AJNS

CLINICAL STUDIES / ETUDES CLINIQUES
 
SPINAL COLUMN AND CORD INJURY IN HARARE CENTRAL HOSPITAL



  1. Harare, Zimbabwe

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SUMMARY

Seventy-three cases of injury to the spinal column are reviewed. Fifty percent (36) suffered bony injury without neurological damage. Road traffic accidents were the commonest cause. All patients did well. Twenty percent (15) suffered minor neurological damage, again road traffic accidents predominated as the cause by the bony injuries were more severe than in the first group. There was no mortality. Thirty percent (22) suffered bony injury and total paraplegia or quadriplegia., Eleven patients (50%) died in hospital, 9 being quadriplegic. The high mortality in these cases appears related to respiratory problems. It was noted that high cervical injuries (to the C1-C2 levels) rarely result in severe cord damage.


RESUME

Les auteurs ont revu 73 cas de lésions traumatiques de la colonne vertebrale:
-  50% (36) avaient une lésion osseuse, sans lésion nerveuse. Les accidents de la route en étaient la cause la plus fréquente. Tous ces patients étaient asymptomatiques.
-  20% (15) présentaient des troubles neurologiques mineurs. Il s’agissait pour la plupart d’accidents de la circulation. Les lésions osseuses étaient plus graves que dans les premiers groupes, mais il n’y a pas eu de déces.
-  30% (22) avaient une paraplegie ou une quadriplegie secondaire à des lésions osseuses.11 patients soit 50% sont décédés à I’hopital dont 9 etaient quadriplegiques. Cette mortalite élevée étaient liées à des troubles respiratoires. Le niveau lésionnel haut, C1C2 déterminait peu de lésions médullaires.

INTRODUCTION

We are presenting a review of 73 cases of trauma to the spinal column and cord which have been seen by us over the past few years. They fall into three groups, those without nervous system damage, those with minor neurological involvement and those with severe and usually permanent paraplegia or quadriplegia.

CASE ANALYSIS

1. Thirty-six (50%) suffered bony injuries without neurological damage. There were 26 males and 10 females. The ages ranged between 18 and 63 years and averaged 36 years.

Table 1

Road Traffic Accidents 19 (51%)
Falls 11 (30%)
Assaults 4 (11%)
Sack falling on patients 1 (3%)
Explosion 1 (3%)

There was no difference by sex as far as as age distribution or causation was concerned except that both the sack and explosion injuries occurred in men. (Table 1). Most of the bony injuries were of the type with which a better prognosis is associated.

Table 2

Fractures (C1 Arch-1, C2 Odontoid Peg-3, C2 Pedicle-2) 6
Single vertebral compressions 20
Subluxation and minor dislocations 5
Other injuries 5

The injuries were located as follows:

Table 3

High Cervical (C1-2) 6 (19%)
Low Cervical (C3-7) 9 (25%)
Dorsal (T1-T10) 4 (11%)
Lumbodorsal (T11-L1) 5 (14%)
Lumbar 12 (31%)

These were treated conservatively or by anterior cervical fusion if the subluxation or minor dislocations appeared unstable. All patients did well.

2. Fifteen patients (20%) (13 males, 2 females) suffered minor neurologival damage. This ranged from weakness of one arm associated with overriding of a facet joint to more severe compressions than we saw in the previous group and are what we can only consider to be, lucky escapes. The average age was 38 years with a spread from 12 years to 60 years.

Table 4

Road traffic accident 8 (53%)
Falls 4 (26%)
Assault 1 (7%)
Tree fell on patient 1 (7%)
Sack fell on patient 1 (7%)

The causes were very similar to those of the “no cord damage” group. However the nature is more severe. There were high cervical injuries.

Table 5

Fractures (C1 Arch-1, C2 Odontoid Peg-1, C2 Pedicle Fracture-1) 3
Dislocations (with one facet overriding) 7
Single vertebra compressions 4
No Fracture seen 1

The compression were more severe and the dislocations more obvious than in the former group. They were located as follows:

Table 6

High cervical 3 (20%)
Low cervical 6 (40%)
Thoracic 1 (6%)
Thoraco-lumbar (T11-L1) 3 (20%)
Lumbar 2 (14%)

All the patients with the high cervical lesions and two others had recovered by the time of discharge. Unfortunately we do not have a follow-up on the others at this time.

3. The third group comprises those 22 patients whose injuries were severe enough to render them totally paraplegic and quadriplegic. The average age was 31 years with a spread of 3 years to 70 years. Falls predominated over road traffic accidents

Table 7

Falls 9 (40.5%)
Road Traffic Accidents 7 (31.5%)
Axe, Gunshot Wound, stab 3 (13.5%)
Diving 1 (4.5%)
Roof fall 1 (4.5%)
Drum fall 1 (4.5%)

There were none of the lifesaving C1-C2 level injuries and the dislocations and compressions were much more serious than in the previous group.

Table 8

Dislocations 10
Compressions 8
No fracture 2
Axe 1
Stab 1

(Note: there were no C1-C2 injuries)

They were located as follows:

Table 9

Low cervical 13 (59%)
Thoracic 3 (13%)
Lumbodorsal 4 (18%)
Lumbar 2 (9%)

Eleven patients died in hospital, 9 of whom had cervical lesions while one boy who was totally quadriplegic was taken home by his family and undoubtedly demised. The verv high mortality is surprising - there are a considerable number of quadriplegic patient around. However these patients very easily develop respiratory problmes in the early davs after their injury - the aetiology of this, whether it is spinal cord oedema, or pulmonary oedema is uncertain but it has been noted that sometimes they develop severe laryngeal spasm and stridor. It has been necesary to intubate or do a tracheotomy on these patients at times.

Comments
Interesting points were that road traffic accidents predominated in the cases where there was no or only minor injury, while falls produce the most serious injuries involving damage to the spinal cord. Furthermore high cervical injuries to the C 1 -C2 level do not result in severe cord damage because of the large cross sectional area subtented by the arches of C1-C2 and the fact that when the odontoid peg fractures it is held in its normal relationship to the anterior arch of the atlas by the transverse ligament of the atlas. There were no injuries to the transverse ligament which could have freed the odontoid peg and allowed it to travel posteriorly onto the cord. Thus there were 9 C1-C2 injuries in the groups with no or minor neurological damage and none in the group with severe neurological damage.


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ISSN: 1992-2647