The operative management of thoracic and lumbar spine injuries

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University of Dar es Salaam
One hundred and three consecutive patients, 67 (65.0%) males and 36 (35.0%) female with a men age of 41.2 years (range 15 – 84 years), operated upon for thoracic and lumbar spine injuries at the neurosurgical department of the University of Ulm in Gunzburg between January 1990 and December 1994 inclusive, were studies to evaluate the efficacy and outcome of operative treatment. The follow-up period was between 8 and 36 months with a mean of 14.2 months. The most frequent cause of injury was road traffic accidents (31 patients; 30.0%), followed by domestic (27 patients; 26.2%) and industrial (18 patients; 17.6%) accidents, sporting activities (16 patients; 15.5%), suicidal attempts (7 patients 6.8%) and pathological fractures (4 patients; 3.9%). The commonest site of injury was the thoracolumbar junction with 66.9% of all injury levels. Nine patients (8.6%) had multiple level injuries being contiguous in 5 (4.9%) and non-contiguous in 4 (3.9%) of them. Magerl’s type A injuries dominated (86.4%) over type B (5.8%) and type C (7.8%) injuries. Neurological deficits were found in 34 patients (33.0%). Frankel grade B (1.0%) was the least, then grade A (7.8%), grade C (8.7%), grade D (15.5%) and grade E (67.0%) Intraoperative myelography was done in 34 patients (33.0%), MRI in 7 (6.8%), conventional tomography in 45 patients (43.7%) in addition to plain X-rays and ICT-scans that were done routinely in all patients. Deformities were seen in 86 patients (84.5%), the kyphotic predominating (80.6%) over the scoliotic type (3.9%). Translational displacement was seen in 8 patients (7.8%). A kyphotic angle greater than 50 was found in 72 patients (69.9%). Eighty four patients (81.6%) had spinal canal narrowing, posteriorly displaced fracture fragments being the commonest cause. Ten patients (9.7%) were operated within the first 24 hours from their injury while another 9 (8.7% patients were operated within the next 24 hours (between 24 and 48 hours). Only angle stable transpedicular screw system and the Dick (Umkirch-Germany),, fixateur interne” being used in 61 (59.2%) and 37 patients (35.9) respectively, only one level above and one below the injured level were included within the stabilizing system, Spinal canal revision and decompression followed by posterior interbody fusion (PIF) was realized in 38 patients (36.9%). Forty six (44.7%) patients and transpedicular spongioplasty (TPSP) whereas twenty (19.4%) had other operative and/or fusion procedures. Intraoperative complications occurred in 14 (13.6%). Seventeen patients had posterior element fractures, dural tears and nerve root encroachment. Reoperations were done in 73 patients (70.9), in 63 (61.2%) being for removal of the internal fixator. Kyphotic deformity was corrected to less than 50 in 47 patients (65.3% of those with deformity). The average loss of correction was 50. No patients with initial corrected translational or rotational displacement had loss of correction whereas partial loss of correction in corrected vertebral height was seen in 3 patients. Restoration of the spinal canal’s mid-sagital diameter was realized in 94 patients (91.1%) solid fusion was seen in97.1% Twenty three or 67.7% of the patients who had initial neurological deficits improved, nineteen of them improving to motor useful levels. Six or 8.7% of patients who had no initial deficit worsened. From this study it was found that elderly ladies have more tendency to remain with neurological deficits than young ladies and men in general the difference being statistically significant (p<0.05). The earlier the operation from the time of injury the better the chances for neurological recovery. The difference between patients operated within the first 24 hours and those operated later was statistically significant (p<0.005). The level of injury was not a determinant for neurological recovery (p<0.05). The severer the Magerl’s type of injury (A3 and above) the lesser the chances for neurological recovery (p<0.001). Narrowing of the spinal canal had a bearing on the final neurological outcome. However, there was no correlation between severity of neurological deficit and severity of the narrowing (p>0.005). The initial kyphotic angle influenced significantly the final pain (p<0.01). The average hospital stay was 12.1 days. Eighty nine patients (86.4%) had pain that did not interfere with their activities out of whom 46 patients (44.6%) had no pain at all. Seventy four patients (71.84%) had resumed their previous activities fully although they had residual non debilitating neurological deficits. It is concluded that, with clear indications, operative intervention in patients with thoracic and lumbar spine injuries is efficient, leading to short hospital stay ambulation and high fusion rates with low rates of loss of correction of deformities. Neurological recovery rate is high; complications are minimal and return to initial activities exemplary.
Available in print form, East Africana Collection, Dr. Wilbert Chagula Library, Class mark (THS EAF RD533.K3)
Spinal cord, Wounds, Injuries, Spine, Chest, Thoracic surgery
Kahamba, J.F. (1997) The operative management of thoracic and lumbar spine injuries, Master dissertation, University of Dar es Salaam