Отправить письмо автору 
Написать комментарий 
PERCUTANEOUS METHODS OF SPINAL STABILIZATION IN ELDERLY AND SENILE PATIENTS WITH ASSOCIATED INJURIES
Slinyakov L.Yu., Chernyaev A.V., Lipina M.M., Kalinskiy E.B., Simonyan A.G.
Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
According to WHO experts’ opinion, ageing of population
is a global problem at the present time [1]. It is assumed that injuries to
vertebral bodies in elderly and senile patients are caused by low-energy
injuries owing to presence of osteopenia [1, 2, 3]. However increasing social
activity in patients of this age group leads to increase in number of
high-energy injuries and polytrauma [1].
Absolute indications for instrumental stabilization of
uncomplicated spinal injuries are their unstable pattern [1, 2, 4, 5].
Currently, the issue of fixation of stable osteoporotic fractures of vertebral
bodies has not any uniform solution [1, 2, 6, 7]. So, the use of transpedicular
systems in osteoporosis causes the risk of unstable implants and their migration
in the early postsurgical period [1, 2, 6, 8]. Currently, the wide-spread
puncture methods of stabilization (vertebroplasty and kyphoplasty) are not
related to standard treatment and are considered as an option [1, 2]. However
it is necessary to note that the classic conservative treatment of compression
fractures of vertebral bodies is not acceptable for patients with polytrauma. Long
term bed rest and external fixators (braces, body posture correctors) can cause
hypostatic complications (pneumonia, thromboembolic complications and others)
and also decompensation of existent somatic pathology [1, 4, 6]. At the same
time, early activation of patients and early axial load in the injury site
causes a kyphotic deformation and development of persistent vertebrogenic pain
syndrome [4]. Also one of unfavorable outcomes of incorrect treatment protocol
for such injuries is development of mobile deformations and, as result, pain
syndrome [8]. Therefore, treatment of patients with spinal injuries and
multiple and associated injuries presents the difficult task, which requires
strict adherence to management protocols and formation of indications for
surgical treatment with consideration of polymorphism of injuries.
Objective – to substantiate the use of percutaneous methods of
spinal stabilization in patients with polytrauma of elderly and old age.
MATERIALS AND METHODS
The
study included 105 patients (40 men – 38.1 %, 65 women – 61.9 %) who were
treated in the clinical basis of traumatology, orthopedics and disaster medicine
department of Sechenov University in 2011-2017. The patients were distributed
in compliance with the age and WHO classification: elderly age (60-74 years):
men – 12 (11.4 %), women – 25 (23.8 %); senile age (75-90 years): men – 28
(26.7 %), women 40 (38.1 %). The mean age of patients was 77.4 ± 1.2.
The
analysis of causes of injuries was conducted. The main cause was road traffic
accidents – 85 (80.9 %) cases. Other causes were catatrauma – 15 (14.3 %) cases,
and sport injuries – 5 (4.8 %). Considering the associated pattern of injury
and presence of concurrent somatic pathology, all patients were in the
intensive care unit immediately after hospital admission. The
mean
ICU
stay
was
9.2 ± 1.1 days.
The
table 1 presents the structure of the injuries.
Table 1. Structure of associated injuries in the examined group of patients
|
Pattern of associated injury |
Number of patients, abs. (%) |
|
Chest injuries (uncomplicated fractures of ribs and sternum; hemo/pneumothorax without need for surgical treatment; lung contusion) |
30 (28.6) |
|
Closed traumatic brain injury (brain concussion, mid brain contusion) |
23 (21.9) |
|
Pelvic injuries (stable fractures) |
10 (9) |
|
Pelvic injuries (unstable) |
5 (4.8) |
|
Upper extremity fractures |
27 (25.7) |
|
Lower extremity fractures |
52 (49.5) |
All
complex of anti-shock measures was conducted at the critical care stage,
including primary external stabilization for long bones and unstable pelvic
injuries according to Damage Control.
According
to results of radial examination (radiography, computer imaging – 100 % of
cases), locations of spinal injuries and their patterns according to
AO/ASIF-Magerl were estimated (the tables 2, 3). ASIA – Type E was used for
estimation of neurological deficiency (100 %).
Table 2. Distribution of incidence of vertebral body injuries according to anatomic regions
|
Injury level |
Number, abs. (%) |
|
Th6-Th9 |
22 (21) |
|
Th10-L1 |
52 (49.5) |
|
L2-L5 |
18 (17.1) |
|
Multiple injuries (2 and more vertebrae) |
13 (12.4) |
Table 3. Distribution of injuries to vertebral bodies in concordance with AO/ASIF-Magerl classification
|
Injury type |
Number, abs. (%) |
|
А1 |
65 (61.9) |
|
А2 |
15 (14.3) |
|
А3 |
17 (16.2) |
|
В1 |
8 (7.6) |
After
transfer from ICU, the complex and dynamic estimation of somatic status was
conducted. It included laboratory, instrumental and clinical methods. If
somatic pathology in the decompensation stage was found, the corresponding
therapy was conducted under supervision of profile specialists.
The estimation of risks of anesthesiology was
conducted with ASA from American Association of Anesthesiologists. The patients
of the examined group had the second (73 (69.5 %) patients) and third (32 (30.5
%) risk degrees.
Considering the characteristics of spinal injuries,
the patients received puncture vertebroplasty of a broken vertebral body
(Vertecem and Vertaplex vertebral bodies), multiple puncture vertebroplasty for
multi-level injuries, percutaneous transpedicular fixation in combination with
vertebral body plasty (if indicated), percutaneous transpedicular fixation with
stabilizing system screw augmentation (Expedium LIS transpedicular fixators).
In all cases, CT showed the absence of spinal canal stenosis (80 patients, 76.2
%) or stenosis was not more than 25 % (25 patients, 23.8 %) that did not
require for opened decompression of the spinal canal, considering the absence
of neurological complications. Puncture vertebroplasty was conducted for stable
fractures of vertebral bodies without injuries to posterior wall of the body.
The technique was used for 60 (57.1 %) cases. Multiple vertebroplasty (up to 3 levels)
was performed for 13 (12.4 %) patients.
The
indications for percutaneous transpedicular fixation were unstable injuries
with kyphotic deformation of spinal column axis. Puncture cement plasty of
vertebral body for stabilization of ventral column of the spine was conducted
in absence of injuries to posterior wall of vertebral body. Percutaneous transpedicular
fixation was performed for 15 (14.3 %) cases including 7 (6.7 %) in
combination with puncture vertebroplasty.
In
10 (9.5 %) cases, the patients received percutaneous transpedicular fixation
with augmentation of screws of the system. The indication for use of this
stabilization type was unstable injuries to vertebral bodies with intense
osteoporotic changes of bone tissue in vertebrae adjacent to injured bodies,
with necessary conduction of intrasurgical reposition and reduction
manipulations owing to risk of instability of screws of fixing system and their
migration. Osteoporotic changes (haemangioma-similar changes in vertebral
bodies, formation of cysts) were visualized with multispiral computer
tomography.
The
X-ray examination was conducted for all patients before surgical treatment.
During
surgery, biplanar monitoring technique with use of two electronic optical
converters in mutually perpendicular planes was used. This technique showed its
efficiency in reduction of surgery time, decrease in radial load for patients
and surgery team [9].
Before
discharge for outpatient treatment all patients received standard X-ray
examination of the spine.
For
objectivation of treatment results, all patients received the questionnaire
with the following scores [1]:
Estimation
of pain syndrome in the back with VAS (Visual Analogue Scale);
Estimation
of total life quality with SF-36 (The Medical Outcomes Study 36-Item Short Form
Health Survey);
Estimation
of functional outcome of injury with FCI (the Functional Capacity Index).
Estimation
of results was conducted with the following scheme:
1.
Before surgical treatment – questionnaire with VAS, SF-36 and FCI.
2.
Before discharge for outpatient treatment – control X-ray examination of the
spine, questionnaire with VAS, SF-36, FCI.
3.
6 months from surgery – multispiral computer tomography of the spine,
questionnaire with VAS, SF-36 and FCI.
4.
After 12 months and then 1 time per year – spinal X-ray examination,
questionnaire with VAS, SF-36 and FCI.
Maximal period of follow-up was 6 years (23 patients,
21.9 %). The mean time of follow-up was 3.4 ± 0.6 years.
The especially important issue was a possibility of
simultaneous operations if several segments of the locomotor system were
injured and surgical treatment was required. Owing to low invasive pattern of
vetrebrologic surgeries, spinal stabilization was carried out simultaneously
with fixation of fractures of extremities and the pelvis in 84 (80 %) cases,
i.e. it showed simultaneous pattern. In 15 cases (14.3 %), stabilization of
spinal injuries showed the isolated pattern in patients with thoracic injuries.
6 patients (5.7 %) refused from offered simultaneous vertebroplasty, but they
were operated within 5-7 days owing to increasing pain in the back.
The statistical analysis was conducted with Statistica
8.0 for Windows (StatSoft Inc., USA). Parametrical statistical techniques
(Student’s test) were used for calculation of probabilities of parametrical
values relating to normal distribution. The mean values were presented as М ± σ. Qualitative variables were described with absolute
and relative frequencies (percentage). Differences
were
statistically
significant
at
p
< 0.05.
The study corresponds to World Association Declare of
Helsinki – Ethical Principles for Medical Research with Human Subjects, 2000,
and the Rules for Clinical Practice in the Russian Federation confirmed by the
Order of Russian Health Ministry on 19 June, 2003, No.266. All patients gave
their written consent for participation in the study and publication of
results.
RESULTS AND DISCUSSION
The mean VAS was 6.1 ± 0.8 before surgical treatment.It corresponds to pain of middle intensity. The patients with associated
injuries to chest organs and the thoracic spine demonstrated the higher value,
which corresponded to strong pain. It is explained by anatomic and functional
relationship of injured structures. Estimation with SF-36 showed
43.17 ± 4.8 %. Presurgical FCI was 49.4 ± 1.7.
All patients received surgical stabilization of the
spine with adherence to the standard protocol. Intrasurgical use of biplanar
monitoring with electronic optical converter reduces the surgery time and
presents the efficient preventive measure of such intrasurgical complications
as malposition of screws of the fixing system, distribution of bone cement into
the spinal canal and others. Strict adherence to the technique prevented the
intrasurgical complications in 100 % of cases.
The X-ray control examination before discharge for
outpatient treatment showed the correctness of performed surgical procedures
and did not differ from intrasurgical one. The results of questionnaire with
VAS, SF-36 and FCI are presented in the table 4.
Table 4. Results of questioning of patients
|
Score |
After surgery |
6 months |
12 months |
2 years |
3 years |
4 years |
5 years |
6 years |
|
VAS |
5.2 ± 0.8 |
4.9 ± 0.5* |
3.2 ± 0.4* |
3.8 ± 0.7* |
4.0 ± 0.2* |
3.2 ± 0.4 |
2.9 ± 0.5 |
3.1 ± 0.6 |
|
SF-36 |
54.2 ± 1.3 |
68.2 ± 2.1* |
78.1 ± 2.3* |
77.5 ± 1.7* |
78.1 ± 1.0* |
77.1 ± 2.4* |
75.5 ± 1.3* |
76.3 ± 2.4* |
|
FCI |
49.6 ± 2.1 |
67.8 ± 1.7* |
80.4 ± 1.7* |
89.2 ± 1.5* |
92.3 ± 1.4* |
90.4 ± 1.2* |
95.1 ± 1.3 |
94.8 ± 1.8 |
Note: * – differences are statistically significant in comparison with basic data, p ≤ 0.05.
As the data shows, the results of the chosen treatment
techniques were improvement in life quality with SF-36 and significant increase
in FCI, indicating the good functional result of treatment. The statistically
significant and reliable results were received within 4 years of the follow-up.
The number of observed patients decreased. 3 years
after surgery, 14 (13.3 %) patients of senile age died. Death of the patients was not related to polytrauma. In 17 (16.2 %) cases, the patients were excluded from the study because
of injuries in different locations. In other cases, the patients refused from
live consultation and questionnaire.
The X-ray examination of the patients 6 months after
surgical treatment showed the signs of bone tissue resorption around fixing
screws without signs of migration in 5 (4.8 %) patients. There was not any
correlation with clinical picture of vertebrogenic pain syndrome.
12 months after surgery, 10 (9.5 %) patients after
puncture vertebroplasty showed stable compression fractures of adjacent
vertebral bodies. All patients received conservative treatment with external
fixators (braces, posture correctors). Further follow-up did not show any
increasing deformation of a fractured vertebral body or increasing pain.
1 (0.95 %) patient showed the incomplete migration of
augmented screws at the background of an abnormal fracture of vertebral body.
The patient refused from revision intervention. The dynamic follow-up did not
show any negative trends in the radial picture, but pain of middle intensity
persisted.
The patients with previous bone tissue resorption
around screws did not show any migration of implants.
The described changes can be explained by existence
and progression of systemic osteoporosis and were not associated with errors in
selection of treatment techniques. One should note all patients received the
recommendations for diagnosis and pharmaceutical treatment of systemic
osteoporosis after hospital discharge.
Also the study group was analyzed for early
postsurgical complications. There were not any local purulent septic
complications in the site of approach to the spinal column. Local purulent
septic complication in osteosynthesis site of extremity bones and the pelvis
were identified in 10 (9.5 %) cases. Hypostatic pneumonia was identified in 13
(12.4 %) patients. Thrombosis of lower extremity veins were diagnosed in 39 (37
%) cases and only in 9 (8.6 %) cases in early postsurgical period. The received
results of incidence of complications correspond to available literature data
[10, 11, 12].
Therefore, the used percutaneous techniques of spine
stabilization showed their efficiency in the patients of older and senile age
with multiple and associated injuries.
CONCLUSION
1. Percutaneous techniques for spine stabilization in
patients with multiple and associated injuries present efficient surgical
treatment.
2. Being low invasive techniques, the described spine
stabilization techniques can be used as a part of the concept of simultaneous
surgery.
3. Percutaneous techniques for spine stabilization do
not increase the risk of purulent septic and thromboembolic complications in
patients with polytrauma.
4. One should extend the list of indications for
puncture vertebroplasty, considering the impossibility of adequate conservative
treatment in patients of older age with uncomplicated stable spinal injuries.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of clear and potential
conflicts of interests relating to publication of this article.
REFERENCES:
1. Kolesov SV, Ptashnikov DA, Shvec VV. Injures of the spinal cord and vertebral column. Moscow:
Author’sAcademy, 2018. 568 p. Russian (Колесов С.В., Пташников Д.А., Швец В.В.
Повреждения спинного мозга и позвоночника. М.: АвторскаяАкадемия, 2018. 568 с.)
2. VaccaroAR, Lehman RAJr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R et al. A
new classification of thoracolumbar injuries: the importance of injury
morphology, the integrity of the posterior ligamentous complex, and neurologic
status. Spine. 2005; 30: 2325-2333
3. Wu YS, Lin Y, Zhang XL, Tian NF, Sun LJ, Xu HZ et al. Management ofhangman's fracture with percutaneous transpedicular
screw fixation. Eur Spine J. 2013;
22(1): 79-86
4. Stadler DI. Transcutaneous transpedicular fixation in victims
with unstable fractures of thoracal and lumbar spine. Cand. med. sci. diss. Kurgan. 2011. 122 p. Russian (Штадлер Д.И. Транскутанная транспедикулярная фиксация у
пострадавших с нестабильными переломами нижних грудных и поясничных позвонков: дис.
… канд. мед. наук. Курган. 2011. 122 с.)
5. Paredes I, Panero I, Cepeda S, Castaño-Leon AM, Jimenez-Roldan L, Perez-Nuñez Á et al. Accuracy of percutaneous pedicle screws for
thoracic and lumbar spine fractures compared with open technique. J Neurosurg Sci. Epub. 2018; Jun 14. URL: https://www.ncbi.nlm.nih.gov/pubmed/29905430
6. Nakano M, Hirano N, Matsuura K, Watanabe H, Kitagawa H, Ishihara H, Kawaguchi Y. Percutaneous
transpedicular vertebroplasty with calcium phosphate cement in the treatment of
osteoporotic vertebral compression and burst fractures. J Neurosurg. 2002; 97(3 Suppl): 287-293
7. Brovkin SS, Kavalerskiy GM, Makirov SK,
Slinyakov LYu, Chenskiy AD, Cherepanov VG. Puncture method of surgical
treatment of osteoporotic vertebral body fractures. RMJ. 2006; (16):
1175. Russian (Бровкин С.С., Кавалерский
Г.М., Макиров С.К., Слиняков Л.Ю., Ченский А.Д., Черепанов В.Г. Пункционный
метод оперативного лечения переломов тел позвонков при остеопорозе //РМЖ. 2006. № 16. С. 1175)
8. Slinyakov LYu, Kavalerskiy GM, Chenskiy AD,
Bobrov DS, Chernyaev AV. Vertebroplasty of mobile deformations of the osteoporotic vertebral
bodies. Department of Traumatology and Orthopedics. 2014; (2): 5-10.
Russian (Слиняков Л.Ю., Кавалерский Г.М.,
Ченский А.Д., Бобров Д.С., Черняев А.В. Вертебропластика мобильных деформаций тел
позвонков на фоне остеопороза //Кафедра травматологии
и ортопедии. 2014. № 2. С. 5-10)
9. Chernyaev AV. Applications of minimally
invasive technologies in the lumar spine stabilization at degenerative
diseases. Cand. med. sci. diss. Moscow,
2011. 110 p. Russian (Черняев А.В.
Применение малоинвазивных технологий в задней стабилизации поясничного отдела
позвоночника при дегенеративно-дистрофических заболеваниях: дис. … канд. мед. наук.
М., 2011. 110 с.)
10. Agadzhanyan VV. Septic complications in polytrauma. Polytrauma. 2006; (1): 9-17.
Russian (Агаджанян В.В. Септические осложнения при политравме //Политравма. 2006.
№ 1. С. 9-17)
11. Dorzheev VV, Miromanov AM, Davydov SO, Miromanova NA, Vitkovsky YuA.
The personalized aspects of development of venosus thromboembolic complications
in polytrauma. Polytrauma.2016; (4):
31-39. Russian (Доржеев В.В., Мироманов А.М., Давыдов С.О., Мироманова Н.А., Витковский
Ю.А. Персонализированные аспекты развития венозных тромбоэмболических
осложнений при политравме //Политравма. 2016. № 4. С. 31-39)
12. Bondarenko AV, Gerasimova OA, Lukyanov VV, Timofeev VV, Kruglykhin IV. Composition, structure
ofinjures, mortality and features of rendering assistance for patients during
treatment of polytrauma. Polytrauma. 2014; (1): 15-22. Russian (Бондаренко А.В., Герасимова О.А., Лукьянов В.В., Тимофеев В.В., Круглыхин
И.В. Состав, структура повреждений, летальность и особенности оказания помощи у
пострадавших на этапах лечения политравмы //Политравма. 2014. № 1. С.15-22)
Статистика просмотров
Ссылки
- На текущий момент ссылки отсутствуют.
