NEUROSPINE INSTRUMENTATIONS IN SANGLAH GENERAL HOSPITAL-BALI

JUNE 2005-JUNE 2007

Tjok G.B. Mahadewa, Sri Maliawan Neurospine Division - Neurosurgery Depatient-Sanglah General Hospital

ABSTRACT

Rehabilitation for spinal cord lesion is mandatory where the rigid spine construct

facilitate early mobilization. Conservative treatment for unstable spine related with late

mobilization and increase complications. There are many kinds of segmental spinal

instrumentations (SSI) can be done for unstable spine i.e. anterior and/or posterior ones.

Stable spine related with early mobilization to prevent complications. The etiologies of

the cases were traumatic, tumor, infection, congenital and degenerative. The purpose of

this study was to elucidate the distribution of spinal cases, the prompatient treatment were

done and those significance with the results. This was a retrospective study, using 173

patients who were treated by the author in Sanglah General Hospital, Bali during

observation in 2 years from 2005-2007. Most of the spinal cases were degenerative, in

Frankel E, by decade V of life, with male predominance. Most of the treatment was

surgery with instrumentations, Frankel conditions has significance between surgery with

the result for trauma, tumor and degenerative, for cervical and thoracic region. Surgery

has significance with the result in non instrumented cases, infection, degenerative,

thoracolumbal and lumbar cases.

Key words: Spinal Cases, Neurospine Instrumentations, Early Mobilization

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NEUROSPINE INSTRUMENTASI DI RSUP-BALI JUNI 2005-JUNI 2007

ABSTRAK

Rehabilitasi pada lesi medulla spinalis merupakan keharusan dimana konstruksi tulang

belakang yang rigid memfasilitasi program mobilisasi awal. Penanganan secara

konservatif untuk tulang belakang yang tidak stabil berkaitan dengan mobilisasi yang

lambat dan meningkatkan komplikasi. Terdapat bermacam tipe segmental spinal

instrumentasi (SSI) yang bisa dilaksanakan pada tulang belakang yang tidak stabil seperti

pendekatan anterior dan atau posterior. Tulang belakang yang stabil berhubungan dengan

kemampuan mobilisasi awal untuk mencegah komplikasi. Etiologi dari kasus-kasus ini

adalah trauma, tumor, infeksi, kongenital dan degeneratif. Tujuan dari penelitian ini

adalah untuk mengetahui distribusi kasus-kasus tulang belakang, penanganan yang

dilakukan dan hal-hal yang mempengaruhi hasil penanganan. Penelitian ini merupakan

studi retrospectif, menggunakan 173 pasien yang dirawat oleh penulis di RSUP Sanglah,

Bali selama observasi 2 tahun, dari tahun 2005-2007. Kebanyakan kasus tulang belakang

adalah degeneratif, masuk dengan Frankel E, usia dekade V kehidupan, dengan dominan

pasien laki-laki. Sebagian besar kasus ditangani dengan pembedahan disertai pemasangan

instrumen, kondisi Frankel preoperasi mempunyai pengaruh yang bermakna terhadap

hasil pembedahan pada kasus trauma, tumor and degeneratif, terutama kasus regio

servikal dan thorak. Pembedahan mempunyai efek yang bermakna terhadap hasil pada

kasus tanpa pemasangan instrumen, pada kasus infeksi, degeneratif, terutama kasus

thorakolumbal and lumbal.

Kata kunci: Kasus Tulang Belakang, Neurospine Instrumentasi, Mobilisasi awal

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Introduction

Spine injuries have increased the number among the traumatic patients in Sanglah

General Hospital, Bali. The treatment consists of conservative and surgery, the choice is

based on the spine condition whether its stable or unstable. If the spine was considered

unstable, surgery is mandatory to facilitate stability of the spine. From 2000-2004, there

were 344 spine cases, 85 surgeries (24, 7%) were done, consist of 45 cervical, 14 thoracic

and 26 lumbar cases. Conservative treatment for unstable spine related with late

mobilization and increase complications.1, 2

Despite the trauma cases others are tumor, infection, congenital and degenerative

which also contributing the spinal construct and compromising the spinal cord. 3, 4 The

patients usually complained of pain on the vertebra with or without neurological deficit.

The treatment will provide adequate decompression for the spinal cord or nerve roots but

sometimes compromising the spine stability.5

There are many kinds of instrumentations can be done for unstable spine i.e.

anterior and/or posterior ones. Stable spine related with early mobilization to prevent

complications. 6

In order to elucidate the distribution of spinal cases, the prompatient treatment

were done and those significance with the results, the authors retrospectively evaluated

173 spine cases admitted to Sanglah General Hospital, Bali, Indonesia.

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Patients and method

This was a retrospective descripatientive-analytic study, using 173 patients who

were treated by the authors in Sanglah General Hospital, Bali during observation in 2

years from 2005-2007. The variables were documented i.e. sex, age, etiology, location,

diagnostic, Frankel type, treatment, instrumentations and results. Statistical analysis by

SPSS 11, 5 for Window, using Chi-square test was applied to overcome the differences

between treatment, instrumentations, Frankel, location, and etiology with the results.

Result and Discussion

During the study period were admitted 173 patients, consists of 140 male

(80,9%), 33 female(19,1%), mostly in decade 5th of life 59 patients(34,1%), decade 6th 49

patients(28,3%), decade 4th 26 patients(15%), followed by after decade 6th 21

patients(12,1%), decade 3rd 13 patients (7,5%) and before decade 3rd 5 patients(2,9%), As

in graphic 1 shown the etiology were degenerative 73 patients(42,2%), trauma 61

patients(35,3%), tumor 31 patients(17,9%), Infection 7 patients(4%) and vascular 1

patient(0,6%).

Graphic 1.Etiology’s Distribution

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Graphic 2. Location’s Distribution

The location were mostly at cervical 67 patients(38,7%), Lumbar 51 patients,

thoracic 29 patients, thoracolumbal 21 patients and lumbosacral 5 patients with mostly in

Frankel E 28,3%. (Graphic 2) Surgery were conducted in 161 (93, 1%) of 173 cases

(Table 1), 121 patients were instrumented (69, 9%). Significance between Frankel

conditions, in the surgery cases, with result (p=0, 00), not significance in conservative

(p=0,132) as shown in Table 1 this results suggested that the better result could be

reached by operative method to facilitate the decompression procedure and performed

segmental spinal instrumentation (SSI) for early mobilization. 6

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Table 1. Patient Distribution by Therapy, Frankel and Result

Most cases are Degenerative, significance between Frankel conditions with result

in trauma (p=0, 00), tumor (p=0, 00) and degenerative (p=0,002) as shown in table 2.

Not significance between surgery and conservative with result for trauma (p=0,467), but

significance between surgery and conservative with result for infection (p=0,008) and

degenerative (p=0,038) as shown in table 3. Previous Frankel type is compromising the

surgery result especially for trauma, tumor and degenerative cases that means the better

Frankel type before surgery the better result that we could gain after surgery due to the

limitation of the spinal cord capability for recover moreover in trauma cases. 7, 8

Therapy RESULT     Total

p

value

 

no

change better worse death    

Surgery Frankel A 11 6 0 11 28 0.000

    B 5 14 0 4 23  

    C 1 22 1 1 25  

    D 15 26 0 0 41  

    E 7 37 0 0 44  

  Total 39 105 1 16 161  

  % 24.2 65.2 0.6 9.9 100  

Conservative Frankel A 1 0 0 1 2 0.132

    B 0 0 0 0 0  

    C 1 3 0 0 4  

    D 1 0 0 0 1  

    E 4 1 0 0 5  

  Total 7 4 0 1 12  

      % 58.3 33.3 0 8.3 100  

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The most frequent location are cervical 67 patients (38, 7%), significance between

Frankel conditions with result in the cervical (p=0, 00) and thoracic (p=0, 00). Not

Etiology RESULT     Total p value

  no change better worse death    

Trauma Frankel A10

0 0 11 21 0.000

    B 3 5 0 4 12  

    C 0 14 0 1 15  

    D 2 4 0 0 6  

    E 5 2 0 0 7  

  Total 20 25 0 16 61  

Tumor Frankel A 2 3 0 0 50.000

    B 1 6 0 0 7  

    C 0 0 1 0 1  

    D 10 4 0 0 14  

    E 0 4 0 0 4  

  Total 13 17 1 0 31  

Infection Frankel A 0 1 0 0 10.831

    B 0 0 0 0 0  

  C 0 1 0 0 1  

  D 1 3 0 0 4  

    E 0 1 0 0 1  

  Total 1 6 0 0 7  

Degenerativ Frankel A 0 2 0 1 30.002

    B 1 3 0 0 4  

    C 2 10 0 0 12  

    D 3 15 0 0 18  

    E 5 31 0 0 36  

  Total 11 61 0 1 73  

Vascular E 1 0 0 0 1

Total 1 0 0 0 1

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Table 2. Patient Distribution by Etiology, Frankel and Result

significance between surgery and conservative with result for cervical (p=0,566), but has

significance for thorakolumbal (p=0,029) and lumbar (p=0,011) as shown in table 4. The

higher level of the spine injury related with the amount of paralyze muscle and sensation

abnormality which related closely with the common complication for bed ridden patient,

such as: Deep Vein Thrombosis (DVT), Acute Respiratory Distress syndrome (ARDS),

Pneumonia, Ulcer, SIRS and Sepsis that can cause death.

In the sympatientomatic individual who is being considered for operative

stabilization there is considerable anatomical distortion, hence, there have been a wide

range of approaches and techniques of stabilization described in the literature, all of

which have quoted good results. The diversity of these techniques with or without

instrumentation, in situ fusion compared with reduction and fusion, and anterior,

posterior, or circumferential approaches suggests an element of controversy regarding the

ideal technique. 9, 10 Overall the result after surgery were improve 109 patients (63%), no

change 47(27, 2%), worsening 1 (0, 6%), death 16 (9, 2%). Instrumentations were used,

Hartshill 60, Luke 27, lateral mass plate 10, sub laminar wiring 4, pedicle screw 14,

expandable cage 1, and lamina hook-rod 5 patients.

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Etiology RESULT     Total p value

  no change better worse death    

Trauma Treatment Surgery 16 22 0 15 530.467

    Conservative 4 3 0 1 8  

Total 20 25 0 16 61  

 TumorTreatment Surgery 13 17 1 0 31

    Conservative 0 0 0 0 0  

    Total 13 17 1 0 31  

Infection Treatment Surgery 0 6 0 0 60.008

    Conservative 1 0 0 0 1  

    Total 1 6 0 0 7  

 DegenerativeTreatment Surgery 9 60 0 1 70

 0.038

    Conservative 2 1 0 0 3  

Total 11 61 0 1 73

 Vascular  Surgery 1 0 0 0 1  

    Conservative 0 0 0 0 0  

Total 1 0 0 0 1

Table 3. Patient Distribution by Etiology, Treatment and Result

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Location RESULT     Total p value

  no change better worse death    

Cervical Treatment Surgery 18 25 0 15 580.566

    Conservative 4 4 0 1 8  

Total 22 29 0 16 67  

 ThoracalTreatment Surgery 11 17 1 0 29

    Conservative 0 0 0 0 0  

    Total 11 17 1 0 29  

Thoracolumbal Treatment Surgery 3 15 0 1 190.029

    Conservative 2 0 0 0 2  

    Total 5 15 0 1 21  

 LumbalTreatment Surgery 6 44 0 0 50

 0.011

    Conservative 1 0 0 0 1  

Total 7 44 0 0 51

 Lumbosacral  Surgery 1 4 0 0 5  

    Conservative 0 0 0 0 0  

Total 1 4 0 0 5

Table 4. Patient Distribution by Location, Treatment and Result

In all the reported cases in which this form of stabilization is used there has been

1 case of thoracic extradural metastasis tumour of unknown origin with neurological

deterioration 5 days after surgery which previously no change after surgery unfortunately

the patient refused to be examined further and released from the hospital. There have

been no incidents of surgery site infection, no failures of the instrumentation, and

although only a medium number of cases have been reported, there have been no failures

of fusion in primary or revision surgery situations but we have collected 17 patients were

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death due to respiratory failure due to ARDS 4 patients and Sepsis 13 patients. There

have been no reports of the follow up greater than 12 months in patients who have

undergone surgery in which this technique was used. This series with its results at a

follow up of between 6 and 12 months confirms that the initial good results are

maintained in the midterm.

Conclusion

Most of the spinal cases were degenerative, in Frankel E, by decade V of life,

with male predominance. Most of the treatment was surgery with instrumentations,

Frankel conditions has significance between surgery with the result for trauma, tumor and

degenerative, for cervical and thoracic region. Surgery has significance with the result in

non instrumented cases, infection, degenerative, thoracolumbal and lumbar cases.

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