A retrospective study of surgical treatment of spinal injuries with rehabilitation program

Introduction: Traumatic injuries of the spinal column are among the most devastating injuries in orthopedics. The primary goals of rehabilitation of these injuries are prevention of secondary complications, maximizing physical functioning and reintegration into the community. Rehabilitation after spinal injury reqires multidisciplinary team approach. Team members include, but are not limited to, physical therapists, occupational therapists, nurses, psychologists, health care managers and social workers, with each member having role and responsibility in their area of expertise. This study aimed to determine the difference in the occurrence of spinal injuries according to gender, age, cause of injury, neurological phenomenon in injured patients, the treatment and physical procedures used in the early stages of rehabilitation. Methods: The study was conducted as a retrospective and comparative at the Department of Orthopedics and Traumatology of Clinical Center University of Sarajevo. Medical records of 100 patients, treated at from January 1st 2007 till June 30th 2008, were processed and data about outpatient protocols and surgery protocols analyzed. Results: The results obtained from the data showed greater proportion of women (56%) compared to men (44%). Most patients were in the age group between 41 and 60. Injuries were most often due to falls from height and make 32%, fall from a tree 25%, traf c accidents 12% ( 2=17.94, p=0.0061). 88% of patients were without neurologic events, while the neurological disturbances occurred 12% ( 2=3.397, p=0.3343). 56% of patients with spinal injuries were treated surgically, while 41% were treated conservatively ( 2=7.264, p= 0.00153). 73% patient had physical therapy program of early rehabilitation exercises, with at least at least only a massage in 4% of patients ( 2 = 6.573, p = 0.04270). Conclusion: The adoption of national protocols is necessary for future treatment of patients with spinal fractures. © 2011 University of Sarajevo Faculty of Health Studies


Sažetak
Uvod: Traumatske povrede kiþmenog stuba spadaju meÿu nejviše razarajuüe povrede u ortopediji.Primarni ciljevi rehabilitacije ovih povreda su prevencija sekundarnih komplikacija, maksimiziranje ¿ ziþkih funkcija i reintegracija u zajednicu.Rehabilitacija nakon povrede kiþme zahtjeva multidisciplinarni timski pristup.U þlanove tima ukljuþeni su ¿ zioterapeut, radni terapeut, medicinske sestre, psiholog, zdravstveni menadžer i socijalni radnik, svaki sa svojom ulogom i odgovornošüu u svojoj oblasti struþnosti.Ova studija ima za cilj utvrditi razlike u pojavi povreda kiþmenog stuba prema spolu, starosnoj dobi, uzroku povrede, pojavi neuroloških ispada, naþinu lijeþenja i korištenih ¿ zikalnih procedura u ranoj fazi rehabilitacije.Metode: Istraživanje je provedeno kao retrospektivno i komparativno na Klinici za ortopediju i traumatologiju KCU Sarajevo.Historije bolesti 100 bolesnika, tretiranih od 01.01.2007.do 30.06.2008.su obraÿeni i podaci o ambulantnim i hirurškim protokolima analizirani.Rezultati: Rezultati su pokazali veüi udio žena (56%) u odnosu na muškarce (44%).Veüina pacijenata je bilo u starosnoj grupi izmeÿu 41 i 60 godina.Najþešüe uzrok povreda je bio pad sa visine (32%), pad sa drveta (25%), saobraüajna nezgoda (12%) (Ȥ²=17,94, p=0,0061).88% pacijenata je bilo bez neuroloških ispada, dok je 12% imalo takve poremeüaje (Ȥ²=3,397, p=0,3343).56% pacijenata sa povredom kiþme je tretirano hirurški, dok je 41% tretirano konzervativno (Ȥ²=7,264, p= 0,00153).Od korištenih procedura ¿ zikalne terapije u programu rane rehabilitacije su bile vježbe 73 %, a najmanje samo masaža kod 4 % pacijenata (Ȥ²= 6,573, p= 0,04270 Mechanical forces aff ects on the spinal column in the form of compression, extension, torsion and sliding disintegration "(translation).Th ese forces cause the proper tension, deformation and migration of certain elements of spine: vertebral body, intervertebral discs, posterolateral joints and ligaments.Similar eff ects on these structures have forced movements of the spinal column such as fl exion, extension, lateral bending and axial rotation.Th e eff ect of these mechanisms of injury depends on the anatomical structure: occipito-atlanto epistropheus complex is anatomically diff erent from "the lower cervical spine (C3 -C7).Surgery may be indicated aft er attempt of closed reduction still persist "stuck" articular socket, compression of the spinal cord and spinal nerves.In the case of articular fractures and arch extensions immediately undertake operative reduction.Depending on the neurological defi cits and associated injuries, the patient is allowed to get out of bed in the next postoperative day.In severe cases, requires a longer period of immobilization (2).In the thoracic spine fl exion -compression fractures (wedge compression) were followed normal neurological fi ndings or incomplete lesion medullae spinalis.Axial -compression fractures (burst), sagittal -broken fracture and anterior dislocation are accompanied by complete lesion of spinal cord injury (3).Minimal subluxation and small bending -compression fracture of thoracic spine are treated conservatively, casting (with the help of prosthetic device) in hyperextension of the thoracic spine during the 3 to 4 months.In other cases, these injuries are treated with internal fi xation and operational fusion.Treatment of patients with fractures of the thoracolumbar and lumbar spine without neurological defi cit contains lying in bed.If a neurological defi cit more is pronounced, in the treatment of external immobilization (in hyperextension) orthopedic tools.If many signs of posterior ligament rupture occur, last fusion and fi xation is performed (4).Physical therapy of patients aft er injury of the spinal column is divided into: early postoperative inpatient therapy and late continuing physical therapy.Early physical therapy is done in order to prevent post injury -post-operative complications (thrombosis and thromboembolism, pneumonia, prepares muscles for walking with crutches and the rapid re-socialization).Prerequisites are operated on a patient -the stabilization of the fracture was made, the funds are protected with anticoagulant and catheterized with paper diapers, eliminated primary postoperative pain.Physical Th erapy in the program includes: breathing exercises, active and passive exercises, massage, electro, etc. (5)(6)(7).At a later stage (3 weeks) begins the process of mobilization of the patient (sitting and rising).Getting up and walking is performed using the additions to stabilize the patient in the form of chest corset (diff erent types) and crutches or walkers and with neurologic defects necessary to provide and orthotics for the lower extremities.Aft er the expiration of a period of 3 weeks of stay in surgical facility the patient was transferred to the Institute of Physical Th erapy, where rehabilitation is done in a period of 4-6 weeks or longer, if it is verifi ed neurological impairments.Due to specifi c spine fractures a patient is required to perform independently in a home program taught therapeutic procedure.Later, organized intensive physical therapy begins upon expiration of the primary period of fracture healing.It is necessary that from the date of injury (stabilization) passes a period of three months (10 -12 weeks).
If the process is organized, the patient is capable of independent physical therapy in which places special emphasis on strengthening segment of paravertebral muscle.Paravertebral muscle strength is one of the prerequisites for the successful healing of creation and the reduction of residual spine gibus and compression of the spinal canal and paravertebral important structures, especially radicular nerve (8).Th is study aimed to determine the diff erence in the occurrence of spinal injuries according to gender, age, cause of injury, neurological phenomenon in injured patients, the treatment and physical procedures used in the early stages of rehabilitation.Th e working hypothesis suggests that there is a statistically signifi cant diff erence in the use of certain procedures of physical therapy at an early stage of rehabilitation of patients with injury of the spinal column.Null hypothesis indicates that there is no statistically signifi cant diff erence in the use of certain procedures of physical therapy at an early stage of rehabilitation of patients with injury to the spinal column.

Methods
Th e study was conducted as a retrospective and comparative to the department of Orthopedics and Traumatology at the Clinical Center University of Sarajevo.Hundred of patients treated at this clinic from January 1 st 2007 till June 30 th 2008 were processed inquiring the medical records of outpatient protocols and surgery protocols.During statistical analysis, the level of signifi cance was determined by Ȥ² -test, and correlation was analyzed using Pearson's correlation coeffi cient.Th e level of signifi cance was defi ned as p <0.05.Average age of patients was calculated by the arithmetic mean and the age structure is determined by the standard deviation and median.Th e results are presented in tables and graphs.

Results
Th ere were accounted 44% of male and 56% of female patients, as can be seen from the tables and graphics.Th e average age of our patients was 50.4,with the youngest patient age 18 and the oldest 80 years old.Most patients were in the age group of 41-60, at least in the age group of 61-70 years old.
Most oft en injuries 38%, were due to falls from a height, falling from a tree was the cause of injuries in 25% of cases of aught other causes involved made, while traffi c accidents accounted for 12%.
Without neurologic impairments were 88% of patients, while the neurological disturbances were 12% of patients.Most patients with spinal injuries were treated surgically, 56% of them and 42% of patients treated with conservative measures.
As can be seen from the table, the most used procedures of physical therapy in early rehabilitation exercises 73%, and the only massage in case of 4% of patients.In case of all patients breathing exercises were performed.

Discussion
In the period from January 2007 until June 2008, at the Clinic of Orthopedics and Traumatology there were 3600 bone fractures, of which 270 fractures of the spinal column.Th is survey included patients older than 18 and those with pathological fractures.Based on these data we can conclude that spine fractures represent 3.6% of total fractures.Of the total registered 100 cases of spine fractures in patients older than 18 years, who are selected randomly, 44% of fractures refer to men, while 56% of fractures refer to women.Injury of the spine mainly occurs in case of middle aged and elderly people.Th e highest incidence of injuries on the subject of men is ranging from 40 to 70 and for women aged 30 to 70.Our results are similar for men and women, so the most common injuries occur in the age between 40 and 45.Based on these data we can conclude that injuries arise at the time of greatest creativity in life of each individual.Injuries of the spinal column are very complicated and beside health damages, those injuries lead to frequent absenteeism and jeopardizing social -economic opportunity for the injured.Certainly, the most diffi cult consequence of spinal injury is a disability which leads to the psychological trauma of patients and their families, as well as society as a whole.Th is is particularly true for paraplegics, who need 24 -hour medical care (9).With thoracolumbar fractures and lumbar spine there is no correlation between neurological defi cit and recovery pattern with the extent of canal compromise.Like other bones, vertebral fractures are also undergoing signifi cant remodeling, so that the size and shape of the spinal canal improves with time.However, this remodeling has no impact on neurological recovery (10).
Regarding the presence of fractures due to seasons, we can see that the most common fractures appear in the period of spring and winter.Th is phenomenon can be explained by the beginning of intensive agriculture and construction, as well as falls on the ice in winter.
It is important to note that the seemingly simple falls at home (especially the female population) result in fractures of the spine.In addition to these, a common cause of spinal fractures of women is osteoporosis, which usually aff ects young and middle-aged women (11).Th e most common cause of injury is fall from height (especially tree fall) during the summer period, then aft er followed by traffi c accidents, something more commonly men involved.Very oft en the injury occurs as a result of tumor metastases in the vertebral column, which secondarily damages the vertebral and spinal cord.
According to data from English authors we can fi nd the following: • Th e ratio of injured men compared to women is 4:1, while in our country this ratio is approximately 1: 1.6.According to their data the most aff ected are men between 25 and 60 and women aged 60 and more.Our results are similar for men and women, so the most frequent injuries occur in the age between 40 and 45. • Diff erences also exist in the nature of injury.According to English author most common cause of injury of males are traffi c accidents, while in case of women injury was result of osteoporosis bone fractures.• A large number of fractures are treated surgically, which is also the case with the treatment of our patients.According to English author, conservative treatment causes a high percentage of deformities of fl exional type: further increase in vertebral body compression in 40% of cases, gibbous in 23%, scoliosis in 23% and spondylotic changes in 46% of cases.Also, they found that the relationship between the spine and symptoms statistically signifi cant (12).

Conclusion
Based on the foregoing, we conclude that one of the necessary things for the future treatment of these patients is the adoption of national protocols to assist people with spinal fractures.It is necessary to educate a certain number of qualifi ed personnel and provide funds for the purchase of necessary equipment.
). Diff erent types of long and short stabilization is used and the installation of various fi xations.Rehabilitation aft er such injuries is a long process (1).
IntroductionOboInjuries of the spinal column can occur in diff erent ways.Usually occur as a result of falls from a height or traffi c accidents.Th e treatment of these injuries, particularly the fractures of the vertebrae, is usu-ally surgical.

TABLE 1 .
Age distribution of patients with fractures of spine

TABLE 2 .
Cause of injury

TABLE 3 .
The occurrence of neurologic events in patients with spinal injury

TABLE 4 .
Method of treatment of spinal fractures

TABLE 5 .
Physical therapy methods used in early rehabilitation