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Outcomes of Operative Treatment of Traumatic Spinal Injuries: 2-Year Follow-Up
Mehdi Mahmoodkhani1, Majid Rezvani2, Arman Farshin3, Pouria Ghasemi3, Donya Sheibani Tehrani4
1 Department of Neurosurgery, School of Medicine, Neurosciences Research Center, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Neurosurgery, School of Medicine, Neurosciences Research Center, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of General Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of IT, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| Date of Submission | 27-Feb-2023 |
| Date of Acceptance | 23-Jul-2023 |
| Date of Web Publication | 31-Aug-2023 |
Correspondence Address:
Arman Farshin
Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan
Iran
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/abr.abr_82_23
Background: Spinal cord injury (SCI) is the second cause of complications and disability after brain injury. Although primary prevention is the best strategy, obtaining the necessary knowledge about the patient's condition and follow-up treatment can lead to the use of safety measures and appropriate healthcare planning. This is the basis of this study with the aim of a two-year follow-up of patients with traumatic SCI (TSCI) who underwent surgery.
Materials and Methods: This study was a descriptive and analytical type that examined 79 patients with TSCI who had undergone surgery two years ago. The data were collected by a standard questionnaire and analyzed in Statistical Package for the Social Sciences (SPSS) version 24 software.
Results: Among the patients in our study, 39.2% of them had the initial C American Spinal Injury Association (ASIA) score followed by patients with grade D (31.6%), grade A (15.2%), and grade E (14%), respectively, and also, a most common type of vertebral column injuries is burst fractures with a prevalence of 62%, followed by fracture–dislocation injury (25.3%) and compressed fracture (12.7%). Regarding the improvement of patients according to ASIA grade, the highest percentage of improvement is seen in grad grades D (84% and 77%), and grade A patients have improved to grade B by about 33.3%. In the study conducted, 5% of patients died during 24 months of follow-up, which means 75% of the deceased patients were grade A patients at the time of admission.
Conclusion: As mentioned, the most important predictor of the patient's prognosis is the patient's initial condition.
Keywords: Disability, spinal cord injury, traumatic spinal injuries
How to cite this article:
Mahmoodkhani M, Rezvani M, Farshin A, Ghasemi P, Tehrani DS. Outcomes of Operative Treatment of Traumatic Spinal Injuries: 2-Year Follow-Up. Adv Biomed Res 2023;12:217 |
How to cite this URL:
Mahmoodkhani M, Rezvani M, Farshin A, Ghasemi P, Tehrani DS. Outcomes of Operative Treatment of Traumatic Spinal Injuries: 2-Year Follow-Up. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:217. Available from: https://www.advbiores.net/text.asp?2023/12/1/217/384885 |
| Introduction | |  |
Spinal cord injury (SCI) is common and can occur thousands of times a day worldwide. The global incidence of traumatic SCI (TSCI) is about 10.5 cases per 100,000 persons.[1] Its devastating complications can cause difficulties for injured people and their families for years.[2],[3],[4] For patients with TSCI, life expectancy increased substantially over the last few decades owing to medical advances.[5]
The most significant principle is that treatment for patients should be done as soon as possible, and maximum recovery should be achieved in the shortest time.[6]
Despite significant advances in spine surgery in recent decades, it is still considered one of the most demanding surgeries. The main cause of TSCI is mainly the mechanical damage that occurs during the accident, which is the primary damage. The mechanism of secondary damage plays a role in a delay compared with the primary damage. The goal of surgery is to relieve tension in the spinal canal, restore spinal alignment, and get the patient up and running as quickly as possible.[7]
Rath et al. in a study in 2017 entitled “Spinal cord injury - the role of surgical treatment for nerve healing” stated that early surgery within 24 hours after injury is safer and better than late surgery to prevent secondary SCI.[8] As can be seen, most studies have examined the status of SCI at the time of occurrence and the type of treatment, but it is necessary to pay attention to these patients' months after the accident and surgery.
According to the Kumar et al. study in 2018, road traffic accidents (39.5%) followed by falls (38.8%) were the most common mechanisms for TSCI worldwide. Worldwide, the mean age of TSCI patients was 39.8. When the average age was analyzed by income classification, low-income countries exhibited the youngest average age at the time of injury. Also, males were more commonly affected by TSCI, with an average male-to-female ratio (M: F) of 3.37: 1 worldwide through all World Health Organization (WHO) regions and income levels.[1]
It is noteworthy that in most countries, the average age is less than 45 years[9] (mean age in Iran = 31 ± 6),[10] so it is clear if that individual does not recover after surgery, the patient will spend more years with a disability. Due to the contents stated above, this issue can be trouble for the patient and the country's economy.
For patients with TSCI, the SCI literature routinely reports mortality rates that are two to three times higher than in the general population.[11] Unfortunately, despite advances in medical technology and rehabilitation, many studies have found limited or no improvement in long-term mortality.[12],[13] In a 2017 study, Savic et al. reported respiratory disease (including infections), cardiovascular disease, and neoplasms as the leading causes of death in those who survived at least 1 year after injury.[14]
Patient mortality rate after surgery is a significant factor that can be considered a bias in studies that follow patients for a very long time. According to a systematic review conducted in 2018, 12.8% of patients with thoracolumbar injuries die after about 4.5 years. This statistic jumps to more than 20% after 10 years of follow-up.[15] Accordingly, long-term follow-up of patients can have unrealistic results.
To the best of our knowledge In Iran, few studies have examined the follow-up of patients after surgery, and all of them have followed patients for a long time. In this study, with the follow-up of patients in a reasonable period, it is possible to more realistically predict the likelihood of disability in patients with SCI after surgery.
| Materials and Methods | | |
This descriptive, nonrandomized study was conducted to predict the disability rate of patients after SCI surgery. The data used in this study are all related to patients with TSCI who were referred to the emergency department immediately after the injury from April 2019 to March 2020 and who were surgically managed in the Department of Neurosurgery, Kashani Hospital, Isfahan. It should be noted that all surgeries were performed by the same team.
The study was approved by the Institutional Ethics Committee of Isfahan University of Medical Sciences, Iran.
The inclusion criteria include all patients with TSCI due to spinal fractures referred to Kashani Hospital for spinal surgery on the mentioned date. Patients were excluded from the study only if they were unwilling to cooperate, had incomplete information, and had an underlying disease affecting the bone, for example, osteomyelitis, osteodiscitis, thyroid disease, and parathyroid disease. For each patient, the American Spinal Injury Association (ASIA) score is recorded 24 to 30 months after surgery with a complete examination. The ASIA impairment scale describes a person's disability due to SCI. This scale indicates how much sensation a person feels after light touch and a pinprick at multiple points on the body and tests key motions on both sides of the body.
LT = light touch; PP = pinprick; DAP = deep anal pressure; AIS = ASIA Impairment Scale; NLI = neurological level of injury
- Grade A = Complete. No sensory or motor function is preserved in the sacral segments S4-5.
- Grade B = Sensory incomplete. Sensory but no motor function is preserved below the neurological.
- Grade C = Motor incomplete. Less than half of key muscle functions below the single NLI have a muscle grade <3.
- Grade D = Motor incomplete. At least half (half or more) of key muscle functions below the single NLI have a muscle grade ≥3.
- Grade E = Normal.[15]
In addition to the information collected by the ASIA scoring system, the occupation of the individuals, demographic information, the cause of the trauma, type of spinal column injury, and magnetic resonance imaging/computed tomography (MRI/CT) images are collected. The collected information will be compared and evaluated from sensory and motor aspects. Furthermore, recovery of cervical, thoracic, and lumbar spinal cord injuries will also be compared. To reduce study bias, the number of patients who died after surgery will be reported.
Patients' sphincteric complaints were evaluated in person and at the time of the patients' visit. Data analysis is performed using Statistical Package for the Social Sciences (SPSS) software (SPSS Inc., Chicago, IL, USA) version 24, and in all analyses, a significance level of 0.05 will be considered. Quantitative data will be reported as mean and standard deviation, and qualitative data will be reported as distribution and frequency percentage.
| Results | | |
Study population
Through the census (April 2019 to March 2020), a total of 102 patients were enrolled in the study, 79 of whom had complete file information and were referred for follow-up. A descriptive analysis is shown in [Table 1]. The highest number of patients in this study is related to the age range of 23–37 years (24%). The average age of the patients in this study was 39.64 years (from 9 to 75 years). Among the patients, 74.7% were men with a M: F of 2.95:1. Also, more than 55% of patients under study are self-employed and employees are the least frequent. The most frequent injury mechanism is motor vehicle accidents (54.4%) followed by falls (36.7%). Most of the patients referred to Kashani Hospital in the mentioned period were with ASIA grade C (39.2%), followed by patients with grade D (31.6%). Regarding the prevalence of vertebral column injuries in the study population, as can be seen, the most common type of injury is burst fractures with a prevalence of 62%, followed by fracture–dislocation injury (25.3%). Regarding sphincter dysfunction at the admission time, about 28% and 23% had urinary and anal sphincter dysfunction, respectively.
Clinical characteristics
The initial ASIA grades and subsequent changes after 24 months are shown in [Table 2]. A change in neurological status of ≥1 ASIA grade from the date of admission to 24 months of follow-up was considered an improvement. Among the categories based on the ASIA grade, the highest percentage of improvement is seen in grade D (84%), and in the next rank are patients with grade C, who have improved by about 77%. Also, grade A patients have improved to grade B by about 33.3%. In the study conducted, 5% of patients died during 24 months of follow-up, which means 75% of the deceased patients were grade A patients at the time of admission. Regarding the cause and time of death in these patients, all four patients died within one year after the accident. Pulmonary infection and cardiorespiratory arrest can be mentioned among the causes of mortality in these patients. | Table 2: Improvement in American Spinal Injury Association grades at 24-month follow-up
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Improvement of the urinary and bowel emptying after 24 months of follow-up after surgery is given in [Table 3]. As can be seen, 83% of patients with anal sphincter dysfunction at the time of SCI remained without recovery; however, bladder emptying improved in about 64% of patients with urinary sphincter dysfunction. | Table 3: Urinary/anal sphincter function after 24-month follow-up in patients with urinary/anal sphincter dysfunction in admission time
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[Figure 1]: Distribution of sensory and motor scores of patients according to age at the time of SCI and follow-up 24 months later. X scale: age; Y scale: sensory/motor score. | Figure 1: Trend lines of the distribution of sensory and motor scores of patients according to age at the time of spinal cord injury and follow-up 24 months later
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Lines (1) and (2) show the total motor scores of the upper and lower limbs of patients at the time of injury and at the 2-year follow-up time, respectively.
Lines (3) and (4) show the total sensory scores of patients (light touch and pinprick test) at the time of injury and at the 2-year follow-up time, respectively.
Level of SCI
In [Table 4], the recovery of patients with SCI has been examined and compared according to the change in ASIA grade. Patients with a change in ASIA grading from A to B and C to D are classified as relative recovery, and a change from C to E or D to E is classified as complete recovery. In the studied population, lumbar SCI is the most common level of injury in patients with SCI (44.3%), followed by cervical SCI, which includes about 32% of cases. Among the people with different locations of SCI who underwent surgery, the highest change in ASIA grade and complete recovery of the patient is related to lumbar spinal cord injuries, followed by cervical spinal cord injuries. It should also be mentioned that 75% of the patients who died during the follow-up period are from people with a cervical level of SCI. | Table 4: Comparison of improvement in cervical, thoracic, and lumbar cord injuries
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| Discussion | | |
SCI not only affects patients' physical, mental, and social well-being but also imposes a heavy burden on families, communities, and healthcare systems. Therefore, investigating and evaluating the factors affecting the recovery rate of patients with SCI can significantly reduce the mentioned problems.
In the conducted study, the average age of patients with SCI is 39.64. This means that if the person does not recover after the operation, he will spend more years with a disability (mean age in Iran = 31 ± 6 (5)). Since road accidents are the most common cause of spinal cord injuries (54.4% of cases), the first measure to reduce the complications of spinal cord injuries is to prevent road accidents.
The initial ASIA grade was the subject of several studies, which had an effect on outcomes. Coleman and Geisler[16] opined that SCI severity is the main predictor of the outcome of patients with SCI. They also reported that ASIA grades C and D had a significantly better recovery than ASIA grade B, and grade B subsequently achieved better results than grade A.[17]
In this study, at 24 months postoperatively, improvement in patient condition was observed in 33%, 77%, and 84% of grade A, C, and D patients, respectively. No patient experienced neurological grade deterioration. In general, after 24 months from the time of TSCI and surgery, 38% of the patients have reached full recovery with grade E and this grade change is related to the initial grade of the patients; the better the initial grade, the more likely it is to achieve a full recovery (grade E) and 24% of all people are living with a brief neurological deficit with grade D. In other words, in our study, performing surgery for patients with TSCI in 62% of patients caused a change of 1 or more in the ASIA grade (grade D to E, n = 21; grade C to E, n = 9; grade C to D, n = 15; grade A to B, n = 4).
Regarding emptying the bladder and intestine, in our study following SCI, the rate of urinary sphincter disorder was higher than that of anal sphincter disorder (28% and 23%, respectively), but the rate of recovery is higher in people with bladder emptying disorder than in bowel emptying disorder (36% and 17%, respectively).
Regarding the effect of surgery on the sensory and motor condition of patients according to [Figure 1], mentioned above, the crossing point of the pair of lines shows the peak age of the effect of surgery on the recovery of people up to the mentioned age, which is 65.14 and 65.33 years for the motor and sensory recovery of people, respectively. In other words, the younger a person is to 65 years old, the more useful it is to undergo surgery to improve their motor and sensory scores. Also, the angle between the pair of lines (1) and (2) “about 9 degrees” compared with (3) and (4) “about 18 degrees” indicates the effect of surgery on the improvement of patients' motor scores compared with their sensory scores, which considering the greater angle between the two lines related to sensory scores, the effect of surgery is significantly greater on improving the sensory condition of patients.
Regarding the long-term complications and ambulation of spinal cord injuries, we can mention spasticity, flaccidity, and muscle atrophy in grades A and B; also, we can see respiratory complications in about 20% of patients with cervical SCI (of five of 25 patients with cervical SCI, three of them have died during 2-year follow-up). These complications have socioeconomic consequences for the patients and society. In our study after 2 years of follow-up, about 11% of patients use wheelchairs for ambulation (n = 9), about 32% of patients need assistance, e.g., a cane for ambulation (n = 25), and the rest of them (57% of patients) can ambulate independently.
| Conclusion | | |
As mentioned, SCI has significant mortality and morbidity and occurs in the age range of 40 years. Since a patient's baseline status is the most important predictor of patient prognosis, traffic accident prevention is the most important factor in reducing the burden of disease on individuals and society. Also, paying more attention to patients with cervical SCI during hospitalization and follow-up can reduce the mortality rate caused by respiratory problems such as pneumonia.
Acknowledgment
The authors would like to thank all the neurosurgical attending professors, medical residents, and nursing staff for data collection and for their meticulous patient care.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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