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Úvod: Kvalita ošetření zlomenin páteře s neurologickým postižením spočívá ve volbě správné operační strategie, ve správném načasování její realizace a ve správném technickém provedení. Selhání kterékoliv z uvedených složek ošetření výrazně negativně ovlivňuje další péči o zraněného. Korektnost technického provedení je v řadě případů velmi sporná. Je třeba věnovat pozornost zdokonalení techniky použití spinálních implantátů, aby mohla postakutní i chronická fáze péče o pacienty s neurologickým postižením probíhat nerušeně. Materiál a metoda: Retrospektivní analýza kvality primárního chirurgického ošetření pacientů s traumatickou míšní lézí hospitalizovaných na spinální jednotce Krajské nemocnice Liberec v letech 2003–2012 a na spinální jednotce FN v Motole v letech 2004–2012. Výsledky: V průběhu sledovaného období bylo nevhodné ošetření zjištěno u 191 pacientů ze 775 (24,6 %). V suboptimálním ošetření dominovala chybná repozice u 111 případů (58,1 %) a chybné zavedení pedikulárních šroubů v 78 případech (48,8 %). Následovala chybná dekomprese v 52 případech (27,2 %). U 85 pacientů (44,5 %) bylo nutné kompletní přepracování stabilizace. Nebyl zaznamenán žádný vývoj v počtu nesprávně ošetřených pacientů v jednotlivých letech. U suboptimálně ošetřených pacientů s poraněním v krční, hrudní i bederní oblasti se shodně prodloužila hospitalizace v průměru o 9,58 dne. Závěr: Autoři doporučují důsledné dodržování operační techniky a kritické pooperační rentgenové kontroly. Další pokrok spatřují v kvalitním vzdělávacím systému ve spondylochirurgii.

Introduction: Right surgical strategy, optimal timing and correct surgical technique are crucial for the quality of treatment of spinal fractures associated with neurological deficit. Failure of any of these parts of treatment has an immensely negative effect on subsequent patient care. In many cases, the quality of technical performance of the surgery is controversial. It is desirable to improve the use of spinal implants to achieve undisturbed course of subacute and chronic phases of treatment. Material and methods: Retrospective analysis of the quality of primary surgical treatment of patients with posttraumatic spinal cord injury treated at the Spinal Unit of the Regional Hospital Liberec between 2003 and 2012 and at the Spinal Unit of the University Hospital Motol in Prague between 2004 and 2012. Results: Incorrect surgical treatment was delivered in 191 of 775 cases (24.6%). Wrong fracture reduction was preformed in 111 cases (58.1%). Incorrect pedicle screw insertion was found in 78 cases, followed by insufficient decompression of the spinal channel in 52 cases. A revision surgery with complete reinstrumentation was required in 85 patients (44.5%). We identified no development in the number of suboptimally treated patients over the analyzed years. The length of hospital stay in suboptimally treated patients was prolonged by the mean of 9.58 days. Conclusion: The authors recommend strict compliance with the surgical technique and rigorous post-operative X-ray follow ups. This field could further be improved with high-quality spinal surgery educational system. Key words: spinal cord injury – spinal cord decompression – spinal fracture reduction – spine stabilization The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

Článek online

Timing operací páteře při akutním poškození míchy a jeho vliv na vývoj neurologického nálezu
[Timing of surgical intervention in acute spinal cord injury and post-operative neurological recovery]

Acta chirurgiae orthopaedicae et traumatologiae Čechoslovaca. 2012 ; 79 (3) : 233-237.

Acta chir. orthop. traumatol. Čechoslovaca
ISSN 0001-5415
Medvik
Zdroj

PURPOSE OF THE STUDY The effect of an early surgical intervention in the traumatised spine on resolution of neurological deficit still remains a topic of professional discussions. The aim of this retrospective study was to find a correlation between the length of an injury-to-surgery interval and the development of a post-operative neurological deficit, and thus to answer the question of whether early surgical decompression and stabilization gives better chance of neurological recovery. MATERIAL AND METHODS Medical records of consecutive surgical patients admitted between 2007 and 2010 with traumatic spinal cord injury were reviewed and the injury-to-surgery interval and post-operative development of neurological deficit at a minimum follow-up of 6 months was evaluated. The initial neurological finding and the finding at 6 months of follow-up were classified on the Frankel scale and the outcome was assessed as improved or unimproved. The patients were allocated to four subgroups according to the time that elapsed between injury and surgery, i.e., time up to 24 h, 24 - 72 h, 72 h - 1 week, and longer than 1 week. The percentage of improved patients was calculated in each subgroup and the results were statistically evaluated using the Kruskal-Wallis test at a significance level of 0.1. RESULTS Out of the total number of 32 evaluated patients, 28 had at least partial neurological recovery. In the subgroup treated within first 24 h, improvement was found in 93 % of the patients, in the 24 - 72 h subgroup it was 80%, in the 72 h - 1 week subgroup it was 60% and surgery later than a week after injury resulted in improvement in 42% of the patients. Based on statistical evaluation, the time between injury and surgery appeared to be a significant prognostic factor. When a paired comparison of subgroups was made, the only significant difference was found between the subgroup treated within 24 hours of injury and that operated on later than a week after injury. The other paired comparisons failed to show a significant difference due to a small number of patients; however, a tendency to better functional results was observed in all earlier-treated subgroups. DISCUSSION The authors are aware of few limitations of the study. Its retrospective character, a relatively small number of patients and a single institution setup may limit the interpretation. Despite this fact, the message is clear. Similar studies carried out prospectively at several institutions may, however, provide results with a higher validity. CONCLUSIONS Patients with traumatic spinal cord injury who undergo early decompression and stabilisation have a higher chance of at least partial neurological recovery.

Článek online

Odeznění traumatické pentaplegie u pacienta po kombinované zlomenině C1–C2
[Reversal of traumatic pentaplegy after combined C1–C2 fracture]

Česká a slovenská neurologie a neurochirurgie. 2012 ; 75 (2) : 240-243.

Čes. slov. neurol. neurochir. (Print)
ISSN 1210-7859
Medvik
Zdroj

Do té doby zcela zdravý, 32letý muž byl nalezen tetraplegický a nedýchající na místě pádu z korby nákladního automobilu. Po zabezpečeném transportu na příjmový úsek nemocnice byla stanovena diagnóza tříúlomkové zlomeniny atlasu Jeffersonova typu společně se zlomeninou zubu čepovce II. typu. Doplněné vyšetření magnetickou rezonancí zobrazilo míšní otok v rozsahu C0–C3. Vzhledem k nepříznivé oběhové situaci pacienta jsme k chirurgické stabilizaci předním přístupem mohli přikročit až třetí poúrazový den. Stabilizace spočívala v kombinaci přímé osteosyntézy zubu čepovce a v anterolaterální transartikulární déze C2–C1. V průběhu pooperační pasivní rehabilitace pacient začal 10. den po traumatu interferovat s umělou plicní ventilací a elevoval ramena. Ústup těžkého neurologického deficitu však pokračoval i nadále, takže po třech týdnech jsme měli možnost konstatovat suficientní spontánní dýchání a polykání. Regrese tetraplegie pacientovi postupně umožnila aktivní rehabilitaci horních končetin a nácvik chůze s výstupní samostatnou chůzí za lehkého patologického stereotypu. Tento mimořádně pozitivní klinický výsledek je argumentem pro aktivní terapeutický přístup včetně chirurgické intervence, a to i v případě pacientů se vstupně značně nepříznivými prognostickými ukazateli klinického stavu.

Otherwise healthy 32-year-old man was found quadriplegic and without any signs of breathing at a site of his fall from a body of a truck. The diagnosis of three fragment Jefferson's type fracture of atlas together with incidental type II fracture of the dens of C2 was made at an emergency unit were the mechanically ventilated patient was transported. MRI subsequently revealed C0–C3 spinal cord oedema. Surgical stabilization of the fracture of both uppermost cervical vertebras was postponed to the third day after the trauma due to the patient's haemodynamic instability. The circulatory system instability was also the reason for selecting the anterior approach. A combination of anterolateral transarticular screws together with a single screw for direct osteosynthesis of the dens stabilized the C1–C2 complex. At day 10 of postsurgical passive physiotherapy, the patient began to interfere with the mechanical ventilation. Gradual reversal of neurological deficit continued, so that three weeks after the trauma, the patient developed a sufficient spontaneous breathing. Improving paraparesis allowed him to walk. The patient, walking just with a pathological gait stereotype, continued his functional treatment at a specialized rehabilitation institute eight weeks after the accident. This extremely positive outcome supports the use of a proactive and early surgical approach even in patients with complete spinal cord injury at the upper cervical levels.

Klíčová slova
trauma kraniocervikálního přechodu, posttraumatický edém míchy, stabilizace,
MeSH
dospělí MeSH
edém MeSH
fraktury páteře chirurgie MeSH
kostní šrouby MeSH
krční obratle chirurgie zranění MeSH
kvadruplegie diagnóza etiologie terapie MeSH
lidé MeSH
poranění míchy etiologie terapie MeSH
regenerace míchy MeSH
úrazy pádem MeSH
vnitřní fixace fraktury metody MeSH
Check Tag
dospělí MeSH
lidé MeSH
mužské pohlaví MeSH
Publikační typ
kazuistiky MeSH

Článek online

Současný pohled na užívání methylprednisolonu v léčbě akutního poškození míchy
[Current role of methylprednisolone in the treatment of acute spinal cord injury]

Acta chirurgiae orthopaedicae et traumatologiae Čechoslovaca. 2011 ; 78 (4) : 305-313.

Medvik
Zdroj

High doses of methylprednisolone (MPSS) came into use as part of a therapeutic protocol for acute spinal cord injuries following the published results from the NASCIS II study in 1992; they soon became a standard of care around the world. However, the results of this study have been critically reviewed and questioned by many authors since the beginning. The major argument is based on the fact that its effectiveness in reducing post-injury neurological damage has not been conclusively proved; in addition, there has been increasing evidence of serious side effects of steroids administered at high doses. In the Czech Republic, as part of pre-hospital care, MPSS according to the NASCIS II (or NASCIS III) protocol is used in all regional centres of emergency medical service. In the Czech spinal surgery centres involved in treating acute spinal cord injuries, there are 19 of them, attitudes towards the use of MPSS vary. In 16% of the centres a certainty of its beneficial effect is still maintained, faith in its effect together with fear of a "non-lege artis" procedure is the reason for MSPP use in 21%, and the fear of sanctions only leads to its use in 63% of the centres. There is no standard practice in application of the NASCIS II and NASCIS III protocols and no standard exclusion criteria exist. The two protocols are used equally, and one institution has its own modification. The recommended MPSS dose is administered with no exception in 63% of the centres; dose adjustment is employed according to the form of spinal cord lesion in 11%, the level of spinal cord injury in 5%, associated diseases in 16% and patient age in 11% of the spinal surgery centres. After the results of studies on MPSS administration in acute spinal cord injury have been analysed, many medical societies have changed their recommendations. In view of later relevant publications it is no longer possible to regard MPSS administration as a standard of cure for acute spinal cord injury. Current evidence suggests that MPSS administration in a 24-hour regimen after an initial dose given within 8 hours of injury is the therapeutic procedure that needs individual consideration in each patient according to their state of health and potential complications. MPSS administration at an interval longer than 8 hours after injury and for more than 24 hours is not justified, nor is it justified to use a high MPSS dose at the place of injury by an emergency ambulance crew.