NEUROSPINE INSTRUMENTATIONS IN SANGLAH GENERAL HOSPITAL-BALI
JUNE 2005-JUNE 2007
Tjok G.B. Mahadewa, Sri Maliawan Neurospine Division - Neurosurgery Depatient-Sanglah General Hospital
ABSTRACT
Rehabilitation for spinal cord lesion is mandatory where the rigid spine construct
facilitate early mobilization. Conservative treatment for unstable spine related with late
mobilization and increase complications. There are many kinds of segmental spinal
instrumentations (SSI) can be done for unstable spine i.e. anterior and/or posterior ones.
Stable spine related with early mobilization to prevent complications. The etiologies of
the cases were traumatic, tumor, infection, congenital and degenerative. The purpose of
this study was to elucidate the distribution of spinal cases, the prompatient treatment were
done and those significance with the results. This was a retrospective study, using 173
patients who were treated by the author in Sanglah General Hospital, Bali during
observation in 2 years from 2005-2007. Most of the spinal cases were degenerative, in
Frankel E, by decade V of life, with male predominance. Most of the treatment was
surgery with instrumentations, Frankel conditions has significance between surgery with
the result for trauma, tumor and degenerative, for cervical and thoracic region. Surgery
has significance with the result in non instrumented cases, infection, degenerative,
thoracolumbal and lumbar cases.
Key words: Spinal Cases, Neurospine Instrumentations, Early Mobilization
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NEUROSPINE INSTRUMENTASI DI RSUP-BALI JUNI 2005-JUNI 2007
ABSTRAK
Rehabilitasi pada lesi medulla spinalis merupakan keharusan dimana konstruksi tulang
belakang yang rigid memfasilitasi program mobilisasi awal. Penanganan secara
konservatif untuk tulang belakang yang tidak stabil berkaitan dengan mobilisasi yang
lambat dan meningkatkan komplikasi. Terdapat bermacam tipe segmental spinal
instrumentasi (SSI) yang bisa dilaksanakan pada tulang belakang yang tidak stabil seperti
pendekatan anterior dan atau posterior. Tulang belakang yang stabil berhubungan dengan
kemampuan mobilisasi awal untuk mencegah komplikasi. Etiologi dari kasus-kasus ini
adalah trauma, tumor, infeksi, kongenital dan degeneratif. Tujuan dari penelitian ini
adalah untuk mengetahui distribusi kasus-kasus tulang belakang, penanganan yang
dilakukan dan hal-hal yang mempengaruhi hasil penanganan. Penelitian ini merupakan
studi retrospectif, menggunakan 173 pasien yang dirawat oleh penulis di RSUP Sanglah,
Bali selama observasi 2 tahun, dari tahun 2005-2007. Kebanyakan kasus tulang belakang
adalah degeneratif, masuk dengan Frankel E, usia dekade V kehidupan, dengan dominan
pasien laki-laki. Sebagian besar kasus ditangani dengan pembedahan disertai pemasangan
instrumen, kondisi Frankel preoperasi mempunyai pengaruh yang bermakna terhadap
hasil pembedahan pada kasus trauma, tumor and degeneratif, terutama kasus regio
servikal dan thorak. Pembedahan mempunyai efek yang bermakna terhadap hasil pada
kasus tanpa pemasangan instrumen, pada kasus infeksi, degeneratif, terutama kasus
thorakolumbal and lumbal.
Kata kunci: Kasus Tulang Belakang, Neurospine Instrumentasi, Mobilisasi awal
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Introduction
Spine injuries have increased the number among the traumatic patients in Sanglah
General Hospital, Bali. The treatment consists of conservative and surgery, the choice is
based on the spine condition whether its stable or unstable. If the spine was considered
unstable, surgery is mandatory to facilitate stability of the spine. From 2000-2004, there
were 344 spine cases, 85 surgeries (24, 7%) were done, consist of 45 cervical, 14 thoracic
and 26 lumbar cases. Conservative treatment for unstable spine related with late
mobilization and increase complications.1, 2
Despite the trauma cases others are tumor, infection, congenital and degenerative
which also contributing the spinal construct and compromising the spinal cord. 3, 4 The
patients usually complained of pain on the vertebra with or without neurological deficit.
The treatment will provide adequate decompression for the spinal cord or nerve roots but
sometimes compromising the spine stability.5
There are many kinds of instrumentations can be done for unstable spine i.e.
anterior and/or posterior ones. Stable spine related with early mobilization to prevent
complications. 6
In order to elucidate the distribution of spinal cases, the prompatient treatment
were done and those significance with the results, the authors retrospectively evaluated
173 spine cases admitted to Sanglah General Hospital, Bali, Indonesia.
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Patients and method
This was a retrospective descripatientive-analytic study, using 173 patients who
were treated by the authors in Sanglah General Hospital, Bali during observation in 2
years from 2005-2007. The variables were documented i.e. sex, age, etiology, location,
diagnostic, Frankel type, treatment, instrumentations and results. Statistical analysis by
SPSS 11, 5 for Window, using Chi-square test was applied to overcome the differences
between treatment, instrumentations, Frankel, location, and etiology with the results.
Result and Discussion
During the study period were admitted 173 patients, consists of 140 male
(80,9%), 33 female(19,1%), mostly in decade 5th of life 59 patients(34,1%), decade 6th 49
patients(28,3%), decade 4th 26 patients(15%), followed by after decade 6th 21
patients(12,1%), decade 3rd 13 patients (7,5%) and before decade 3rd 5 patients(2,9%), As
in graphic 1 shown the etiology were degenerative 73 patients(42,2%), trauma 61
patients(35,3%), tumor 31 patients(17,9%), Infection 7 patients(4%) and vascular 1
patient(0,6%).
Graphic 1.Etiology’s Distribution
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Graphic 2. Location’s Distribution
The location were mostly at cervical 67 patients(38,7%), Lumbar 51 patients,
thoracic 29 patients, thoracolumbal 21 patients and lumbosacral 5 patients with mostly in
Frankel E 28,3%. (Graphic 2) Surgery were conducted in 161 (93, 1%) of 173 cases
(Table 1), 121 patients were instrumented (69, 9%). Significance between Frankel
conditions, in the surgery cases, with result (p=0, 00), not significance in conservative
(p=0,132) as shown in Table 1 this results suggested that the better result could be
reached by operative method to facilitate the decompression procedure and performed
segmental spinal instrumentation (SSI) for early mobilization. 6
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Table 1. Patient Distribution by Therapy, Frankel and Result
Most cases are Degenerative, significance between Frankel conditions with result
in trauma (p=0, 00), tumor (p=0, 00) and degenerative (p=0,002) as shown in table 2.
Not significance between surgery and conservative with result for trauma (p=0,467), but
significance between surgery and conservative with result for infection (p=0,008) and
degenerative (p=0,038) as shown in table 3. Previous Frankel type is compromising the
surgery result especially for trauma, tumor and degenerative cases that means the better
Frankel type before surgery the better result that we could gain after surgery due to the
limitation of the spinal cord capability for recover moreover in trauma cases. 7, 8
Therapy RESULT Total
p
value
no
change better worse death
Surgery Frankel A 11 6 0 11 28 0.000
B 5 14 0 4 23
C 1 22 1 1 25
D 15 26 0 0 41
E 7 37 0 0 44
Total 39 105 1 16 161
% 24.2 65.2 0.6 9.9 100
Conservative Frankel A 1 0 0 1 2 0.132
B 0 0 0 0 0
C 1 3 0 0 4
D 1 0 0 0 1
E 4 1 0 0 5
Total 7 4 0 1 12
% 58.3 33.3 0 8.3 100
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The most frequent location are cervical 67 patients (38, 7%), significance between
Frankel conditions with result in the cervical (p=0, 00) and thoracic (p=0, 00). Not
Etiology RESULT Total p value
no change better worse death
Trauma Frankel A10
0 0 11 21 0.000
B 3 5 0 4 12
C 0 14 0 1 15
D 2 4 0 0 6
E 5 2 0 0 7
Total 20 25 0 16 61
Tumor Frankel A 2 3 0 0 50.000
B 1 6 0 0 7
C 0 0 1 0 1
D 10 4 0 0 14
E 0 4 0 0 4
Total 13 17 1 0 31
Infection Frankel A 0 1 0 0 10.831
B 0 0 0 0 0
C 0 1 0 0 1
D 1 3 0 0 4
E 0 1 0 0 1
Total 1 6 0 0 7
Degenerativ Frankel A 0 2 0 1 30.002
B 1 3 0 0 4
C 2 10 0 0 12
D 3 15 0 0 18
E 5 31 0 0 36
Total 11 61 0 1 73
Vascular E 1 0 0 0 1
Total 1 0 0 0 1
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Table 2. Patient Distribution by Etiology, Frankel and Result
significance between surgery and conservative with result for cervical (p=0,566), but has
significance for thorakolumbal (p=0,029) and lumbar (p=0,011) as shown in table 4. The
higher level of the spine injury related with the amount of paralyze muscle and sensation
abnormality which related closely with the common complication for bed ridden patient,
such as: Deep Vein Thrombosis (DVT), Acute Respiratory Distress syndrome (ARDS),
Pneumonia, Ulcer, SIRS and Sepsis that can cause death.
In the sympatientomatic individual who is being considered for operative
stabilization there is considerable anatomical distortion, hence, there have been a wide
range of approaches and techniques of stabilization described in the literature, all of
which have quoted good results. The diversity of these techniques with or without
instrumentation, in situ fusion compared with reduction and fusion, and anterior,
posterior, or circumferential approaches suggests an element of controversy regarding the
ideal technique. 9, 10 Overall the result after surgery were improve 109 patients (63%), no
change 47(27, 2%), worsening 1 (0, 6%), death 16 (9, 2%). Instrumentations were used,
Hartshill 60, Luke 27, lateral mass plate 10, sub laminar wiring 4, pedicle screw 14,
expandable cage 1, and lamina hook-rod 5 patients.
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Etiology RESULT Total p value
no change better worse death
Trauma Treatment Surgery 16 22 0 15 530.467
Conservative 4 3 0 1 8
Total 20 25 0 16 61
TumorTreatment Surgery 13 17 1 0 31
Conservative 0 0 0 0 0
Total 13 17 1 0 31
Infection Treatment Surgery 0 6 0 0 60.008
Conservative 1 0 0 0 1
Total 1 6 0 0 7
DegenerativeTreatment Surgery 9 60 0 1 70
0.038
Conservative 2 1 0 0 3
Total 11 61 0 1 73
Vascular Surgery 1 0 0 0 1
Conservative 0 0 0 0 0
Total 1 0 0 0 1
Table 3. Patient Distribution by Etiology, Treatment and Result
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Location RESULT Total p value
no change better worse death
Cervical Treatment Surgery 18 25 0 15 580.566
Conservative 4 4 0 1 8
Total 22 29 0 16 67
ThoracalTreatment Surgery 11 17 1 0 29
Conservative 0 0 0 0 0
Total 11 17 1 0 29
Thoracolumbal Treatment Surgery 3 15 0 1 190.029
Conservative 2 0 0 0 2
Total 5 15 0 1 21
LumbalTreatment Surgery 6 44 0 0 50
0.011
Conservative 1 0 0 0 1
Total 7 44 0 0 51
Lumbosacral Surgery 1 4 0 0 5
Conservative 0 0 0 0 0
Total 1 4 0 0 5
Table 4. Patient Distribution by Location, Treatment and Result
In all the reported cases in which this form of stabilization is used there has been
1 case of thoracic extradural metastasis tumour of unknown origin with neurological
deterioration 5 days after surgery which previously no change after surgery unfortunately
the patient refused to be examined further and released from the hospital. There have
been no incidents of surgery site infection, no failures of the instrumentation, and
although only a medium number of cases have been reported, there have been no failures
of fusion in primary or revision surgery situations but we have collected 17 patients were
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death due to respiratory failure due to ARDS 4 patients and Sepsis 13 patients. There
have been no reports of the follow up greater than 12 months in patients who have
undergone surgery in which this technique was used. This series with its results at a
follow up of between 6 and 12 months confirms that the initial good results are
maintained in the midterm.
Conclusion
Most of the spinal cases were degenerative, in Frankel E, by decade V of life,
with male predominance. Most of the treatment was surgery with instrumentations,
Frankel conditions has significance between surgery with the result for trauma, tumor and
degenerative, for cervical and thoracic region. Surgery has significance with the result in
non instrumented cases, infection, degenerative, thoracolumbal and lumbar cases.
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