Abstract

Background: Cervical spinal cord injury (SCI) is a life-threatening condition. Prompt surgical intervention is needed to avoid hemodynamic and respiratory catastrophe. In Indonesia, however, spine surgery is more common in tertiary hospitals and thus might prolong the time gap to surgery due to referral waiting time.

Case Description: We performed an emergency surgery for a patient with complete SCI due to unstable cervical fracture. The patient was in spinal shock and experienced respiratory arrest after radiological workup. Stability was achieved in the ICU and patient was directly sent to operating theater. Anterior-posterior approach was chosen to decompress and stabilize the cervical spine. The patient was discharged on postoperative day 17 and was seen well at 1-month follow-up.

Conclusion: The capability to perform spine procedures should not be exclusive to tertiary hospitals in Indonesia. Satisfying results can be achieved with the presence of capable neurosurgeons or orthopedic surgeons and anesthesiologists in lower-level hospitals.

Keywords: Cervical, Emergency surgery, Referral, Secondary hospital, Spinal cord injury

INTRODUCTION

Spinal cord injury (SCI) worsens patients’ quality of life due to its impact on sensory, motor, and autonomic function.[ 13 , 21 ] Traumatic events due to automobile accident and fall are said to be the most common causes of SCI.[ 6 ] The incidence of SCI is estimated to be 10.5 cases/100.000, with higher proportion occurring in low-to-middle-income countries,[ 15 ] although this number might vary among studies. Life expectancy among patients with SCI is generally lower than normal population.[ 17 , 14 ] Patients with higher level of lesion[ 23 ] and those with more severe ASIA impairment scale have been reported to fare worse.[ 26 ] Cervical injury is probably the most dangerous among SCIs due to impairment of respiratory muscles.[ 13 ]

Spine surgery in Indonesia is more commonly performed in a tertiary hospital. Transporting patients with SCI, however, require careful manipulation to avoid worsening the injury.[ 3 ] Patients with SCI are in danger of cardiovascular instability and, in those with cervical injury, respiratory arrest. Surgery is needed immediately to avoid complications and mortality. We present our experience performing emergency surgery to treat a complete SCI due to unstable cervical fracture in a secondary hospital in Surabaya, Indonesia.

CASE REPORT

We report a 52-year-old old female who presented to our hospital with tetraplegia for the past 1 h before admission after falling from her house’s roof, approximately 4m height. Primary survey was notable for neck pain, abdominal labored breathing, signs of spinal shock with blood pressure of 77/46 mmHg, tetraplegia, scalp laceration at right parietal, deformed left femur, flaccid anal sphincter, and absent bulbocavernosus reflex. The patient was fully conscious during the examination. Blood pressure improved after initial fluid resuscitation only to redeteriorated around 2 h afterward and therefore vasopressor was started.

Cervical CT scan reveals a burst fracture and translational injury of C5 and split fracture of C6 [ Figure 1 ]. The patient was then taken for emergent cervical MRI, on which a massive spinal cord edema was seen extending to the level of C2 and T1 from the epicenter of injury. Unilateral left facet dislocation between C4 and C5 was identified [ Figure 2 ]. The spinal cord was seen kinked at the level of C7-T1 [ Figure 3 ]. Brain CT scan revealed no abnormality. Plain X-ray showed fractured left femoral shaft. After radiologic workup, the patient experienced apnea and was, therefore, intubated and transferred to ICU.

Figure 1:

(a-c) Cervical CT scan showed a burst fracture with translational injury of C5 (top) and split fracture and right laminar fracture of C6 (middle). The fractured C5 body was partially lodged behind the body of C4. Bilateral facet dislocation was also noticed.

Figure 2:

(a and b) Cervical MRI shows a spinal cord edema from C2-T1 level and kinked spinal cord at C7-T1 level.

Figure 3:

Anterior plating of C4 and C6 with cage in place of C5. Lateral mass screws were inserted at C3, C4, and C6.

The patient was assessed with complete SCI (ASIA type A), translational injury of C5 (AOSpine C) and split fracture of C6 (AOSpine A2). Rather than looking to refer the patient, immediate surgery on the following day (22 h after admission) was preferred after respiratory and hemodynamic stability in the ICU was achieved. Combined anterior and posterior approach was preferred for this patient. Anterior cervical corpectomy and fusion with hollow cage at C5 and subsequent anterior plating were performed first. After anterior approach was completed, the patient was positioned prone for total laminectomy of C4 and C5 and lateral mass screw of C3, C4, and C6 [ Figure 3 ]. Rupture of posterior supraspinous and interspinous ligaments was found during surgery.

Postoperative cervical evaluation showed satisfactory position of lateral mass screw [ Figure 3 ]. Postoperative Cobb angle was corrected to 17° lordotic angle, whereas the preoperative was 19° kyphotic angle [ Figure 4 ].

Figure 4:

Comparison of postoperative (left side picture, 17° lordotic angle) and preoperative Cobb angle (right side picture, 19° kyphotic angle).

DISCUSSION

SCI due to cervical fracture is a life-threatening condition.[ 13 ] Most cervical spine injuries occur in the subaxial cervical.[ 22 ] Subaxial cervical injuries are often unstable and frequently involve damages to the anterior column and posterior osteoligamentous complex,[ 7 ] as are in the present case. The patient was present with abdominal breathing and even fell into respiratory arrest. Although the injury occurred at C5, the spinal cord edema extended cranially beyond the level of injury, thus incapacitating the patient’s ability to breathe.[ 4 ] The loss of motor, sensory, and autonomic function below the level of injury indicated a complete SCI in the present case.

MRI was performed before surgery mainly to help prognostication and to better appreciate the involvement of ligaments and other soft tissues.[ 5 , 10 ] The presence of extensive spinal cord edema and kinked spinal cord in the present case indicated a severe injury with poor prognosis. Aarabi et al. found that preoperative intramedullary lesion length (IMLL) on MRI is inversely related with the odds of recovery.[ 1 ] Previously, the same author reported that 1 mm increases of IMLL correlates with 4% decreases of the odds of AIS improvement.[ 2 ] In the present case, the length of spinal cord edema extends to approximately 7.3 cm [ Figure 5 ].

Figure 5:

The extend of spinal cord edema from C2 to C7.

The decision to perform surgery at our hospital was mainly based on the poor clinical condition and the radiological evidence of instability. Transporting patients with unstable hemodynamic and imminent respiratory arrest to another hospital certainly carry a substantial risk of deterioration. A cadaveric studies found that log-roll maneuver during physical examination or during an attempt to put a spinal board does not exclude the possibility of spinal column movement.[ 16 ] A study found that as many as 10.7% of patients with SCI worsened during interfacility transfer.[ 20 ]

We deem it best to stabilize the patient in the ICU and to go straight for surgery rather than refer the patient and, therefore, prolong the time gap to surgery. Given the dreadful radiological findings, however, the surgery focused more on lifesaving rather than restoring independence and mobility. Our goal was to alleviate the threat to patient’s breathing and circulation, and to allow safe mobilization to prevent further complications. After achieving relatively stable hemodynamic state, the patient was sent to the operating room at 22 h after injury. Surgery within the first 24 h has been addressed as “early surgery”[ 27 ] and has been encouraged in various published studies.[ 11 , 25 , 9 , 28 ] Although there are studies with differing results,[ 24 ] there is a general acceptance on early surgery for SCI. A large study on cervical SCI, on the other hand, found that patients who had early surgery had better odds of 2 AIS grade improvement.[ 11 ] Doubts regarding early surgery are mainly on whether some groups of patients with certain characteristics would benefit less from early surgery than some certain others.[ 27 ]

Combined anterior and posterior approach was preferred due to (1) frank anterior pathology, (2) interlocked fracture segments behind the C4 body, (3) evidence of instability with (4) suspected posterior osteoligamentous involvement, and (5) spinal cord compression. In the present case, anterior approach was performed mainly to remove fracture segments, fuse the bone, and restore some physiological alignment. Posterior approach was mainly to stabilize and decompress. Difficulties encountered in the operating room in the present case were the occasional hemodynamic changes during surgery and positioning. Sudden hemodynamic changes (hypotension and bradycardia) during prone positioning are a known phenomenon[ 8 ] and have been reported previously.[ 18 , 19 ] The role of anesthesiologist is vital in overcoming such hemodynamic instability. The fractured femur was operated by the orthopedic surgeon right after the spine surgery concluded.

Passive mobilization could be done safely after surgery. A week after surgery, the patient was cleared from the ICU. The patient developed pneumonia during hospitalization which clinically improved after antibiotic administration. As clinical and neurological condition remained stable, the patient was discharged on the 17^th postoperative day for home care and further rehabilitation. The patient was seen well at the outpatient unit at 1-month follow-up.

CONCLUSION

Although spine surgery is more common in tertiary hospital in Indonesia, we successfully achieved satisfying result in the present case. Direct surgery after restoring hemodynamic stability in cervical cases should be the priority. Considering referral in such case might put the patient at risk of deterioration. The presence of neurosurgeons or orthopedic surgeons who have been trained for spine surgery, along with competent anesthesiologist in a secondary hospital, would be very helpful in treating life-threatening cervical SCI without further delay due to referral waiting time. Therefore, the capability to perform spine procedures, especially cervical ones, should not be exclusive to tertiary hospitals

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Rizki Meizikri is an awardee of Indonesia Endowment Fund for Education (Lembaga Pengelola Dana Pendidikan Republik Indonesia) and, therefore, might receive financial rewards for publishing papers on Scopus-indexed journal.

Conflicts of interest

There are no conflicts of interest.

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