. Forty-five patients had permanent injury to the vertebral column and/or spinal cord, while 18 suffered only transient spinal cord symptoms. Football mishaps accounted for the highest number of injuries, followed by wrestling and gymnastics. Twelve patients had complete spinal cord injury, 14 patients had incomplete spinal cord injury, and 19 patients had injury to the vertebral column alone. The majority of the spinal cord lesions occurred at the C4 and C5 levels, while bony injuries of C4 through C6 predominated. Twenty-five patients required surgical stabilization, and 20 were treated with orthosis only. There was no instance of associated systemic injuries, and hospital complications were few. The mean time of hospitalization was 19.1 days for injured patients and 3.0 days for patients with transient symptoms. A classification was developed to assist in the management of these patients: Type 1 athletic injuries to the cervical spine are those that cause neurological injury; patients with Type 1 injuries are not allowed to participate in contact, competitive sporting events. Type 2 injuries consist of transient neurological deficits without radiological evidence of abnormalities; these injuries usually do not prohibit further participation in contact sports unless they become repetitive. Type 3 injuries are those that cause radiological abnormality alone; these represent a heterogeneous group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pathomechanisms of spinal cord injuries caused by injuries of the cervical spine

The pathomechanism of injuries of the spinal cord due to injuries of the cervical spine in 158 patients treated during the last ten years has been presented. It has been determined that total and irreversible injuries of the spine occurred most often after fractures of the spine with displacement from hyperflexion (29.7 per cent) crushed fractures (24.7 per cent), and dislocation of the spine (24.7 per cent). In the majority of the patients, the spinal cord was irreversibly damaged already at injury, and in 29.2 per cent, the symptoms of deformity of the lumen of the vertebral canal and compression of the spinal cord remained. In about 24 per cent of the patients, the symptoms of congenital or habitual relative stenosis of the vertebral canal occurred. The performed examination has shown that knowledge of the pathomechanism of injury of the spine may facilitate determination of the degree of injury of the spinal cord as early as immediately after trauma.     

Penetrating gunshot wounds of the chest in civilian practice: experience with 250 consecutive cases

Our experience indicates a continued rising incidence of gunshot wounds of the chest in the United States. During the past 4 1/2 years, 250 consecutive cases were treated at the King-Drew Medical Center in Los Angeles. Ninety per cent presented with a haemothorax or haemopneumothorax. Pneumothorax alone was present in only 3 per cent of cases. Twenty per cent had associated intra-abdominal injuries, involving mostly the diaphragm, liver, spleen and the gastrointestinal tract. Eighty per cent were treated with tube thoracostomy and among these there were 2 deaths, neither being related to the chest injury. About 16 per cent underwent thoracotomy with a mortality of 12.8 per cent, all the deaths being caused by severe cardiac wounds. The overall mortality was 2.8 per cent. The complication rate was 5.3 per cent, most complications occurring in patients with associated intra-abdominal and spinal cord injuries. The average period of hospitalization was 6.5 days. The management plan and the indications for the two courses of therapy are discussed.     

The anaesthetic management of acute spinal injury patients

The incidence of acute spinal injuries in the UK is estimated to be 20 per million population per year, with spinal cord injury at 3.5 per million population per year. The mortality associated with spinal injuries, in patients who are alive on admission to hospital is probably less than 10%. These patients require resuscitation appropriate to the extent of their injuries in order to maintain adequate perfusion and oxygen delivery to organ systems, including their spinal cord.Mismanagement and inappropriate handling of unstable spinal column injuries may convert a simple bone injury into a spinal cord injury.There is evidence that the use of high dose steroids and aggressive early treatment of cardiorespiratory derangements may lead to an improved neurological outcome.¹⁷This article looks at the physiological changes associated with acute spinal cord injury, the early management of these patients and some aspects of their anaesthetic management.     

Associated injuries in patients with spinal injury

The associated injuries found in 100 consecutive spinal injuries are described. Fifty-one of the patients had injuries of the cervical cord, 31 per cent complete. A total of 75 per cent of the patients had associated injuries, the commonest being a head injury. Chest injuries were the next most frequent. The management of these injuries in the presence of a severe spinal injury is described. The importance of early tracheostomy and prophylactic anticoagulant therapy is stressed in reducing the mortality to the order of 2 per cent. The value of spinal injury units is emphasized.     

Spinal cord concussion

The hallmark of concussion injuries of the nervous system is the rapid and complete resolution of neurological deficits. Cerebral concussion has been well studied, both clinically and experimentally. In comparison, spinal cord concussion (SCC) is poorly understood. The clinical and radiological features of 19 SCC injuries in the general population are presented. Spinal cord injuries were classified as concussions if they met three criteria: 1) spinal trauma immediately preceded the onset of neurological deficits; 2) neurological deficits were consistent with spinal cord involvement at the level of injury; and 3) complete neurological recovery occurred within 72 hours after injury. Most cases involved young males, injured during athletics or due to falls. Concussion occurred at the two most unstable spinal regions, 16 involving the cervical spinal and three the thoracolumbar junction. Fifteen cases presented with combined sensorimotor deficits, while four exhibited only sensory disturbances. Many patients showed signs of recovery with the first few hours after injury and most had completely recovered within 24 hours. Only one case involved an unstable spinal injury. There was no evidence of ligamentous instability, spinal stenosis, or canal encroachment in the remaining 18 cases. Two patients, both children, suffered recurrent SCC injuries. No delayed deterioration or permanent cord injuries occurred. Spinal abnormalities that would predispose the spinal cord to a compressive injury were present in only one of the 19 cases. This suggests that, as opposed to direct cord compression, SCC may be the result of an indirect cord injury. Possible mechanisms are discussed.     

The need for multidisciplinary management of patients with upper thoracic spine fractures caused by high-velocity impact: a review of 32 surgically stabilised cases

PURPOSE: To analyse the characteristics of patients who underwent surgery for fractures of the upper thoracic spine (T1-T6) in our institution. The thoracic spine is supported by the rib cage and associated ligaments; therefore, displacement and fracture of the upper thoracic spine in healthy young adults require a great force. The relatively narrow spinal canal around the spinal cord in this area could result in severe neurological deficit should fractures occur. METHODS: The treatment course of 32 patients (26 men and 6 women) who underwent surgery for fractures of the upper thoracic spine between February 1995 and March 2001 was retrospectively reviewed. Parameters of injuries and treatment methods were evaluated. RESULTS: Of the 32 patients, 29 were injured in traffic accidents (15 motorcycle and 14 vehicle), 2 in falls, and one by a heavy door falling on his back. 29 patients had spinal fractures at more than one level. 23 patients had complete, 7 had incomplete, and 2 had no neurological deficit. 30 patients required multiple modalities of radiological imaging (in addition to plain radiography) for diagnosis. 20 patients sustained other injuries apart from spinal fractures, 15 of them had associated chest injuries. CONCLUSION: High-velocity fractures of the upper thoracic spine are injuries with devastating consequences, and can result in severe neurological deficit and concomitant injuries. These patients are best treated by a multidisciplinary approach.     

All terrain vehicles (ATVs). A recreational gamble

Over the period September 1985 to July 1986, the authors reviewed 28 admissions to the Level I trauma center as a result of all-terrain vehicle (ATV) accidents. The patients ranged in age from 6 to 71 years, with nearly 33 per cent (9), under age 16. There were 22 (78.6%) male and 6 (21.4%) female patients. All suffered multiple abrasions, lacerations, and contusions. In addition, 21 (75%) patients had a fracture of some type. Eight (28.6%), had head injuries and 3 (10.7%) sustained spinal cord injuries with a permanent neurologic deficit. Intrathoracic injury occurred in 2 patients (7.1%) and intraabdominal injuries occurred in 1 (3.6%). Moreover, death occurred in 3 (10.7%). Simultaneously reviewed were admissions resulting from motor vehicle accidents (MVA) and motorcycle accidents (MCA) during the same period. By comparison, the death rates (DR), fracture rates (FR), and spinal cord lesions with deficit (SLR) were significantly higher in accidents with ATVs than with MVAs or MCAs. The death rates for ATVs, MVAs, and MCAs were 10.7 per cent, 4.6 per cent, and 1.2 per cent, respectively, with significance between the MCA and ATV groups, P = .0395. The FR were 75 per cent, 53 per cent, and 65 per cent, respectively, with P = .265. SLR was found in 10.7 per cent, 2.3 per cent, and 4.4 per cent of these same groups, with P = .0001. These data suggest that ATV riders are at a higher risk for sustaining fractures, significant spinal cord injuries, or death. ATVs clearly present a health hazard to riders of all ages.     

Abdominal trauma during thirty years: analysis of a large case series

Studies have been made in 1407 patients of the causes, the organs involved and the outcome of injury to the abdomen in patients needing admission to hospital in an area of Southern Sweden, between 1950 and the end of 1979. The proportion of female patients and those aged over 60 increased significantly. The seasonal distribution of the injuries showed significant change, with a drop in the initially high frequency sustained during the summer months. Penetrating injuries were rare, but increased in the 1970s. Road traffic accidents as the cause of abdominal injuries rose to a maximum of 56 per cent in the late 1960s. The numbers of injured organs and the frequency of other associated injuries rose gradually until the mid-1970s, after which there was a slight decrease. The spleen, liver and large blood vessels were the organs which were increasingly often injured. The annual incidence of various visceral injuries per 100 000 population was calculated. The number of patients with a delay of at least 24 hours before operation fell significantly and there was a tendency to shorter hospital stay. The mortality curve showed a peak in the late 1960s.     

Tuberculous spondylitis in adults

We treated 107 adults with spinal tuberculosis. The average age was 41.8 years (range, sixteen to seventy-five years). Diagnosis was difficult: bone scans were negative in 35 per cent; gallium scans, negative in 70 per cent; and results of tuberculin skin tests, negative in 14 per cent. Five neurologically impaired patients had no discernible bone lesions when they were first seen but were found to have either intradural or extradural tuberculomas or tuberculous arachnoiditis. Our indications for a spinal operation were neurological impairment, spinal instability, or failure of medical management, and an operation was required in fifty-three of the 107 patients. Anterior decompression and fusion was the surgical procedure of choice. Ninety-four per cent of neurologically impaired patients recovered normal neurological function after anterior decompression; 79 per cent, after non-surgical treatment; and 55 per cent, after laminectomy. Neurological recovery and relief of pain occurred more rapidly in the surgically treated group. Kyphosis did not worsen in any patient, whether treated medically or surgically. There were no organisms that were resistant to isoniazid, rifampin, or ethambutol, and there was neither progression nor reactivation of disease after twelve months of adequate chemotherapy.     

Therapeutical concept for injuries of the lower cervical vertebral column

Over a period of two and half years, the Spinal Surgery Working Group of the Deutsche Gesellschaft für Unfallchirurgie (German Association for Trauma Surgery) DGU has carried out a prospective study of relevant injuries of the cervical vertebral column in 544 patients. The lower section C3 to Th1 of the cervical vertebral column was affected in 308 cases (56 per cent). The injuries of the cervical vertebral column were caused primarily by accidents in road traffic and in the pursuit of recreational activities. More than half of the patients had multiple injuries. The share of degenerative concomitant changes as a cause for relevant injuries increased with age considerably. In case of a qualified trauma with the suspicion of an injury, the immobilisation of the cervical vertebral column has to be retained until the X-ray diagnosis inclusive of a computer tomography has been completed as this is obligatory for the clarification of suspected findings or for pre-operative planning, respectively. The diagnostic range is complemented by guided function imaging to reveal instabilities, and magnetic resonance imaging, which has to be carried out in case any X-ray pathology is absent and neurological functional deficit exists. Patients with neurological deficits, which were found in 43 per cent of the cases suffering from injuries of the lower cervical vertebral column, should be treated as quickly as possible with a high dose of methyl prednisolone. A recovery of the neurological abolition by at least one ASIA level was observed in 10 per cent of the patients concerned. A conservative therapy with a cervical collar was pursued in 24 per cent of the cases with stable injuries. An operative treatment indication, which was diagnosed in 76 per cent of the cases, aims at the early recovery of the anatomy with decompression of the spinal cord, reposition, and stabilisation of segments concerned. The point of the operation was determined by the neurological status, the existing dislocation, and the increasing instability as well as the concomitant injuries. Positioning necessary for intensive medical interventions required an early stabilisation of the spinal column. The front access with plate spondylodesis as a standard procedure with various special implants has proved to be safe and reliable in the healing result. Dorsal accesses shall remain reserved for definable individual indications and should be prevented in case of injuries of the cervical medulla, if possible, to spare the cervical muscles.     

Care of post-traumatic spinal cord injury patients in India: An analysis

Background:

The spinal cord injured patients if congregated early in spinal units where better facilities and dedicated expert care exist the outcome of treatment and rehabilitation, can be improved. The objective of this study is to find out the various factors responsible for a delay in the presentation of spinal injury patients to the specialized spinal trauma units and to suggest steps to improve the quality of care of the spinal trauma patients in the Indian setup.

Materials and Methods:

Sixty patients of traumatic spinal cord injury admitted for rehabilitation between August 2005 and May 2006 were enrolled into the study and their data was analyzed.

Results:

Eighty-five per cent of the spinal cord injured patients were males and the mean age was 34 years (range 13-56 years). Twenty-nine (48.33%) of the spinal injuries occurred due to fall from height. There was an average of 45 days (range 0-188 days) of delay in presentation to a specialized spinal unit and most of the time the cause for the delay was unawareness on the part of patients and/or doctors regarding specialized spinal units. In 38 (62.5%) cases the mode of transportation of the spinal cord injured patient to the first visited hospital was by their own conveyance and the attendants of the patients did not have any idea about precautions essential to prevent neurological deterioration. Seventeen (28.33%) patients were given injection solumedrol with conservative treatment, 35 (60%) patients were given only conservative treatment and seven patients were operated (11.66%) upon at initially visited hospital. Of the seven patients operated five were fixed with posterior Harrington instrumentation (71.42%) and two (28.57%) were operated by short segment posterior pedicle screw fixation. None of the patients were subjected to physiotherapy-assisted transfers or wheel chair skills or even basic postural training, proper bladder/ bowel training program and sitting balance.

Conclusion:

Awareness on the part of the general population, attendants of the patients, clinical and paraclinical team regarding spinal cord injury needs to be addressed. Safe mode of transportation of spinal cord injured patient and early presentation at tertiary spinal care center with comprehensive spinal trauma care team should be stressed upon.     

Spinal fracture in the course of spondylarthritis ankylopoietica (Bechterew disease)]

In 1965-1986 fifty-six patients were treated for fracture of the spine in the course of spondyloarthritis ankylopoetica. In 47 patients the cervical spine was injured. In 53 patients concomitant neurological symptoms were observed. Total or partial palsy were dominant in injuries of the cervical spine (72 per cent). A marked neurological improvement was achieved in the course of treatment in most of the patients. The authors recommend non-surgical treatment.     

Verletzungen der Halswirbelsäule beim Kopfsprung ins Wasser

116 patients with cervical spine injuries due to water sport accidents treated in eight Austrian institutions from 1991 to 1998 were reviewed retrospectively. There were 93% male, 72% were 15 to 29 years of age. 93% had injuries from diving into swimming pools or into open water. At discharge 58 patients had Frankel A lesions, 39 had incomplete cord lesions Frankel B to D, and 19 patients had no neurological injury. This data suggest that in Austria approximately one person per one million inhabitants per year sustains a spinal cord injury in a diving accident in shallow water.