RESULTS OF INTENSIVE THERAPY OF COMPLICATED THORACIC SPINE INJURY

Pervukhin S.A., Lebedeva M.A., Elistratov A.A., Ivanova E.Yu., Statsenko I.A., Palmash A.V., Fomichev N.G.  

   Novosibirsk Research Institute of Traumatology and Orthopaedics named after Ya.L. Tsivyan, Novosibirsk, Russia

 RESULTS OF INTENSIVE THERAPY OF COMPLICATED THORACIC SPINE INJURY

Spine and spinal cord injury account for up to 20 % of all skeletal injuries. For the last 70 years the amount of patients with spine and spinal cord injury (SSCI) increased 200 times. More than 8,000 patients with such injuries are recorded each year in Russia [1-6]. Uncomplicated injuries to the thoracic spine are diagnosed in 29.2-43.9 % of cases. Th12 vertebral fractures are 25 % of all thoracic spinal injuries. SSCI in thoracic damages are diagnosed in 15-15.6 % of cases [7, 8]. Associated SSCI is observed in 36-72 % of patients in the structure of spine and spinal cord injuries. Multiple extravertebral injuries are the dominant damages in thoracic spine fractures: fractures of the extremities in 10.3-48 %, damages of the chest and thoracic organs in 52 %, severe traumatic brain injury in 18-72 %. The feature of SSCI in associated injuries is mutual burdening syndrome from one side, and syndrome of unclear clinical picture from other side. At the moment of admission, the severity of patients’ condition is determined by presence of intracavitary bleeding or TBI that cannot allow suspecting spinal injuries in all cases, even in the complicated pattern of an injury. So, in a spine and spinal cord injury at the lower thoracic and upper lumbar levels in combination with abdominal injuries, a patient has not any abdominal pain complaints since pain sensitivity is absent. The absent muscular tone at the level lower a spinal cord injury does not allow clinical diagnosing the whole range of injuries to the abdominal cavity organs. All these factors favor the delay in diagnosis of the whole range of injuries, and, sometimes, incorrect interpretation of some symptoms [3, 9].
The results of a severe thoracic spine and spinal cord injury is persistent loss of work capability or death after disorders of vital functions that is determined by reflectory depression at the level lower a spinal cord injury as result of disruption of descending stimulating impulsation from the upper centers. Severe SSCI (above Th6), which is accompanied by complete anatomic or functional disorder of the spinal cord, is accompanied by the clinical course of neurogenic shock – bradycardia, hypotonia, decreasing peripheral vascular resistance. Upper spinal cord injuries are accompanied by paralysis or paresis of chest muscles. Paralysis of the intercostal and abdominal muscles causes the alveolar hypoventilation and weakening cough reflex, resulting in delaying secretion in the tracheobronchial tree and development of pneumonia. Development of acute respiratory insufficiency requires for long term respiratory therapy [10-17].
A spinal injury is often accompanied by gastral and intestinal atonia. Paralytic ileus can last from two to four weeks, with high risk of microbial flora translocation through the disordered intestinal barrier [18, 19]. A spinal cord injury is almost always accompanied by urinary system damage, endocrine system dysfunction, disordered thermoregulation and water electrolytic balance. The rate of deep venous thrombosis reaches 49-72 % during two weeks after trauma, with development of pulmonary embolia in 4.6 % of patients [4, 6, 19].
Therefore, the result of spinal cord injury is dysfunction in almost all vital organs and systems of the body; at the background of neurogenic dysfunction, it causes some infectious complications with high possibility of an unfavorable outcome.
The study objective – to analyze the immediate results of intensive therapy of patients with spine and spinal cord injury in the thoracic region.

MATERIALS AND METHODS

The retrospective analysis included 55 patients with severe complicated thoracic spinal injury (Th3-Th12) who were treated in the intensive care unit, Novosibirsk Research Institute of Traumatology and Orthopedics, in 2009-2016. The age of the patients was from 20 to 76 (35.1 ± 11.6 years on average). There were 38 men (69.1 %). The causes of the complicated thoracic injury were falling from height – 35 (63.6 %), road traffic accident – 18 (32.7 %), others – 2 (3.6 %). All patients were admitted in the acute period of traumatic disease of the spinal cord.
The spinal cord injury severity was estimated with the classification from ASIA/IMSOP (1992) [19]. At the moment of hospital admission, 42 (76.4 %) patients demonstrated the clinical course of complete spinal cord injury (ASIA A). ASIA B degree was determined in 2 (3.6 %), ASIA C – in 5 (9.1 %), ASIA D – in 6 (10.9 %) patients. The spinal injury was mainly at the level of Th11-Th12 (54.5 %). The table 1 shows the distribution of the patients in dependence on the level of a spinal injury. Associated SSCI was diagnosed in 33 patients (60 %), single injury – in 22 (40 %). The patients with associated SSCI had the following injuries: injury to the chest and its organs in 29 patients (87.9 %), traumatic brain injury in 9 (27.3 %), blunt abdominal injury in 4 (12.1 %), fractures of the extremities in 3 (9 %).

Table 1. Distribution of patients depending on level of thoracic spine injury

Th3-Th4,
n (%)

Th5-Th6,
n (%)

Th7-Th8,
n (%)

Th9-Th10,
n (%)

Th11-Th12,
n (%)

Total,
n (%)

2 (3.6 %)

6 (10.9 %)

8 (14.5 %)

9 (16.4 %)

30 (54.5 %)

55 (100 %)


At the moment of hospital admission, the patients received the amnestic, general clinical, neurological and radiologic examination, CT and MRI. All patients received the surgical management for spinal cord decompression, restoration of the biomechanical axis and stabilization of the injured spine part. The patients were admitted to ICU after the surgical intervention. The main aim of intensive care in ICU was supporting the patient’s life, prevention of secondary spinal cord injury, minimizing risk of organ dysfunctions and prevention of multiple organ dysfunction. The main goal-oriented techniques of intensive care were:
1. Supporting the adequate perfusion pressure – infusion and symptomatic therapy for stabilizing mean arterial pressure (85-90 mm Hg), central venous pressure (8-12 cm H2O), achievement of Ht > 25 %, diuresis of 0.5-1 ml/kg/h, venous blood saturation > 60 %. Atropine was used for treating bradycardia determined by loss of sympathetic afferent stimulation of cardiac activity and unlimited vagal influence. The volume and the qualitative composition of the infusion program were determined by hypovolemia degree, albumin level in the blood, severity of pulmonary and renal injuries.
2. Respiratory therapy was conducted with ALV devices Drager, Germany (Savina, Evita XL). The main aim of respiratory support is achievement and maintenance of adequate gas exchange, decreasing energetic costs of patient’s breathing and his\her comfort optimization, provision of maximal safety in relation to alveolar injury. The ventilation parameters were selected for providing normocapnia with PaCO2 = 35-45 mm Hg, with no hypoxemia (targeted PaO2 > 65 mm Hg) and pH within the physiological range (7.35-7.45). The preferred ALV mode was pressure controlled ventilation (PC, BiPAP, APRV, CPAP). The concept of protective lung ventilation was used: DO – 5-10 ml/kg, PPLAT – < 35 cm H2O, positive end expiratory pressure – 5-15 cm H2O. Early tracheostomy was conducted if long term ALV was required. Ventilator-associated pneumonia was prevented with single-use breathing circuits, moisturizers, air mixture heaters, antibacterial filters, continuous drainage from the space over the cuff, intubation and tracheostomy tubes. The pressure in the cuff of intubation tubes was supported at the level of 25-30 mm H2O. Tracheobronchial tree sanitation was conducted with sterile solutions and the closed aspiration systems. The patients were placed onto the functional beds, with their upper part of the body elevated under the angle of 30-45°. The oropharynx was cleaned with chlorhexidine water solution. Exogenous contamination was prevented with hand hygiene for medical staff, and disinfection of the respiratory equipment and bronchoscopes. Pulmonary draining function was improved with kinesitherapy, incentive spirometry, deep breathing and expectoration stimulation.
3. Nutritive therapy: after estimation of the nutritive status and metabolic requirements within 24-36 hours, nutritive support was initiated on the basis of 25-30 kcal/kg of body weight per day. The technique of nutritive support was selected according to the functional state of the gastrointestinal tract: oral intake of enteral diets, enteral tube feeding, parenteral nutrition, mixed nutrition. At the first phase, enteral nutrition included the semi-elemental mixtures and mixtures with high level of glutamine. Enteral tube nutrition was initiated from the first day: constant infusion of 10 ml per hour with subsequent increase by the days 14-21. Enteral nutrition was supplemented with parenteral feeding in insufficient fulfillment of protein-energetic requirements. Glucose was supported at the level of 6-10 mmol/l. All patients received the prevention of stress ulcers: proton pump inhibitors. Intestinal paresis was corrected with nasogastral aspiration, prokinetics, peristaltic stimulation and bowel evacuation.
4. Deep venous thrombosis prevention: prescription of subcutaneous injections of low molecular heparin, compression knitwear and the devices for intermittent pneumatic compression for the lower extremities (SCD Express, USA).
5. Control of infectious complications: monitoring of biological fluids inoculations 2-3 times per week with identification of microorganisms and estimation of sensitivity to the antimicrobial agents with use of the analyzers BacT/ALERT and Vitek 2 (Biomerieux, France) in compliance with CLSA criteria (2009) [19]. If the infectious complications appeared, antibacterial therapy with consideration of results of the microbiological examination was conducted.
6. Obligatory safety monitoring: continuous pulse oximetry, capnography, registration of ECG, heart rate and body temperature, control of arterial pressure with Infinity Gamma XL (Drager, Germany), gas composition and acid-base balance of the blood (GEM Premier 3000, USA).
The number of the patients requiring for prolonged ALV, duration of ALV, tracheostomy rate, rate of hospital pneumonia, the features of organ dysfunctions, ICU stay, intrasurgical blood loss volume and mortality were recorded.
The statistical analysis of the results was performed with the standard software Microsoft Office 2007 for PC. The standard analysis of the ordered samples included the calculation of mean arithmetic (M), standard deviations (σ) and confidence intervals (m). Mann-Whitney test was used for testing the reliability of differences between two groups. The statistically significant differences were the differences with p < 0.05.

RESULTS AND DISCUSSION

The cause of SSCI was falling from height and road traffic accident in most cases. The most common injury was the spinal injury at the level of Th11-Th12. It corresponds with the data from other researchers [3, 4, 8, 9]. In 100 % of the cases, the volume of urgent surgical treatment included the opened instrumental decompression of the spinal cord trough the posterior approach and fixation with reposition-stabilization transpedicular system.
Urgent diagnosis of life threatening conditions and their urgent correction were carried out along with the spine surgery. Pleural cavity draining of hemopneumothorax was conducted for 18 patients. One patient required for thoracotomy and lung rupture suturing. Laparotomy was conducted for 2 patients with hemoperitoneum after the splenic rupture.
The postsurgical course of the disease was mainly determined by the level and degree of spinal cord injury, presence of traumatic injuries and blood loss severity.
Blood loss degree was directly associated with injury severity (single or associated SSCI), presence of thoracic and abdominal organs damages and the volume of surgical interventions. The patients were distributed according to severity of the registered blood loss: small (up to 15 % of CBV) – 33 (60 %) patients, mean (15-30 % of CBV) – 10 (18.1 %), heavy (30-40 % of CBV) – 6 (10.9 %), massive (> 40 % of CBV) – 6 (10.9 %). The intrasurgical blood loss volume for single SSCI was 725 ± 460 ml, for associated SSCI – 1,214 ± 1,142 ml (p < 0.05).
One of the directions of intensive care for acute spinal cord injury was early prescription of high dosage of methylprednisolone for decreasing secondary injury and provision of regeneration of injured neurons. The efficiency was confirmed by the results of the national studies (NASCIS I, II) [20, 21]. However the recent studies challenged the appropriateness of its use, considering the high rate of side effects such as immune suppression, high risk of infectious complications (pneumonia, urologic infection, wound infection), gastrointestinal bleeding and hyperglycemia. In 2013 American Association of Neurological Surgeons (AANS) published the recommendations. According to these recommendations, there are not any evidences of clinical improvement with methylprednisolone administration for treating acute spinal cord injury. Also therapy with high dosages of hormones is associated with side effects including infectious, respiratory and hemorrhagic complications, and death [22]. Currently, we adhere to the modern point of view and excluded the use of methylprednisolone as a component of intensive care for SSCI.
It is known that spinal cord perfusion is regulated independently in normal physiological conditions. Autoregulation of spinal cord perfusion violates after trauma. Spinal blood flow acquired the direct relationship with the level of perfusion pressure. Low perfusion pressure requires the immediate use of the agents for increasing vascular tone and/or cardiac inotropic function. According to the recommendations from American Association of Neurosurgeons, for successful correction of long term ischemia and secondary spinal cord injury, mean AP should be maintained at the level of 85-90 mm Hg within 5-7 days, with prevention of SAP < 90 mm Hg [23, 24]. In our study we used the vasoactive agents only for 3 (5.5 %) patients: 2 patients with complete spinal cord injury at the level of Th3-Th4, 1 patient with associated SSCI with massive blood loss. This circumstance shows that thoracic spinal cord injury is associated with hemodynamic disorders with less intense patterns in comparison with complicated cervical injury, where the symptomatic support was conducted for more than 60 % of the patients (25) according to our observations.
Respiratory insufficiency developed in 25.5 % of the patients (the table 2). The high rate and severity of respiratory insufficiency depended on the level of patterns of spinal cord injury and was the result of combination of respiratory musculature paresis with injury to the chest and its organs. It is known that the main breathing muscles are the diaphragm (C3-C5) and the intercostal muscles (Th1–Th11). The additional muscles participating in the breathing act are clavisternomastoid, trapezoid (innervation with 11th pair of cranial nerves) and scalenus (C3–C8). The expiration is passive, but the forced expiration and cough, which are necessary for airway cleaning, require for participation of the abdominal wall muscles (Th6–Th12). Complete spinal cord injury in the upper thoracic spine causes the development of alveolar hypoventilation. In such cases, the efficiency of breathing depends only on the diaphragm functioning. The inability to evacuate the sputum as result of the abdominal wall muscles causes obstructive and restrictive disorders with subsequent appearance of infectious complications, along with increasing production of bronchial secretion owing to disorder of neurogenic control of secretory glands. As a rule, it causes the decompensation on the days 3-4 after injury [26, 27]. Therefore, respiratory support should be one of the key moments of intensive care for patients with complicated upper thoracic spinal injury with disordered innervation of the respiratory muscles. Such patients may require ALV in the early period.

Table 2. Frequency and patterns of organ dysfunctions and sepsis

Organ pathology

Patients (n = 55)

Respiratory, n (%)

14 (25.5 %)

Cardiovascular, n (%)

3 (5.5 %)

Gastrointestinal, n (%)

6 (10.9 %)

Renal, n (%)

4 (7.3 %)

Cerebral, n (%)

2 (3.6 %)

Multiple organ insufficiency, n (%)

3 (5.5 %)

Sepsis, n (%)

4 (7.3 %)

 

Long term ALV (> 2 days) was conducted for 10 (18.2 %) patients owing to severe respiratory insufficiency. Tracheostomy was required for 5 cases. The mean duration of ALV was 14.6 ± 14 days. The requirement for ALV was conditioned by respiratory insufficiency of central origin owing to complete spinal cord injury at the level of Th3-Th5 in 3 patients. Long term ALV was conducted for 7 patients because of severe respiratory insufficiency as result of associated SSCI at the level of Th7-Th12 and the thoracic and abdominal organs. Hospital pneumonia was diagnosed in 10 (18.2 %) patients. Ventilator-associated pneumonia complicated the disease course in 6 (10.9 %) patients. Acute lung injury was diagnosed in 12 (21.8 %) patients. Pulmonary embolism developed in 2 (3.6 %) patients.
The important role is taken by other aspects of intensive care: nutritive support, correction of disordered functions of the gastrointestinal and genitourinary system organs, prevention of stress ulcers and gastrointestinal bleedings, prevention of deep venous thrombosis and thromboembolic complications and treatment of infectious complications, supporting normal body temperature.
It is known that gastrointestinal paresis of various severity is a common complication of acute period of spinal injury. Suppressing motional activity of the intestine is a reflectory consequence of spinal injury. The disorder of “balance” of sympathetic and parasympathetic nerve influences is the basis of slowing intestinal movements. Loss of rectal reflexes and intestinal movements can be complicated by intestinal obstruction. Moreover, the cause of paresis can be formation of retroperitoneal hematoma, which encounters in 17 % of cases with spinal injuries according to Grin A.A. [2]. In our study, intestinal paresis complicated the disease course in 6 (10.9 %) patients with severe associated spinal injury at the level of Th5-Th10. Two of them had the blunt abdominal injury with injuries to the internal organs.
Disordered function of the pelvic organs is a cause of acute delay of urine that requires bladder catheterization. Long term stay of the urethral catheter in patients with spinal cord injury can be a cause of infectious complications. The events of urologic infection developed in 5 (9.1 %) patients.
Sepsis was recorded in 4 (7.3 %) patients. Sepsis of pulmonary origin at the background of ventilator-associated pneumonia was identified in 2 cases (3.6 %). Sepsis was caused by catheter-associated infection of blood stream in 1 (1.8 %) patient and by urologic infection in 1 patient.
The hospital mortality depends on the degree of spinal cord injury and associated early and late complications. This rate is 8-58.3 % according to the literature data [5, 28-31]. The study by Usikov V.D. showed the lethal outcomes in 6 of 190 patients (3.2 %) [4]. The common cause of lethal outcomes in patients with SSCI in the thoracic spine is hemorrhagic, septic and thromboembolic complications according to the literature data. The lethal outcome among the patients included into this study was in 1 (1.9 %) patient with associated SSCI at the level of Th10 accompanied by multiple fractures of the ribs with lung injuries, blunt abdominal injury with splenic rupture, acute massive blood loss (6,000 ml, 107 % of CBV), which was the cause of perfusion arrest and clinical death. The intensive care restored the cardiac activity and stabilized the hemodynamics. However the lethal outcome happened on 24th day as result of postresuscitation disease and multiple organ dysfunction.
The patients with thoracic SSCI were in ICU during 6.9 ± 12.7 days. Severity, volume of injuries and blood loss degree in the patients with associated injury caused longer treatment in ICU (10.7 ± 15.4 days), whereas 1.4 ± 0.9 days (p < 0.05) in the patients with single injury. Maximal ICU stay was 79 days in the patient with thoracic SSCI.

CONCLUSION

The complicated thoracic spinal injury is a severe injury accompanied by development of severe neurologic deficiency, disordered vital functions of the body and possibility of unfavorable outcome. According to our observations, associated SSCI took place in 60 % of the cases with thoracic spine injury. This associated SSCI can be defined as extreme condition of the body and determined by concurrent damage of two or more anatomical regions. Associated SSCI is accompanied by injury to the chest and its organs in 87.9 % of cases. Respiratory failure as result of the thoracic organs injury in 25.5 % of the patients was the most common cause of multiple organ dysfunction and severe condition.
The analysis of the treatment results of the patients with complicated thoracic spine injury showed that only administration of the wide range of the modern techniques of intensive care for patients with both single and associated SSCI, with decreasing mortality up to 1.9 %.  

Information about 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 the publication of this article.

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