Spine injuries Which cases should have early surgery? And which should NOT?

Transcription

1 Spine injuries Which cases should have early surgery? And which should NOT? Tolga Aydoğ, MD, PhD Acıbadem Fulya Hospital Acıbadem Sports Acıbadem Mehmet Ali Aydınlar University Eczacıbaşı Sports Club

2 Spine problems can cause serious problems, even if they are relatively minor Low back pain affects Up to 80% of the general population, Nearly 30% of athletes All spine injuries 55% is cervical spine 45% is split thoracal, thoracolumbar, lumbosacral Totally 12,500 SCI new cases each year in US In athlets 9% of these Li Y, Hresko MT. Clin Sports Med 2012

3 The content of the talk Evaluation on sideline Who can continue to game, who has to out? Should we take out? Take him to hospital and how? Injuries requiring surgery Early In coming period Take home message

4 Gordon J, Nordstrom A. Ency of Football Med 2017 Evaluation on sideline 1 st Step Airway (with C-spine) 2 nd Step Breathing 3 rd Step Circulation 4 th Step Disability 5 th Step Extraction from field of play

5 Rackauskas Z et all. J Neurol Surg A 2016 Gordon J, Nordstrom A. Ency of Football Med 2017 Evaluation on sideline Primary injuries; direct trauma affect the bone and/or soft tissue Secondary injuries; Arterial disruption, arterial thrombosis Hypoxia (ischemia free radicals due to reperfusion) Hypovolemia microcirculation breakdown, loss of autoregulation, etc Deterioration of energy metabolism

6 Evaluation on sideline Mechanism of injury; Falling onto face; Central cord injury Falling flexion position with axial load; Vertebral wedge fracture Falling from height onto the head Burst fracture of the C % of the cervical vertebrae injuries Accompanied by spinal injuries in the other region Anderson S, Schnebel B. Curr Pain Headache Rep 2016 Gordon J, Nordstrom A. Ency of Football Med 2017

7 Evaluation on sideline Cervical injury CCS (Canada Cervical Spine) rules Absence of posterior midline C-spine tenderness GCS = 15 An absence of focal neurological deficit (motor or sensory) Lateral neck rotation > 45 Axial load to head or fall from elevation < 90cm An absence of any distracting injury Open fracture Visceral organ injury Gordon J, Nordstrom A. Ency of Football Med 2017

8 Evaluation on sideline Possibility of cervical injury according to CCS Immobilization Hard Collar Transfer to hospital Gordon J, Nordstrom A. Ency of Football Med 2017

9 Treatment algorithm for C- spine injury Huang P et all. Sports Health 2016

10 Imaging in spinal injuries X-ray Cervical AP, lat ve open mouth AP graphy (for odontoid) 93% sensitive for fracture + Flex/ext X-ray (attention) 99% negative predictive value CT-scan For cervicothoracic region absolutely Other region may be add MRI Effective in revealing disc and ligamentous structure Huang P et all. Sports Health 2016 Chin LS et all. e-medicine 2017 Puvanesarajah V et all. Clin Spine Surg 2017

11 Indications for surgery Early surgery Acute fractures with instability Compression on spinal cord and cauda equina Surgery in the following period Do not response conservative treatment Progressive weakness Eddy D et all. Clin J Sports Med 2005 Rackauskas Z et all. J Neurol Surg A 2016

12 Early surgery Fracture and ligamentous C-Spine injury SLIC (Subaxial Cervical Injury Classification) Patel AA et all. Spine 2010

13 Early surgery Fracture and ligamentous C-Spine injury SLIC (Subaxial Cervical Injruy Classification) For morphology X-ray ve CT-scan is enough, MRI makes a serious contribution For discoligamantous complex X-ray and CT are effective to demonstrate complete rupture, MRI is effective in partially injured Neurological status MRI effective Finally 1-3 cons, 4 cons/surgery, >4 operation Patel AA et all. Spine 2010

14 Early surgery Fracture and ligamentous C-Spine injury = = = 4 Patel AA et all. Spine 2010

15 Early surgery Fracture and ligamentous TL-Spine injury AOSpine Classificatios System were based on: Morphology of the fracture Neurological status Clinical modifiers The classical AO-Magerl system s describe the observed mode of failure of the spinal column as a mechanical construct. Type A: Compression injuries with intact tension band. Type B: Failure of the posterior or anterior tension band through distraction. Type C: Failure of all elements leading to dislocation, translation, or displacement in any plane. Schnake KJ AA et all. J Orthop Trauma 2017

16 Early surgery Morphology of fracture TL-Spine injury Type A- Compression injuries with intact tension band A0 mechanically insignificant fractures A1 compression or impaction fractures a single endplate A2 are coronal split of pincer-type fractures involving both endplates A3 incomplete burst fractures affecting a single endplate with any involvement of the posterior vertebral wall. A4 complete burst fractures affecting both endplates with any involvement of the posterior vertebral wall. Schnake KJ AA et all. J Orthop Trauma 2017

17 Early surgery Morphology of fracture TL-Spine injury Type B: Failure of the posterior or anterior tension band through distraction B1 monosegmental osseous failure of the posterior tension band extending into the vertebral body. B2 disruption of the posterior tension band with or without osseous involvement. B3 anterior tension band injury with disruption or separation of the anterior structures (bone/disc) with tethering Schnake KJ AA et all. J Orthop Trauma 2017

18 Early surgery Morphology of fracture TL-Spine injury Type C Injuries: Displacement / Translational Injury No subdivision Highly unstable due to separation, displacement, or translation of 1 vertebral body (or elements) relative to another in any direction. Schnake KJ AA et all. J Orthop Trauma 2017

19 Early surgery Morphology of fracture TL-Spine injury Reinhold M et all. Eur Spine 2013

20 Early surgery Morphology of fracture TL-Spine injury Reinhold M et all. Eur Spine 2013

21 Early surgery Morphology of fracture TL-Spine injury Reinhold M et all. Eur Spine 2013

22 Early surgery Conus medullaris or cauda equina syndrome Cauda equina syndrome (CES) - multiple 2 nd motor neurons injury, Conus medullaris - 1 st w/wo 2 nd motor neuron injury Neurological pathologies in lower extremity Tingling / numbness (saddle anesthesia) Weakness Urinary-bowel (red flag) Incontinence Retention Leg pain Impotence Dawadu ST et all. e-medicine 2017 Hsu WK, Jenkins TJ. JAAOS 2017

23 Early surgery Conus medullaris or CES Conus medullaris CES Presentation Sudden and bilateral Gradual and bilateral Reflexes Knee jerks preserved but ankle jerks affected Both ankle and knee jerks affected Radicular pain Less severe More severe Low back pain More Less Motor strength Sensory symptoms Typically symmetric More localized to perianal area; symmetrical Asymmetric areflexic paraplegia More localized to saddle area; asymmetrical Impotence Frequent Less frequent Sphincter dysfunction Urinary retention, atonic anal sphincter Present late in course of disease

24 Causes Early surgery Conus medullaris or CES Herniated nucleus pulposus (cause of 2-6% of cases of cauda equina syndrome Lumbar spinal stenosis Inflammatory conditions (such as AS) Infections of the spinal canal Tumors/neoplasms Trauma to the lumbar spine, Hsu WK, Jenkins TJ. JAAOS 2017

25 Tx Early surgery Conus medullaris or CES Specific treatment due to the primary cause The application of steroids is controversial, but doctors want to apply it If no relief of symptoms is achieved during 24h, immediate surgical decompression is necessary to minimize the chances of permanent neurologic injury Most surgeons suggest decompression as soon as possible (within 8h) the onset of symptoms if symptoms develop suddenly. Hsu WK, Jenkins TJ. JAAOS 2017

26 Early surgery Conus medullaris or CES Morbidity rates are determined by the underlying etiology. Bilateral sciatica Complete perineal anesthesia The extent of perineal or saddle sensory deficit Females and patients with bowel dysfunction have been reported to have a less favorable prognosis

27 Early surgery Spinal Cord Compression Meredith BS et all. AJSM 2013

28 Early surgery Spinal Cord Compression Meredith BS et all. AJSM 2013

29 Eddy D et all. Clin J Sports Med 2005 Huang P et all. Sports Health 2016 Early surgery Spinal Cord Compression and Cord Neuropraxia Spinal cord compression may disrupts motor, sensory and autonomic functions Compression due to The bony structure Cervical spine C3-7 less 13mm at lateral cervical on X-ray Thoracal spine Stenosis is low, because the spinal cord / canal ratio Soft tissue structure (to disc, facet or ligament) Spinal Cord Injury Without Radiological Abnormality (SCIWORA) Actually better prognosis with SCI+radiologic evidence

30 Eddy D et all. Clin J Sports Med 2005 Huang P et all. Sports Health 2016 Early surgery C-Spine stenosis and Cord Neuropraxia Torg-Pavlov ratio; cervical canal /body of vertebra > 1 < 0.8 stenosis (it is not always true) Sensitivity 93% in American football siti Positive Predictive Value 0.2%

31 Cord Neuropraxia A Cervical cord neurapraxia is characterized by a transient neurologic deficit Fully recovers without any apparent structural damage If the player has cord neuropraxia Need to plain radiographs and MRI Stenosis, ligamentous injury, cord defects, or edema, RTP is contraindicated?? Eddy D et all. Clin J Sports Med 2005 Huang P et all. Sports Health 2016

32 Early surgery Central Cord Syndrome (CCS) Hyperextension injury Compression fracture Fracture dislocation especially in a congenitally narrowed spinal canal Axonal disruption in the lateral columns at the level of the injury of the spinal cord Motor impairment results from the pattern of lamination of the corticospinal and spinothalamic tracts Eddy D et all. Clin J Sports Med 2005 Rackauskas Z et all. J Neurol Surg A 2016

33 Symptoms Early surgery Central Cord Syndrome Greater impairment of motor function in the upper extremities than in the lower Bladder dysfunction A variable amount of sensory loss below the level of injury DTRs may initially be absent but will eventually return along with variable degrees of spasticity in affected muscles. Eddy D et all. Clin J Sports Med 2005 Rackauskas Z et all. J Neurol Surg A 2016

34 Early surgery Central Cord Syndrome Surgery is rarely indicated Because of the inherently favorable prognosis for patients with central cord syndrome Surgery; Compression of the spinal cord persists Gross spinal instability is present Neurologic deficits progress Guidelines (2016 by Wilson), early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome. Wilson JR et all. Neurosurgery 2016 Rackauskas Z et all. J Neurol Surg A 2016

35 Hsu WK et all. Spine J Huang P et all. Sports Health 2016 Surgery in the following period Herniated Nuclues Pulposus (HNP) Although frequent in sports, there is no treatment guide. Surgery need if Conservative tx not responding within 6w Progressive neurological deficits Pain interferes with social, work and home life The flagship study of the lumbar HNP in the athlete Cons 82% Opere 81% An additional 3.3 years to their careers

36 Surgery in the following period Surgery for huge HNP Patients with Lomber HNP In 46% of pateints, % resorption of HNPs Saal JA et all. Spine 1990 In 48% of patients, 70% resorption of HNPs, and 15% of patients, 30% to 70% resorption of HNPs Bozzao A et all Radiology 1992 Eddy D et all. Clin J Sports Med 2005

37 Surgery in the following period Surgery for much pain in HNP Initial treatment of HNP is conservative, we have to decrease the pain In 17 athlets, 37 were injected during 27 attacks The injections were administered at an average of 4 days after the acute pain RTP 89% after injection (24 of27) Missed # training 2.8 (0-12), missed # match 0.6 (0-2) 4 athletes needed 2nd injection for pain, 3 of them went to surgery The main underlying cause is sequestre disc and the presence of weakness Krych AJ et all. Med Sci Sports Exerc 2012

38 Surgery in the following period Surgery for hyperintense site in spinal cord Is hyperintense site present on the cervical cord an indication for surgery? Hyperintense in the cord can be completely remedied by treatment Temple ZJ et all. Neurosurg 2015 Joaquim AF et all. Neurosurg Focus 2016

39 Li Y, Hresko MT. Clin Sports Med 2012 Kang DG ve ark. Clin Sports Med 2016 Possible surgery - early return? Lumbar HNP

40 Surgery in the following period Spondylolysis 3-6% in the general population, 80% asymptomatic 14% for young athletes The cause of 47% of young athletes with back pain It is high in some sports (diving, dancing, wrestling, shooting sports, rowing and gymnastics) Li Y, Hresko MT. Clin Sports Med 2012 Burgmeier RJ, Hsu WK. Asian J Sports Med Huang P et all. Sports Health 2016

41 Tx; Surgery in the following period Conservative tx Spondylolysis Rest and Boston / TLS Orthosis Use may be interrupted when the pain is reduced Surgery tx Do not respond to 6 months of conservative tx If go to lystesis Stubborn neurological deficit Non-contact sports RTP at 6 months 62-66% Li Y, Hresko MT. Clin Sports Med 2012 Burgmeier RJ, Hsu WK. Asian J Sports Med Huang P et all. Sports Health 2016

42 Eddy D et all. Clin J Sports Med 2005 Huang P et all. Sports Health 2016 Surgery in the following period Stingers / Burners Brachial plexus and cervical root affected, Sensory and / or motor-related burning, tingling. Three mechanisms: 1. Nerve tension (as opposed to the head symptomatic side, shoulder and arm depressed on the symptomatic side) 2. Foraminal compression when the head is on the symptomatic side and in the extension 3. Direct trauma to the brachial plexus

43 Surgery in the following period Stingers / Burners Every year, half of college-level footballers suffer Repeat 20% Athlete should see a doctor who has had three problems at the same season More than half of those living in this condition have less than 1 day of RTP For conservative treatment-resistant conditions resulting from foraminal or HNP go to surgery Eddy D et all. Clin J Sports Med 2005 Huang P et all. Sports Health 2016

44 Take home message Maximum attention to athlete who are likely to suffer spinal injuries Midline C-spine tenderness, GCS <15, neurologic deficient, side rotation <45, falling type, distracting injury Emergent surgery Unstable fracture, Spinal cord compresion and CES No need emergent surgery HNP Based on MRI or pain Early return to play Spondylolysis Central cord syndrome Dependent to etiology

45 Thank you

46 Early surgery Fracture and ligamentous C-Spine injury 32y hockey player Violent collision with another player Neurolocial Exam is normal, X-ray and CT-scan showed isolated right C5-6 fascet fracture and instability PLL partially injured in MRI but no stenosis or cord injury Tx: Cervical discectomy, fusion was applied, RTP after 6 months and continued for 3 years. Molinari RW et all. Global Spine J 2016

47 Early surgery Neurlogical status TL-Spine injury Neurological status : N0 neurologically intact. N1 transient neurological deficit, which is no longer present by the time of clinical examination. N2 symptoms or signs of radiculopathy., N3 incomplete spinal cord or cauda equina injury. N4 complete spinal cord injury. NX neurology undetermined (due to intubation, sedation, intoxication, cerebral trauma etc).