Đặc điểm hình thái tổn thương và kết quả phẫu thuật điều trị gãy cột sống ngực, thắt lưng đa tầng tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING DEFENSE MINISTRY OF NATIONAL MILITARY MEDICAL UNIVERSITY LE HUU TRI MORPHOLOGICAL CHARACTERISTICS OF MULTILEVEL THORACIC AND LUMBAR VERTEBRAL FRACTURE AND THE EFFECTIVENESS OF SURGICAL TREATMENT Speciality: Surgery Code: 9720104 SUMMARY OF MEDICAL THESIS HA NOI - 2020 THESIS IS COMPLETED AT MILITARY MEDICAL UNIVERSITY Supervisor: Associate Prof PhD Vu Van Hoe Associate Prof PhD Vo Van Nho Reviewer 1: PhD Hoang Gia Du Reviewer 2: Associate Prof PhD Bui Van Lenh Reviewer 3: Associate Prof PhD Nguyen Tho Lo The thesis will be defended by University’s Council at: The thesis can be found at: National Library INTRODUCTION Multilevel noncontiguous spinal fractures (MNSF) are defined as fractures of the vertebral column at more than one level According to many reports, multilevel noncontiguous spinal fractures are found at from 3.2% to 16.7% Multilevel spine injuries are often uncommon, occur commonly as a result of high-speed road traffic accidents or falls from a height Multilevel spine injuries tend to be more severe than unilevel because of the other injuries combined Rapid diagnosis of MNSF is essential since a misdiagnosis or delayed diagnosis may complicate the clinical picture Therefore, the role of a thorough physical and radiological examination is the key to not to miss any lesions Although there are many studies evaluating and treating single level spine fractures, there have not been many reports of multilevel spine injuries In Vietnam, there are not many researches on this issue So we work for: “Morphological characteristics of multilevel thoracic and lumbar vertebral fracture and the effectiveness of surgical treatment” with these targets: Describing the morphological characteristic of multilevel fractures thoracic in which and lumbar surgical vertebral treatments are indicated at Da Nang Hospital Evaluating the outcome of surgical treatment for multilevel thoracic and lumbar vertebral fractures at Da Nang Hospital - New main scientific contributions of the thesis: The research subjects are lesions in multilevel thoracic - and lumbar vertebral fractures Providing the evidence of the effectiveness of surgical treatment for multilevel thoracic and lumbar vertebral fractures - Structure of the thesis: the thesis includes 127 pages with 40 tables, 27 pictures and 10 charts Introduction (2 pages); Chapter 1: Overview (31 pages); Chapter 2: Subjects and Methods of the study (26 pages); Chapter 3: The results of the study (31 pages); Chapter 4: Discussion (33 pages); Conclusion (2 pages); Petition (1 page); List of published articles related to the results of the thesis (1 page); References (138 documents including 33 documents in Vietnamese, 105 documents in English); The appendices SECTION OVERVIEW 1.1 A brief history of treatment of spine fractures 1.1.1 In the world Multilevel spine injuries have been reported for a long time Griffith H.B., Gleave J R W, Taylor R G (1966) reported patients accounting for 3.2% of 155 cases of thoracic and lumbar spine fractures Lizbeth C A M G et al (2018) reported 47 cases of multilevel spinal surgery at the Center Dr Manuel Dufoo Olvera in Mexico Thus, the multilevel spine fractures have been studied for a long time, but they are still separated There are no single reports on multilevel spinal injuries 1.1.2 In Vietnam Previous studies inside the country have only studied one-level fractures, there were some authors who mentioned several cases of multilevel spinal injuries And there are no separate studies on multilevel thoracic and lumbar spinal injuries 1.2 Classification of multilevel thoracic and lumbar veterbral fractures 1.2.1 Classification of Denis In 1983, Denis introduced the definition of "threecolumn spine": the anterior, middle and posterior column; and it has been widely applied 1.2.2 Classification of Margel (AO) In 1994, Margel proposed a classification according to AO (Arbeitsgemeinschaft fur Osteosynthesefragen) which mainly assess spinal morphological damage 1.2.3 Load Sharing Classification (LSC) In 1994, Mc Cormack and colleagues released a new classification to assess vertebrae damage based on three criteria: the amount of damaged vertebral body, the spread of the fragments in the fracture site, the amount of corrected traumatic kyphosis 1.2.4 Classification of multilevel thoracic and lumbar spinal injury based on the severity of lesion In 2005 Vaccaro A.R et al proposed a Thoracolumbar Injury Classification and Severity Score (TLICS) which is is based on three major categories, known as parameters: injury morphology, posterior ligamentous complex integrity, patient neurology 1.4 Imaging Tests 1.4.1 X-ray X-rays are the fastest technique to assess the overall picture of the spine and bone anatomy - To locate lesions - To identify changes in the overall spine: angulation, displacement, spondylolisthesis, and rotation by evaluating over lines in a straight posture (spinous process line, pedicles line and lateral border) - To measure local Kyphotic Angle (LKA) and Cobb Angle 1.4.2 Computed Tomography Scan Computed tomography (CT-scan) provides greater details and resolution for evaluation of the bone elements and assessment of the entire spinal canal CT-scan allows us to assess bone lesions, fracture lines, fracture fragments, lesions of processes, joints, holes, posterior arcs, damaged fragments moving into the spinal canal, and spinal stenosis 1.5 Methods of Spine Stabilization 1.5.2 Posterior Stabilization Systems Posterior stabilization systems can restore vertebral body height by distraction forces Furthermore, anterior and middle columns maintained their normal length during correction of kyphosis Distractive forces provided by the posterior stabilization system developed a tensile strength in the posterior longitudinal ligament which pushes back the retro-pulsed bone fragments forward This process has been termed ligamentotaxis and it is beneficial particularly if performed at the early period 1.5.2.3 Posterior lumbar interbody fusion surgery (PLIFs) Transpedicular screw is now the standard of spine fusion surgery for many spinal diseases We use a "free hand" technique with screws are parallel to the joint of the vertebra and we use X-rays for guiding during surgery 1.6 Indications of surgical treatment for multilevel thoracic and lumbar fractures Greenberg M.S (2010) refers to a treatment indication based on a clear, complete description of the morphological characteristics of lesions in three columns, signs of neurological damages and their associations They also consider the characteristics of the fracture group as well as the location of fractures in assessing the instability of the injury In this document, author McAfee presents the specified surgery in the case 1.7 Evaluation the results of surgical treatment 1.7.1 The assessment of the results of spinal correction and stabilization surgery Anteroposterior (AP) and oblique X-rays on all patients; measuring local LKA and Cobb Angle on oblique X-rays is the most commonly used method today 1.7.2 The assessment of the neurological recovery after surgery Based on the neurological damage classification table according to Frankel: Pre-operative evaluation, post-operative evaluation, and evaluations in follow-up visits, monitoring changes in Frankel level between two consecutive visits CHAPTER SUBJECTS AND METHODS OF STUDY 2.1 Subjects 2.1.1 The criteria for selecting research patients - All patients diagnosed with multilevel vetebral fractures (≥ levels) from the fourth thoracic vertebra to the fifth lumbar vertebra, having unstable fracture, and caused by trauma These include multilevel vertebral fractures emphasized on thoracic-thoracic, thoracic-lumbar, and lumbar-lumbar segments -All patients who have plain and oblique X-rays, computerized tomography scan and posterior stabilization of at least one fractured vertebra body 2.1.2 Exclusion criteria -Elderly patients with osteoporosis, bone tumors, tuberculosis, cardiovascular disease, coagulopathy, etc Patients with brain sequelae or brain entity pathologies, spinal cord sequelae or paralysis of peripheral nerves in the lower extremities due to pathology, mental disorders that distort nerve assessment at the spinal cord Patients who had surgery then lost information, did not come back for examination, or did not cooperate with treatment 2.2 Research method 2.2.1 Sample size Convenience sampling method, including all patients who match selection and exclusion criteria during the research period 2.2.2 Method of data collection Clinical and radiological findings : routine X-ray, CTscan; the results of treatment are collected based on a pre-set form Direct clinical examination, assessment of symptoms, analysis of results of X-rays, CT scans before surgery Perform posterior stabilization surgery, evaluate the postoperative results All patients receive discharge instruction in self-care and mobilization Re-examination after 06 months: examination of clinical symptoms such as movement on ASIA scale, sensation, reflexes, urination, incisions, neurological recovery according to Frankel level, urinary tract infections, pneumonia, muscle atrophy, regular X-ray 10 measuring KLA, height of fractured vertebra, screw position 2.3 Method of Data Analysis Collected data were processed in the statistical software 12.2.1.0 20 CHAPTER DISCUSSION 4.1 Clinical and radiological characteristics of multilevel thoracic and lumbar vertebral fractures 4.1.1 General characteristics 4.1.2.6 The degree of neurological injuries according to the Frankel Grade classification In table 3.5 we find that patients with normal sensory and motor function (Frankel E) accounted for the highest proportion with 30 cases (56.63%) The number of patients with symptoms of complete paralysis (Frankel A) ranked second with 10 patients (18.86%) The rate of paralysis varies by author, depending on research subjects 4.1.2.7 Associated injuries Patients with multilevel spinal injuries were mostly caused by a complex, strong traumatic mechanism, which often resulted in other traumas Patients with other accompanied injuries accounted for the highest proportion with 36 cases (67.93%), in which multiple injuries ( types of combined injuries or more) had 11 patients (20.78%) Our research had a high percentage of combined 21 injuries due to the strong traumatic mechanism of multilevel spinal injuries that caused damage to organs of the body 4.1.3 Radiological findings 4.1.3.1 Detection of vertebral lesions on regular X-ray and CT-scan In all cases where only one fractured vertebra was detected on X-rays, more than one fracture was detected on CT-scans CT-scans revealed 118 fractures in 53 cases (ratio: 2.22 fractures/1 patient) Reasons for missing lesions on X-ray films: poor image quality, not capturing the entire spine at our request, initial examinations by inexperienced physicians This shows that lesions will be more accurately detected in CT-scanned patients than in patients with x-rays only This is considered the best method for assessing lesions of bone today 4.1.3.2 Distribution of lesions of multilevel spinal fractures Figure 3.7 shows that the most common segment among all patients suffering multilevel spinal fractures were concentrated in thoracic+thoracic segment with 11 cases (20.76%), thoracic+lumbar segment and lumbar+ lumbar segment with 21 cases (39.62%) Most injuries emphasized on the thoracic+lumbar segment and lumbar+ lumbar segment because these segments are mobile vertebrae that are prone to 22 injury And the thoracic segment has protection of the ribs and back muscles so it is less vulnerable We found that the lesions in two separate sections of lumbar and thoracic spine accounted for a relatively high proportion (39.62%) Therefore, we recommend that in case of multiple injuries, it is essential to have a careful examination and X-ray of the entire spine to avoid missing multilevel noncontiguous spinal fractures to prevent complications from errors of omission 4.1.3.4 Detection of contiguous or noncontiguous fractures on CT-scan Figure 3.8 showed that there were 36 patients with contiguous fractures, accounting for a high rate of 67.93% and 17 patients with non-contiguous fractures (32.07%) The rate of fracture detection in our study is relatively high compared to other previous reports, probably because our hospital is a general hospital, not a specialty hospital We not only treat spinal injuries but also treat other injuries such as thoracic, abdominal, or extremity fractures; and more importantly, our hospital has intensive unit care which is essential for treatment of patients with severe injuries Therefore, most of traumatic cases were admitted to our hospital 23 4.1.3.6 The fragment of bone causing spinal stenosis on CT-scan Figure 3.9 shows that fragments of bones causing spinal stenosis> 50% were 21 patients, accounting for 39.63% Bone fragments causing spinal stenosis ≥ 50% were 24 patients, accounting for 45.28% This suggests that the majority of patients with multilevel spinal injuries due to a strong, complex trauma often have severe spinal stenosis 4.1.9 The correlation between clinical and radiological findings Table 3.16 shows the relationship between lesion images on CT-scans and clinical features The number of patients with spinal fractures accounted for the highest proportion with 38 cases (71.69%), followed by fracture-dislocations with cases (17%), in which paralysis caused by fracture-dislocations accounted for the highest rate with 8/9 cases ( 88.88%) The number of cases of vertebral fractures showing signs of neurological lesion were 15/38 patients, accouting for 39.47% Neurological lesions were more common in the fracture-dislocations of spine, which is also reasonable due to the fact that the most common anatomical lesions in the compression fractures and the dislocations are worse than in the other two groups Evaluation of neurological lesions in diagnostic imaging was determined only on magnetic resonance 24 images In our study, there was no pre-surgery MRI, which was also the problem of the study 4.1.10 The correlation between neurological lesions and the degree of spinal stenosis on CTscan Table 3.17 shows that out of 10 patients with paralysis (80%) had spinal stenosis of 50% or more, patients with Frankel B (100%) had spinal stenosis of 50% or more out of patients with Frankel C (71.42%) had spinal stenosis of 50% or more Thus, the majority of patients with spinal stenosis of 50% or more had more severe neurological lesions There was a correlation between the degree of spinal stenosis and the degree of paralysis This relevance is statistically significant This is a problem that many authors are interested in finding the link between spinal stenosis and neurological lesions Several studies have shown that fragments of bones narrowing the spinal canal are the causes of neurological lesions This study also shows that CT has great value in the diagnosis of spinal stenosis, but CT has certain limitations, making it difficult to assess ligament and disc injuries 4.2 Surgical Results 4.2.1 Surgical factors 4.2.1.1 Time of surgery Table 3.18 shows that there was only patient had 25 surgery within day (24 hours), accounting for 1.88% The longest time from admission to surgery was 21 days The majority of patients had surgery after days, accounting for 84.92% Average time 7.37 ± 4.37 days In our view, in multilevel spinal injuries, there are many other injuries accompanied The first hours or the first day after injury is the stage of spinal shock if the patient has spinal cord injury At this stage it is difficult to fully assess the neurological lesions, so the prognosis and determination of surgical approaches are difficult to avoid shortcomings, or errors Surgery should be performed after days because at this time the status of spinal shock and other injuries is stable Furthermore, at this stage, neurological lesions can be clearly identified clinically, accompanied by imagining findings and laboratory tests 4.2.1.6 Overlapping surgeries Table 3.23 showed that 14/53 cases (26.41%) had overlapping trauma surgeries, of which cases had fixation surgeries, accounting for 11.32%; and cases were accompanied by surgeries for thoracostomy + fixation surgery The rate of our overlapping surgeries is relatively high, which means that the majority of multilevel spinal injuries have other accompanied injuries and even require surgery Multilevel spinal injury is a severe injury 26 4.2.2 Surgical results 4.2.2.1 The result of neurological recovery after surgery Our surgery time after injuries was usually after days For patients with shock or other accompanied injuries, this period would be temporarily stable Therefore, the neurological evaluation of this phase was relatively accurate After surgery, there were 44 patients (83.01%) with neurological signs unchanged We found that patients with severe preoperative neurological lesions (Frankel A, B) restored normal motor functions (Frankel D, E) worse than patients with previous neurological lesions at the other remaining levels Patients having mild to moderate neurological lesion (Frankel D, C) showed a higher level of recovery (Frankel E, D) than patients at other levels There was a significant association between the level of neurological lesion (severe, mild) before surgery and the postoperative neurological recovery Surgery contributes to facilitating better neurological recovery Our postoperative neurological recovery rate was only 8/53 patients (15.11%), which was still very modest The reason is that multilevel spine injuries have a strong trauma mechanism, which cause most of patients suffer severe neurological lesions that limited the recovery after surgery This implies that neurosurgery including correction, fixation and stabilization only create conditions for neurological 27 functions to be restored, not regenerated 4.2.2.3 Results of neurological recovery after reexamination There were 17 level patients (32.07%) who were able to return to work like before injury, 12 level patients (22.66%), lost their ability to work completely, 13 level patients (24.52%) who could not return to their previous jobs, but were still capable of working full time The patients of our research were mostly workers, who had to strenuous works Moreover, patients had long-segment spinal fixations with many screws during surgery, as well as surgeries for other accompanied injuries such as skulls, brain, chest, limbs, etc Therefore, after surgeries, patients still suffered back pains The other accompanied injuries were not stable so it was difficult for them to return to works requiring strenuous physical exertion As a result, although there were 30 patients graded Frankel E before surgery, only 17 patients were able to return to their strenuous works Re-examination after months was not a long enough period of time for monitoring and assessing the ability of returning to the previous works or not Results of neurological recovery at the time of reexamination after 06 months: There were 46 discharged patients (including 10 patients graded Frankel A, patient graded Frankel B, patient graded 28 Frankel C and 34 patients graded Frankel E) whose grades did not change when re-examined out of graded Frankel C patients proceed to Frankel D All four patients with Frankel D advanced to Frankel E No patients were worse The neurological recovery follows the rule: the lower the level of neurological lesions patients have, the faster they will recover Therefore, a thorough examination is needed to accurately assess the extent of neurological damage, as this will contribute to treatment decisions 4.2.2.4 The results of improvement of local kyphotic angle Table 3.28 shows that the LKAs after surgery and in re-examination is much lower than LKAs before surgery: LKAs before surgery 18.73 ± 7.38 ; LKAs after surgery 10.56 ± 5.530 improved 8.170 (43.61%) The difference is statistically significant (p < 0.05) This shows that surgery is really effective in the correction After months of follow-ups, patients with re-examination, LKAs increased by 2.81 0, LKAs after surgery and in re-examination were similar (p > 0.05) So after a period of fixation with screws, there were phenomena of increased LKAs In our opinion the cause of increased LKAs may be due to the following causes: LKAs increase with time due to several factors 29 Intrinsic factors include the quality of bone grafts, bones in place and fixation devices External factors include the time from surgery to start sitting and walking again and patients wearing additional supportive spinal braces after surgery or not From the above results, we found that, to reduce spinal kyphosis in patients with multilevel spine injuries, it is needed to use long-segment fixation with several screws, especially screws at the place of ruptured vertebrae to avoid angular displacements and to facilitate better alignment 4.2.2.5 Results of improvement of vertebral body compression recovery after surgery Table 3.30 shows the results of improvement of postoperative vertebral body compression recovery The average rate of vertebra collapse after surgery and re-examination were lower than before surgery After surgery and re-examination, vertebrae body heights were similar After surgery, the rates of vertebral compression improved by 13.6%, when examined again The vertebrae heights decreased by 0.38% This result is statistically significant (p < 0.05) The restoration of the anterior height of the vertebra body also directly affects the condition of the local kyphotic angle Surgical results of pedicle screw fixation showed an improvement of the compression percentage 4.2.2.7 Overall outcome of treatment vertebral body 30 Table 3.32 shows an overall assessment of treatment outcomes No patients died Good and fair results accounted for 75.45% The average was 22.67% poor case accounted for 1.88% This result is statistically significant (p < 0.01) Our overall result of pedicle screw fixation was relatively satisfactory Thus, fixation surgery in multilevel spinal fractures restored the stability of spine and neurological functions CONCLUSION Through multilevel researching thoracic and 53 cases lumbar of surgery fractures for having indications of screw fixation surgery we obtained the following results: Characteristic of multilevel thoracic and lumbar fractures The majority of patients with multilevel thoracic and lumbar fractures had normal sensory and motor function (Frankel E), accounting for the highest rate with 30 patients (56.63%) The majority of patients with multilevel thoracic and lumbar fractures had normal sensory and motor function (Frankel E), accounting for the highest rate with 30 patients (56.63%), followed by complete paralysis patients (Frankel A) with 10 cases, accounting for 18.86% There were 36 patients (67.93%) with other injuries 31 Most notably, there were 11 patients with multiple injuries (20.78%) CT revealing fractures had the highest rate with 44 patients (83.01%), in which cases having or vertebrae fractures were one, accounting for 1.88% (p < 0.05; χ2 = 96.962) Among them, 36 patients with contiguous fractures accounted for a high rate of 67.93% Compression fracture was the most common type of fracture with 38 patients, accounting for 71.69% There were only two cases of seatedbelt fracture, accounting for the lowest rate of 3.77% (p 0.05; χ2 = 1.339) Bone fragments causing spinal stenosis ≥ 50% accounted for the highest proportion with 24 patients (45.28%) Among 10 patients who were completely paralyzed, 8/10 patients (80%) had stenosis ≥ 50% patients (100%) of spinal stenosis ≥ 50% graded Frankel B 32 There was a correlation between the degree of spinal stenosis and the degree of paralysis (p < 0.05) The study showed that the average LKA after injury was 18.730 ± 7.3800 and the average of vertebral body height after injury was 38.52 ± 17.81% These are not related to the degree of paralysis after injury (p > 0.05) Decompression, correction and posterior screw pedicle fixation surgery of the spine The results after surgery and re-examination were quite good, almost no complications After surgery, there were 44 patients (83.01%) who did not have changes in the neurological signs There were cases (15.09%) that improved neurological function after surgery There was case (1.88%) getting worse from Frankel E to Frankel C (p