Study the Neurological Improvement after Surgical Management of Traumatic Paraplegia in Traumatic Thoracolumbar Fractures

Ab s t r Ac t Background: Traumatic paraplegia is an unanticipated catastrophe in an individual’s life, posing a huge economic as well as social burden. We evaluated all the patients for neurological improvement after surgical management of traumatic paraplegia in traumatic thoracolumbar fractures. Materials and Methods: The prospective study was conducted in the department of orthopedics of a tertiary care teaching institute in Kolkata, West Bengal, India. The patients were evaluated by X-ray of spine (anteroposterior and lateral view) and sometimes computed tomography scan. In most cases, pedicle screw with plate or rod was used and posterior stabilization and posterior fusion with corticocancellous bone graft from posterior iliac crest were done. Pre-operative and post-operative neurological charts (according to Frankel’s grade and American Spinal Cord Injury Association score [motor and sensory]) were maintained with regular assessment for proper postoperative neurological recovery assessment. Results: Forty-six patients in whom posterior stabilization of the spine was done in this institution and followed up for a period ranging from 6 months to 2 years, 4 of 46 patients lost follow-up. Remaining 42 patients were considered for the study. When decompression done within the 1st week in incomplete paraplegia, 80% of the patients show Grade 3 power return, whereas 25% of the patients show return of Grade 3 power when decompression done in the 3rd week in incomplete paraplegia cases. In complete paraplegia cases, 11% of the patients had return of power up to Grade 3 when decompression done within the 1 week, where no cases showed return of Grade 3 power when decompression done after the 2nd or 3rd week. In incomplete paraplegia, 80% of the patients had onset of sensory recovery within 1 week, when the decompression done within the 1st week. In complete paraplegia, 11% of the patients had sensory recovery within 2 weeks when decompression done within 1 week. Conclusion: Hence, our conclusion is that early decompression definitely has some role regarding motor and sensory function return, both in complete and incomplete paraplegia.


IntroductIon
Biomechanically, thoracolumbar junction is susceptible to injury and is the most commonly injured portion of the spine. [1,2] Once one spine injury is diagnosed, it is especially important to examine the rest of the spine since non-contiguous injuries can be present 15% of the time. [3,4] Three main categories with a common injury pattern were formed: Type A -vertebral body compression (compression force), type B -anterior and posterior element injury with distraction (tensile force), and type C -anterior and posterior element injury with rotation (axial torque). [4] The treatment options for the unstable thoracolumbar spine fractures and fracture dislocations are ridden with controversies. Most authors agree that neurological improvement is independent of the treatment modality. [5,6] However, the advocates of surgical decompression point at theoretical advantages of surgery in improving neurological deficits. Lately, consensus is evolving around the world for stabilization of spine with fusion and instrumentation in unstable fractures. Surgical treatment can be by anterior, posterior, lateral, or anteroposterior (AP) approaches. As most orthopedicians and spine surgeons are more experienced in posterior approach, it is a safe alternative. Many instruments are available to stabilize spine by posterior approach. [7] Traumatic paraplegia is an unanticipated catastrophe in an individual's life, posing a huge economic as well as social burden. The health care does not end with fixation of spine and inculcates a programmed rehabilitation and preventive management plan involving multiple personnel and family members. Early surgery Neurological improvement after surgical management of traumatic paraplegia www.apjhs.com traumatic paraplegia and loss of manpower are well imaginable. Data of traumatic paraplegia at a tertiary care hospital, Kolkata, were analyzed with the analysis of the results of surgical management of traumatic paraplegia, complete or incomplete. We evaluated all the patients for neurological improvement after surgical management of traumatic paraplegia in traumatic thoracolumbar fractures.

MAterIAls A n d Methods
The prospective study was conducted in the department of orthopedics of a tertiary care teaching institute in Kolkata, West Bengal, India. The Institutional Ethics Committee permission was sought before enrollment of study subjects in the above study. The study participants were followed up for 6 months in post-operative period. The cases included in this study were the patients attending outdoor and emergency with traumatic paraplegia involving the dorsolumbar spine.

Inclusion Criteria
The presence of traumatic paraplegia (complete or incomplete) and fulfilled the following criteria: • Fracture and/or dislocation of the vertebra of dorsolumbar spine involving D8-L5 spine • Fractures involving one or maximally two vertebrae • Skin condition of the operative field normal patients and party agreed to has a surgical decompression.

Exclusion Criteria
The following criteria were excluded from the study: Patients presenting late (more than 1 month after injury) • Patients with traumatic paraplegia but without signs of cord compression on magnetic resonance imaging (MRI) (where paraplegia is due to cord edema or myelomalacia). Informed consent was taken after proper counseling and proper pre-anesthetic check-up. The patients were evaluated by X-ray of spine (AP and lateral view) and sometimes computed tomography scan or MRI [ Figures 1-3]. Due to financial constraint, contrast myelography was done only few cases. In most cases, pedicle screw with plate or rod was used and posterior stabilization and posterior fusion with corticocancellous bone graft from posterior iliac crest were done. In all the cases, water bed was used during pre-operative and post-operative period to prevent bed sore. Pre-operative and post-operative neurological charts (according to Frankel's grade and American Spinal Cord Injury Association [ASIA] score [motor and sensory]) were maintained with regular assessment for proper post-operative neurological recovery assessment. [9] Recovery from spinal shock was noted using clinical methods like return of bulbocavernosus reflex. Direct or indirect decompression was done. In most of the cases,    In all cases, some return of power was there, mostly from Grade 3 or Grade 4 or Grade 5 [ Table 3].
Return of power in complete paraplegia: • Hip flexors within Grades 3 and 4.

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Tibialis anterior/EHL/FHL and gastrosoleus: Power did not return at all [ Table 4]. In all complete paraplegia cases, autonomic function of bowel and bladder had recovered. In incomplete paraplegia cases, 9 cases became normal and 11 cases still persist hesitancy and incontinence [ Table 5].  laminectomy was done for direct decompression. Decompression was confirmed using a narrow gauge rubber tube. Condition of the spinal cord was checked by direct vision. Any retropulsed fragment compressing on the cord was taken out.
Pedicle screws were inserted into the proximal and distal stable vertebra under image intensification. Then, the fracture was stabilized by rods or plates [ Figure 3a and b, Figure 4a and b]. The pedicle entry points were identified (by intersection method and confirmed by image intensifier guidance) and opened, probed all around, and the pedicle screw was introduced. Peroperatively, features such as cord pulsation, cord atrophy, and lacerations were looked for. Postoperatively, wound healing, amount of drainage, neurological recovery, radiological assessment, time taken ambulation, and ultimate recovery were recorded. We used Frankel grade and ASIA scoring system for preand post-operative neurological assessment. [9] In all cases, long dorsolumbar brace was given to the patients after removal of stitches at the 14 th post-operative day. Patients were discharged with advice for follow-up.

Follow-up
First follow-up was done after 2 week, 2 nd follow-up after 6 weeks. Then, monthly follow-up until the radiological sign of solid fusion was seen on X-ray. Patients were assessed for neurological recovery and assessment of return of bowel and bladder function in every follow-up. Some case was referred to urosurgery department for the management of bladder function problems.

results
Forty-six patients in whom posterior stabilization of the spine was done in this institution and followed up for a period ranging from 6 months to 2 years, 4 of 46 patients lost follow-up. Remaining 42 patients were considered for the study [ Table 1]. Majority of traumatic paraplegia was reported to be 21-25 years age group (38.09%) followed by 26-30 years age group (28.57%). Male was much more common than female cases (76.19% vs. 23.81%).

Stability of Implants
We got three patients where there was pull-out of the screws completely out of the pedicle. In one patient, there was loosening of the outie/innie followed by loosening of the rod. In all three cases, this happened within 4 weeks postoperatively. In these patients, we had to continue on conservative management and solid bony fusion developed between 12 and 20 weeks [ Table 6].

dIscussIon
Thoracolumbar junction is the commonest area involved in spinal injury. This area represents the transition from thoracic kyphosis to lumber lordosis and the axis of the body passes in front of this junction when the patient is erect. Hence, there is anterior bending moment working at this junction resulting in maximum stress concentration in this area which may be responsible for implant failure in this junction. [10] [11][12][13] Regarding neurological recovery, some amount, be it complete or incomplete, be it early, or be it sensory or motor or bowel and bladder function, was noticed in all the cases [Tables 3-5 and 7-9]. As per report published by Denis, there is improved neurological       www.apjhs.com Neurological improvement after surgical management of traumatic paraplegia outcome in effective cord compression after injury, stands for our findings regarding post-operative neurological recovery in spinal injury patients. [14,15] In all the cases of spinal injury, where it was treated by surgical management, the onset of sensory recovery was earlier than motor recovery in all the cases [Tables 10 and 11]. Almost 75% of the cases showed some amount of sensory recovery within the first 5 days of the operation. The onset of sensory recovery continued for maximally up to 4 th week postoperatively in the cases studied by us. According to Kostuik, persistent neural compression can inhibit neurologic recovery and anterior decompression can provide dramatic improvement in many patients. [16] In the present studies, patients were divided into three categories:  Table 10]. In complete paraplegia cases, 11% of the patients had return of power up to Grade 3 when decompression done within 1 week, where no cases showed return of Grade 3 power when decompression done after the 2 nd or 3 rd week [ Table 11].
In incomplete paraplegia, 80% of the patients had onset of sensory recovery within 1 week, when the decompression done within the 1 st week [ Table 12]. In complete paraplegia, 11% of the patients had sensory recovery within 2 weeks when decompression done within 1 week [Table 13]. Hence, our conclusion is early decompression definitely has some role regarding motor and sensory function return, both in complete and incomplete paraplegia.
However, the timing of surgery for spinal cord injuries is controversial. Most authors agree that in the presence of a progressive neurological deficit, emergency decompression is indicated. In patients with complete spinal cord injuries or static incomplete spinal cord injuries, some authors advocate delaying surgery for several days to allow resolution of cord edema, whereas others favor early surgical stabilization. There is no conclusive evidence in the literature that early surgical decompression and stabilization improve neurological recovery or that neurological recovery is compromised by a delay of several days.
The role of early surgical stabilization and resultant early mobilization as a method to reduce morbidity and mortality associated with these fractures has sparked significant interest. Surmised benefits of early stabilization include improved neurological recovery, improved pulmonary function, reduced pain with mobilization, decreased intensive care unit length of stay (LOS), decreased hospital LOS, and decreased mortality. [17,18] Studies by Bohlman et al., Transfeldt et al., Bradford et al., and others have documented return of neurological function after anterior decompression done more than a year after the initial injury. [19][20][21][22] For neurological normal patients with unstable spinal injuries and those with non-progressive neurological injuries, we believe that open reduction and internal fixation should be carried out as soon as possible. Mirza et al. in a recent study concluded that patients who sustain acute traumatic injuries to the cervical spine with associated neurologic deficit may benefit from cervical decompression and stabilization within 72 h of injury. Surgery within 72 h of injury is not associated with a higher complication rate. Early surgery may improve neurological recovery and decrease hospitalization time in patients with cervical spinal cord injuries. [23] In some patients in our study, it has been found that some return of sensory or motor function was possible even when the MRI findings showed that there was complete transaction of the cord.
About 4% of these patients initially assessed as complete converted late to incomplete status. Of these six cases, four regained continence and two became ambulatory with a reciprocal gait. In contrast, those with incomplete paraplegia had the following results: 85% of the muscles graded 1-2 on a scale of 5 at 1 month improved to Grade 3 or greater at 1 year and of the muscles graded 0/5 at month fully 55% regained some volitional control and 26% regained useful motor function. In most of the patients, the total amount of blood transfused preoperatively and postoperatively to keep the hemoglobin level above 10 g% is between 3 and 5 units. In one patient, we had to transfuse 7 units and in three patients 3 units and all these cases late decompression was done.
Regarding the return of bowel and bladder function in all the cases, this was automatic in complete paraplegia. In two cases, where suprapubic cystostomy was done, fistulae developed from bladder to anterior abdominal wall. In one patient, scrotal fistula developed. In 9 out of 20 patients of incomplete paraplegia, bowel and bladder function got almost normal in 6 months follow-up, whereas rest of the patients developed hesitancy or incontinence. However, the bladder sensation returned beck in 15 patients (75%) of incomplete paraplegia. According to Burns et al., most patients with paraplegia can regain social continence with appropriate rehabilitative training, urologic care, and surveillance. [24] Reinhold et al. reported complete neurologic deficits after injury to the thoracic spine improved in 9% of the cases, whereas 59% of the cases with complete neurologic deficit improved after injury to the thoracolumbar junction. [25] Prominence of screw was a problem in only patient in our series which was symptom free. The patients were treated with reassurance and that did not pose any problem to the patient in 1 year follow-up. Post-operative neurologic deficit can be classified according to the severity of the deficit. Minor deficit takes the form of radiculopathy, sensory impairment without motor loss, temporary dysesthesias in the feet, or lesser degrees of neurologic deficit. Major deficits are considered those in which the patient suffers from postoperative paraparesis, paraplegia, or a spinal cord syndrome. Among these 70% deficits are transient, according to the literature. The Stagnara wake up test is still the gold standard test to detect gross motor deficit. In our series, we had one patient with incomplete paraplegia who had deterioration of 1 grade of power postoperatively. [26] The patient was taken back to operation