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Late laminectomy in traumatic paraplegia
414
Surg Neurol 1983;20:414-6
Late Laminectomy in Traumatic Paraplegia B. Ramamurthi, Ravi Ramamurthi, and R. Narayanan Dr. A. Lakshmipathi Neurosurgical Centre, V.H.S., Madras, and Thanjavur Medical College and Hospital, Thanjavur, India
Ramamurthi B, Ramamurthi R, Narayanan R. Late laminectomy in traumatic paraplegia. Surg Neurol 1983;20:414-6.
Long-term observation in cases of spinal injury with subarachnoid block, treated by laminectomy and removal of compressing elements, shows worthwhile results in a good percentage.Twenty-seven cases of fractures of the spine at the dorsolumbar and lumbar levels with conus and cauda equina injury were treated by laminectomy and decompression from 6 to 12 weeks after the injury, and have been followed for periods of 3-27 years. Surgical intervention was offered only in those cases in which myelography demonstrated a subarachnoid block. Most of the cases were operated on at 6-12 weeks after the injury. Displaced laminae, thickened ligamentum flavum, and arachnoidal adhesions were the common causes of compression. In six cases there was also an arachnoid cyst. Long-term follow-up showed improvement in bladder function in 14 of 27 patients, and in motor function in 8 of 27. In dorsolumbar and lumbar injuries in which there is a subarachnoid block, decompressive laminectomy is a worthwhile procedure. KEYWORDS: Trauma; Spinal-cord injury; Laminectomy
It is generally accepted that in acute trauma of the spine with a crushing injury to the spinal cord, laminectomy with decompression of the spinal cord is ineffective. However, experience has shown that when the neural injury is partial, and when neural symptoms persist due to factors other than the immediate trauma, a decompression by laminectomy may help the patient, especially if a block in the subarachnoid space can be demonstrated. As early as 1952, Ramamurthi [4] reported four cases in which laminectomy was done some weeks after the injury, with beneficial results. These involved certain types of compression fracture -dislocations in the dorsolumbar and lumbar regions. The injuries were sustained as the result of a fall from
Address reprint requests to: Dr. B. Ramamurthi, Neurosurgeon, V.H.S. Madras-600 113, India. Based on a paper presented at the Neuro Traumatology Meeting of the World Federation of Neurosurgical Societies, Edinburgh, September 1982.
© 1983 by Elsevier Science PublishingCo., lnc.
a height, and the damage to the spinal cord was partial. When, in such cases, investigation proved the presence o f compression o f the spinal cord, laminectomy resulted in improvement of function in the lower limbs, and especially in bladder function, in more than one-third of the cases.
Material A long-term follow-up study has been done of 27 patients with fractures in the dorsolumbar and lumbar regions, and who had decompressive laminectomies some time after the spinal injury (Tables 1, 2, and 3). These patients have been followed-up for a period ranging from 3 - 2 7 years. All of the patients were male and belonged in the 2 2 - 4 3 age group. The fracture involved D-12 in four cases, L-1 in 15 cases, L-2 in three cases, and L-3 and L-4 in five cases. Thus, in the majority of cases the injury involved the T 1 2 - L 1 level, with injury to the conus medullaris. Only eight patients of the 27 had fractures below the level of the conus with trauma o f the cauda equina. Depending on the level of injury (Table 4) and the time at which the patients reported to the neurosurgical department, they had varying degrees of weakness of the knees and ankles, with sensory loss involving the lower sacral nerves. Their main disabling complaint was difficulty in micturition. Nineteen had overflow incontinence and four had true incontinence (Tables 5 and 6). O f the 27 cases, 20 had shown some improvement in their neurological condition with conservative therapy (bed rest) from the time of the accident. The majority sought expert medical help 6 - 1 2 weeks after the injury, when there was no further improvement in their disability. Two patients reported 3 months after the injury. All of the 27 patients under review had lumbar puncture and myelography (Tables 7 and 8); all showed a complete or partial subarachnoid block at the site of the fracture dislocation. The cerebrospinal fluid (CSF) proteins were over 200 mg in 8 patients, and between 100 and 200 mg in 17 patients. Myelography was done with iophendylate (Myodil; Pantopaque), and showed complete block of the subarachnoid space in 18 and partial block in 9 patients. 0090-3019/83/$3.00
Traumatic Paraplegia
T a b l e 1. Male patients Age Groups
T a b l e 7. Lumbar Puncture Queckenstedt Test Done in
All Cases
Cases
22-25 25-30 31-35 36-40 43 Total
CSF proteins
11 7 5 3 1 27
Over 400 mg 200-400 mg 100-200 mg 40-100 mg
1951-55 1956-60 1961-65 1966-70 1971-75 1976-79
2 6 17 2
T a b l e 8. Myelography
T a b l e 2. Postoperative Observation Years
415
Surg Neurol 1983;20:414-6
Complete block Partial block
Cases 6 2 4 5 6 4
18 9
T a b l e 9. Operative Findings Bony compression by displaced lamina Thickened and fibrosed Ligamentum Flavum Arachnoidal adhesions
20 19
T a b l e 3. Time Elapsed Between Injury and Operation 6 weeks 8 weeks 9 to 12 Over 12 weeks
12 cases 8 cases 5 cases 2 cases
T a b l e 10. Surgical Procedures Release of adhesions Drainage of traumatic cyst Microsurgical release of nerve roots Duraplasty
17 6 4 12
T a b l e 4. Neurological Level of Injury Conus medullaris Conus and cauda Cauda equina
Operative Findings
13 6 8
T a b l e 5. Presenting Disability Bladder Overflow incontinence True incontinence Motor disability Sensory difficulties Pressure sore (heel) Pressure sore (sacral)
19 4 21 19 4 13
T a b l e 6. Fracture Sites D-12 L-1 L-2 L-3 L-4
A t o p e r a t i o n , t h r e e l a m i n a e w e r e r e m o v e d (Tables 9 and 10). T h e lamina o f the v e r t e b r a b e l o w the site o f the fracture was always r e m o v e d to e n s u r e a d e q u a t e d e c o m p r e s s i o n . A l m o s t all o f the p a t i e n t s s h o w e d a t h i c k e n e d l i g a m e n t u m flavum and a fair a m o u n t o f hyp e r t r o p h y o f e x t r a d u r a l fibrous tissue. T h e d u r a m a t e r was o p e n e d in e v e r y case. T h e c o m p r e s s i n g e l e m e n t was f o u n d to be a d i s p l a c e d l a m i n a in 20 p a t i e n t s , a t h i c k e n e d and fibrosed l i g a m e n t a m flavum in 19, and a r a c h n o i d a l a d h e s i o n s in 17 cases. T h e a d h e s i o n s w e r e r e l e a s e d as far as possible. D u r i n g the later p e r i o d o f this s t u d y (the past 6 years), it was p o s s i b l e , t h r o u g h the use o f m i c r o surgery, to release m o s t a d h e s i o n s w i t h o u t d a m a g i n g t h e spinal c o r d o r n e r v e roots. A n a r a c h n o i d cyst c o m p r e s s ing the c o r d was f o u n d in six cases and was d r a i n e d by a d e q u a t e excision o f the cyst wall. D u r a p l a s t y was d o n e in 12 cases to e n s u r e a w i d e d u r a l canal.
4 15 3 3 2
Subsequent Course P o s t o p e r a t i v e studies s h o w e d i m p r o v e m e n t in the muscle p o w e r o f t h e legs in 8 p a t i e n t s , and i m p r o v e m e n t in
416
Surg Neurol 1983;20:414-6
Ramamurthi et al
bladder function in 14 (Tables 11 and 12). These two features tended to accompany one another. Cystometric studies confirmed the clinical improvement. T h e neurological improvement became apparent 2 - 4 weeks after operation and continued o v e r a period of 6 - 9 months. Fww patients who did not show some sign of improvement in the first 4 weeks had any i m p r o v e m e n t later.
Discussion The indications for laminectomy in posttraumatic spinalcord damage are controversial. T h e general experience has been that decompressive procedures in acute spinalcord injuries, do not yield any benefit. Within this gloomy picture, however, are a few bright circumstances in which it is possible for the neurosurgeon to offer positive ben-
Table 11. Results Improvement in motor power in 21 patients with motor disability Good Moderate Sensory disability and pressure sores in 19 patients Improved No improvement Bladder function involved in 23 patients Good improvement Moderate improvement Nil
2 patients 6 patients 3 patients 16 patients 3 patients 11 patients 9 patients
Table 12. Improvement According to Level of Lesion and Neurological Level Level of lesion D-12 (4 patients) L-1 (15 patients) L-2 (3 patients) L-3 (3 patients) L-4 (2 patients) Neurological level Conus medullaris lesion Cauda equina lesion
Improved 1 7 2 2 2 19 patients 8 patients
efit to the patient. O n e of these areas involves cases in which there is a partial preservation of sensory and motor function with evidence of compression of the spinal cord, especially by fractures of the dorsolumbar and lumbar spine. Chenggi [1] found i m p r o v e m e n t in 5 o f 10 such cases. In 1978, W e n d t and Mucke [6] suggested that efforts must be made to diagnose a block in the subarachnoid space in cases of an incomplete static or chronic neurological deficit, and to offer surgical treatment if there is any such block. We believe, with Ransohoff et al [5], that in such cases the neurosurgeon should approach the problem in a m o r e aggressive manner, thus offering the possibility o f improvement. In support of this view, Jelsma et al [3,4] have recently presented favorable results obtained from surgical decompression and stabilization of the spine in cases of spinal-cord injury in which there is evidence of compression of the cord, and have concluded that neural compression is an indication for operation regardless of the degree of neurological deficit. The experience presented above shows that decompressive laminectomy has a place in the treatment of fracture dislocations of the dorsolumbar and lumbar spines in cases in which there is a partial neurological deficit. If myelography confirms a block in such an instance, surgical intervention may relieve the condition in about 4 0 % of patients.
References 1. Chenggi W, Jintang C, Qisben F. Anterolateral decompression for spinal fractures complicated by paraplegia. Chin Med J (Peking) 1975;92: 149-54. 2. Jelsma RK, Rice JF, Kirsch T. The demonstration and significance of neural compression after spinal injury. Surg Neurol 1982;18:79-92. 3. Jelsma RK, Kirsch PT, Jelsma RF, Ramsey WC, Rice JF. Surgical treatment of thoracolumbarfractures. Surg Neurol 1982;18:156-66. 4. Ramamurthi B. Late laminectomy in traumatic paraplegia. Ind J Surg 1952; 16,2,183-4. Excerpta Medica, 6, 1462, 1953. Bulletin of the International Congress of Neurology, Lisbon, 376-378 (Sep 1953). 5. RansohoffJ, Benjamin MV, Engler G, Flamm ES. Surgical intervention in spinal cord injury. Semin Neurol Surg 1979;1:353-61. 6. Wendt H, Mucke R. Posttraumatic spinal cord compressions.When does operative decompression make sense? (German) Nervensarzt 1978;49:208-16.
Surg Neurol 1983;20:414-6
Late Laminectomy in Traumatic Paraplegia B. Ramamurthi, Ravi Ramamurthi, and R. Narayanan Dr. A. Lakshmipathi Neurosurgical Centre, V.H.S., Madras, and Thanjavur Medical College and Hospital, Thanjavur, India
Ramamurthi B, Ramamurthi R, Narayanan R. Late laminectomy in traumatic paraplegia. Surg Neurol 1983;20:414-6.
Long-term observation in cases of spinal injury with subarachnoid block, treated by laminectomy and removal of compressing elements, shows worthwhile results in a good percentage.Twenty-seven cases of fractures of the spine at the dorsolumbar and lumbar levels with conus and cauda equina injury were treated by laminectomy and decompression from 6 to 12 weeks after the injury, and have been followed for periods of 3-27 years. Surgical intervention was offered only in those cases in which myelography demonstrated a subarachnoid block. Most of the cases were operated on at 6-12 weeks after the injury. Displaced laminae, thickened ligamentum flavum, and arachnoidal adhesions were the common causes of compression. In six cases there was also an arachnoid cyst. Long-term follow-up showed improvement in bladder function in 14 of 27 patients, and in motor function in 8 of 27. In dorsolumbar and lumbar injuries in which there is a subarachnoid block, decompressive laminectomy is a worthwhile procedure. KEYWORDS: Trauma; Spinal-cord injury; Laminectomy
It is generally accepted that in acute trauma of the spine with a crushing injury to the spinal cord, laminectomy with decompression of the spinal cord is ineffective. However, experience has shown that when the neural injury is partial, and when neural symptoms persist due to factors other than the immediate trauma, a decompression by laminectomy may help the patient, especially if a block in the subarachnoid space can be demonstrated. As early as 1952, Ramamurthi [4] reported four cases in which laminectomy was done some weeks after the injury, with beneficial results. These involved certain types of compression fracture -dislocations in the dorsolumbar and lumbar regions. The injuries were sustained as the result of a fall from
Address reprint requests to: Dr. B. Ramamurthi, Neurosurgeon, V.H.S. Madras-600 113, India. Based on a paper presented at the Neuro Traumatology Meeting of the World Federation of Neurosurgical Societies, Edinburgh, September 1982.
© 1983 by Elsevier Science PublishingCo., lnc.
a height, and the damage to the spinal cord was partial. When, in such cases, investigation proved the presence o f compression o f the spinal cord, laminectomy resulted in improvement of function in the lower limbs, and especially in bladder function, in more than one-third of the cases.
Material A long-term follow-up study has been done of 27 patients with fractures in the dorsolumbar and lumbar regions, and who had decompressive laminectomies some time after the spinal injury (Tables 1, 2, and 3). These patients have been followed-up for a period ranging from 3 - 2 7 years. All of the patients were male and belonged in the 2 2 - 4 3 age group. The fracture involved D-12 in four cases, L-1 in 15 cases, L-2 in three cases, and L-3 and L-4 in five cases. Thus, in the majority of cases the injury involved the T 1 2 - L 1 level, with injury to the conus medullaris. Only eight patients of the 27 had fractures below the level of the conus with trauma o f the cauda equina. Depending on the level of injury (Table 4) and the time at which the patients reported to the neurosurgical department, they had varying degrees of weakness of the knees and ankles, with sensory loss involving the lower sacral nerves. Their main disabling complaint was difficulty in micturition. Nineteen had overflow incontinence and four had true incontinence (Tables 5 and 6). O f the 27 cases, 20 had shown some improvement in their neurological condition with conservative therapy (bed rest) from the time of the accident. The majority sought expert medical help 6 - 1 2 weeks after the injury, when there was no further improvement in their disability. Two patients reported 3 months after the injury. All of the 27 patients under review had lumbar puncture and myelography (Tables 7 and 8); all showed a complete or partial subarachnoid block at the site of the fracture dislocation. The cerebrospinal fluid (CSF) proteins were over 200 mg in 8 patients, and between 100 and 200 mg in 17 patients. Myelography was done with iophendylate (Myodil; Pantopaque), and showed complete block of the subarachnoid space in 18 and partial block in 9 patients. 0090-3019/83/$3.00
Traumatic Paraplegia
T a b l e 1. Male patients Age Groups
T a b l e 7. Lumbar Puncture Queckenstedt Test Done in
All Cases
Cases
22-25 25-30 31-35 36-40 43 Total
CSF proteins
11 7 5 3 1 27
Over 400 mg 200-400 mg 100-200 mg 40-100 mg
1951-55 1956-60 1961-65 1966-70 1971-75 1976-79
2 6 17 2
T a b l e 8. Myelography
T a b l e 2. Postoperative Observation Years
415
Surg Neurol 1983;20:414-6
Complete block Partial block
Cases 6 2 4 5 6 4
18 9
T a b l e 9. Operative Findings Bony compression by displaced lamina Thickened and fibrosed Ligamentum Flavum Arachnoidal adhesions
20 19
T a b l e 3. Time Elapsed Between Injury and Operation 6 weeks 8 weeks 9 to 12 Over 12 weeks
12 cases 8 cases 5 cases 2 cases
T a b l e 10. Surgical Procedures Release of adhesions Drainage of traumatic cyst Microsurgical release of nerve roots Duraplasty
17 6 4 12
T a b l e 4. Neurological Level of Injury Conus medullaris Conus and cauda Cauda equina
Operative Findings
13 6 8
T a b l e 5. Presenting Disability Bladder Overflow incontinence True incontinence Motor disability Sensory difficulties Pressure sore (heel) Pressure sore (sacral)
19 4 21 19 4 13
T a b l e 6. Fracture Sites D-12 L-1 L-2 L-3 L-4
A t o p e r a t i o n , t h r e e l a m i n a e w e r e r e m o v e d (Tables 9 and 10). T h e lamina o f the v e r t e b r a b e l o w the site o f the fracture was always r e m o v e d to e n s u r e a d e q u a t e d e c o m p r e s s i o n . A l m o s t all o f the p a t i e n t s s h o w e d a t h i c k e n e d l i g a m e n t u m flavum and a fair a m o u n t o f hyp e r t r o p h y o f e x t r a d u r a l fibrous tissue. T h e d u r a m a t e r was o p e n e d in e v e r y case. T h e c o m p r e s s i n g e l e m e n t was f o u n d to be a d i s p l a c e d l a m i n a in 20 p a t i e n t s , a t h i c k e n e d and fibrosed l i g a m e n t a m flavum in 19, and a r a c h n o i d a l a d h e s i o n s in 17 cases. T h e a d h e s i o n s w e r e r e l e a s e d as far as possible. D u r i n g the later p e r i o d o f this s t u d y (the past 6 years), it was p o s s i b l e , t h r o u g h the use o f m i c r o surgery, to release m o s t a d h e s i o n s w i t h o u t d a m a g i n g t h e spinal c o r d o r n e r v e roots. A n a r a c h n o i d cyst c o m p r e s s ing the c o r d was f o u n d in six cases and was d r a i n e d by a d e q u a t e excision o f the cyst wall. D u r a p l a s t y was d o n e in 12 cases to e n s u r e a w i d e d u r a l canal.
4 15 3 3 2
Subsequent Course P o s t o p e r a t i v e studies s h o w e d i m p r o v e m e n t in the muscle p o w e r o f t h e legs in 8 p a t i e n t s , and i m p r o v e m e n t in
416
Surg Neurol 1983;20:414-6
Ramamurthi et al
bladder function in 14 (Tables 11 and 12). These two features tended to accompany one another. Cystometric studies confirmed the clinical improvement. T h e neurological improvement became apparent 2 - 4 weeks after operation and continued o v e r a period of 6 - 9 months. Fww patients who did not show some sign of improvement in the first 4 weeks had any i m p r o v e m e n t later.
Discussion The indications for laminectomy in posttraumatic spinalcord damage are controversial. T h e general experience has been that decompressive procedures in acute spinalcord injuries, do not yield any benefit. Within this gloomy picture, however, are a few bright circumstances in which it is possible for the neurosurgeon to offer positive ben-
Table 11. Results Improvement in motor power in 21 patients with motor disability Good Moderate Sensory disability and pressure sores in 19 patients Improved No improvement Bladder function involved in 23 patients Good improvement Moderate improvement Nil
2 patients 6 patients 3 patients 16 patients 3 patients 11 patients 9 patients
Table 12. Improvement According to Level of Lesion and Neurological Level Level of lesion D-12 (4 patients) L-1 (15 patients) L-2 (3 patients) L-3 (3 patients) L-4 (2 patients) Neurological level Conus medullaris lesion Cauda equina lesion
Improved 1 7 2 2 2 19 patients 8 patients
efit to the patient. O n e of these areas involves cases in which there is a partial preservation of sensory and motor function with evidence of compression of the spinal cord, especially by fractures of the dorsolumbar and lumbar spine. Chenggi [1] found i m p r o v e m e n t in 5 o f 10 such cases. In 1978, W e n d t and Mucke [6] suggested that efforts must be made to diagnose a block in the subarachnoid space in cases of an incomplete static or chronic neurological deficit, and to offer surgical treatment if there is any such block. We believe, with Ransohoff et al [5], that in such cases the neurosurgeon should approach the problem in a m o r e aggressive manner, thus offering the possibility o f improvement. In support of this view, Jelsma et al [3,4] have recently presented favorable results obtained from surgical decompression and stabilization of the spine in cases of spinal-cord injury in which there is evidence of compression of the cord, and have concluded that neural compression is an indication for operation regardless of the degree of neurological deficit. The experience presented above shows that decompressive laminectomy has a place in the treatment of fracture dislocations of the dorsolumbar and lumbar spines in cases in which there is a partial neurological deficit. If myelography confirms a block in such an instance, surgical intervention may relieve the condition in about 4 0 % of patients.
References 1. Chenggi W, Jintang C, Qisben F. Anterolateral decompression for spinal fractures complicated by paraplegia. Chin Med J (Peking) 1975;92: 149-54. 2. Jelsma RK, Rice JF, Kirsch T. The demonstration and significance of neural compression after spinal injury. Surg Neurol 1982;18:79-92. 3. Jelsma RK, Kirsch PT, Jelsma RF, Ramsey WC, Rice JF. Surgical treatment of thoracolumbarfractures. Surg Neurol 1982;18:156-66. 4. Ramamurthi B. Late laminectomy in traumatic paraplegia. Ind J Surg 1952; 16,2,183-4. Excerpta Medica, 6, 1462, 1953. Bulletin of the International Congress of Neurology, Lisbon, 376-378 (Sep 1953). 5. RansohoffJ, Benjamin MV, Engler G, Flamm ES. Surgical intervention in spinal cord injury. Semin Neurol Surg 1979;1:353-61. 6. Wendt H, Mucke R. Posttraumatic spinal cord compressions.When does operative decompression make sense? (German) Nervensarzt 1978;49:208-16.