Characteristics of vertebral injury in the thoracolumbar - Lumbar spinal injuries at 103 military hospital – Hoang Thanh Tung

Journal of military pharmaco-medicine n 0 8-2017 237 CHARACTERISTICS OF VERTEBRAL INJURY IN THE THORACOLUMBAR - LUMBAR SPINAL INJURIES AT 103 MILITARY HOSPITAL Hoang Thanh Tung*; Vo Van Nho**; Nguyen Hung Minh** SUMMARY Objectives: To study the description and characteristics of vertebral body lesions based on the classification of Denis for thoracolumbar and lumbar spine injury. Subjects and methods: 89 patients with thoracolumbar and lumbar spine injury have been taken X-ray spine and computer tomography scanner spine. The cases of neurogical injuries will be taken clinical examination and injuries ligament will be operated. Results: The rate of fracture based on Denis’s classification included compression fracture: 19.10%; burst fracture 75.28%; distraction fracture 0%; dislocation fracture 5.62%. Neurological deficit was listed such as compression fractures 17.65%; burst fracture 43.28%; dislocation fracture 60%. Ligament injuries consisted of compression fracture 23.53%; burst fracture 14.93%; dislocation fracture 100%. Narrow spinal canal comprised compression fracture 11.76% and 0%; burst fracture 38.81% and 49.25%; dislocation fracture 40% and 60%). Position of narrow spinal canal: 1/2 upper 79.11%; 1/2 lower 13.43%; wholes 7.46%. Conclusion: The fracture at L1 and burst fracture are the most common. The ratio of narrow spinal canal and neurological deficit are high in burst fracture and dislocation fracture types. The position of narrow spinal canal at 1/2 upper accounted for high percentage. * Keywords: Vertebral injury; Thoracolumbar lumbar spinal injuries; Neurogical injuries. INTRODUCTION Thoracolumbar and lumbar spine injuries are the most common types of trauma to the spine, accounting for 90%. According to Mark S. Greenberg, the incidence of thoracolumbar junction spinal injuries was 64% [1]. Diagnosis and treatment depends on many factors such as types of fracture, surgical instruments and surgical qualifications. Therefore, studying and mastering the characteristics of vertebral fractures in the thoracolumbar and lumbar spine trauma will help the treatment in general, the surgery in particular to be effective, contributing to reduce the sequelae, improve the efficiency of recovery and soon return to normal working labor and reduce the burden on society. Therefore, we carried out the study with a view to: Determining characteristics of vertebral injury in the thoracolumbar and lumbar spine injuries. SUBJECTS AND METHODS 1. Subjects. * Inclusion criteria: Patients were diagnosed thoracolumbar and lumbar spine injuries and corrective surgery, fixation screws with decompression in the posterior approach. + Gender: Male or female, age ≥ 18 years old. * 103 Military Hospital ** International Neurosurgery Hospital Corresponding author: Hoang Thanh Tung ([email protected]) Date received: 29/08/2017 Date accepted: 28/09/2017 Journal of military pharmaco-medicine n 0 8-2017 238 * Exclusion criteria: Patients with chronic diseases (heart failure, liver, kidney failure), severe joint injuries combined (head trauma, abdomen, chest injury), suspected injuries combined due to cancer, psychotic tuberculosis. Patients do not cooperate in treatment, do not comply with the follow-up and do not have full research records. 2. Methods. * Research location: Neurousurgery and Spine Surgery Department, 103 Military Hospital. * Study time: from 12 - 2010 to 1 - 2013. * Research design: Interventional study. * Research content: Characteristics of patients: age, gender, job, cause of trauma, time from trauma to the hospital admisson. Table 1: The modified Frankel’s grading system (Frankel - Bradford) [2]: Grade Neurological status A Complete motor loss and sensory loss B Preserved sensation only, voluntary motor function absent C Preserved motor less than fair grade (nonfunctional for any useful purpose) D D1 Preserved motor at lowest functional grade 3/5 and/or with bowel or bladder paralysis with normal or reduced voluntary motor function D2 Preserved motor at midfunctional grade 3/5 to 4/5 and/or with neurogenic bowel or bladder dysfunction D3 Preserved motor at high - functional grade 4/5 to 5/5 and normal voluntary bowel or bladder function E Complete motor loss and sensory function normal (may still have abnormal reflexes) - Vulnerability assessment on conventional X-ray film: Position of fracture, Denis’s classification. - Vulnerability assessment of vertebral on computerized tomography film: Denis’s classification, narrow spinal canal, position of spinal canal compression. - Data were collected and processed according to medical statistics mathematics (SPSS 16.0). RESULTS 1. Level fracture. Level fracture at L1 had 41/89 cases (46.07%); T12 had 18/89 cases (20.22%); L2 had 15/89 cases (16.85%); L3 had 12/89 cases (13.48%); T11 had 2/89 cases (2.25%); L4 had 1/89 cased (1.12%). Thoracolumbar junction (T11-L2) is the most common (85.40%). 2. Fracture types according to Denis’classification. Burst fracture: 67/89 cases (75.28%); compression fracture: 17/89 cases (19.10%) and dislocation fracture: 5/89 cases (5.62%) and distraction fracture: 0 case (0%). Journal of military pharmaco-medicine n 0 8-2017 239 3. Fracture type and level of narrow spinal canal. Table 2: Level Types Total Normal spinal canal Normal spinal canal < 50% Normal spinal canal ≥ 50% n % n % Compression fracture 17 14 (82.35) 3 17.65 0 0 Burst fracture 67 8 (11.94) 26 38.81 33 49.25 Dislocation fracture 5 0 2 40.00 3 60.00 Compression fracture: normal: 82.35%; < 50%: 17.65%; ≥ 50%: 0%. urst fracture (narrow spinal canal: 88.06%; normal: 11.94%. Inside < 50%: 38.81% and ≥ 50%: 49.25%). Disloacation fracture (narrow spinal canal: 100%. Inside ≥ 50%: 60% and < 50%: 40%). 4. Position of spinal canal compression (n = 67 cases). 1/2 upper: 53 cases (79.11%); 1/2 lower: 9 cases (13.43%); whole: 5 cases (7.46%). 5. Injuries of posterior ligament system. Table 3: Characteristics Groups Number Injuries of posterior ligament system Determining methods Number Rate (%) Surgery Rate (%) Compression fracture 17 4 23.53 4 100 Burst fracture 67 10 14.93 10 100 Distraction fracture 0 0 0 Dislocation fracture 5 5 100 5 100 Total 89 19 21.35 19 100 There were 19/89 injuries (21.35%) of posterior ligament system. 6. Neurological deficit. Table 4: Neurological deficit Groups Total Nonneurological deficit Neurological deficit n % n % n % Compression fracture 17 19.10 14 82.35 3 17.65 Burst fracture 67 75.28 38 56.72 29 43.28 Dislocation fracture 5 5.62 2 40.00 3 60.00 There were diffirences in the rate of neurological deficit between fracture groups. Journal of military pharmaco-medicine n 0 8-2017 240 7. Neurological deficit and level of narrow spinal canal in fracture types. Table 5: Level of narrow spinal canal - neurological deficit Types Normal spinal canal Normal spinal canal < 50% Normal spinal canal ≥ 50% Neurological deficit Non neurological deficit Neurological deficit Non neurological deficit Neurological deficit Non neurological feficit Compression fracture 2 13 1 1 0 0 Burst fracture 0 8 3 23 26 7 Distraction fracture 0 0 0 0 0 0 Dislocation fracture 0 0 0 2 3 0 Total 2 21 4 26 29 7 Compression fracture had 3 cases of neurological deficit, among which 2 cases of narrow spinal canal were normal; 1 case of narrow spinal canal was < 50%. Burst fracture had 29 cases of neurological deficit, among which 26/29 cases of narrow spinal canal (89.66%) were ≥ 50%, 3/29 cases of narrow spinal canal (10.34%) were < 50%. Dislocation fracture had 3 cases of neurological deficit, which accounted for 100% of the cases of narrow spinal canal. DISCUSSION 1. Level of fracture. In our study the highest fracture rates were L1 (46.07%), followed by T12 (20.22%) and L2 (16.85%). This result was consistent with the structure of the thoracolumbar - lumbar spine, including thoracolumbar junction segment (from T12 to L2) and a lumbar spine segment (from L3 - L5), in which the hinge spine is the transition between static spinal region and active spinal region. This segment is considered as spinal segment straight from the local kyphosis angle ranged from 0 to 8 degrees, so when the impact force, particularly compression force of the longitudinal axis or damage occurs here. 2. Rate of groups according to the Denis’classification. We all know that fracture depends on the mechanism, the cause of the injury and the force impact on the spine. Therefore, the environment, living conditions and labor characteristics in each country will affect the rate of fractures in injury. These ratios were consistent with the cause, the injury mechanism. In this study, occupational accidents and labour accidents with the vertical compression mechanism were predominant. In the study by Mc Cormack, the high falling created a major traumatic compression mechanism, where burst fracture and compression fractures were majority [4]. Journal of military pharmaco-medicine n 0 8-2017 241 No distraction fracture seen in the study (0%) reveals the cause of traffic accidents in high speed motorways in the countries. 3. Neurological deficit, fracture groups and level of narrow spinal canal. When studying the lumbar spine trauma, the correlation between fracture and spinal stenosis, the cause of the spinal canal narrowing and the level of nerve damage should be addressed. Evaluation of spinal stenosis with the aim of establishing a surgical indication and decompression for the relief of nerve damage [5, 6, 7]. In Vietnam, in a study by Nguyen Duc Tin (2009), 87 cases of burst fracture showed a correlation between fracture severity and spinal stenosis and between levels of spinal stenosis and level of nerve damage, which were statistically significant (p < 0.005) but no association between fracture and nerve injury was found (p > 0.005) [1]. In our study, we assessed this problem for all fracture groups and found that 17/89 cases of compression fracture, of which 17.65% had nerve damage but only 1 of the three cases of spinal stenosis with < 50% accounting for 33.33%; the remaining 2 cases had no narrow spinal canal, accounting for 67.67%. The number of cases with narrowed spinal canal was found in 3/17, accounting for 17.65%. Thus, it can be seen in the compression fracture that the rate of narrow spinal canal and nerve damage was low. Burst fractures accounted for 75.28% of all fractured groups with 88.06% narrow spinal canal and 43.28% nerve damage. In particular, the group of nerve damage with narrow spinal canal ≥ 50% accounted for 89.66%; the incidence of narrow spinal canal < 50% was 10.34% and there were no cases of normal spinal canal. In just narrow spinal canal group, 49.15% had nerve damage. Thus, in the burst fractured with narrow spinal canal and nerve damage in the upper 50% narrow spinal canal group accounted for a high proportion. Distraction fracture was found in the study (0%). Thus, there was no basis for assessing the correlation between spinal stenosis and nerve damage in this group. However, according to studies by foreign authors, this fracture group had a very low rate of spinal stenosis and nerve damage [2]. Dislocation fracture accounted for 5.62% of total fractures with 100% of narrow spinal canal and 60% of nerve damage. In particular, the neurological deficit group did not have any cases of spinal stenosis < 50%. This shows that narrow spinal canal was a cause of neurological damage [5, 7]. In addition, it can be due to the mechanism of trauma and foce trauma. The prevalence of spinal stenosis was mainly in the group of burst fracture and dislocation fractures, which accounted for 88.06% and 100%, respectively. 4. Position of spinal canal compression. According to Mark S. Greenberg, due to the characteristics of vertebral fractures, the spinal stenosis was mainly seen in the burst fracture group and in the upper half Journal of military pharmaco-medicine n 0 8-2017 242 and the lower half. However he did not give a specific rate [2]. In Vietnam, Nguyen Duc Tin, who studied 87 cases of burst fracture, found that 65 out of 87 cases with hemiparesis occurred in 74.70% and 2/87 cases of compression at the lower half position accounted for 2.30% [1]. In our study, among 89 cases of thoracolumbar, lumbar fracture had 67 cases of spinal stenosis, 75.28% of which were narrow spinal canal, at the position 1/2 upper had 53/67 cases (79.11%), the compression ratio in the lower half position was 13.43% (9/67 cases); in the whole position was 7.46%. Therefore, the compression position at 1/2 upper occupies the majority. This result is consistent with the research by Nguyen Duc Tin. 5. Injuries of posterior ligament system. The posterior ligament system plays an important role in the firmness and elasticity of the spine. This is the joint- ligaments. Considering the spinal motility with the medial column as the ligament, the ligaments with the longest arm, the ligaments play an important role in maintaining the firmness of the spine. Thus, when the posterior ligaments are damaged, the structural integrity of the spine is adversely affected by spinal distortion [8]. In our study, 19 of 89 cases had posterior ligament damage (21.35%). Of which, the compression fracture group was seen in 4 cases (23.53%); burst fracture group with 10 cases accounted for 14.93%; dislocation fracture group encountered 5 cases (100%). All 19 cases were identified during surgery. Thus, assessment of posterior ligament damage during surgery to avoid missing lesions contributes to the stability of the spine when fixed. CONCLUSIONS Based on the study on the characteristics of traumatic injury on 89 patients with thoracolumbar and lumbar spine injuries, we draw some conclusions: The level of fracture at L1 and burst fracture are the most common, which accounts for 44.95% and 75.28%, respectively. The ratio of narrow spinal canal and neurological deficit are high in burst fracture and dislocation fracture types, which has correlation between severity spinal stenosis and never damage. The position of narrow spinal canal at 1/2 upper accounted for high ratio as many as 79.11%. We consider assessing posterior ligament system during surgery. 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