Timing of Decompression Surgery for Traumatic Spinal Cord Injury in a Patient with an Incomplete Myelopathy

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Chapter 228 Timing of Decompression Surgery for Traumatic Spinal Cord Injury in a Patient with an Incomplete Myelopathy

Postural Nonoperative Management

The management of complex spine fractures with incomplete spinal cord injury (SCI) in the severely injured polytrauma patients presents the spine surgeon with a difficult clinical scenario.1 These patients often have severe comorbid conditions such as pulmonary contusions, metabolic acidosis, long bone fractures, or acute respiratory distress syndrome. Controversy exists as to the optimal treatment and timing of intervention for unstable spine fractures with neurologic involvement in the severely injured.29 For example, on June 30, 2006, a 74-year-old man was the pilot of a helicopter that crashed after striking power lines. He suffered severe injuries including an open tibia/fibular fracture, complex pelvic fractures, abdominal compartment syndrome requiring emergent laparotomy, bilateral hemopneumothoraxes, traumatic subarachnoid hemorrhage, burst fracture of the L1 and L2 vertebrae, and T12 vertebral body fracture (Fig. 228-1). Neurologically, the patient had no rectal tone but was able move his feet. The patient presented to the ICU after his laparotomy in acute respiratory distress syndrome and was placed on a RotoRest bed (KCI, San Antonio, TX) for ventilatory support. The patient was eventually paralyzed, and an intracranial pressure monitor was placed for declining neurologic exam. The patient underwent tracheostomy and bilateral chest tube placement for pulmonary effusions. He remained in the ICU for nearly 4 weeks. He was not thought to be stable enough to tolerate a prolonged prone procedure for internal reduction and fixation of his thoracolumbar fractures. This scenario is all too common in modern level 1 trauma centers.

Early reports from Frankel et al.,9 Guttmann,10 and Bedbrook11,12 were heavily weighted toward nonoperative treatment. In recent years, nonoperative treatment of intact thoracolumbar fractures has been shown to be associated with excellent results.1319 However, there have been few randomized studies comparing early versus late surgery in SCI. The study by Vaccaro et al.8 involved 34 patients with cervical spine fractures that were randomized to early (<72 hours) surgery and 28 that were randomized to late (>5 days). Unfortunately, the follow-up at 1 year was available on only 23 and 19 patients, respectively. The unanticipated finding by the authors was that there was no significant difference in outcome between the two groups. A retrospective review by Mirza et al.6 involved 43 patients with cervical spine injuries treated at two facilities. Their findings demonstrated improved outcome with early surgery (<72 hours) compared to delayed surgery performed 10 to 14 days after injury. No increased complications were noted in the early surgery group.

Similarly, conflicting results with timing of surgery have been encountered with thoracolumbar fractures. A retrospective study involving thoracolumbar fractures divided patients into three surgical groups: early surgery (<8 hours), more than 8 hours after surgery, and after 10 days.2 There were 26, 50, and 12 patients, respectively, in the three groups with an average follow-up of 5.6 years. Using the Frankel score, this study revealed better outcomes in the early surgery group compared to late surgical groups. There was also better pain control with early rather than delayed surgery. Complication rates did not differ between the three groups. McLain and Benson5 conducted a nonrandomized prospective study in thoracolumbar fractures. Fourteen patients underwent urgent surgery within 24 hours, and 13 patients underwent delayed surgery between 24 and 72 hours following injury. At 2-year follow-up, no significant difference in neurologic outcome between the two groups was noted. There was also no difference between groups in rates of complications, mortality, or morbidity. Cengiz et al.,20 in a prospective, nonrandomized study, compared early stabilization (<8 hours) in 12 patients with thoracolumbar fractures with late (>3 days) stabilization in 15 patients. A statistically significant improvement in motor recovery was noted with early surgery in partial SCI patients. Hospital stays were shorter with early surgery, and the rate of complications appeared higher in the delayed-surgery group.

With incomplete SCI, neurologic improvement has been reported with both operative2125 and nonoperative1319,26,27 techniques, although no consistent improvement has been reported with either modality. Neurologic deficit is more likely due to contusion of the spinal cord at the time of injury and not from persistent bony compression of neural structures. The complications of surgical intervention are by no means negligible and include infection, hardware failure, the need for subsequent surgery, and deep vein thrombosis. These complications in general have exceeded those encountered in recumbency.17,22,23,25,27,28

Owing to the severe pulmonary injury sustained by the patient discussed previously, spine surgery was delayed. The patient was immobilized throughout his intubation period and, once extubated, was fitted with a thoracolumbar spine orthosis and transferred to a rehabilitation facility. On follow-up, the patient remained paraparetic and incontinent of urine with poor rectal tone; he also complained of radicular pain bilaterally. Nearly 3 months following injury, when he had failed to regain the ability to walk, the patient was evaluated by neurosurgery and underwent L2-3 laminectomy, repair of the dural rent, and reduction of the herniated roots, with T12-L4 pedicle screw and rod fixation. Eighteen months postoperatively, the patient had improvement in his pain, had regained bladder but not bowel control, and was ambulatory with ankle braces and the assistance of one person.

The management of complex spine fractures, be they cervical, thoracic, or lumbar, in polytrauma patients remains a challenging arena for the spine surgeon.1,7 The choice of treatment should be individualized to the patient’s medical condition and ability to undergo often lengthy prone spine procedures in the face of multiple comorbidities. Though class I evidence in favor of early surgery for spine fractures is sparse,29 our policy has been to proceed with decompression and stabilization of spine fractures, particularly with deficits, as soon as the patient’s condition allows. Recumbency for thoracolumbar fractures and bracing or traction for cervical fractures can be used as a bridge to surgical stabilization when it is deemed safe and appropriate.

Key References

Cengiz S.L., Kalkan E., Bayir A., et al. Timing of thoracolumbar spine stabilization in trauma patients—impact on neurological outcome and clinical course. A real prospective randomized controlled study. Arch Orthop Trauma Surg. 2008;128:959-966.

Dai L.Y., Jiang L.S., Jiang S.D. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine (Phila Pa 1976). 2008;33(23):2536-2544.

Fehlings M.G., Perrin R.G. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006;31(Suppl 11):S28-S35.

Gaebler C., Maier R., Kutscha-Lissberg F., et al. Results of spinal cord decompression and thoracolumbar pedicle stabilization in relation to the time of operation. Spinal Cord. 1999;37:33-39.

Harris M.B., Sethi R.K. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine (Phila Pa 1976). 2006;31(Suppl 11):S9-S15.

Hitchon P.W., Torner J.C., Haddad S.S., Follett K.F. Management options in thoracolumbar burst fractures. Surg Neurol. 1998;49:619-627.

Kerwin A.J., Frykberg E.R., Schinco M.A., et al. The effect of early spine fixation on non-neurological outcome. J Trauma. 2005;58:15-21.

McKinley W., et al. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil. 2004;85:1818-1825.

McLain R.F., Benson D.R. Urgent surgical stabilization of spinal fractures in the polytrauma patient. Spine (Phila Pa 1976). 1999;24:1646-1654.

Mirza S.K., Krengel W.F.III, Chapman J.R., et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999;359:104-114. 1999

Rechtine G.R.2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006; May 15;31(Suppl 11):S22-S27.

Rechtine G.R.2nd, Cahill D., Chrin A.M. Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment. J Spinal Disorders. 1999;12(5):406-409.

Vaccaro A.R., Daugherty R.J., Sheehan T.P., et al. Neurological outcome of early versus late surgery for cervical spinal cord injury. Spine (Phila Pa 1976). 1997;22:2609-2613.

Wood K., Butterman G., Mehbod A., et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study. J Bone Joint Surgery [Am]. 2003;85:773-781.

References

1. Harris M.B., Sethi R.K. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine (Phila Pa 1976). 2006;31(Suppl 11):S9-S15.

2. Gaebler C., Maier R., Kutscha-Lissberg F., et al. Results of spinal cord decompression and thoracolumbar pedicle stabilization in relation to the time of operation. Spinal Cord. 1999;37:33-39.

3. Kerwin A.J., Frykberg E.R., Schinco M.A., et al. The effect of early spine fixation on non-neurological outcome. J Trauma 2005. 2005;58:15-21.

4. McKinley W., Meade M.A., Kirshblum S., et al. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil. 2004;85:1818-1825.

5. McLain R.F., Benson D.R. Urgent surgical stabilization of spinal fractures in the polytrauma patient. Spine (Phila Pa 1976). 1999;24:1646-1654.

6. Mirza S.K., Krengel W.F.III, Chapman J.R., et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999;359:104-114.

7. Rechtine G.R.2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006;31(Suppl 11):S22-S27.

8. Vaccaro A.R., Daugherty R.J., Sheehan T.P., et al. Neurological outcome of early versus late surgery for cervical spinal cord injury. Spine (Phila Pa 1976). 1997;22:2609-2613.

9. Frankel H.L., Hancock D.O., Hyslop G., et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia, Part I. Paraplegia. 1969;7:179-192.

10. Guttmann L. Surgical aspects of the treatment of traumatic paraplegia. J Bone Joint Surg [Br]. 1949;31:399-403.

11. Bedbrook G.M. Treatment of thoracolumbar dislocation and fractures with paraplegia. Clin Orthop. 1975;112:27-43.

12. Bedbrook G.M. Spinal injuries with tetraplegia and paraplegia. J Bone Joint Surg [Br]. 1979;61(3):267-284.

13. Reid D.C., Hu R., Davis L.A., Saboe L.A. The nonoperative treatment of burst fractures of the thoracolumbar junction. J Trauma. 1988;28(8):1188-1194.

14. Cantor J.B., Lebwohl N.H., Garvey T., Eismont F.J. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine (Phila Pa 1976). 1993;18(8):971-976.

15. Mumford J., Weinstein J.N., Spratt K.F., Goel V.K. Thoracolumbar burst fractures. The clinical efficacy and outcome of nonoperative management. Spine (Phila Pa 1976). 1993;18(8):955-970.

16. Tropiano P., Huang R.C., Louis C.A., et al. Functional and radiographic outcome of thoracolumbar and lumbar burst fractures managed by closed orthopaedic reduction and casting. Spine (Phila Pa 1976). 2003;28(21):2459-2465.

17. Wood K., Butterman G., Mehbod A., et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study. J Bone Joint Surg [Am]. 2003;85:773-781.

18. Thomas K.C., Bailey C.S., Dvorak M.F., et al. Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit: a systematic review. J Neurosurg Spine. 2006;4:351-358.

19. Dai L.Y., Jiang L.S., Jiang S.D. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine (Phila Pa 1976). 2008;33(23):2536-2544.

20. Cengiz S.L., Kalkan E., Bayir A., Ilik K., et al. Timing of thoracolumbar spine stabilization in trauma patients—impact on neurological outcome and clinical course. A real prospective randomized controlled study. Arch Orthop Trauma Surg. 2008;128:959-966.

21. Jacobs R., Asher M., Snider R. Thoracolumbar spinal injuries. A comparative study of recumbent and operative treatment in 100 patients. Spine (Phila Pa 1976). 1980;5:463-477.

22. Gertzbein S.D. Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976). 1992;17(5):528-540.

23. Hitchon P.W., Torner J.C., Haddad S.S., Follett K.F. Management options in thoracolumbar burst fractures. Surg Neurol. 1998;49:619-627.

24. Seybold E.A., Sweeney C.A., Fredrickson B.E., et al. Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-5. Spine (Phila Pa 1976). 1999;24(20):2154-2161.

25. Tator C.H., Duncan E.G., Edmonds V.E., et al. Comparison of surgical and conservative management in 208 patients with acute spinal cord injury. Can J Neurol Sci. 1987;14:60-69.

26. Weninger P., Schultz A., Harald H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg. 2009;129:207-219.

27. Hitchon P.W., Torner J.C. Recumbency in thoracolumbar fractures. Neurosurg Clin North Am. 1997;8(4):509-517.

28. Rechtine G.R.2nd, Cahill D., Chrin A.M. Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment. J Spinal Disorders. 1999;12(5):406-409.

29. Fehlings M.G., Perrin R.G. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006;31(Suppl 11):S28-S35.

Emergent Surgery

Acute spinal cord injury (SCI) has momentous repercussions in our society. Every year, more than 10,000 Americans are victims of SCI and become physically disabled and psychologically affected.1 Without consideration for loss of productivity and income, the estimated cost of care of complete and incomplete SCI patients in the United States is estimated at $28,000 and $17,000 per patient per year,2 respectively. Thus, the optimization of SCI treatment may imply a greater number of SCI patients with timely neurologic recovery, potential return to work, and reinstatement of wages.

Patients with incomplete SCI generally have a higher functional recovery rate than do patients with complete SCI.35 Current neurosurgical and orthopedic practices therefore favor a more aggressive approach and early surgical intervention in this subset of SCI patients.3,68 However, because of the lack of well-designed prospective randomized control trials, there remains a controversy in determining the optimal timing of surgery for SCI patients3,79 Given the emotional driving forces surrounding the treatment of SCI patients, we strongly recommend early surgical intervention, as it comes with minimal risk but high hope of recovery.

Recent laboratory studies have established that SCI is a dynamic process with temporal evolution of pathophysiologic processes.1013 Thus, there are primary and secondary injuries that contribute to the progression of acute SCI. The primary injury corresponds to the immediate effect of trauma with the mechanical spinal cord compression and immediate cellular and axonal damage. The secondary injury refers to the effect of the inflammatory cascades, ischemia, and oxidative damage on the spinal cord parenchymae.14

The initiation of emergency surgical intervention is to prevent or limit secondary injury. However, these effects most likely take place in the first few hours following trauma. Therefore, the critical factor that remains unclear is what time interval defines the surgical window during which secondary injury is still reversible and whether surgery can be performed in the time frame necessary despite the numerous logistical challenges in the trauma population.

Rationale for Early Surgery

Temporal Pathophysiologic Evolution of Spinal Cord Injury

SCI is a dynamic process with temporal evolution of pathophysiologic processes at the cellular level. Fehlings et al.15 characterized five phases of SCI, based on studies conducted on a mouse model. The phases are (1) immediate at less than 2 hours, (2) early acute at less than 48 hours, (3) subacute at less than 14 days, (4) intermediate at less than 6 months, and (5) chronic beyond 6 months. The primary or initial mechanical injury takes place immediately after the injury, resulting in traumatic transection and injury of the axons, hemorrhage, and activation of immunologic cascades. The secondary injury begins during the early acute phase at less than 48 hours. It is thought to result from persistent cord compression and hypoperfusion of the spinal cord resulting in the development of vasogenic and cytotoxic edema, continued hemorrhage, cell death, and necrosis. This continuum of the secondary cascade is aggravated in patients with multiple traumas, who are more likely to become hypotensive and hypoxic from other injuries.11 The current emphasis on the development of neuroprotective pharmacologic therapies in the setting of acute SCI accentuates the importance of a timely intervention to prevent secondary injuries.1517 Thus, there is a potential that early surgical decompression, performed within a therapeutic window, may prevent or revert further damages to the spinal cord.

Experimental Studies with Animal Models: Timing of Decompression

Although clinical results have not shown a dramatic effect on the timing of intervention, animal and laboratory research of acute SCI have consistently shown that secondary injury to the spinal cord is potentially preventable or reversible with timely decompression.1822 These results from 1999 to 2009 on rat and dog models of SCI are reviewed in Table 228-1. Hamamoto et al.19 conducted a study on mouse models of acute SCI evaluating the real-time changes in thoracic spinal cord blood flow as a result of compression forces. They were able to establish that the duration of ischemia resulting from spinal cord compression and the percentage of blood flow recovery following decompression were important factors in the determination of neurologic recovery. They also demonstrated that cases with longer period of spinal cord compression had less recovery of blood flow, more breakdown of the blood–spinal cord barrier, more apoptotic cell death, and less motor function recovery.

Early versus Late Surgery

Early Decompression for Incomplete Spinal Cord Injury

Controversy remains regarding the proper timing of surgical decompression and stabilization in the setting of acute SCI. Studies and reviews conducted to date offer largely class III evidence and some class II evidence either defending or refuting the benefits of early surgical decompression. Table 228-2 provides a summary of literature published in 1999 to 2009 on early decompression of SCI, with a focus on incomplete injuries. Over the past 10 years, several class III evidence studies have reported that early surgical decompression was not associated with improved neurologic recovery.4,23,24 Pointillart et al.23 conducted a nonrandomized prospective study of 66 cervical SCI patients (class II evidence); their study showed no statistically significant difference between groups of patients who had decompression within 8 hours of injury, decompression between 8 and 24 hours after injury, and conservative management. In this study, the lack of randomization constitutes a significant flaw, as a general tendency in current practice is to favor surgical intervention in certain groups of patients who the authors believe have a lower chance of recovery without such intervention. In addition, the time intervals of less than 8 hours versus 8 to 24 hours might show no difference, as they still fall in the therapeutic window of early surgery as defined by newer studies. Pollard and Apple’s25

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