Thoracic Spinal Injuryoperative treatmentandrelated problems - Choratatou

Thoracic Spinal Thoracic Spinal InjuryInjury

operative treatmentoperative treatmentandand

related problemsrelated problemsGeorge SapkasGeorge Sapkas

Asc. ProfessorAsc. Professor--

11stst Orthopaedic Dpt Orthopaedic DptMedical School Medical School

Athens UniversityAthens UniversityMETROPOLITAN HOSPITALMETROPOLITAN HOSPITAL

Mi. – Ch.: Male 35Mi. – Ch.: Male 35constructor constructor History:History:

Fall from 6 -7 meters Fall from 6 -7 meters height on the height on the construction site at 9 construction site at 9 June 2011June 2011

Initial treatmentInitial treatmentTransportation to the Transportation to the First Aids Station First Aids Station of the remote islandof the remote island

Plain x-raysPlain x-rays(not available) (not available) demonstrated:demonstrated:

Injury at the Injury at the thoracic level of thoracic level of the spinethe spine

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Case provided by Asc. Professor: Dr. G. SapkasCase provided by Asc. Professor: Dr. G. Sapkas

Neurologic deficit was Neurologic deficit was detected at that time detected at that time affected mainly the affected mainly the right leg (extensors of right leg (extensors of the foot 3/5)the foot 3/5)

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Following the original Following the original management management he was transported to the he was transported to the main Cyclades’ island main Cyclades’ island where he was submitted where he was submitted in x-rays & CT in x-rays & CT examinationexamination(not available)(not available)

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The The investigations investigations revealed revealed fractures of the fractures of the T4 – T5 – T6 T4 – T5 – T6 vertebrae and vertebrae and haemothorax haemothorax bilaterally bilaterally

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The patient did The patient did not sustained not sustained any injury in any injury in other parts of other parts of his bodyhis bodyThe patient The patient transported to transported to “ATTIKON” “ATTIKON” University University Hospital Athens Hospital Athens

at the same dayat the same day

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On admissionOn admissionClinical Clinical examinationexamination

Deterioration Deterioration of the of the neurologic neurologic deficit deficit

Right leg Right leg (2/5)(2/5)Left leg (4/5)Left leg (4/5)

Sphincteric Sphincteric function: function: unspecified unspecified

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Radiological Radiological investigationinvestigation

CT scanCT scan

MRIMRI

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The CT The CT examination examination made clear that made clear that the spinal injury the spinal injury occurred at the occurred at the level of a level of a pre-existed right pre-existed right thoracic scoliosis thoracic scoliosis estimated estimated approximately approximately at 25 degrees.at 25 degrees.

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CT scanCT scansaggital saggital

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CT scanCT scancoronal coronal

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CT scanCT scanaxial axial

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Total disruption Total disruption of the three of the three spinal columns spinal columns detected as well detected as well as vertebral – as vertebral – ribs ribs articulation, articulation, which made which made clear that gross clear that gross instability instability existed.existed.

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Type CType CCase 01Case 01


Magerl et al. Eur. Spine J 1994

DESTRUCTIONDESTRUCTIONof theof the

33COLLUMNSCOLLUMNS

MAXIMUM INSTABILITYMAXIMUM INSTABILITY

ROTATIONAL ROTATIONAL INJURIESINJURIES

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Magerl et al. Eur. Spine J 1994

M.R.IM.R.Isaggitalsaggital

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What do you What do you propose ?propose ?

Conservative Conservative treatment treatment

Bed restBed restThoracolumbar braceThoracolumbar braceMethylprednisoloneMethylprednisolone

Operative treatmentOperative treatment

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Operative Operative treatmenttreatment

Time of Time of operationoperation

Immediately Immediately or or

As soon as the As soon as the patient condition patient condition permitspermits

ProcedureProcedureAnteriorAnterior

PosteriorPosterior

Combined Combined

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Posterior Posterior procedureprocedure

LaminectomyLaminectomy

VertebrectomyVertebrectomy

Laminectomy & Laminectomy & VertebrectomyVertebrectomy

Stabilization Stabilization In situIn situ

Correction of the Correction of the scoliotic scoliotic deformity deformity and stabilizationand stabilization

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Due to various reasons related Due to various reasons related to the cardio-respiratory to the cardio-respiratory function the operative function the operative treatment postponed until the treatment postponed until the patient’s condition improvedpatient’s condition improvedIn the meantime neurological In the meantime neurological function of the lower limbs function of the lower limbs deteriorated mainly deteriorated mainly of the right oneof the right oneFinally the patient underwent Finally the patient underwent the operation on the operation on 1212thth August 2011 (3 days later) August 2011 (3 days later)

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It is clear the It is clear the total disruption total disruption of the posterior of the posterior spinal elements spinal elements and the lateral and the lateral displacement of displacement of the spinous the spinous process of the process of the vertebra above vertebra above related to the related to the next below next below

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Posterior Posterior procedureprocedure

Neuro monitoring Neuro monitoring

Extensive Extensive laminectomies of the laminectomies of the 55thth and 6 and 6thth vertebra vertebra

Partial Partial vertebrectomies vertebrectomies of the 5of the 5thth and 6 and 6thth vertebravertebra

Pre-bended rods Pre-bended rods according to the according to the scoliotic curve scoliotic curve appliedapplied

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During the During the procedureprocedure

Disturbance of the Disturbance of the neurological function neurological function on both legs whileon both legs whilethe secure screw the secure screw applied on the 8applied on the 8thth right right vertebral screw vertebral screw causing interruption causing interruption of the motor of the motor potentialspotentials

Implants removed Implants removed immediately and the immediately and the motor potentials motor potentials recurrentrecurrent

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Ten minutes later a Ten minutes later a similar effort was similar effort was made and similar made and similar neurologic neurologic disturbance occurred disturbance occurred

Implants removed Implants removed immediately and the immediately and the motor potential motor potential recurrent againrecurrent again

Finally the pre-Finally the pre-bended rods applied bended rods applied over the vertebral over the vertebral screws.screws.The secure screw of The secure screw of the 8the 8thth right vertebral right vertebral screw was not appliedscrew was not appliedNo disturbance of the No disturbance of the neurological function neurological function was notedwas noted

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The post operative The post operative course of the patient was course of the patient was initially normal with initially normal with improvement of his improvement of his neurologic deficitneurologic deficit

On the 9On the 9thth post operative post operative day neurologic day neurologic deterioration appeared deterioration appeared on both legson both legs

The MRI examination The MRI examination revealed an extensive revealed an extensive heamatoma (± CSF)heamatoma (± CSF)

Evacuation of Evacuation of heamatoma (twice)heamatoma (twice)

Thereafter it appeared Thereafter it appeared steady progress of his steady progress of his neurological conditionneurological condition

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He discharged two He discharged two months later being months later being in a very in a very satisfactory satisfactory neurological neurological condition and at 9 condition and at 9 months time he was months time he was back to his work in back to his work in lighter dutieslighter duties

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What is the cause What is the cause of the intra of the intra operative operative deterioration ?deterioration ?

Pressure of the Pressure of the spinal cordspinal cord

Ischemia – occlusion Ischemia – occlusion

of the Adamkiewiczof the Adamkiewicz arteryartery

Both of the above Both of the above due to regional due to regional instability instability

Something elseSomething else

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““ATTIKON” UNIVERSITY ATTIKON” UNIVERSITY HOPSITALHOPSITAL

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Thoracic Spinal Injuryoperative treatmentandrelated problems - Choratatou