Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана
.pdf
betweenthisstudy’sfindingsandothersonthesametopicmaybeduetotheir
wider definition of “early” surgery of ≤72 hours (22) In another prospective
cohort study, itwas reported that early surgical decompression (≤24 hours)in
personswithcompleteSCImayoptimizerecoveryofAIS,especiallyincervical
SCI patients (23). Although most studies support the effectiveness of early
surgery, a recent systematic review revealed that there have been only lowevidencestudiesthatsupportclinicallysignificantbenefitinearlyinterventionto
improvelong-termfunctionaloutcomesafterSCI(24).
CentralCordSyndrome
CCSaccounts forasignificant percentageof traumatic SCI,and itisthe most
commonincompleteSCIsyndrome(25,26).Itiscommonlydiagnosedinelderly
patientswithpreexistingcervicalspondylosiswhopresentafterafall,resulting
incervicalhyperextension,usuallywithoutevidenceoffractureonradiographor
computed tomography (27). The syndrome is characterized by greater
impairment in the upper extremities than in the lower extremities, variable
bladderdysfunction,variablesensoryloss,andearlyneurologicalimprovements
(25).Thischaracteristicpatternofmotorimpairmentisduetothemainfunction
of the corticospinal tract in primates, which is critical for the fine motor
movementstothedistalmusculature,especiallyfortheupperlimbs(28).Inthe
past, surgical decompression was avoided or delayed until their neurological
recovery plateaued out of fear that surgery may interfere with recovery (25).
Although several studies have reported favorable neurological recovery after
conservative management (29,30), recent studies show a clear trend toward a
preferenceforsurgicaldecompression(31,32).
Attention should be paid, however, to decision making in the scenario of
CCS given the significant potential for spontaneous recovery. A prospective
cohortstudyshowedthatpatientswithCCSwhounderwentearlydecompression
(<24hoursafterSCI)hadASIAmotorscoresthatwerehigherby6.31points,
andagreaterchanceofASIAImpairmentScaleimprovement(oddsratio=2.81)
at12-monthfollow-upthanthosewithlatedecompression(≥24hoursafterSCI)
(33).Subsequently,the prospectiverandomizedcontrolledComparing Surgical
DecompressionVersusConservativeTreatmentinIncompleteSpinalCordInjury
(COSMIC,NCT01367405) trialwas initiated in2013(34). However,this trial
wasterminatedin2016becauseofthedifficultiesinpatientenrolment.Onthe
otherhand,severalstudiessupportdelayeddecompressionforCCS(35,36).One
of the advantages of a delayed approach is the time allowed for medical
optimization and thorough risk assessment, particularly in elderly patients.
Indeed, Samuel et al., reported that delayed surgery was associated with a
decreased mortality rate when compared to an early surgery group in a
nationwidetraumadatabase(36).
Clinical practice guidelines for the management of traumatic SCI were
recently developed through the efforts of a multidisciplinary working group
organizedby AOSpine (37,38). Thegroup performedsystematic reviewson a
numberofcontroversialtopicsintraumaticSCItodeterminebestpracticesand
maketreatmentrecommendations.Insummary,despitethelow-qualityevidence,
their current recommendation is to consider early surgery (≤24 hours after
injury)foracuteSCI.includingtraumaticCCS(39).Giventheheterogeneityof
SCIpatients,futureprospectivestudiesarewarrantedtoelucidatethebenefits
andsafetyofearlyinterventioninsubgroupsbasedonneurologicalimpairment
orinjurypatterns,andstudiesfocusingontheefficacyofveryearlyintervention,
suchas8or12hours.
COMORBIDITIES
ImpactofAgeonDecisionMaking
Associetyisconfrontedbyanagingpopulation,themanagementofSCIinthe
elderlypopulationisasignificantconcern(40).Asopposedtoyoungerpatients,
theelderlypopulationismoresusceptibletolow-energytrauma.Therefore,the
most commonly seen injury in this group is CCS associated with preexistent
cervical spondylosis. Although the severity of neurological impairmentvaries,
its impact can sometimes be devastating for elderly patients’ quality of life.
Therefore, old age should not preclude surgical options. However, these age
groups are more likely to have medical comorbidities. For example, in the
National Spinal Cord Injury Study (NASCIS), elderlypatients showedsimilar
motor recovery to younger patients after traumatic SCI, but the mortality rate
wassignificantlyhigher(41).
ConsiderationsforOtherMedicalComorbidities
Comorbidities in SCI patients sometimes affect surgical decision making. A
previous retrospective cohort study analyzed the influence of various
comorbidities(i.e.,cardiovascular,pulmonary,metabolic,tumor,andspinal)and
common complications such as urinary tract infection and pneumonia on the
improvement of ASIAmotor score afterearly surgery (12 hours after SCI) in
133patientswithcervical,thoracic,andthoracolumbarSCI(42).Improvement
in motor function was observed to be significantly reduced if patients had
previous spinal comorbidities such as AS, herniated discs, or spinal stenosis.
However, other comorbidities or complications were not reported to impair
motorfunctionaloutcome.
AS is a seronegative spondyloarthropathy that involves the ligaments and
joints of the spinal column (43). AS has a characteristic caudal to rostral
progression resulting in a “bamboo spine” in which the fused spine acts as a
continuousaxialsupport(44).Previously,anincreasedriskofspinefracturesin
patientswithAShasbeenreportedduetothereducedvertebralbonequalityand
theamplified forcescaused bytherigidspineacting asa lever(45–47).Spine
fractures in AS patients are usually unstable three-column injuries. Therefore,
the risk of SCI is thought to be higher in AS patients than the general spine
fracturepopulation.Accordingtoarecentsystematicreview,81.2%offractures
were in the cervical spine and the rates of SCI (ASIA A–D) were 67.2% in
patients with AS (10). Another large retrospective cohort study using the
National Inpatient Sample (a total of 939 AS patients) demonstrated that AS
patients were at a high risk for in-hospital mortality (6.6%), and 29.4% of
patientshadan adverse event such as urinary tract infection, intubation, acute
kidneyinjury,andpneumoniaduringtheirinpatientstay(48).Moreover,13.1%
ofASpatientshadfracturesinmultipleregionsofthespine(48).
Osteoporosis is the most prevalent human bone disease characterized by
decreasedbonemass,deteriorationofbonetissue,andhighriskoffracture(49).
Osteoporosiscanoftenleadtovertebralcompressionfracturesinelderlypatients
that may eventually require surgery (50). A large retrospective cohort study
analyzed1,602,129patientsundergoingdegenerativecervicalspinesurgeryand
reported on the effect of osteoporosis on complications and outcomes after
cervicalspinesurgery(51).Atotalof32,557(2%)hadosteoporosis,andpatients
with osteoporosis were more likely to undergo posterior cervical spine fusion
when compared with patients without osteoporosis (11.3% and 5.4%,
respectively).Circumferential fusion wasperformed2.7 times more frequently
intheosteoporoticpatients.Intermsofcomplications,postoperativehemorrhage
was more likely to occur in patients with osteoporosis (odds ratio = 1.7).
Furthermore, multivariate analysis for revision surgery demonstrated that
osteoporosispatientsweremorelikelytoundergorevisionsurgery(oddsratio=
1.5)(51).
FIGURE13.2 Acasepresentation for surgicaldecision making. (A)
preoperativesagittalCTimage,(B)preoperativeT2-weightedsagittal
MRI image, (C) preoperative lateral x-ray after Halo traction, (D)
postoperativelateralx-ray,E:postoperativeT2-weightedsagittalMRI
image.
Obesity has become a growing public health issue, with an estimated
prevalenceof34.9%inadultsintheUnitedStates,or78.6millionpeople(52).
Obesity contributes to increased rates of disk degeneration, low back pain,
sciatica, and spine surgery (53–57). Patients with obesity undergoing spine
surgeryhaveahigherriskofmortalityandpostoperativecomplicationssuchas
surgicalsiteinfectionandvenousthromboembolism(58–61).Studieshavealso
demonstrated longer operative duration and increased blood loss in obese
patients(59,61).Althoughthereisnostudyfocusingontheinfluenceofobesity
ondecompression surgeryin SCI, asystematic review regardingthe effectsof
obesity on spine surgery demonstrated similar or better responses to surgical
interventionthaninnonobesecounterparts(62).
CASEPRESENTATION
Anillustrativecasepresentationisshownin(Figure13.2).A66-year-oldpatient
with no medical comorbidities sustained C5/6 bilateral facet dislocation and
presented with SCI (AIS B). The injury was associated with C5/6 translation
with severe anterior and posterior discoligamentous instability. AOSpine
classification was C, and SLICS score was 9 (operative management).
Preoperative Halo traction achieved satisfactory reduction. The decision was
made to perform anterior discectomy and fusion at C5/6 for disc herniation,
followed by C5-7 laminectomy and instrumented fusion. Decompression was
obtainedwithin24hours,andthepatientshowedmarkedneurologicalrecovery
within4weeks(AISD).
CONCLUSIONS
Several factors affect surgical decision making for traumatic SCI. Surgical
indication is determined based on morphology and neurological status
characterizing the injury type. Early decompression for SCI is generally
recommended but more evidence regarding CCS should be gathered. Each
surgicalapproachandfixationtechniquehasitsprosandcons,andthestrategy
shouldbe determinedon a case-by-casebasis. Patientconditionsincluding old
ageandmedicalcomorbiditiesshouldalsobetakenintoconsideration.
REFERENCES
1. JainNB,AyersGD,PetersonEN,etal.TraumaticspinalcordinjuryintheUnitedStates,1993-2012.
JAMA.2015;313:2236–2243.doi:10.1001/jama.2015.6250
2. GrassnerL,MaierD.Impactofsurgeryontheoutcomeafterspinalcordinjury-currentconceptsand
anoutlookintothefuture.NeuralRegenRes.2016;11:1928–1929.doi:10.4103/1673-5374.197132
3. Vaccaro AR, Koerner JD, Radcliff KE, et al. AOSpine subaxial cervical spineinjury classification
system.EurSpineJ.2016;25:2173–2184.doi:10.1007/s00586-015-3831-3
4. Vaccaro AR,HulbertRJ,PatelAA,etal. Thesubaxialcervicalspineinjuryclassificationsystem:a
novel approach to recognize the importance of morphology, neurology,and integrity of the discoligamentous complex. Spine (Phila Pa 1976). 2007;32:2365–2374.
doi:10.1097/BRS.0b013e3181557b92
5. Denis F. The three column spine and its significance in the classification of acute thoracolumbar
spinalinjuries.Spine(PhilaPa1976).1983;8:817–831.doi:10.1097/00007632-198311000-00003
6. Samuel S, Lin JL, Smith MM, et al. Subaxial injury classification scoring system treatment
recommendations: external agreement study based on retrospective review of 185 patients. Spine
(PhilaPa1976).2015;40:137–142.doi:10.1097/BRS.0000000000000666
7. Vaccaro AR,Oner C, KeplerCK, et al. AOSpinethoracolumbar spine injury classificationsystem:
fracturedescription, neurological status, and key modifiers. Spine (Phila Pa 1976). 2013;38:2028–
2037.doi:10.1097/BRS.0b013e3182a8a381
8. Vaccaro AR,LehmanRAJr,HurlbertRJ, et al. Anew classification of thoracolumbar injuries:the
importanceofinjurymorphology,theintegrityoftheposteriorligamentouscomplex,andneurologic
status.Spine(PhilaPa1976).2005;30:2325–2333.doi:10.1097/01.brs.0000182986.43345.cb
9. DvorakMF,FisherCG,FehlingsMG,etal.Thesurgicalapproachtosubaxialcervicalspineinjuries:
an evidence-based algorithm based on the SLIC classification system. Spine (Phila Pa 1976).
2007;32:2620–2629.doi:10.1097/BRS.0b013e318158ce16
10. WesterveldLA,VerlaanJJ,OnerFC.Spinalfracturesinpatientswithankylosingspinaldisorders:a
systematicreviewof theliteratureontreatment,neurologicalstatusandcomplications.EurSpineJ.
2009;18:145–156.doi:10.1007/s00586-008-0764-0
11. CarlsonGD,MinatoY,OkadaA,etal.Earlytime-dependentdecompressionfor spinal cord injury:
vascularmechanismsofrecovery.JNeurotrauma.1997;14:951–962.doi:10.1089/neu.1997.14.951
12. Dimar J, Glassman S, Raque G, et al. The influence of spinal canal narrowing and timing of
decompression on neurologic recovery after spinal cord contusion in a rat model. Spine.
1999;24:1623–1633.doi:10.1097/00007632-199908150-00002
13. Furlan JC, NoonanV, Cadotte DW, Fehlings MG.Timingofdecompressive surgery of spinalcord
aftertraumaticspinalcordinjury:anevidence-basedexaminationofpre-clinicalandclinicalstudies.J
Neurotrauma.2011;28:1371–1399.doi:10.1089/neu.2009.1147
14. BatchelorPE,WillsTE,SkeersP,etal.Meta-analysisofpre-clinicalstudiesofearlydecompressionin
acute spinal cord injury: a battle of time and pressure. PLoS One. 2013;8:e72659.
doi:10.1371/journal.pone.0072659
15. FehlingsMG,VaccaroA,WilsonJR,etal.Earlyversusdelayeddecompressionfortraumaticcervical
spinalcordinjury:resultsoftheSurgicalTiminginAcuteSpinalCordInjuryStudy(STASCIS).PLoS
One.2012;7:e32037.doi:10.1371/journal.pone.0032037
16. vanMiddendorpJJ.Lettertotheeditorregarding:“Earlyversusdelayeddecompressionfortraumatic
cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study
(STASCIS)”.SpineJ.2012;12:540.doi:10.1016/j.spinee.2012.06.007
17. WilsonJR,SinghA,CravenC,etal.Earlyversuslatesurgeryfortraumaticspinal cord injury: the
results of a prospective Canadian cohort study. Spinal Cord. 2012;50:840–843.
doi:10.1038/sc.2012.59
18. Dvorak MF,Noonan VK, Fallah N, et al. The influence of time from injury to surgery on motor
recoveryandlengthofhospitalstayinacutetraumaticspinalcordinjury:anobservationalCanadian
cohortstudy.JNeurotrauma.2015;32:645–654.doi:10.1089/neu.2014.3632
19. GrassnerL,WutteC,KleinB,etal.Earlydecompression(<8h)aftertraumaticcervicalspinalcord
injuryimprovesfunctionaloutcomeasassessedbyspinalcordindependencemeasureafteroneyear.J
Neurotrauma.2016;33(18):1658–1666.doi:10.1089/neu.2015.4325
20. Gupta DK, Vaghani G, Siddiqui S, et al. Early versus delayed decompression in acute subaxial
cervicalspinalcordinjury:aprospectiveoutcomestudyataLevelItraumacenterfromIndia.AsianJ
Neurosurg.2015;10:158–165.doi:10.4103/1793-5482.161193
21. BiglariB,ChildC,YildirimTM,etal.Doessurgicaltreatmentwithin4hoursaftertraumahavean
influenceonneurologicalremissioninpatientswithacutespinalcordinjury?TherClinRiskManag.
2016;12:1339–1346.https://doi.org/10.2147/TCRM.S108856
22. Vaccaro AR, Daugherty RJ,SheehanTP,etal.Neurologicoutcomeof early versus late surgeryfor
cervicalspinalcordinjury.Spine.1997;22:2609–2613.doi:10.1097/00007632-199711150-00006
23. Bourassa-MoreauE,Mac-ThiongJM,LiA,etal.Dopatientswithcompletespinalcordinjurybenefit
from early surgical decompression? analysis of neurological improvement in a prospective cohort
study.JNeurotrauma.2016;33:301–306.doi:10.1089/neu.2015.3957
24. WilsonJ,TetreaultL,KwonBK,etal.Timingofdecompressioninpatientswithacutespinalcord
injury: a systematic review. Global Spine J. 2017;7(3_suppl):95S–115S.
doi:10.1177/2192568217701716
25. SchneiderRC,CherryG,PantekH.The syndromeofacutecentralcervicalspinalcord injury;with
special reference to the mechanisms involved in hyperextension injuries of cervical spine. J
Neurosurg.1954;11:546–577.doi:10.3171/jns.1954.11.6.0546
26. Mckinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical
syndromes.JSpinalCordMed.2007;30:215–224.doi:10.1080/10790268.2007.11753929
27. Fehlings MG, Tetreault L, Nater A, et al. The Aging of the global population: the changing
epidemiology of disease and spinal disorders. Neurosurgery. 2015;77 Suppl 4:S1–S5.
doi:10.1227/NEU.0000000000000953
28. LeviAD,TatorCH,BungeRP.Clinicalsyndromesassociatedwithdisproportionateweaknessofthe
upperversusthelowerextremitiesaftercervicalspinalcordinjury.Neurosurgery.1996;38:179–183;
discussion83–85.doi:10.1097/00006123-199601000-00039
29. NeweyML,SenPK,FraserRD.Thelong-termoutcomeaftercentralcordsyndrome:astudyofthe
naturalhistory.JBoneJointSurgBr.2000;82:851–855.doi:10.1302/0301-620X.82B6.9866
30. IshidaY,TominagaT.Predictorsofneurologicrecoveryinacutecentralcervicalcordinjurywithonly
upper extremity impairment. Spine. 2002;27:1652–1658; discussion 8. doi:10.1097/00007632-
200208010-00011
31. YoshiharaH,YoneokaD.Trendsinthetreatmentfor traumaticcentralcordsyndromewithout bone
injury in the United States from 2000 to 2009. J Trauma Acute Care Surg. 2013;75:453–458.
doi:10.1097/TA.0b013e31829cfd7f
32. BrodellDW,JainA,ElfarJC,etal.Nationaltrendsinthemanagementofcentralcordsyndrome:an
analysisof16,134patients.SpineJ.2015;15:435–442.doi:10.1016/j.spinee.2014.09.015
33. LenehanB,FisherCG,VaccaroA,etal.Theurgencyofsurgicaldecompressioninacutecentralcord
injuries with spondylosis and without instability. Spine. 2010;35:S180–S186.
doi:10.1097/BRS.0b013e3181f32a44
34. Bartels RH, Hosman AJ, van de Meent H, et al. Design of COSMIC: a randomized, multi-centre
controlled trial comparing conservative or early surgical management of incomplete cervical cord
syndromewithoutspinalinstability.BMCMusculoskeletDisord.2013;14:52.doi:10.1186/1471-2474-
14-52
35. Park MS, Moon SH, Lee HM, et al. Delayed surgical intervention in central cord syndrome with
cervicalstenosis.GlobalSpineJ.2015;5:69–72.doi:10.1055/s-0034-1395785
36. SamuelAM,GrantRA,BohlDD,etal.Delayedsurgeryafteracutetraumaticcentralcordsyndrome
isassociatedwithreducedmortality.Spine.2015;40:349–356.doi:10.1097/BRS.0000000000000756
37. Fehlings MG, Kwon BK, Tetreault LA. Guidelines for the management of degenerative cervical
myelopathyandspinalcordinjury:anintroductiontoafocusissue.GlobalSpineJ.2017;7:6S–7S.
doi:10.1177/2192568217701714
38. Fehlings MG, TetreaultLA, WilsonJR, et al. A clinical practice guideline for the management of
acute spinal cord injury: introduction, rationale, and scope. Global Spine J. 2017;7:84S–94S.
doi:10.1177/2192568217703387
39. Fehlings MG, TetreaultLA, WilsonJR, et al. A clinical practice guideline for the management of
patients with acute spinal cord injury and central cord syndrome: recommendations on the timing
(</=24 hours versus >24 hours) of decompressive surgery. Global Spine J. 2017;7:195S–202S.
doi:10.1177/2192568217706367
40. Sokolowski MJ,Jackson AP,HaakMH, et al.Acute mortality and complications ofcervical spine
injuries in the elderly at a single tertiary care center. J Spinal Disord Tech. 2007;20:352–356.
doi:10.1097/BSD.0b013e31802d0bc5
41. Furlan JC,Fehlings MG. The impact of age onmortality,impairment,and disability amongadults
with acute traumatic spinal cord injury. J Neurotrauma. 2009;26:1707–1717.
doi:10.1089/neu.2009.0888
42. KreinestM,LudesL,BiglariB,etal.Influenceofpreviouscomorbiditiesandcommoncomplications
on motor function after early surgical treatment of patients with traumatic spinal cord injury. J
Neurotrauma.2016;33:2175–2180.doi:10.1089/neu.2009.0888
43. Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007;369:1379–1390. doi:10.1016/S01406736(07)60635-7
44. WeinsteinPR,KarpmanRR,GallEP,etal.Spinalcordinjury,spinalfracture,andspinalstenosisin
ankylosingspondylitis.JNeurosurg.1982;57:609–616.doi:10.3171/jns.1982.57.5.0609
45. Hitchon PW, From AM, Brenton MD, et al. Fractures of the thoracolumbar spine complicating
ankylosingspondylitis.JNeurosurg.2002;97:218–222.doi:10.3171/spi.2002.97.2.0218
46. GrahamB,VanPeteghemPK.Fracturesofthespineinankylosingspondylitis.Diagnosis,treatment,
andcomplications.Spine.1989;14:803–807.doi:10.1097/00007632-198908000-00005
47. Olerud C, Frost A, Bring J. Spinal fractures in patients with ankylosing spondylitis. Eur Spine J.
1996;5:51–55.doi:10.1007/BF00307827
48. LukasiewiczAM,BohlDD,VarthiAG,etal.Spinalfractureinpatientswithankylosingspondylitis:
cohort definition, distribution of injuries, and hospital outcomes. Spine. 2016;41:191–196.
doi:10.1097/BRS.0000000000001190
49. CosmanF,deBeurSJ,LeBoffMS,etal.clinician’sguidetopreventionandtreatmentofosteoporosis.
OsteoporosInt.2014;25:2359–2381.doi:10.1007/s00198-014-2794-2
50. TruumeesE.Osteoporosis.Spine.2001;26:930–932.doi:10.1097/00007632-200104150-00016
51. Guzman JZ, Feldman ZM, McAnany S, et al. Osteoporosis in Cervical Spine Surgery. Spine.
2016;41:662–668.doi:10.1097/BRS.0000000000001347
52. OgdenCL,CarrollMD,KitBK,etal.PrevalenceofchildhoodandadultobesityintheUnitedStates,
2011-2012.JAMA.2014;311:806–814.hdoi:10.1001/jama.2014.732
53. ShiriR,SolovievaS,Husgafvel-PursiainenK,etal.Theroleofobesityandphysicalactivityinnon-
specificandradiatinglowbackpain:theYoung Finns study.SeminArthritisRheum.2013;42:640–
650.doi:10.1016/j.semarthrit.2012.09.002
54. ShiriR,KarppinenJ,Leino-ArjasP,etal.Theassociationbetweenobesityandlowbackpain:ameta-
analysis.AmJEpidemiol.2010;171:135–154.doi:10.1093/aje/kwp356
55. TeraguchiM, YoshimuraN, Hashizume H, et al. Prevalence and distribution of intervertebral disc
degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study.
OsteoarthritisCartilage.2014;22:104–110.doi:10.1016/j.joca.2013.10.019
56. SamartzisD,KarppinenJ,CheungJP,etal.Diskdegenerationandlowbackpain:aretheyfat-related
conditions?GlobalSpineJ.2013;3:133–144.doi:10.1055/s-0033-1350054
57. SamartzisD,KarppinenJ,MokF,etal.Apopulation-basedstudyofjuvenilediscdegenerationandits
association with overweight and obesity, low back pain, and diminished functional status. J Bone
JointSurgAm.2011;93:662–670.doi:10.2106/JBJS.I.01568
58. SoroceanuA,BurtonDC,DieboBG,etal.Impactofobesityoncomplications,infection,andpatient-
reported outcomes in adult spinal deformity surgery. J Neurosurg Spine. 2015;23(5):656–664.
doi:10.3171/2015.3.SPINE14743
59. JiangJ,TengY,FanZ,etal.Doesobesityaffectthesurgicaloutcomeandcomplicationratesofspinal
surgery?Ameta-analysis.ClinOrthopRelatRes.2014;472:968–975.doi:10.1007/s11999-013-3346-3
60. Marquez-Lara A, Nandyala SV, Sankaranarayanan S, et al. Body mass index as a predictor of
complications and mortality after lumbar spine surgery. Spine. 2014;39:798–804.
doi:10.1097/BRS.0000000000000232
61. BuerbaRA,FuMC,GruskayJA,etal.ObeseClassIIIpatientsatsignificantlygreaterriskofmultiple
complicationsafterlumbarsurgery:ananalysisof10,387patientsintheACSNSQIPdatabase.Spine
J.2014;14:2008–2018.doi:10.1016/j.spinee.2013.11.047
62. JacksonKL,DevineJG.Theeffectsofobesityonspinesurgery:asystematicreviewoftheliterature.
GlobalSpineJ.2016;6:394–400.doi:10.1055/s-0035-1570750
14
SurgicalManagementforCervicalSpinal
Injuries
ChristineHammer,RavichandraA.Madineni,andJames
S.Harrop
INTRODUCTION
TheNationalSpinalCordInjuryStatisticsCenter(NSCISC)estimatesthatinthe
UnitedStates,spinalcordinjury(SCI)occursatarateof54casespermillion
population in equaling approximately 17,000 new SCI cases per year (1).
Injuries involving the cervical spine make up over half of these cases (2,3).
Mortality prior to discharge from the hospital has been estimated at 6% (4).
Currenttrendsalsoindicatethatcervicalinjuriesarebecomingmorecommon.In
theUnitedStates,thisincreaseisprimarilyduetoanincreaseinC1–C4injuries,
withtheincidenceofC5–C8injuriesinfactdecreasinginthepasttwodecades
(2,3,5).
While SCI is most common between ages 16 and 30, there has been an
increaseintheaverageageofcervicalspineinjury,whichmirrorstheincreasein
the age of the general population,which isalso due to increase in numberof
falls,especiallyintheelderly(2,6,7).Increasedriskoffallsamongtheelderlyis
oftensecondarytomedicalcomorbiditiessuchasdiabeticperipheralneuropathy
orsecondarytomyelopathyrelatedtodegenerativespinalstenosis(8).
Most cervical spine injuries occur in the lower cervical vertebrae, but the
most commonly fractured cervical vertebrae is C2, accounting for just under
25% of all cervical spine fractures (7,9). Among the elderly, C2 fractures
accountforadisproportionatenumberofcervicalspinefractures,withthemost
common underlying mechanism of injurybeing falls (8,9). Of these fractures,
thepercentageofthosepresentingwithSCIisestimatedtobelessthan20%(1).
Hyperostotic conditions such as ankylosingspondylosis and diffuse idiopathic
skeletalhyperostosis(DISH)aswellasdegenerativechangespredisposeelderly
individualswithgreaterriskofcervicalspinefracturewithevenmildtrauma(8).
Odontoidfracturesaccountfor9%to15%ofallcervicalspinefracturesamong
theelderly(10).
Several cervical spine fracture classification systems exist. They can be
classified by fracture location such as the following traditional mechanistic
classification examples: Odontoid fracture, Anderson and D’Alonzo
classification; Hangman (C2) fracture, Levine and Edwards classification;
Subaxialspine, AllenandFergusonclassification; andtheHarris classification
(4,11,12).Morerecently,theSubaxialInjuryClassification(SLIC)andseverity
scalewas introducedby Vaccaroand colleaguestohelp guidemanagement by
observing the morphology of injury, the discoligamentous complex (DLC)
involvement, and neurological status in an attempt to create a functional
classificationssystemforfracturesinvolvingC3toC6(11,13).Whiletraditional
classificationsystemsseektoclarifythetypeofinjurybasedonvectorssuchas
hyperextension, hyperflexion, distraction, dislocation, and/or compression, the
SLICinjuryseverityscoreseekstomovebeyonddescribingthemechanismof
injurytoguidingmanagementdecisions(4,13).
INITIALMANAGEMENT
Assessment
Patients involved in a traumatic event, during which injury to the neck is
suspected,shouldbeinitiallyevaluatedandstabilizedasperapplicablebasicor
advanced trauma life support guidelines. The major cause of death in SCI
includesaspirationandshock.Furthermore,bloodlossmaycausehypotension,
which may impact spinal cord perfusion, thus creating and/or worsening SCI
(14).Thus,immediatecardiovascularassessmentandhemodynamicstabilization
is essential with utilization of a multidisciplinary team as indicated (14).
Extensive literature reviews have been conducted over the years to determine
Соседние файлы в папке Библиотека им академика М.И. Перельмана