Spinal trauma: therapy—options and outcomes

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Abstract

The management of patients with spinal trauma is based on the following goals: (1) the preservation of life; (2) preserving and maximising the neurological function; and (3) providing a stable, painless vertebral column. There have been advances in both non operative as well operative modalities of treatment of patients with spinal injuries. These advances have led to renewed interest in the management of a spinally injured patient. However, despite these advances controversies exist regarding the classification of these fractures, the use of pharmacological intervention, the timing of surgical intervention and indeed the use of surgical intervention itself in the management of these fractures. Most of these controversies surround the treatment of thoracic and lumbar fractures. The purpose of this article is to provide an over view of the therapy options available in the treatment of these fractures. The article shall also look at some of the controversies surrounding the management of these fractures.

Introduction

A neurological injury in spine trauma is a devastating event. Some degree of neurological deficit may occur in 10–25% of patients with spinal trauma [1], [2]. The incidence of spinal injury in the US is between 4 and 5.3 per hundred thousand of population [3]. This amounts to 12 000 new spinal cord injuries every year. The common causes of spinal trauma include road traffic accidents, (45%) falls (20%) and sports (15%) [4]. The male to female ratio is 4:1. The overall survival rate for patients with spinal injuries is 86% at 10 years [4]. This tends to decrease as the patient gets older.

The establishment of centres for the treatment of patients with spinal injuries has improved the outcome in these patients. Historically the concept of a spinal injuries centre was popularised by Sir Ludwig Guttman at the Manderville Hospital in England as early as 1943 [5]. Many such specialised centres now exist in the developed world. This has resulted in shorter hospitalisation, reduced complications and thus a reduced overall cost in the care of the these patients.

Trauma from the vertebral column is transferred to the spinal cord by one of two mechanisms, either a direct injury; by means of excessive flexion; extension or rotation of the spinal cord or an indirect injury resulting from impaction of displaced bone; disc fragments or haematoma. Spinal cord injury may be either compressive or secondary to traction. The latter have a poor prognosis. The consequences of compressive injury depend upon not only the degree of compression but also the duration of compression. Animal studies by Rivlin, Tator, Dolan and Delamarter have shown that the clinical consequences of cord compression were inversely related to duration of cord compression [6], [7], [8], [9]. Delamarter created spinal cord injuries in dogs using constriction bands [7], [8]. They showed that a 50% compression of the cauda led to significant electodiagnostic and neurophysiological changes. At 75% compression there was permanent paraplegia. Recovery following the release of these bands was time dependent. Those animals that underwent decompression either immediately or at 1 h were electrophysiologically normal at 6 weeks. Those animals that were decompressed after 6 h did not make significant recovery.

Ducker et al. found that experimentally injured primates made significantly more neurological recovery following immediate immobilisation [10].

All these studies, and the advances in understanding the pathophysiology, of spinal cord injury form the basis of current principles of treatment of a spinally injured patient. These include the use of pharmacological agents, use of immobilisation, fracture reduction and decompression in these patients.

Section snippets

Initial management

At the scene of the accident, management of a spinally injured patient should follow the protocols laid by the Advanced Trauma Life Support system. This involves the emphasis on maintenance of the airway, breathing and circulation. Those suspected of having a spinal injury should be immobilised on a spinal back board with adequate immobilisation of the cervical spine. The most effective method of initial cervical immobilisation is the use of bilateral sand bags and taping of the patient across

Pharmacological intervention

The secondary phase of spinal cord injury following trauma involves enzymatic lipid peroxidation and ischaemia [17], [18], [19]. In animal studies high doses of methylprednisolone were found to reduce the effects of secondary injury to the spinal cord. Bracken et al. have conducted studies on the use of methylprednisolone in spinally injured patients (NASCIS I, II and III) [17], [18], [19]. In NASCIS II, methylprednisolone was given in a dose of 30 mg per kg body weight as a bolus followed by

Non surgical management of spinal fractures

Modalities for non surgical treatment of patients include: (1) recumbency; (2) use of specific orthosis; and (3) observation alone.

Treatment by recumbency

Historically this has been popularised by several authors including Sir Guttman, Bedbrook and Nicoll [5], [26], [27].

Orthotic management

The rationale behind the use of orthosis is to limit motion of the injured segment and if possible decrease the loads in the spinal column. Bracing is more widely used for thoraco lumbar injuries. The principle of treatment here is to provide a three point pressure. Norton and Brown [31] observed that braces that did not fix adequately to the pelvis tended to produce a concentration of force in the upper lumbar and thoraco lumbar regions. Fiddler and Plasmans [32] found that canvas corsets

Observation alone

Certain fractures may be deemed to be stable on initial presentation. These fractures such as a wedge compression fracture in the thoracic spine may be treated with pain relief and early mobilisation. Serial X-rays may be required to make sure there is no increase in deformity.

Burst fractures

Literature abounds in the controversies regarding the management of these fractures. Controversies in management of these fractures (surgical and non surgical) revolves around the following points.

Principles

The goals of surgery are: (1) to reduce fractures and dislocation; (2) stabilise injured segments; and (3) if possible decompression the neural elements.

Controversies concerning surgical treatment include the timing of surgery and the choice of surgical approach (anterior or posterior). Some indications for surgery include:Dislocations and major ligament disruptions. Ligament injuries in the spine behave similar to ligament injuries involving other joints. These are potentially unstable and

Choice of approach; anterior or posterior surgery

The advantages of posterior surgery include less morbidity and less potential for disturbance of the vascular supply to an already injured cord.

The advantage of anterior surgery includes the possibility of obtaining a more thorough canal clearance in patients with significant canal compromise. Review of literature does not reveal a distinct advantage of one approach over the other. Gertzbein [37] found that anterior surgery was found to be more beneficial in improving complete bladder

Timing of surgery

Concerns for early surgical stabilisation of the spine in the multiply injured patient include, (1) the possibility of aggravating pulmonary decompensation by prone position; (2) blood loss incurred by spinal surgery; and (3) concerns that occult injuries especially to the intra-adbominal viscera may be masked by early surgical intervention.

However, early surgical intervention may have its advantages. It may decrease morbidity and hospital costs [49]. Marshall et al. [50] found that in 134

Conclusion

In the neurologically intact patient good results are obtained with both conservative and non surgical treatment. In patients with neural injury the potential for recovery may depend upon the initial insult at injury. The higher the energy responsible for the injury the more severe the degree of neurological deficit and spinal instability. Some improvement in neurological deficit in incomplete injuries may be expected whatever the modality of treatment.

References (52)

  • D.R. Bodner et al.

    Urologic changes after cauda equina compression in dogs

    J. Urol.

    (1990)
  • C.C. Edwards et al.

    Early rod-sleeve stabilisation of the injured thoracic and lumbar spine

    Orthop. Clin. North Am.

    (1986)
  • D.R. Benson et al.

    Unsuspected associated findings in spinal fractures

    J. Orthop. Trauma

    (1989)
  • R.S. Riggins et al.

    The risk of neurologic damage with fractures of the vertebrae

    J. Trauma

    (1977)
  • D.J. Thurman et al.

    Surveillance of spinal cord injuries in Utah USA

    Paraplegia

    (1994)
  • S.L. Stover et al.

    The epidemiology and economics of spinal cord injury

    Paraplegia

    (1987)
  • L. Guttman

    History of the National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury

    Paraplegia

    (1967)
  • A. Rivlin et al.

    Effect of duration of acute spinal cord compression in new acute spinal cord injury model in the rat

    Surg. Neural.

    (1978)
  • R.B. Delamarter et al.

    Volvo Award in experimental studies. Cauda equina syndrome: neurologic recovery following immediate, early or late decompression

    Spine

    (1991)
  • E.J. Dolan et al.

    The value of decompression for acute experimental spinal cord compression injury

    J. Neurosurg.

    (1980)
  • T.B. Ducker et al.

    Experimental spinal cord trauma III. Therapeutic effects of immobilisation and pharmacologic agents

    Surg. Neurol.

    (1978)
  • J.M. Piepmeier et al.

    Cardiovascular instability following acute cervical spinal cord trauma

    Cent. Nerv. Syst. Trauma

    (1985)
  • F.G. Eismont et al.

    Extrusion of intervertebral disc associated with traumatic subluxation or dislocation of cervical facets

    J. Bone Joint Surg. Am.

    (1991)
  • Y.J. Mahale et al.

    Neurological complications of the reduction of cervical spine dislocations

    J. Bone Joint Surg. Br.

    (1993)
  • P.A. Robertson et al.

    Neurological deterioration after reduction of cervical spine subluxations. Mechanical compression by disc tissue

    J. Bone Joint Surg. Br.

    (1992)
  • A.S. Lee et al.

    Rapid traction for reduction of cervical spine dislocations

    J. Bone Joint Surg. Br.

    (1994)
  • A.M. Star et al.

    Immediate closed reduction of cervical spine dislocation using traction

    Spine

    (1990)
  • M.B. Bracken et al.

    A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. Results of the Second National Acute Spinal Cord Injury Study

    New Engl. J. Med.

    (1990)
  • M.B. Bracken et al.

    Methylprednisolone or naloxone treatment after spinal cord injury: 1 year follow-up data. Results of the Second National Acute Spinal Cord Injury Study

    J. Neurosurg.

    (1992)
  • M.B. Bracken et al.

    Administration of metylprednisolone for 24 or 48 h or tirilazad mesylate for 48 h in the treatment of acute spinal cord injury. Results of the third National Acute Spinal Cord Injury Randomized Controlled trial. National Acute Spinal Cord Injury Study

    J. Am. Med. Assoc.

    (1997)
  • D.J. Short et al.

    High dose methylprednisolone in the management of acute spinal cord injury

    J. Spinal Disord.

    (2000)
  • W.P. Coleman et al.

    A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury

    J. Spinal Disord.

    (2000)
  • R.J. Hurlbert

    Methylprednisolone for acute spinal cord injury: an inappropriate standard of care

    J. Neurosurg.

    (2000)
  • F.H. Geisler et al.

    Recovery of motor function after spinal cord injury. A randomized placebo-controlled trial with GM-1 gangliozide

    New Engl. J. Med.

    (1991)
  • D.K. Anderson et al.

    Pre-treatment with alpha tocopherol enhances recovery after experimental spinal cord injury

    J. Neurotrauma

    (1988)
  • R.Y. Shi et al.

    Calcium antagonists fail to protect mammalian spinal neurons after physical injury

    J. Neurotrauma

    (1989)
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