Perioperative management of traumatic spinal cord injured patients after the acute phase

Objective

To understand the physiopathology and the consequences of a traumatic spinal cord injury after the acute phase. The aim is to describe the preoperative management of these patients and the various anaesthetic techniques available.

Data source

The data were retrieved from the PubMed data base, papers from the major French anaesthesiology and intensive care conventions, publications from the French medico-surgical encyclopaedia, combined with reference analysis of major articles in this field.

Results

In France, there are 40,000 patients with traumatic spinal cord injury. These lesions lead to major handicap and frequent complications particularly urologic and orthopaedic ones. These patients often require surgical procedures under anaesthesia. Besides neurological deficits, the spinal cord injury leads to an imbalance between sympathetic and parasympathetic nervous systems with serious dysautonomic complications. During surgery, anaesthesia is necessary to prevent this autonomic dysreflexia. All anaesthetic techniques are usable and effective, subject to their careful implementation for those patients with cardiovascular and respiratory restricted adaptation. The use of suxamethonium can induce fatal hyperkaliemia for up to 10 years after the initial injury, with maximal frequency at six months post-trauma.

Conclusion

Notwithstanding insensitivity resulting from a spinal cord lesion, it is necessary to anaesthetize these patients before all surgical procedures.     

Depressive burden is associated with a poorer surgical outcome among lumbar spinal stenosis patients: a 5-year follow-up study

Background context

In lumbar spinal stenosis (LSS), conservative treatment is usually the first choice of treatment. If conservative treatment fails, surgery is indicated. Psychological factors such as depression and anxiety are known to affect the outcome of surgery. Previous studies on depression and surgery outcome using long follow-up times are scarce.

Purpose

The purpose of this study was to investigate the effect of depressive symptoms on the surgical outcome during a 5-year follow-up among patients with LSS.

Study design

A prospective observational study.

Patient sample

Patient sample included 102 LSS patients who needed surgical treatment.

Outcome measures

The outcome of surgery was evaluated with the Oswestry Disability Index (ODI), visual analog scale pain assessment, and self-reported walking capacity.

Methods

The patients completed a set of questionnaires preoperatively and 3 and 6 months, as well as 1, 2, and 5 years after the surgery. Depressive symptoms were assessed with the Beck Depression Inventory. The depressive burden was estimated by summing all individual Beck Depression Inventory scores. Statistical analyses included cross-sectional group comparisons and linear regression analyses. No conflicts of interest.

Results

On 5-year follow-up, a high depressive burden associated with a poorer outcome of surgery when assessed with the ODI. In linear regression analysis, a high depressive burden associated with higher ODI score.

Conclusions

Even slightly elevated long-term depressive symptoms in LSS patients are associated with an increased risk of a poorer functional ability after decompressive surgery.     

Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database

Background context

The incidence and relevant risk of ischemic stroke after cervical spine trauma remain unknown.

Purpose

To examine the incidence of ischemic stroke during hospitalization in patients with cervical spine injury, and analyze the impact of different types of cervical spine injuries on the occurrence of ischemic stroke.

Study design

Retrospective analysis of data abstracted from the Diagnosis Procedure Combination database, a nationally representative database in Japan.

Patient sample

We included all patients hospitalized for any of the following traumas: fracture of cervical spine (International Classification of Diseases, 10th Revision codes: S120, S121, S122, S127, S129); dislocation of cervical spine (S131, S133); and cervical spinal cord injury (SCI) (S141).

Outcome measures

Outcome measures included all-cause in-hospital mortality and incidence of ischemic stroke (I63) during hospitalization.

Methods

We analyzed the effects of age, sex, comorbidities, smoking status, spinal surgery, consciousness level at admission, and type of cervical spine injury on outcomes.

Results

We identified 11,005 patients with cervical spine injury (8,031 men, 2,974 women; mean [standard deviation] age, 63.5 [18] years). According to the types of cervical spine injury, we stratified the patients into three groups: cervical fracture and/or dislocation without SCI (2,363 patients); cervical fracture and/or dislocation associated with SCI (1,283 patients); and cervical SCI without fracture and/or dislocation (7,359 patients). Overall, ischemic stroke occurred in 115 (1.0%) patients during hospitalization (median length of stay, 26 days). In-hospital death occurred in 456 (4.1%) patients. Multivariate analyses showed that ischemic stroke after cervical spine injury was significantly associated with age, diabetes, and consciousness level at admission. The highest in-hospital mortality was observed in patients with cervical fracture and/or dislocation associated with SCI (7.6%), followed by cervical SCI without fracture and/or dislocation (4.0%), and cervical fracture and/or dislocation without SCI (2.6%). Unlike mortality, risks of stroke did not vary significantly among the three groups.

Conclusions

This analysis revealed that ischemic stroke after cervical spine injury was not uncommon and was associated with increased mortality and morbidity. Occurrence of ischemic stroke was significantly associated with age, comorbidities such as diabetes, and consciousness level at admission, but not with the type of spine injury.     

Long-term functional results after short-segment pedicle fixation of thoracolumbar fractures

Purpose

A retrospective study to assess the health-related quality of life in patients undergoing posterior fixation of thoracolumbar fractures, and to compare the outcome with norm scores and HRQL in patients undergoing surgical treatment for degenerative conditions of the spine.

Methods

The study population consisted of 93 consecutive patients surgically treated for a thoracolumbar fracture from 2005 to 2009. All patients underwent posterior pedicle screw fixation and fusion. 83 patients were available for follow-up. Three questionnaires reflecting health-related quality of life (HRQL) were mailed to the patients: SF-36, ODI, and EQ-5D.

Results

52 men and 31 women were operated with an average age at the time of surgery of 46 years. All fractures were AO-type A3.1 and A3.2 with L1 being the primary fracture level. All patients were neurologically intact; Frankel E.The overall response rate on the questionnaires was 75% with no significant differences between responders and non-responder on basic demographic characteristics. The median follow up period was 3.8 years (range 2–6 years). The scores on all three questionnaires were significantly reduced compared to the national norm scores (p < 0.05).

Conclusion

Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit.     

Balloon kyphoplasty for osteoporotic spinal fractures with middle column compromise

Background

Balloon kyphoplasty (BKP) is an effective method for osteoporotic vertebral compression fractures. However osteoporotic spinal fractures with middle column compromise are mentioned as a relative contraindication to BKP. Thus we investigated the safety and efficacy of BKP in the treatment of osteoporotic spinal fractures with middle column compromise but without neurological deficit.

Methods

In this retrospective study, 45 patients who suffered osteoporotic fractures with middle column compromise but without neurological deficits were treated by BKP from May 2007 to December 2010. The final follow-ups were finished during the time of July 2011–September 2011. The mean follow-up period was 20.2 months. The height of the compromised vertebral body, the kyphotic angle and spinal canal compromise were measured before surgery, one day after surgery, and at the final follow-up. A visual analogue scale (VAS) and the Oswestry disability index (ODI) were chosen to evaluate pain and functional activity.

Results

The mean VAS and ODI scores improved significantly from pre- to post-operation (p < 0.05), and this improvement was sustained at the final follow-up. The mean anterior vertebral body height ratio improved from 57.6% ± 11.8% preoperatively to 86.2% ± 12.2% postoperatively (p < 0.05), so did the mean middle vertebral body height ratio. The kyphotic angle improved from 16.3° ± 3.7° preoperatively to 9.3° ± 2.6° postoperatively (p < 0.05). At final follow-up, BKP stabilised vertebral height and prevented further kyphotic deformity. While there were no differences in spinal canal compromise between pre-operation and one day after surgery (p > 0.05), there was a significant difference from the measurement at the final follow-up (p < 0.05).

Conclusion

BKP is a safe and effective method for osteoporotic spinal fractures with middle column compromise but without neurological deficit. Spontaneous remodelling of the spinal canal also occurs after BKP.     

Pharmacophysiology of bone and spinal fusion

Background context

In recent years, the number of complex spinal surgeries has increased significantly in the elderly population, where the prevalence of low bone density is highest. Consequently, spine surgeons often treat osteoporotic patients who are associated with higher rates of instrumentation failure. Therefore, establishing a successful fusion requires an appropriate substrate for bone formation and local bone remodeling. The fusion process can be supported by therapies that seek to shift the balance of bone homeostasis to increased formation and reduced resorption.

Purpose

Thorough understanding of the physiology of bone formation and adjunctive therapies can help improve fusion rates. Therefore, we present a thorough review of the latest pharmacologic agents used to enhance bone strength and surgical spinal fusion.

Methods

Systematic review of literature.

Results

Current knowledge on bone physiology has led to the development of several pharmacologic agents that enhance bone formation and strengthen the human skeleton. At present, natural supplements of vitamin D and calcium or synthetic medications like bisphosphonates are widely used before and after spine surgeries to enhance bone fusion. Additional physiologic agents, including testosterone, parathyroid hormone, calcitonin, and growth hormone, have been shown to improve bone mass density or spinal fusion in both animal and human studies. As in other medical fields, gene therapy has shown viability and promise with the use of both viral and nonviral vectors.

Conclusions

Through the understanding of bone physiology, numerous natural and synthetic pharmacologic agents have been developed to enhance the body's skeleton and to improve outcomes of spinal fusion surgery.     

Postoperative spinal deformity after treatment of intracanal spine lesions

Background context

Surgical treatment of intracanal (both intramedullary and extramedullary) spine lesions requires posterior decompressive techniques in nearly all instances. Postoperative spinal deformities, most notably sagittal and coronal decompensation, are of significant concern for both the patient and the spinal surgeon.

Purpose

To review and define principles and features of spinal deformities after posterior spinal decompression for intracanal spinal lesions, and to define patients who may benefit from the concomitant spinal fusion.

Methods

A systematic review of MEDLINE was conducted, including articles published between 1980 and 2011. Articles related to spinal deformities after posterior decompression for the treatment of intracanal spine lesions were identified.

Results

Ten articles met all inclusion and exclusion criteria. All were case series with limited evidence (Level IV). Many risk factors to deformity were implied but with limited evidence. Young age was the most commonly identified risk in these articles.

Conclusions

Spinal deformity after posterior decompression is a common complication, most notably in children and young adults, after the removal of intramedullary tumors. Many risk factors have been implied to increase the postoperative development of spinal deformity, including young age, laminectomy extension, preoperative deformity, and extensive facet resection, among others. However, there is a lack of high-quality evidence to propose an algorithm for treatment or preventive measures. New studies with larger series of patients and standardized clinical outcomes are necessary to establish optimal treatment protocols.     

Chronic expanding hematoma after spinal surgery

Background context

Chronic expanding hematoma after spinal surgery is extremely rare, with no case previously reported in the literature.

Purpose

To report a rare case of a chronic expanding hematoma of the spine that occurred 24 years after thoracic laminectomy and spinal cord tumor resection.

Study design

Case report.

Methods

A 71-year-old man presented with a spinal mass located approximately at the level of the sixth thoracic vertebral body. The patient had undergone thoracic laminectomy with tumor resection 24 years previously. The mass had appeared 5 years after this and had gradually enlarged over 19 years.

Results

The tumor was resected en bloc. The lamina and spinous processes had been partially eroded by the tumor at the fifth and sixth thoracic vertebrae, but the dura was intact. Histopathologic examination confirmed the diagnosis of chronic expanding hematoma. The hematoma had not recurred at the 1-year follow-up.

Conclusion

We report herein an extremely rare case of chronic expanding hematoma after spinal surgery. This entity may be considered a late complication after surgery regardless of the number of years that have passed since the index surgery.     

Noncontiguous double-level unstable spinal injuries

Purpose

Noncontiguous double-level unstable spinal injuries (NDUSI) are uncommon and have not been well described. In this study, we aimed to better understand the patterns of NDUSI, in order to recommend proper diagnostic and treatment methods, as well as to raise awareness among traumatologists about the possibility of these uncommon injuries.

Methods

A total of 710 consecutive patients with spine fractures were treated for >9 years since 2007 at a single regional trauma center. Of them, 18 patients with NDUSI were reviewed retrospectively.

Results

The incidence of NDUSI was 2.5 % of all spine fractures. In 17 of 18 patients (94.7 %), NDUSI was caused by a high-energy trauma. Nine patients (50.0 %) exhibited complete neurological deficit. Spinal cord injury occurred in the cranial injured region in all American Spinal Injury Association grade A cases. In one case, a second fracture was overlooked at the initial examination.

Conclusion

NDUSI are common in cases of high-energy trauma and should be taken into consideration at the initial examination. A second fracture may be easily overlooked because of the high frequency of concomitant severe spinal cord injury in the cranial injured region and/or loss of consciousness due to associated injuries. To avoid overlooking injuries, full spine computed tomography is useful at the initial examination. Operative reduction and internal fixation with instrumentation through a posterior approach is recommendable for cases of NDUSI. In elderly patients, a very rapid stabilizing surgery should be planned before aspiration pneumonia occurs or the pulmonary condition worsens.

     

Change in pain catastrophizing in patients with lumbar spinal surgery

Background Context

Even though catastrophizing can negatively moderate the outcome of surgery for lumbar spinal stenosis (LSS), it is still unclear whether pain catastrophizing is an enduring stable or a dynamic structure related to pain intensity after spine surgery.

CT-based morphological analysis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis

Purpose

To clarify correlations between spinal fracture and delayed paralysis in patients with diffuse idiopathic skeletal hyperostosis (DISH) using computed tomography (CT) with multiplanar reformatting (CT-MPR). DISH increases susceptibility to unstable spinal fractures, leading to neurological deterioration. The pathomechanism of the neurological injury is unclear.

Extreme lateral interbody fusion in spinal revision surgery: clinical results and complications

Purpose of the study

To evaluate clinical outcomes and complications of extreme lumbar interbody fusion (XLIF) in spinal revision surgery comparing our data with the available literature evidence about other fusion techniques.

Materials and methods

Retrospective analysis of patients underwent revision surgery with XLIF as interbody fusion technique. Demographic, comorbidity, surgical data, clinical results, and intraoperative and postoperative complications were recorded.

Results

36 patients, with a minimum follow-up of 28 ± 11.5 months, were included in the analysis. 41 levels were fused with XLIF. The mean number of previous spine surgery was 1.5 ± 0.7. Mean improvement in back pain and leg pain on VAS was 5.6 ± 1.4 (p < 0.01) and 3.5 ± 2 (p < 0.01), respectively. Mean improvement in the ODI score was 30.3 ± 7.3 (p < 0.01). 1 vertebral endplate fracture during interbody space preparation was reported during lateral approach. 5 patients (13.8%) complained quadriceps weakness and anterior thigh hypoesthesia fully recovered after 3 months from surgery, and in one case, a transient contralateral radiculopathy was observed. No implant failure was detected at final follow-up.

Conclusions

XLIF is a reasonably safe and effective fusion technique in revision surgery that allows valid arthrodesis avoiding scarred tissue created by previous surgical approaches. Especially, XLIF reduces the risk of nerve root lesions, postoperative radiculitis, and durotomies compared to posterior fusion techniques.

     

The 9-Item Patient Health Questionnaire (PHQ-9): an aid to assessment of patient-reported functional outcomes after spinal surgery

Background Context

Preoperative depression is increasingly understood as an important predictor of patient outcomes after spinal surgery. In this study, we examine the relationship between depression and patient-reported functional outcomes (PRFOs), including disability and pain, at various time points postoperatively.

Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study

Background context

Lumbar spinal stenosis is one of the most common degenerative spine diseases. Surgical options are largely divided into decompression only and decompression with arthrodesis. Recent randomized trials showed that surgery was more effective than nonoperative treatment for carefully selected patients with lumbar stenosis. However, some patients require reoperation because of complications, failure of bony fusion, persistent pain, or progressive degenerative changes, such as adjacent segment disease. In a previous population-based study, the 10-year reoperation rate was 17%, and fusion surgery was performed in 10% of patients. Recently, the lumbar fusion surgery rate has doubled, and a substantial portion of the reoperations are associated with a fusion procedure. With the change in surgical trends, the longitudinal surgical outcomes of these trends need to be reevaluated.

Purpose

To provide the longitudinal reoperation rate after surgery for spinal stenosis and to compare the reoperation rates between decompression and fusion surgeries.

Study design/setting

Retrospective cohort study using national health insurance data.

Patient sample

A cohort of patients who underwent initial surgery for lumbar stenosis without spondylolisthesis in 2003.

Outcome measures

The primary end point was any type of second lumbar surgery. Cox proportional hazards regression modeling was used to compare the adjusted reoperation rates between decompression and fusion surgeries.

Methods

A national health insurance database was used to identify a cohort of patients who underwent an initial surgery for lumbar stenosis without spondylolisthesis in 2003; a total of 11,027 patients were selected. Individual patients were followed for at least 5 years through their encrypted unique resident registration number. After adjusting for confounding factors, the reoperation rates for decompression and fusion surgery were compared.

Results

Fusion surgery was performed in 20% of patients. The cumulative reoperation rate was 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 5 years. The adjusted reoperation rate was not different between decompression and fusion surgeries (p=.82). The calculated reoperation rate was expected to be 22.9% at 10 years.

Conclusions

The reoperation rate was not different between decompression and fusion surgeries. With current surgical trends, the reoperation rate appeared to be higher than in the past, and consideration of this problem is required.     

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature

Background context

Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.

Purpose

The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

Study design

A case report and review of the previous literature are presented.

Methods

A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

Results

Cervical MRI 36 hours after onset revealed acute hematoma from the C3–C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

Conclusions

Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.     

Neurological complications of thoracic posterior vertebral column resection for severe congenital spinal deformities

Purpose

The risk of neurological injury during vertebral column resection is high. In this study, we investigated the incidence and risk factors for neurological complications when treating spinal deformities by thoracic posterior vertebral column resection (PVCR).

Methods

Between 2008 and 2013, there were 62 consecutive patients (34 female patients and 28 male; the mean age: 16.3 years, range 6–46 years) treated with thoracic PVCR. We retrospectively reviewed the clinical records to obtain demographic and radiographic data, operative time, estimated blood loss (EBL, the ratio between circulating and lost blood), bleeding volume (the lost blood), number of vertebrae fused, number of vertebrae resected, usage of titanium mesh cage, and intraoperative neuromonitoring data. Multi-factor logistic regression was used to find the major risk factors for neurological complications.

Results

The average follow-up period was 46 months (range 24–88 months); no patients were lost to follow up. The average operative time was 524.8 ± 156.8 min (range 165.0–880.0 min), the average bleeding volume was 2585 ± 2210 ml (100–9600 ml), and the average estimated blood loss was 75.8% (9–278%). Ten patients (16.1%) developed post-operative neurological complications (nine transient and one permanent). Multi-factor logistic regression revealed that the risk factors for neurological complications were age ≥18 years, pulmonary dysfunction, and EBL >50%.

Conclusions

Thoracic PVCR can lead to satisfactory outcomes in the treatment of severe spinal deformities. Risk factors for neurological complications include the age over 18 years, presence of pulmonary dysfunction, and EBL greater than 50%. The pulmonary dysfunction can be regarded as the most valuable indicator to measure the severity of the spine deformity.

     

Factors affecting the occurrence of pulmonary embolism after spinal surgery: data from the national administrative database in Japan

Background context

Despite potentially devastating consequences, pulmonary embolism (PE) in patients undergoing spinal surgery remains poorly understood. To the best of our knowledge, few large studies have examined the prevalence and risk factors of PE after spinal surgery.

Purpose

To investigate the prevalence of symptomatic PE in patients undergoing elective spinal surgery and to identify clinical variables associated with the occurrence of postoperative PE.

Study design

A retrospective analysis of data abstracted from the diagnosis procedure combination (DPC) database, a nationally representative database in Japan.

Patient sample

We included all patients with a diagnosis of spinal canal stenosis, disc herniation, spondylosis, spondylolisthesis, trauma, metastatic tumor, or infection who underwent spinal surgery between July 1 and December 31 of 2007 and 2008, respectively.

Outcome measures

The primary end point was defined as the occurrence of postoperative PE during hospitalization. The secondary end point was in-hospital death after postoperative PE.

Methods

We analyzed the association between the occurrence of postoperative PE and clinical variables recorded in the DPC database, including age, sex, comorbidities, location of surgery, primary diagnosis, anterior/posterior approach, use of instrumentation, and duration of anesthesia.

Results

A total of 47,743 patients were identified. Of these, 50 (0.10%) developed PE and four died as a result of PE. Logistic regression analyses revealed that occurrence of PE was associated with older age (70 years or older; odds ratio [OR], 3.15; 95% confidence interval [CI], 1.15–8.69; p=.026) and longer anesthesia time (more than 360 minutes; OR, 2.19; 95% CI, 0.88–5.44; p=.092). Patients with trauma were significantly more likely to have a PE than those with spinal canal stenosis (0.27% vs. 0.09%; OR, 2.86; 95% CI, 1.14–7.18; p=.026).

Conclusions

This retrospective analysis of a nationally representative database identified older age, longer anesthesia time, and spinal trauma as risk factors for increased incidence of postoperative PE. Surgeons should be aware of the increased risk of postoperative PE in these subgroups of patients.     

Complications of spinal surgery for elderly patients with lumbar spinal stenosis in a super-aging country: An analysis of 8033 patients

Background

The Japanese Society for Spine Surgery and Related Research (JSSR) performed a third study on complications in spinal surgery in 2011. The purpose was to present information about surgery and complications in a large amount of elderly patients aged 65 years with lumbar spinal stenosis (LSS) without coexisting spondylolisthesis, spondylolysis, or scoliosis, and to compare patients aged ≥80 years to those aged 65–79 years.

Distal femoral replacement in periprosthetic fracture around total knee arthroplasty

Introduction

Total knee arthroplasty is a common orthopaedic procedure in the UK; consequently, revision surgery and periprosthetic fractures are increasing in incidence. Strategies for management of these cases include non-operative strategies, internal plate fixation and revision of the distal femoral component. One under-reported practice is to perform distal femoral replacement in cases with poor distal femoral bone stock.

Materials and methods

The department's electronic database was searched for all patients undergoing revision of total knee arthroplasty. From these, all patients having distal femoral replacement for periprosthetic fracture around the distal femoral component using the Stryker Global Modular Replacement System (GMRS) implant were filtered. A retrospective analysis of the patient notes was performed to examine the patient demographics, surgical factors and postoperative complications. Postoperative scores were performed for these patients.

Results

From 2005 onwards, 11 patients (mean age 81 years, range 61–90 years) had their implants revised with a distal femoral replacement for periprosthetic fracture with associated poor bone stock. Follow up was for a mean of 33 months (range 4–72 months). One of these patients died of causes unrelated to their operation. Of the rest, all implants survived without the need of re-operation. The mean postoperative Oxford Knee Score for these patients was 22.5 (range 5–34).

Conclusions

Distal femoral replacement for patients with fracture around a total knee arthroplasty has been performed in our department with few complications and acceptable functional outcomes. It is a technically challenging operation and it should be a salvage procedure reserved for patients with poor bone stock and low demands where other methods of fixation are not suitable.

Level of evidence

IV.     

Problématique de la prise en charge des traumatismes graves du rachis cervical en pays sous-développé

Background and purpose

The management of cervical spine injuries requires a multidisciplinary approach based on emergency management and rehabilitation. In our context this chain fails, especially on the post-hospital care. Our goal is to explain the difficulties we had in the management of these patients in Dakar.

Methods

This retrospective cohort study (2005–2009) included 99 patients admitted for severe cervical spinal cord injury in two hospitals in Dakar. The clinical signs, treatment and outcome were studied. The follow up was between 3 and 54 months.

Results

The average age of patients was 36.1 years and the traffic accidents were the main etiology (73.7%). Medical transport of patients was done in 65.7% with an admission average time of 64.86 hours. On admission, 57.6% of patients had Frankel score A or B. Dislocations (59.6%) and Tear drop fractures (16.2%) were the main lesions. The surgery was performed in 83.8% with a mean interval of 128.84 hours after the trauma. Outpatient rehabilitation was offered whatever the patient's neurological status. Recovery was complete in 20.2% and partial in 31.3% with a mortality rate of 37.4%. Most deaths occurred between 1 and 6 months (59.5%) mainly due to decubitus complications (56.8%).

Conclusion

The efficacy of the management of severe spinal cord injuries is based on reducing the preoperative time and rehabilitation.