Đặc điểm hình thái tổn thương và kết quả phẫu thuật điều trị gãy cột sống ngực, thắt lưng đa tầng tt tiếng anh

AND TRAINING NATIONAL DEFENSEMILITARY MEDICAL UNIVERSITY LE HUU TRI MORPHOLOGICAL CHARACTERISTICS OF MULTILEVEL THORACIC AND LUMBAR VERTEBRAL FRACTURE AND THE EFFECTIVENESS OF SURGICAL T

AND TRAINING NATIONAL DEFENSE

MILITARY MEDICAL UNIVERSITY

LE HUU TRI

MORPHOLOGICAL CHARACTERISTICS OF MULTILEVEL THORACIC AND LUMBAR VERTEBRAL FRACTURE AND THE

EFFECTIVENESS OF SURGICAL TREATMENT.

Speciality: SurgeryCode: 9720104

SUMMARY OF MEDICAL THESIS

HA NOI - 2020

MILITARY MEDICAL UNIVERSITY

Supervisor:

1 Associate Prof PhD Vu Van Hoe

2 Associate Prof PhD Vo Van Nho

Reviewer 1: PhD Hoang Gia Du

Reviewer 2: Associate Prof PhD Bui Van Lenh

Reviewer 3: Associate Prof PhD Nguyen Tho Lo

The thesis will be defended by University’s Council at:

The thesis can be found at:

1 National Library

2 Library of Military Medical University

Multilevel noncontiguous spinal fractures (MNSF) aredefined as fractures of the vertebral column at morethan one level According to many reports, multilevelnoncontiguous spinal fractures are found at from 3.2%

to 16.7% Multilevel spine injuries are oftenuncommon, occur commonly as a result of high-speedroad traffic accidents or falls from a height Multilevelspine injuries tend to be more severe than unilevelbecause of the other injuries combined Rapid diagnosis ofMNSF is essential since a misdiagnosis or delayed diagnosis maycomplicate the clinical picture Therefore, the role of athorough physical and radiological examination is thekey to not to miss any lesions Although there aremany studies evaluating and treating single level spinefractures, there have not been many reports ofmultilevel spine injuries In Vietnam, there are notmany researches on this issue So we work for:

“Morphological characteristics of multilevel thoracic and lumbar vertebral fracture and the effectiveness of surgical treatment” with these targets:

1 Describing the morphological characteristic

of multilevel thoracic and lumbar vertebral fractures in which surgical treatments are indicated at Da Nang Hospital.

2 Evaluating the outcome of surgical treatment for multilevel thoracic and lumbar vertebral fractures at Da Nang Hospital.

New main scientific contributions of the thesis:

-The research subjects are lesions in multilevelthoracic and lumbar vertebral fractures

-Providing the evidence of the effectiveness ofsurgical treatment for multilevel thoracic and lumbarvertebral fractures

- Structure of the thesis: the thesis includes 127 pages with 40 tables, 27 pictures and 10 charts Introduction (2 pages); Chapter 1: Overview (31 pages); Chapter 2: Subjects and Methods of the study (26 pages); Chapter 3: The results of the study (31 pages); Chapter 4: Discussion (33 pages); Conclusion (2 pages); Petition (1 page); List of published articles related to the results of the thesis (1 page); References (138 documents including 33 documents in Vietnamese, 105 documents in English); The appendices.

SECTION 1 OVERVIEW 1.1 A brief history of treatment of spine fractures.

1.1.1 In the world

Multilevel spine injuries have been reported for along time Griffith H.B., Gleave J R W, Taylor R G.(1966) reported 5 patients accounting for 3.2% of 155cases of thoracic and lumbar spine fractures Lizbeth

C A M G et al (2018) reported 47 cases of multilevelspinal surgery at the Center Dr Manuel Dufoo Olvera

in Mexico Thus, the multilevel spine fractures havebeen studied for a long time, but they are stillseparated There are no single reports on multilevelspinal injuries

1.1.2 In Vietnam

Previous studies inside the country have onlystudied one-level fractures, there were some authorswho mentioned several cases of multilevel spinalinjuries And there are no separate studies onmultilevel thoracic and lumbar spinal injuries

1.2 Classification of multilevel thoracic and lumbar veterbral fractures

1.2.1 Classification of Denis

In 1983, Denis introduced the definition of column spine": the anterior, middle and posteriorcolumn; and it has been widely applied

"three-1.2.2 Classification of Margel (AO)

In 1994, Margel proposed a classification according

to AO (Arbeitsgemeinschaft fur Osteosynthesefragen)which mainly assess spinal morphological damage

1.2.3 Load Sharing Classification (LSC)

In 1994, Mc Cormack and colleagues released a newclassification to assess vertebrae damage based onthree criteria: the amount of damaged vertebral body,the spread of the fragments in the fracture site, the

amount of corrected traumatic kyphosis.

1.2.4 Classification of multilevel thoracic and lumbar spinal injury based on the severity of lesion.

In 2005 Vaccaro A.R et al proposed aThoracolumbar Injury Classification and Severity Score(TLICS) which is is based on three major categories,known as parameters: injury morphology, posteriorligamentous complex integrity, patient neurology

- To measure local Kyphotic Angle (LKA) and CobbAngle

1.4.2 Computed Tomography Scan.

Computed tomography (CT-scan) provides greaterdetails and resolution for evaluation of the boneelements and assessment of the entire spinal canal.CT-scan allows us to assess bone lesions, fracturelines, fracture fragments, lesions of processes, joints,holes, posterior arcs, damaged fragments moving intothe spinal canal, and spinal stenosis

1.5 Methods of Spine Stabilization.

1.5.2 Posterior Stabilization Systems

Posterior stabilization systems can restore vertebral body height

by distraction forces Furthermore, anterior and middle columnsmaintained their normal length during correction of kyphosis.Distractive forces provided by the posterior stabilization systemdeveloped a tensile strength in the posterior longitudinal ligamentwhich pushes back the retro-pulsed bone fragments forward Thisprocess has been termed ligamentotaxis and it is beneficialparticularly if performed at the early period

1.5.2.3 Posterior lumbar interbody fusion surgery (PLIFs).

Transpedicular screw is now the standard of spinefusion surgery for many spinal diseases We use a

"free hand" technique with screws are parallel to thejoint of the vertebra and we use X-rays for guidingduring surgery

1.6 Indications of surgical treatment for multilevel thoracic and lumbar fractures

Greenberg M.S (2010) refers to a treatmentindication based on a clear, complete description ofthe morphological characteristics of lesions in threecolumns, signs of neurological damages and theirassociations They also consider the characteristics ofthe fracture group as well as the location of fractures

in assessing the instability of the injury In thisdocument, author McAfee presents the specifiedsurgery in the case

1.7 Evaluation the results of surgical treatment

1.7.1 The assessment of the results of spinal

correction and stabilization surgery

Anteroposterior (AP)and oblique X-rays on all patients;measuring local LKA and Cobb Angle on oblique X-rays

is the most commonly used method today

1.7.2 The assessment of the neurological recovery after surgery

Based on the neurological damage classificationtable according to Frankel: Pre-operative evaluation,post-operative evaluation, and evaluations in follow-upvisits, monitoring changes in Frankel level betweentwo consecutive visits

CHAPTER 2 SUBJECTS AND METHODS OF STUDY

2.1 Subjects

2.1.1.The criteria for selecting research patients

- All patients diagnosed with multilevel vetebralfractures (≥ 2 levels) from the fourth thoracic vertebra

to the fifth lumbar vertebra, having unstable fracture,and caused by trauma These include multilevelvertebral fractures emphasized on thoracic-thoracic,thoracic-lumbar, and lumbar-lumbar segments

-All patients who have plain and oblique X-rays,computerized tomography scan and posteriorstabilization of at least one fractured vertebra body

2.1.2 Exclusion criteria

-Elderly patients with osteoporosis, bone tumors,tuberculosis, cardiovascular disease, coagulopathy,

etc Patients with brain sequelae or brain entitypathologies, spinal cord sequelae or paralysis ofperipheral nerves in the lower extremities due topathology, mental disorders that distort nerveassessment at the spinal cord Patients who hadsurgery then lost information, did not come back forexamination, or did not cooperate with treatment.

2.2 Research method

2.2.1 Sample size

Convenience sampling method, including allpatients who match selection and exclusion criteriaduring the research period

2.2.2 Method of data collection

Clinical and radiological findings : routine X-ray, scan; the results of treatment are collected based on apre-set form Direct clinical examination, assessment

CT-of symptoms, analysis CT-of results CT-of X-rays, CT scansbefore surgery

Perform posterior stabilization surgery, evaluate thepostoperative results All patients receive dischargeinstruction in self-care and mobilization

Re-examination after 06 months: examination ofclinical symptoms such as movement on ASIA scale,sensation, reflexes, urination, incisions, neurologicalrecovery according to Frankel level, urinary tractinfections, pneumonia, muscle atrophy, regular X-raymeasuring KLA, height of fractured vertebra, screwposition

2.3 Method of Data Analysis

Collected data were processed in the statisticalsoftware 12.2.1.0.

CHAPTER 3 RESEARCH RESULTS 3.1 Clinical and radiological characteristics of multilevel thoracic and lumbar vertebral fractures

3.1.1 General characteristics

3.1.1.1 Age, gender, occupation

Age group 20-19 accounted for the majority of caseswith 19 patients (35.84%) The youngest age 16, theoldest age Average age was 37.47 ±13.47.Male/Female ratio: 4.88/1

Workers accounted for the higest rate with 26cases (49.05%) The majority were workers andfreelancers with 36 cases, accounting for 67.85%

3.1.2 Clinical conditions of patients on admission

3.1.2.6 The degree of nerve damage according to Frankel

Table 3.5 Patient classification according to Frankel

neurological damage

Frankel

No.

Patients (n)

Percentag

e (%)

p <0.01

Table 3.6 The associated injuries

Associated

lesions

No

Patients (n)

Percenta

ge (%)

p <0.01

3.1.3.2 Distribution of multilevel vertebral fractures

Chart 3.7 Distribution of multilevel vertebral fractures

3.1.3.4 Detecting contiguous or noncontiguous lesions

Chart 3.9 Spinal stenosis

3.1.9 The correlation between clinical and radiological findings

Table 3.16 The correlation between Denis classification of spinalfractures and The Frankel Grade classification

Denis Frankel

Total

n, (%)

p =0.0319

7(13.20)

4 (7.54)

30(56.63)

53 (100)

3.1.10 The correlation between neurological damage and degree of spinal stenosis on CT- scan

Table 3.17 The correlation between degree of spinal

stenosis and degree of paralysis

p <0.05

stenosis

< 50%

21 (39.63)Spinal

stenosis

≥ 50%

24 (45.28)Total

n, (%)

10(18.8

6)

2(3.77)

7(13.20)

4(7.54)

30(56.63)

53(100)

84.92% The earliest time from admission to surgerywas within 1 day, the longest time from admission tosurgery was 21 days Average time 7.37 ± 4.37 days.

Percent age (%)

p <0.01

The Frankel Grade classification

Table 3.24 Neurological recovery after operation

n, (%)

p < 0.000 1

n, (%)

10 (18.8 6%)

2 (3.7 7%)

7 (13.2 0%)

4 (7.5 4%)

30 (56.

63%

)

53 (100%)

3.2.2.3 Results of neurological recovery after re-examination

The Denis Pain and Work Scale: there were 17

graded level 1 patients (32,07%) who were able toreturn to work and 12 graded level 5 patients (22,66%)completely lost working capacity.

Table 3.27 Neurological recovery after 6 months

Frankel

n, (%)

p < 0.00 01

(71.72%

) Total

n, (%)

10 (18.86

%)

1 (1.88

%)

4 (7.54

%)

4 (7.54

%)

34 (64.18

%)

53 (100%)

3.2.2.4 The result of local kyphosis angle recovery results

Table 3.28 Local kyphosis angle recovery results

Local

kyphosis

angle

Lowe st

High est Mean

Compare (p)

operation

10 27 0 10.56 ± 5.530

(2)

Re-examination 2

0 29 0 13.37 ± 5.940

(3)

3.2.2.5 The results of vertebral body compression recovery after surgery

Table 3.30 Anterior Vertebral Body Compression

Percentage Results

Index

operation (1)

Pre- surgery (2)

Post- examinati

Re-on (3)

Compare (p)

24.92 ± 16.03 (0.08- 67.02)

25.30 ± 16.03 (1.59- 76.31)

p12= 0.0001 p13= 0.0001 p23= 0.9031

p <0.0001

CHAPTER 4 DISCUSSION

4.1 Clinical and radiological characteristics of multilevel thoracic and lumbar vertebral fractures

4.1.1 General characteristics

4.1.2.6 The degree of neurological injuries according

to the Frankel Grade classification

In table 3.5 we find that patients with normalsensory and motor function (Frankel E) accounted forthe highest proportion with 30 cases (56.63%) Thenumber of patients with symptoms of completeparalysis (Frankel A) ranked second with 10 patients(18.86%)

The rate of paralysis varies by author, depending onresearch subjects

4.1.2.7 Associated injuries

Patients with multilevel spinal injuries were mostlycaused by a complex, strong traumatic mechanism,which often resulted in other traumas Patients withother accompanied injuries accounted for the highestproportion with 36 cases (67.93%), in which multipleinjuries ( 2 types of combined injuries or more) had 11patients (20.78%)

Our research had a high percentage of combinedinjuries due to the strong traumatic mechanism ofmultilevel spinal injuries that caused damage toorgans of the body.

in 53 cases (ratio: 2.22 fractures/1 patient)

Reasons for missing lesions on X-ray films: poorimage quality, not capturing the entire spine at ourrequest, initial examinations by inexperiencedphysicians

This shows that lesions will be more accuratelydetected in CT-scanned patients than in patients withx-rays only This is considered the best method forassessing lesions of bone today

4.1.3.2 Distribution of lesions of multilevel spinal fractures.

Figure 3.7 shows that the most common segmentamong all patients suffering multilevel spinal fractureswere concentrated in thoracic+thoracic segment with

11 cases (20.76%), thoracic+lumbar segment andlumbar+ lumbar segment with 21 cases (39.62%).Most injuries emphasized on the thoracic+lumbarsegment and lumbar+ lumbar segment because