1993 nternatinal Medical Sciety f Paraplegia eurlgical utcme frm cnservative r surgical treatment f cervical spinal crd injured patients J E Kiwerski Spinal Department f Metrplitan Rehabilitatin Centre, Knstancin, Pland. This is an analysis f the results f treatment f 1761 patients with traumatic injury f cervical spinal crd, admitted t hspital within the first hurs r days after injury. Analysis f the results f cnservative treatment in 798 patients and f surgical treatment in 963 patients has shwn that the results are t a large extent dependent n the methd f treatment and when specialist treatment was started. Keywrds: cervical spinal crd injury neurlgical imprvement; cnservative treatment; surgical treatment. ntrductin Early, prper medical management f patients with spinal crd injury is crucial fr the future f such patients. n ur pinin it is wrng t assume that either surgical r cnservative treatment is the nly apprpriate way f managing such patients. The decisin cncerning the kind f treatment shuld be made deliberately, taking int accunt factrs such as: type f spinal injury, degree f spinal crd injury, general cnditin f the patient, age f the patient, accmpanying injuries, etc. We attempt t chse the treatment which will secure the best pssible pprtunity t btain neurlgical imprvement and stable cnslidatin f the injured spine, and t shrten the perid f immbilisatin f the patient, while at the same time nt significantly increasing the risk f a fatal utcme r causing neurlgical deteriratin. Clinical material n the years 1965-1991, 1761 patients with cervical spinal crd injuries, were admitted and treated in the Spinal njury Department f ur hspital within the first hurs r days after injury (up t 2 weeks). Table gives the level and degree f spinal crd injury. Table Level and degree f spinal crd injury Degree f spinal Level f spinal injury crd injury C-C3 C3-C5 C5-Tl Ttal Cmplete 11 270 473 754 B 16 84 152 252 ncmplete C 32 147 179 358 D 48 133 216 397 Ttal 107 634 1020 1761 B. C. D = Frankel grades' Partial injuries f spinal crd are divided int 3 grups,1.2 crrespnding t grades B. C. D f the Frankel classificatin.' The largest grup are thse with cmplete spinal crd injuries (43% f patients). Our department is ne f the few specialist departments in Pland managing spinal crd injuries in the acute perid. Therefre patients sent t us are mre ften thse wh present with significant management prblems. With regard t the level f spinal injury the least cmmn is the C1-C3 segment (including C3 bdy fractures) injuries at C3-C5 cme next. The mst frequent incidence is at C5-Tl, making up 58% f the patients.
Treatment f cervical spinal crd injuries 193 Methds The methd f prcedure is greatly dependent n the nature f the spinal injury. Cmpressin fractures usually require cnservative treatment with immediate skull tractin. f the spinal crd injury is fund nt t be clearly related t the degree f spinal clumn injury, then cntrast radilgical examinatin f the vertebral canal is perfrmed in rder t exclude the pssibility f a prlapsed intervertebral disc. Such studies are als perfrmed in patients with a spinal crd injury if there is n radilgical evidence f changes in plane xrays f the spine. Massive fractures knwn as 'burst fractures' with bne fragments dislcated int the vertebral canal are treated surgically with early decmpressin f the spinal crd. Fracture f the anterir part f a vertebra frm a flexin mechanism is treated in a similar way as fr a cmpressin fracture, by skull tractin. Dislcatin withut a vertebral bdy fracture is usually treated surgically by stabilising the spine at the site f injury with an autgenus bne graft by a anterir apprach. Spinal injury frm an extensin frce is usually treated cnservatively by immbilisatin f the spine in an rthpaedic cllar. Regardless f the basic methd f treat- ment, nursing and rehabilitatin prcedures are applied the mment the patient is admitted t hspital. n the early psttraumatic perid particular attentin is paid t breathing exercises and early elevatin f the patient in specially designed beds. 4 Results The results f treatment are set ut in Tables 1a and lib. The neurlgical state n admissin is cmpared t that btained after hspitalisatin. eurlgical imprvement was achieved in 51 % f patients n the cmpletin f treatment. n the cnservatively treated grup neurlgical imprvement ccurred in 40% f patients, and in the surgically treated grup in 60%. The mrtality rate was 14%, accunted fr by the large number f cmplete spinal crd injuries. Mrtality in thse with a cmplete spinal crd injury was 27%, and in thse with an incmplete spinal crd injury 4%. Tables la, b and V present the results f treatment with regard t the time frm the injury t the cmmencement f treatment in a specialist spinal centre. Table" la and b present the results f cnservative and surgical treatment, respectively. The results f treatment were Table a Cnservative treatment Spinal crd damage Discharge n admissin Cmplete B C D rmal Mrtality Ttal mprvement Cmplete 214 6 6 3 132 361 7% B 9 42 2 8 95 90% 34 C 32 102 11 18 163 78% D 62 115 2 179 65% Table lb Surgical treatment Spinal crd damage Discharge n admissin Cmplete B C D rmal Mrtality Ttal mprvement Cmplete 256 22 23 17 75 393 19% B 10 41 93 9 4 157 93% C 9 132 51 3 195 95% D 25 192 218 88% B, C, D = Frankel grades3
194 Kiwerski Paraplegia 31 (1993) 192-196 Table la Results f cnservative treatment njury-admissin Results f trauma Ttal time Gd Fair imprvement Deaths p t 6 hurs 85 42 72 60 259 7-12 h 42 27 67 41 177 13-24 h 33 35 68 45 181 2-3 days 16 22 39 10 87 4-7 days 3 12 30 3 48 Over 7 days 4 41 1 46 Ttal 179 142 317 160 798 Table 1b Results f surgical treatment njury-admissin Results f trauma Ttal time Gd Fair imprvement Deaths p t 6 hurs 156 47 7-12 h 94 30 13-24 h 73 39 2-3 days 42 43 4-7 days 14 24 Over 7 days 6 12 Ttal 385 195 81 25 309 58 21 203 52 23 187 36 9 130 34 3 75 39 2 59 300 83 963 evaluated n the basis f the cmparisn f the patient's neurlgical state n admissin t the state btained after cmpletin f hspital treatment. The neurlgical imprvement was classified as gd r fair. The imprvement was regarded as gd if the pareses disappeared r neurlgical imprvement was sufficient t advance by at least 2 degrees f the scale. eg frm grup 1 fr incmplete injuries (mtr paralysis). t grup 3 (pareses f lesser intensity). The result was regarded as fair if the neurlgical scre changed by ne degree f the scale. t appears that early admissin t a specialist department is relevant fr a better result f treatment. Thus. in the cnservatively treated grup f patients admitted within 6 hurs after injury gd results were btained in 33%. whereas in thse admitted t hspital 2-3 days after injury such results amunted t 18%. n the grup admitted 4-7 days after injury such results were nted in 6% f cases. Similar results were recrded in the grup f patients treated surgically. n the grup f patients admitted within 6 hurs after injury gd results were recrded in 50% f cases; thse admitted n the secnd r third day after injury btained such results in 32%; whereas in the grup admitted within the secnd week after injury gd results were fund in 10%. Duratin f hspitalisatin Hspitalisatin time is highly dependent n the degree f spinal crd injury. This is shwn in Table V. The lngest time f hspitalisatin is seen in patients admitted with symptms f cmplete injury f spinal crd. Their treatment usually takes 4-6 mnths. but urinary and respiratry cmplicatins. decubiti etc frequently lengthen this perid t ver 10 r even 12 mnths. The average hspitalisatin time in this grup f patients was 27 and 17 weeks respectively. when cnservative r surgical treatment was used. Patients admitted with a partial injury. grup 1. treated cnservatively and surgically were hspitalised fr a perid f 15 and 11 weeks. respectively. The hspitalisatin
Treatment f cervical spinal crd injuries 195.c: C E,.-< S C/.c: C E 0- r-- a "'111'" 8 E? E? Vl C f) -- ''>D time fr surgically treated patients with a partial injury, grup 3, was a little lnger than thse with cnservative treatment (4.9 and 4.7 weeks, respectively). Discussin Fr many years the prblem f treating patients with spinal crd injuries has been the subject f passinate discussin and argument amng the adherents f cnservative and surgical methds f treatment. n the light f ur wn clinical experience and the presented analysis f clinical material, we are f the pinin that bth methds may lead t the desired results f treatment. direct cmparisn f the cnservatively and surgically treated can be made due t the fact that there was lack f randmisatin in assigning the patients t the 2 grups. The practice in ur centre t assign patients t surgery r t n surgery is based mainly n the mechanism f the injury. Therefre, the surgical and cnservative grups d nt have an equal number f patients with all the mechanisms represented. n ur pinin, selectin f an apprpriate frm f treatment shuld be made individually and be based n a reliable analysis f pssible neurlgical imprvement and the preclusin f cmplicatins. t is evident that the medical staff managing such patients prefer the prcedure with which they have mre experience. But this preference t apply the favurite methd f treatment regardless f ther circumstances shuld be avided in rder t prevent any disadvantage t the patient. n ur cuntry, where there is a shrtage f specialist hspitals and spinal departments, there is a tendency t prefer surgical treatment, which in mst cases allws a reductin the time f hspitalisatin (Table V). Wrng qualificatin fr surgery, and surgery perfrmed by a surgen with insufficient experience in this field, culd nt nly lead t adverse effects and lengthen the time in hspital, but may als affect the general and neurlgical state f the patient. Therefre, while cnsidering the indicatins fr a particular methd f treatment it is vital fr us t have in view the main bjective, the gd f the patient.
196 Kiwerski Paraplegia 31 (1993) 192-196 References Haftek J, Rudnicki S, Kiwerski J (1968) Acute trauma f the cervical segment f the spinal crd. n: M. Weiss, editr. Cmpensatin f the Spinal Crd "-linerill. PZWL, Warszawa: 75-85. 2 Kiwerski J (1989) Spring allplasty in the treatment f fractures f the thracic and lumbar spine. lltern Orthp 13: 33-37..3 Frankel HL, Hancck DO. Hyslp G. Melzak LS. Michaelis GH. ngar JDS et al (1969) The value f pstural reductin in the initial management f clsed injuries f the spine with paraplegia and tetraplegia. Paraplegia 7: 179-192..: Kiwerski J (in press) Respiratry prblems in patients with quadriplegia after a high lesin f the cervical spinal crd. ] ntern Rehabil.