Immediate Decompression of Cervical Spinal Cord Injury in County Hospital versus Delayed Decompression in Spinal Center

Transcription

1 Immediate Decompression of Cervical Spinal Cord Injury in County Hospital versus Delayed Decompression in Spinal Center Marin F. Stancic M.D. Department of Neurosurgery The University of Zagreb School of Medicine, Zagreb, Croatia The role of early spinal cord decompression for the treatment of cervical spinal cord injury is controversial (6,7). The pilot study that evaluated protocol for a decompressive surgery within 8 hours showed that the proposed trial is unfeasible (5). The aim is comparison of time interval between injury and surgical decompression of the patient treated in nearest community hospital and the patients trasferred to the Level I trauma center. Methods Patients included in the study sustained cervical spine fracture dislocation and had total sensomotor deficit at admission. The protocol group (No=12) patients were treated in the County Hospital of Pula in Croatia.The control group was comprised of surgically tre-ated patients in the Clinical Hospital for Traumatology, transported by a car following initially admission in a near-est community hospital. In the protocol group X-ray and CT scan were performed while the control group patients were evaluated by CT-myelography or MRI. Statistic Analysis: Picking sound from noise expressed as a signal-to -noise rate ratio. Fig. 1 Injured in Istra peninsula underwent surgery in the county hospital (Blue lines & Circles); The patients with first addmission in Split Hospital were secondary transported to the Spinal Center without surgical decompression (Black lines & Triangles). Fig. 2 MRI of the patient working premorbid job. Results The average time from injury to the surgicay was significantly shorter in the protocol group. Among 12 protocol group patients all were men while in the control group there were 10 men and 2 women. Median (range, hours) from accident to surgery in the protocol group was 6h (2 1/2-9) while in the control group was 18 (10-24). There were no neurological improvement in the control group while three patients in the protocol group recovered their neurological function. Signal to noise rate ratio was 6 [(3/12)/(0.5/12)=6]. Illustrative cases: 1) A 32year old male sustained a compressive fracture of C7 while head diving. His neurological findings were ASIA A below dermatome C7. The decompression started 3 1/2 hours following injury. He passed rehabilitation program in his country, and returned to the premorbid job 5 months following injury (Fig 2). 2) A 16-year old male sustained C5 compre-ssive fracture hitting a sea bottom while head diving. His neurological deficit below injury level was graded as ASIA A. The surgery started 4 hours following injury. After 8 years he is able to walk with crutches (Fig 3). Fig. 3 Illustrative case 2 can walk with crutches. Fig. 4 3) A 18-year old male patient sustained compressive fracture of C5 vertebra in MVA with ASIA A deficit. The decompression started after 5 hours. After 8 years he's graded ASIA C (Fig 4). Conclusions Our study showed that the decompression is possible inside the proposed 8 hours. Time will be saved if limited resources are dynamically allocated and the surgery completed in a hospital of the first admission (4). The rate ratio between early (sig-nal) and late (noise) decompression outcomes was 6. While the ratio between 5 and 10 is required to exclude association between outcome and confounding factors the rate of 6 suggests that neurological recovery in proposal group is significant (3). In addition, our clinical results agreed with the laboratory & some clinical studies (1,2). References Illustrative case 3 recovered sensory and motor function below level of injury that is graded as ASIA C. 1. Aebi M, et al. Clin Orthop Relat Res 1986;203: Dimar. Spine 1999;24: Glasciou. BMJ Gonzalez C, Brunstein A. J Trauma 2009; 67:S Ng WP, et al. Neurosurgical Focus 1999;1:Article 3 6. Papadopoulos SM, et al. J Trauma 2002;52: Vaccaro AR, et al. Spine 1997;22:2609

2 Fig. 1 Injured in Istra peninsula underwent surgery in the county hospital (Blue lines & Circles); The patients with first addmission in Split Hospital were secondary transported to the Spinal Center without surgical decompression (Black lines & Triangles).

3 Fig. 2 MRI of the patient working premorbid job.

4 Fig. 3 Illustrative case 2 can walk with crutches.

5 Fig. 4 Illustrative case 3 recovered sensory and motor function below level of injury that is graded as ASIA C.