- Cedarcrest Hospital, Abuja, Nigeria
Correspondence Address:
Biodun Ogungbo
Cedarcrest Hospital, Abuja, Nigeria
DOI:10.4103/2152-7806.89854
Copyright: © 2011 Ogungbo B. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Ogungbo B. Anterior decompression, fusion and plating in cervical spine injury: Early experience in Abuja, Nigeria. Surg Neurol Int 14-Nov-2011;2:156
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Abstract
Background:We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria.
Methods:The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1 August 2009 till 30 August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access® database (Microsoft Group of Companies). Frankel grading was used for pre- and immediate post-operative evaluation (within 48 hours). The Barthel index (BI) was used to classify patients as dependent or independent at follow-up.
Results:Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. Twenty anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. Seven patients have made a full recovery and seven remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society.
Conclusion:The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.
Keywords: Anterior cervical discectomy, cervical spine traumatic instability, Nigeria, outcome, surgical fixation, trauma
INTRODUCTION
Literature from Nigeria on spinal injury is not only scanty, but also the majority of the existing ones have been by non-neurosurgeons.[
Surgical management of spinal injuries has been rare in the reports. Therefore, the advances in spinal injury management practiced in other parts of the World have not been reflected in the published reports from Nigeria.
The management of spinal trauma in Abuja, Nigeria, is now undergoing change with the recent arrival in the city of another neurosurgeon who is particularly interested in the open surgical reduction and fixation of suitable cases. Patients can now be admitted and offered surgical intervention as soon as possible. This allows them to be mobilized and presented to rehabilitation centers early. The new service came into existence in August 2009 and has provided active surgical intervention and management for patients with spinal trauma. The patients in this report were operated via an anterior approach with decompression, iliac graft fusion, and plating (ACDF).
MATERIALS AND METHODS
We have kept a prospective database of all patients admitted with acute cervical spine trauma and cervical spinal cord injury. The demographics includes the age, gender, clinical presentation, type of injury, level of injury, radiological information, disability as measured with the Frankel grading scale, management, and outcome. Pre-operative and post-operative Frankel grades within the first 48 h were recorded. Final outcome, evaluated using the Bathel disability index, was scored by 30 September 2010. Patients and or their carers were contacted and the index applied by telephone questioning, clinic, and home visits.
The patients
The patients in this report were admitted and treated at two hospitals in Abuja. These were the National Hospital, Abuja, which is a public hospital and Cedarcrest Hospital, a private orthopedic/neurosurgery hospital. The patients had suffered a road traffic accident (19 cases) and diving accident (1 case), resulting in cervical spinal column injury and varying degrees of spinal cord injury.
Patients with acute cervical spine injuries have screening x-rays of the cervical spine to review spinal alignment and confirm the level of injury. The majority (19 of 20 patients) were investigated with an MRI scan [
Table 1
Shows the radiology of the patients admitted with acute spinal cord injury. The level of injury and modality of investigation preoperative and post operatively is shown. The actual significant spinal cord injury is recorded as contusion, transection, root injury or disc prolapse. Two patients were not operated and one died early before post operative imaging
The operation
The operations were usually performed on the day of admission or as soon as possible depending on other issues such as clinical condition, costs, and availability of personnel or equipment. All patients with unstable cervical spine injuries and those with compressive cord lesions (bone compression, hematoma, and disc prolapse) were offered urgent surgical intervention. The exclusion criteria for surgery were medical problems precluding anaesthesia and respiratory distress requiring airway control. Cost may have also been an issue in one case where the relatives refused surgical intervention.
The operation, ACDF, was a single level decompression in all these cases. Operations were performed as per routine approaches as previously documented by others. All patients had ceftriaxone, antibiotic, as prophylaxis at induction of anaesthesia and subsequently for 2 days after the operation. Surgery was performed following general anesthesia with the patient's supine and controlled neck traction using Gardner Wells skull traction. Weights were however only attached after established muscular paralysis or in some cases only after performing the discectomy. This was done in cases where there was a mass of disc behind the vertebrae. An image intensifier was used to localize the level of injury, review the spinal alignment and facetal reduction. The discectomies were performed using curettes and rongeurs. We did not use a microscope or high speed drill. Once the spinal cord was decompressed, an iliac graft was obtained and interposed using a Clowards disc spreader and skull traction. The anterior cervical plate (Implants International, Thornaby, UK) was applied. A wound drain was always utilized in the neck but occasionally in the hip wound.
Post-operative care and rehabilitation
A standard post-operative regimen was developed to care for the patients after surgery. This includes regular turns, close nursing care to prevent the following: aspiration, chest infection, urinary tract infection, and constipation. Early sitting up, a hard cervical collar, and physiotherapy were key elements of the post-operative care. Few of the patients required post-operative intensive care. Five of the patients could afford the cost of travel abroad for rehabilitation after surgery. All the others were managed locally and discharged home as soon as practicable.
RESULTS
Twenty patients have been admitted following an accident, with acute cervical spine and spinal cord injury. There were 17 men and 3 women. All except one had been involved in a road traffic accident (RTA). One young patient sustained neck trauma after he dived into a shallow swimming pool. The age range was 20 to 53 years (mean age 37.4). The patients had sustained injury to different parts of the cervical vertebrae but most of the injuries were at the C5/C6 level [
Of the 20 patients, 18 were operated and most within 48 h. The operation was performed on the day of the accident and as soon as possible following admission in 11 patients and at varying periods in the remainder. In one patient, it was performed as late as 3 weeks due to late referral and subsequent pre-operative complications (urinary tract infection and epistaxis). In a few cases, the operation was delayed because the surgeon was not available and due to early respiratory problems in one patient. We were unable to operate on two patients. One was not operated because the family refused treatment. We do not have any follow-up information. One other patient had respiratory distress and underwent an early tracheostomy. He was nursed in the intensive care unit for weeks before discharge to a rehabilitation center.
Eighteen patients underwent 20 operations. One patient re-dislocated 5 days after surgery and had a repeat operation performed. He was involved in a road traffic accident which led to a C6/C7 subluxation and complete spinal cord injury[Figures
Figure 1
T1- and T2-weighted sagittal MRI scans showing the traumatic spondylolisthesis at C6/C7 (a-c). The image b demonstrates the facetal dislocation. The image on the right (c) shows the related spinal cord injury and a posterior disc fragment. This precludes spinal traction before reduction as the disc may be pushed back into the spinal cord causing more injury
Seven patients had severe dislocations (grade 4) of the vertebrae and bifacetal dislocations posteriorly. We were unable to achieve posterior fracture/dislocation reduction in two patients. None underwent posterior fixation due to non-availability of instrumentation. One was described above. The other patient also had a C6/C7 grade 4 spondylolisthesis and fractures of the posterior elements [
Figure 5
MRI scan of the patient (T2 sagittal images) showing the level of injury and dislocation, C6/C7 with spinal cord transection. Pre-operative image (a). The disc prolapse behind the vertebral body is significant. The post-operative image (b) is also shown following anterior approach, discectomy, and fixation with a hip graft and plate
We performed an urgent tracheostomy in four patients for respiratory distress and to aid airway toileting. Two of these patients died subsequently from respiratory failure.
Complications during surgery included a case in which there was leakage of cerebrospinal fluid seen at the time of the operation. This was related to the injury and not a surgical mishap. It was managed with a lumboperitoneal shunt. Otherwise all the operations were uneventful.
Morbidity and mortality in our patients are detailed in
Table 2
Shows the outcome of the patients admitted with acute spinal cord injury. The frankel grade was applied at admission preoperatively and postoperatively within 48 hours. Bathel Index was used for outcome and dichotomised into dependent and independent of activities of daily living. The follow up period in weeks after surgery is shown. Two patients were not operated and one died a day after surgery.
DISCUSSION
Following a Medline search, no articles were found reporting exclusively on cervical spine trauma in Nigeria. There are also no previous reports on the management of such problems in Abuja. However, there are many reports about spinal trauma and spinal cord injury in Nigeria, notably from Maiduguri and Enugu.[
Spinal cord injury is often associated with lifetime morbidity so early active management is crucial.[
Initial care of the spinal injured
The initial care of patients with acute traumatic lesions of the cervical spine is of paramount importance. Neurologic function at both the nerve root and cord levels can be adversely affected by excessive motion of the unstable spine.[
Diagnosis
Early diagnostic and clinical evaluations are important in determining the severity of the injury and making plans for subsequent management. Timely and appropriate imaging studies using x-rays, CT and MRI scans are essential to the cervical spine evaluation.[
Skull traction for facetal dislocation
Operations were performed routinely after attaching a Gardner Wells tong to the head. We did the traction in theatre under image guidance and not on the wards. No pre-operative closed reduction was performed because we had no means of checking the reduction on the wards. As in the cases illustrated in Figures
Anterior/and or posterior fixation
We performed only an anterior approach and discectomy with fracture fixation using an anterior cervical plate in all our patients. This proved adequate in 16 patients. However, posterior facetal reduction and fixation and subsequent anterior decompression and fixation would have been of benefit in at least three of our patients. We did not perform posterior cervical operations primarily due to non-availability of equipment for posterior fixation and other issues. Some of these issues are cost, length of operations, and subsequent need for intensive care.
We accept that surgical stabilization should be individualized for each patient. The procedure used should provide both immediate and prolonged stability at the site of instability.[
Conservative management of cervical spinal instability
Patients and their families have to pay for all operative interventions and acute care: the cost of a CT scan examination (CT spine) is uniformly about N40, 000 ($250 approximately) and MR is double that (average monthly salary in Nigeria is about N20, 000 or $120 approximately). The operation costs about N1,000,000 (one million Naira or equivalent of $6250 on average). The cost is therefore challenging for the average Nigerian. In this regards, conservative management remains a viable alternative and is often practiced. Management such as hard cervical collar, skull traction, Minerva jackets and plaster casts are sometimes used. The halo fixator has a well-defined place in the management of fractures of the cervical spine. Available evidence suggest that management of upper cervical spine fracture with halo fixator is safe and effective.[
Morbidity and mortality
The report details the management and outcome of patients with significant spinal column and spinal cord injury in Abuja. Morbidity in this series included significant bed sores, malaria, respiratory, and urinary tract infections. Considering the significant morbidity of these patients who were previously managed conservatively, our reported rate of clinically significant complications could be considered acceptable. It could be further minimized by good pre-operative planning, careful surgical technique, expert nursing care, and improved intensive care facilities.[
Rehabilitation
Prolonged survival has resulted from better understanding of the pathophysiology of cord damage, as well as from the advances in antibiotic and ventilatory therapy.[
CONCLUSION
We have presented early and evolving experience of the management of patients with significant cervical spinal column and spinal cord injury in Abuja. We are advocates for early surgical management via an anterior approach, even with the limited complement of equipment. Posterior stabilization may however be required in a few patients, especially those with complete dislocation of the spine where 360° fusion may be more appropriate. Improved outcomes can be achieved with a careful approach and multidisciplinary integrated care including improvements in intensive care and effective rehabilitation centers.
This report could be a template for stimulating early surgical treatment for this group of patients in the country as a whole.
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