Delayed surgery in Lumbar spine fractures: Do severe caudaequina lesions recover?
Authors: MihirBapat, Mir Tariq, SushmitNaskar, Vishal Patil
Authors Affiliations: Kokilaben DhirubhaiAmbani Hospital and Medical Research Institute, Four Bunglows, Andheri West, Mumbai-400053
Address of correspondence: Dr. Mir Tariq, Kokilaben DhirubhaiAmbani Hospital and Medical Research Institute, Four Bunglows, Andheri West, Mumbai-400053
Early decompression in the first week after injury is argued to favorably influence neurological recovery in lumbar fractures. Prognosis predictions in delayed decompression after 4weeks of injury are unclear in literature. In developing countries, it is not uncommon for surgery to be delayed as patient battles through the lacunae in the health care delivery system.
We present the recovery patterns in 20 patients with delayed presentation treated with surgery and an average follow-up of 2years.
Materials and Methods
20 delayed fractures underwent surgery from 2000 to 2008. The timing of surgery ranged from 2weeks to 36weeks (average 6.2weeks). The delay in surgery was due to co-morbid injuries (4) and delay in transit (16). The average age was 24.5years (range 11 to 46years) and 16patients were males. The thoraco-lumbar injury severity score (TLISS) was 7 (n=15), 8 (n=2), 9 (n=2) and 10 (n=1). All fractures involved the lumbar spine below the level of L1vertebra and showed an incomplete caudaequina injury. 4 patients recovered more than one grade before the surgery was performed but all patient demonstrated non-functional motor power distal to the level on injury. The ASIA grade was B in 7 and C in 13 patients. The apex was L2 (n=10), L3 (n=6), L4 (n=2) and more than one levels in 2patients. The ASIA score was calculated for each patient and compared with the outcomes at 2years.
A stand-alone anterior decompression and instrumentation was performed in 8 via the retroperitoneal approach. In the remaining 12patients, a posterior and anterior surgery was performed. The patient was mobilized bed side in the first week after surgery and rehabilitated as per neurological recovery. The follow-up was prospectively maintained by the treating surgeon using a pre-designed software ‘Horizon’ at 3monthly intervals for the first year and then by yearly assessments. The average follow-up was 2years (2 to 6years).
4 patients (57%) in the ASIA B group did not show neurological recovery. Of the remaining 3patients one recovered by one MRC grade, one by 2grades (ASIA D) and one by more than 2grades (ASIA E).
Out of the 13 patients in pre-operative ASIA C group, 12 (92%) improved by more than 1 grade (ASIA D =7 and ASIA E = 5).
Out of 20 patients showing ASIA D and E recovery (n=15), 12 patients (60%) showed poor recovery of L5 root (Unilateral 8 and bilateral in 4). Nerve conduction study confirmed severe de-innervation in the affected muscles
The neurological recovery started within 2weeks in two patients and was complete by 3months. In 13 patients clinical noticeable recovery was seen by 3months and plateaued by 9 to 12months.
Pre-operatively, 9 patients presented with severe bladder affection. 3 patients recovered near normal bladder function and showed mild detrussor dysfunction with void delay on urodynamic study. 5 required pressure voiding and intermittent catheterization for a hypo-contractile detrussor. 1 patient demonstrated dribbling incontinence with prolonged catheterization.
The average visual analogue pain score at 2years was 4.3 out of 10 and the ODS was 28.5. Only 3 out of 15 patients returned to a near normal functional status.
Fusion was seen in 19patients with maintenance of correction. Implant failure occurred in one and was revised. The problems encountered were sacral pressure sore in 2, recurrent urinary infection in 3, superficial posterior surgical wound infection in 1 and paralytic ileus in the immediate post-operative period in 1.
- In incomplete lesions of the caudaequina significant neurological recovery can be expected even when the fracture management is delayed.
- Probably ASIA C has a potential to recovery significantly.
- Persistent foot drop is common and may be the only residual weakness.
- It can be suggested that canal clearance anteriorly should be attempted wherever possible.
|How to Cite this Abstract|
|Bapat M. Delayed surgery in Lumbar spine fractures: Do severe caudaequina lesions recover?
International Journal of Conference Proceedings. March 2015;(2015):26