Outcomes Of Multi-Level Thoraco-Lumbar Spinal Injury Treated With Pedicle Screw Fixation At Danang Hospital – Le Huu Tri

Journal of military pharmaco-medicine n o 3-2019 145 OUTCOMES OF MULTI-LEVEL THORACO-LUMBAR SPINAL INJURY TREATED WITH PEDICLE SCREW FIXATION AT DANANG HOSPITAL Le Huu Tri1; Vu Van Hoe2 Vo Van Nho3; Nguyen Van Hung2 SUMMARY Objectives: To evaluate patients with multi-level thoraco-lumbar spinal injuries who had pedicle screw fixation. Subjects and methods: Observational study on 53 patients with multi- level thoraco-lumbar spinal injuries admitted to Danang Hospital from March 2014 to May 2018 who underwent pedicle screw fixation. Results and conclusions: Male/female ratio was 4.88/1, mean age was 37 years old. Common types of injuries were work-related (39.62%) and fall (39.62%). Burst spine fractures were 71.69%, dislocation spine fractures were 17%. * Keywords: Multilevel thoraco-lumbar; Spine fractures; Computerized tomography. INTRODUCTION Spinal injury is a common emergency in the developing countries with such serious and fatal consequences from mild level to disablity, often leaves many sequelae for the patient and is a burden for the patient’s family and society [1]. Spinal injury at more than one level is uncommon. Therefore, awareness of multi-level injury of the spine and the associated neurological patterns is very important for the proper initial management. While a single-level injury can be easily detected and managed early, a multi-level thoraco-lumbar spinal injury usually occurs as a result of high-energy trauma [7], a fall or traffic accident and the patient might not have quick access to proper medical care. The injury may present with local pain, instability and/or deformation, paraplegia, quadriplegia, or even death. Multi-level thoraco-lumbar spinal injuries have long been reported worldwide. However, there has not been many researches on this subject in Vietnam. In this article we present evaluation of 53 patients with multi-level thoraco-lumbar spinal injuries who were treated with pedicle screw fixation at Danang Hospital. SUBJECTS AND METHODS We performed observational review of 53 patients who had multi-level thoracic and lumbar spinal injuries from March 2014 to May 2018 at Danang Hospital. The patients all underwent surgery by pedicle screw fixation. Data analysis was done with MedCalc 12 software. 1. Danang Hospital 2. 103 Military Hospital 3. International Neurosurgery Hospital Corresponding author: Le Huu Tri (drtrilh@gmail.com) Date received: 15/11/2018 Date accepted: 19/02/2019 Journal of military pharmaco-medicine n o 3-2019 146 Table 1: Frankel impairment scale [8]. Classification Description A: Complete No motor or sensory function preserved B: Incomplete Sensory but no motor function preserved below the neurologic level (includes sacral segments S4 - 5) C: Incomplete Motor function preserved below the neurologic level (more than half of key muscles below the neurologic level had a muscle strength grade < 3) D: Incomplete Motor function preserved below the neurologic level (more than half of key muscles below the neurologic level had a muscle strength grade ≥ 3) E: Normal Sensory and motor function normal RESULTS AND DISCUSSION 1. Ages, sex and type of injuries. Table 2: Distribution by age group and sex. Male Female Total Age group (years old) No. (%) No. (%) No. (%) < 20 1 2.27 1 11.11 2 3.76 20 - 29 17 38.63 2 22.22 19 35.84 30 - 39 5 11.36 1 11.11 6 11.32 40 - 49 15 34.08 3 33.33 18 33.96 ≥ 50 6 1.32 2 22.22 8 15.12 Total 44 83.01 9 16.99 53 100 Mean age 37.22 ± 13.21 38.66 ± 15.49 37.47 ± 13.47 Age group 20 - 29 years old had the most number of patients (19 patients = 35.84%). The youngest was 16 years of age and the oldest 81 years old. Average age was 37.47 ± 13.47 (χ2 = 2.475, p > 0.05). Male/female ratio was 4.88/1. Our findings were similar to other reports in Vietnam like Vo Xuan Son (1998) [2]. Tearse D.S [6] reported male/female ratio of 5.5/1, with the average age being 28.7 (18 - 70). The result was consistent with the culture of Vietnam where young men are the main source of physical labor for the family and therefore they are at higher risk, physically demanding professions. Journal of military pharmaco-medicine n o 3-2019 147 2. Type of injuries. Type of injuries No. Percentage (%) Labour accident 21 39.62 Fall from height 21 39.62 Traffic accident 11 20.76 Total 53 100 Patients suffering from work-related and fall accidents made up high proportion: 21 cases (39.62%); traffic accident related injuries accounted for the lowest incidence (20.76%). Nguyen Trung Dinh (2004) [3] also reported similar findings. In contrast, traffic accident-related injuries were reported by Tearse D.S (1987) [10] to be the highest incidence in developing countries. The difference in findings was very likely due to economic and social conditions. 3. Clinical status of patients at admission. * Patient classification according to Frankel neurological damage: According to Frankel neurological damage classification, patients at level Frankel E accounted for the highest proportion (30 patients = 56.63%). Followed by completely paralyzed Frankel A (10 patients = 18.86%). Two patients (3.77%) were at Frankel B, seven patients (13.2%) were at Frankel C and four patients (7.54%) were at Frankel D (p < 0.005, χ2 = 47.849). Vo Xuan Son et al (1998) reported 76.7% of patients were completely paralyzed since the authors only studied paralyzed patients [2]. Gupta A et al (1989) conducted a study on 91 patients with spinal cord injury and found that 55% of patients with multi-level fractures were not completely paralyzed [8]. So the presence of neurological signs in trauma patients will raise the physician’s awareness of more serious multilevel thoracic and lumbar injuries. 4. Paraclinical patients at admission. Burst fractures accounted for 71.69% (38 patients). This results was similar to Vo Ba Tuong’s finding (2008), which was 59.18% [9]. Followed by dislocation fractures (9 patients = 17%). Seat-belt fracture occupied the lowest percentage (2 patients = 3.77%). Our findings were consistent with other reports in Vietnam but were different from reports by foreign authors. For example, seat-belt fracture is a type of decelerated fracture injury in patients wearing seat belts in high speed accidents in developed countries. In our country, due to work- related and fall accidents being more common, also automobile transportation is much less common, and the people do not have the habit of wearing seat belt, thus the types of vertebral fractures are very different compared to other foreign countries. On CT image, we found that 36 patients had contiguous fractures, accounting for a high percentage (67.93%), compared to only 17 patients with noncontiguous fracture (32.07%). Tearse D.S (1987) reported that among 78 patients with multi-level injuries, only 13 patients had non contiguous fractures (16.7%) [10]. Journal of military pharmaco-medicine n o 3-2019 148 Detection rate for spine fractures in this study was relatively high compared with reports by others, probably because our study subjects were patients at General Trauma Hospital with other different types of injuries. 5. Results after operation. Table 3: Neurological recovery after operation. Preoperation Frankel A B C D E Total A 10 0 0 0 0 10 (18.86%) B 0 1 0 0 0 1 (1.88%) C 0 0 3 0 1 4 (7.54%) D 0 1 2 1 0 4 (7.54%) After operation E 0 0 2 3 29 34 (64.18%) Total 10 (18.86%) 2 (3.77%) 7 (13.20%) 4 (7.54%) 30 (56.63%) 53 (100%) p < 0.0001 34 patients (64.18%) recovered to Frankel E; 4 patients (7.54%) were at Frankel D; 4 patients (7.54%) were at Frankel C and 1 patient (1.88%) was at Frankel B. 10 patients (18.86%) did not improve and remained at Frankel A. We re-evaluated most of our surgical patients after 3 days with a full neurological examination looking for evidence of spinal cord shock injury and other severe lesions to understand the full extent of the injuries. We found that the majority of Frankel A group did not change. Nguyen Vu et al (2014) reported 54 cases of thoraco-lumbar injuries with spinal cord injuries. Before surgery, 16/54 patients (29.62%) at Frankel A were completely paralyzed and 38/54 patients (70.36%) suffered from incomplete paralysis. After surgery, 28/54 patients (51.85%) were at Frankel E, 9/54 patients (16.66%) at Frankel D, 4/54 patients (7.40%) at Frankel C, 2/54 patients (3.70%) at Frankel B and 11/54 patients (20.39%) at Frankel A [5]. Our postoperative recovery rate of only 8/53 patients (15.11%) was very modest. The reason was that our patients had multilevel thoraco-lumbar injuries with severe neurological damage therefore, postoperative recovery was very limited. Journal of military pharmaco-medicine n o 3-2019 149 5. Results after 06 months. Table 4: Neurological recovery after 6 months. Post-operation Total Frankel A B C D E A 10 0 0 0 0 10 (18.86%) B 0 1 0 0 0 1 (1.88%) C 0 0 1 0 0 1 (1.88%) D 0 0 3 0 0 3 (5.66%) Re-examination E 0 0 0 4 34 38 (71.72%) Total 10 (18.86%) 1 (1.88%) 4 (7.54%) 4 (7.54%) 34 (64.18%) 53 (100%) p < 0.0001 Table 6 showed neurological recovery when patients were examined after 6 months. 4 patients with Frankel D classification at discharge improved to Frankel E and was able to walk normally. However, there was no change in 10 patients in Frankel A, 1 patient in Frankel B, 1 patient in Frankel C and 34 patient in Frankel E when examined. Patients with complete paralysis did not show any signs of recovery. No patients showed worsening injuries (p < 0.0001, χ2 = 159). Nguyen Trung Dinh (2004) re-examined 91 patients (85.8%). Of those, 24 patients (26.4%) recovered to Frankel E. However, 12 patients remained Frankel A (13.18%), 17 patients (18.7%) at Frankel B, 25 patients (27.5%) at Frankel C and 13 patients (14.3%) at Frankel D [7]. The recovery process in patients with neuro-surgery is long-term and can last for months and years. According to the literature, complete recovery in patients with spinal cord injuries still is a matter of debate in different studies. 7. Local kyphosis angle. Table 5: Local kyphosis angle recovery results. Local kyphosis angle Lowest Highest Mean Comparison (p) Pre-operation 50 420 18.73 ± 7.380 (1) Post-operation 10 270 10.56 ± 5.530 (2) Re-examination 20 290 13.37 ± 5.940 (3) p12 < 0.0001 p13 = 0.0001 p23 = 0.0132 Recovery results of local kyphosis decreased both post-operation and re- examination at 6 months; however, there was an improvement at 8.170 (43.61%). The difference was statistically significant (p < 0.005). After 6 months, local kyphosis angle rose to 2.810. Post-operation and re-examination results were similar (p > 0.05). Journal of military pharmaco-medicine n o 3-2019 150 8. Anterior vertebral body compression percentage. Table 6: Index Pre-operation (1) Post-operation (2) Re-examination (3) Comparison (p) Anterior vertebral body compression 38.52 ± 17.81 (7.16 - 89.39) 24.92 ± 16.03 (0.08 - 67.02) 25.30 ± 16.03 (1.59 - 76.31) p12 = 0.0001 p13 = 0.0001 p23 = 0.9031 Table 6 shows there was an improvement in postoperative vertebral body collapse after surgery and follow-up at 6 months compared to before surgery. Re-examination and post-operation data were very similar. Post-surgical improvement was 13.6%, while on re-examination at 6 months, anterior vertebral body compression was just 0.38% more. The recovery height of the anterior vertebral body directly affects local kyphosis angle. According to Nguyen Vu Hoang (2012), surgery resulted in 18% of reduction in vertebral body compression. However, when patients were followed an additional 12.3 months, no further improvement of vertebral body compression was noted [6]. 9. Postoperative complications. * Early postoperative complications: Postoperatively, we had one patient (1.88%) with epidural hematoma at thoracic spine level D7D8 causing lower extremity weakness and difficulty with urination. Vo Xuan Son et al (1998) reported 1 patient went home against medical advice (0.7%), 4 patients with ulcers (2.7%) and 3 patients with infection (2%) [2]. Our case with epidural hematoma complication was mostly likely due to incomplete hemostasis leading to gradual spinal cord compression. * Complications upon re-examination: We had 11 patients (20.75%) with muscular atrophy, 5 patients (9.43%) with urinary tract infections and 3 patients (5.66%) with ulcers. We did not have any complications due to wrong, broken, or loose screws because we always used C-arm (fluorescent brightening screen) for guidance. Eldin M.M.M et al (2014) reported that 90% of screw failure (broken or loose screw) occurred 6 months after surgery. No further complication was reported after 1 year. This shows that if the screw was not placed parallel to the plate, there was an increased risk of gradual instability over time. However, screw failure could also be due to a clinical problem, namely the integrity of the patient's spine [12]. We had 5 patients with urinary tract infections. This was due to loss of bladder control caused by damage to the cauda equina. As a result, prolonged sonde placement led to urinary tract infections, a typical complication in spine trauma with specific nerve damage. Urinary tract infections occurred due to a lack of care. Although uncomplicated urinary tract infections were usually resolved before Journal of military pharmaco-medicine n o 3-2019 151 patients were discharged with antibiotics treatment, sanitary spot and set bladder instillation, lack of proper medical care at home caused the recurrence of urinary tract infections. Large pressure ulcers will cause loss of fluid and blood leading in patient’s clinical deterioration. Severe ulcers with secondary infection can lead to sepsis. Most common locations of pressure ulcers in spine trauma patients are first the sacrum and then lower back. This can be explained by the natural position of the patient on the bed, leading to insufficient local perfusion and ischemia. Our patients were discharged home with good care without involvement of local health facilities. 10. Assessment of overall results. Table 7: Overall results. Result n Percentage (%) Good 38 71.69 Moderately good 2 3.76 Average 12 22.67 Bad 1 1.88 Total 53 100 p < 0.0001 As can be seen from overall results, no deaths were noted. Good and moderately good results were 75.63%. Averaged result was 22.67%. And bad result was 1 case (1.88%), p < 0.0001. Nguyen Vu Hoang (2012) reported 76.6% good results 11.3% moderately good. The difference was statistically significant with p < 0.01; there was only one case of bad result, in which the instruments had to be removed due to a curved screw causing neurological complications [6]. CONCLUSIONS - The youngest patient: 16 years old, the oldest 81 years old. Average age 37.47 ± 13.47. Male/female ratio: 4.88/1. - Patients suffering from work-related and fall accidents were of high proportion: 21 cases (39.62%). Traffic accidents had the lowest incidence (20.76%). - Patients presented with Frankel E accounted for the highest proportion (30 patients = 56.63%). Followed by Frankel A patients with complete paralysis (10 patients = 8.86%). 2 patients (3.77%) had Frankel B, 7 patients (13.2%) and 4 patients had Frankel C (7.54%) Frankel D (p < 0.005), respectively. 36 patients had contiguous fractures, accounting for a high percentage of 67.93%. The noncontiguous fracturegroup group had 17 patients (32.07%). - Postoperatively, 1 patient (1.88%) suffered from epidural hematoma complication at thoracic spine segment D7-D8 causing legs’ weakness and difficulty with urination. - Complications after 06 months: No deaths, mainly muscular atrophy in 11 cases (20.75%), followed by urinary tract infections (5 cases = 9.43%), and pressure ulcers in 3 cases (5.66%). - Overally, there were no deaths. Good and moderate good results were 75.63%. Average result was 22.67%. Bad outcome was 1 case (1.88%). Journal of military pharmaco-medicine n o 3-2019 152 REFERENCES 1. Dương Đại Hà, Trần Trung Dũng. 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