Abstract
Background
Traumatic spinal cord injuries on cervical canal stenosis represent a steadily increasing pathology, of which clinical and functional outcomes remain largely unknown.
Material and methods
We present the results of a prospective study of 20 patients followed for one year who had presented with traumatic spinal cord injury involving initially acute neurological symptoms and cervical canal stenosis defined in the imaging by a Torg ratio < 0.8 and a medullary canal ratio > 0.65, without vertebral fracture.
Results
Traumatic spinal cord injuries on cervical canal stenosis are caused mainly by falls in the elderly population and by unsafe behaviour among younger subjects. Most of the patients present with initially incomplete tetraplegia, and two thirds have centromedullary syndrome. Association of complete tetraplegia with advanced age would seem to be a predictive factor of death in the early post-traumatic period. For incomplete tetraplegics, the main phase of neurological and functional recovery is observed over the first six months. Radiological data and timing of surgery do not appear to affect the prognosis.
Conclusion
This study underlines the need for individualized specialized care of patients with spinal cord injuries on cervical canal stenosis, particularly according to their demographic and lesional characteristics.
Résumé
Contexte
Les traumatismes vertébromédullaires sur canal cervical étroit sont une pathologie en constante augmentation, dont l’évolution clinique et fonctionnelle restent mal connues.
Matériel et méthode
Nous exposons les résultats d’une étude prospective portant sur 20 patients, suivis durant un an, présentant un traumatisme vertébro-médullaire avec initialement un tableau neurologique aigu, et un canal cervical étroit défini à l’imagerie par un Torg ratio < 0,8 et un rapport médullocanalaire > 0,65, sans fracture vertébrale.
Résultats
Les traumatismes vertébromédullaires sur canal cervical étroit sont principalement liés à des chutes chez les sujets âgés, et à des conduites à risque chez les sujets jeunes. La plupart des patients présentent une tétraplégie incomplète, dont les deux tiers ont un syndrome centromédullaire. L’association d’une tétraplégie complète et d’un âge avancé semble un facteur prédictif de décès dans la phase précoce post-traumatique. Pour les tétraplégiques incomplets, l’essentiel de la récupération neurologique et fonctionnelle est observé au cours des six premiers mois. Les données radiologiques et les conditions de prise en charge chirurgicale ne semblent pas influencer le pronostic.
Conclusion
Cette étude souligne la nécessité d’une prise en charge spécialisée et individualisée des patients blessés médullaires sur canal cervical étroit, notamment selon leurs caractéristiques démographiques et lésionnelles.
1
English version
1.1
Introduction
In 2000, the relative occurrence of traumatic spinal cord injuries (TSCI) in France was 19.4 persons aged over 15 years for one million inhabitants, with 934 new cases a year .
Frequently associated with spine fracture, TSCI may lead to a medullary lesion without bone damage, particularly when cervical stenosis (CSS) already exists . Half of all people over 50 years of age and 75% of those over 65 years of age have a narrow cervical canal, which represents the most frequent risk factor for a cervicomedullary traumatism in the adult population . Moreover, the cervical spinal cord is particularly vulnerable because it is not thoroughly vasculaized, especially in the elderly population.
CSS is classically defined by the Torg ratio, which corresponds on standard lateral x-rays to the quotient between the anteroposterior diameter of the spinal canal and the anteroposterior diameter of the vertebral body at its center . A Torg ratio lower than or equal to 0.8 indicates a narrow cervical canal with sensitivity of 93% . The medullary canal ratio (MCR) used by Berge et al. is defined at MRI in T2 sequences as the quotient between the anteroposterior diameter of the spinal cord measured at the level of the intervertebral disk and the anteroposterior diameter of the vertebral canal measured halfway up the vertebral body . A MCR higher than 0.65 suggests a CSS .
According to the study of Pascal-Mousselard et al., the most frequent clinical picture in vascular medullary trauma (VMT) with CSS consists mainly in the central cord syndrome with incomplete tetraplegia described by Kahn and Schneider (62% of the patients), with a marked predominance of C on the ASIA Impairment Scale (AIS) (72.4%) .
There exists no consensus on the screening of this population, and more precisely on the indications and scheduling for surgery aimed at decompression and stabilization. During the acute phase, the most frequently observed indications consist in the existence of signs of clinical and/or radiological instability. The classical criteria favorable to remote surgery are neurological aggravation or stagnation subsequent to a phase of improvement .
Different studies appear to show that after two years, conservative management and surgery lead to the same functional outcome, but that early surgery may possibly facilitate more rapid recovery, with fewer secondary complications .
Our prospective study is a descriptive analysis of the mechanisms, the impact of surgery, and the clinical and functional evolution over one year of tetraplegic patients subsequent to decompensated CSS without fracture. We particularly wish to focus upon screening procedures and thereby highlight the specific characteristics of patients with medullary injuries, particularly as pertains to their demographic and lesional characteristics.
1.2
Patients and methods
We present a prospective descriptive study with an inclusion period of 16 months and a follow-up phase of one year. Inclusion criteria consist in VMT with an acute neurological profile, which means on the one hand motor and/or sensory deficit and/or vesico-sphincter dysfunction and no x-rayed vertebral fracture, and a CSS defined by a Torg ratio < 0.8 and a medullary canal ratio > 0.65 ( Fig. 1 ). Exclusion criteria consist in absence of acute neurological disorders, absence of narrow cervical canal, presence of cervical spine fracture(s) and/or other spine fracture(s) irrespective of the posterior wall.
Patients are assessed on arrival in the emergency ward and seen again by the same doctor a week, a month, six months and a year after the accident. Neurological data are collected according to the recommendations of the American Spinal Injury Association (ASIA). Evolution of the ASIA motor score (AMS) and ASIA sensory score (ASS) is measured. Motor recovery percentage is calculated with the formula used by Waters et al. in 1996: [(AMS 365 –AMS 0 )/(100–AMS 0 )] × 100, where AMS 0 and AMS365 are respectively initial AMS and AMS one year later . We have evaluated the percentage of overall recovery and the percentage of recovery during each interval between two successive evaluations. Sensory recovery percentage is calculated in the same way: [(ASS 365 –ASS 0 )/(112–ASS 0 )] × 100. Recovery percentage compensates for the ceiling effect: a subject with a high initial score has fewer points to recover than a person with a low initial score.
Functional status is assessed in terms of the functional independence measure (FIM). The same formulas as before are used in order to determine the degree of functional recovery. Ambulatory status (walking without restriction, walking with assistive devices, not walking) and functional status of the hand (no use, partial use, total recovery) are assessed by interrogation and clinical follow-up consultation.
Complications, image-related data and management up to and including surgery are duly noted.
The various data are brought together and collated in a standard booklet preliminarily tested on two patients before being adopted in its definitive form.
The statistical data including means and standard deviations are calculated as regards the different demographic data and their evolution. The Mann and Whitney test is used to compare independent quantitative data, and the Fisher test to examine the significance of the association of two qualitative variables. The significance threshold has been set at p < 0,05.
1.3
Results
1.3.1
Admission data
Table 1 summarizes the admission data. Our study included 20 patients over 16 months, of whom three quarters were males, of an average age of 62 years. Four of the nine patients aged over 60 lived in a retirement home and were dependent in their everyday activities prior to the accident (Katz index < 6). Six patients (30%) had presented with paresthesia and/or weakness of the upper and/or lower limbs before the trauma, thereby suggesting preexisting CSS with myelopathy.
| Patient | Age | Etiology | GCS | Neurological level | AIS | Syndrome | CSS level | Time before surgery |
|---|---|---|---|---|---|---|---|---|
| 1 | 81 | Fall from height | 15 | C4 | D | Brown Sequard | C3-C5 | 8 weeks |
| 2 | 42 | Diving accident | 15 | C5 | D | Anterior | C3-C5 | 21.5 weeks |
| 3 | 57 | Fall from tree | 15 | C4 | B | Central | C3-C5 | – |
| 4 | 45 | Bicycle accident | 15 | C4 | C | Central | C3-C5 | 12 weeks |
| 5 | 66 | Fall from height | 6 | C4 | D | Central | C4-C6 | – |
| 6 | 49 | Motorcycle accident | 15 | C3 | A | Complete | C3-C5 | D0 |
| 7 | 57 | Fall against an obstacle | 15 | C6 | D | Brown Sequard | C3-C4, C5-C6 | 12 weeks |
| 8 | 43 | Diving accident | 3 | C4 | D | Central | C4-C6 | 24 weeks |
| 9 | 76 | Fall from horse | 15 | C4 | C | Central | C3-C4 | D1 |
| 10 | 90 | Fall from height | 15 | C5 | C | Central | C4-C6 | – |
| 11 | 77 | Fall from height | 15 | C3 | A | Complete | C4-C6 | – |
| 12 | 78 | Fall from height | 15 | C4 | D | Central | C3-C7 | – |
| 13 | 63 | Fall in staircase | 15 | C4 | B | Central | C3-C5 | 20 weeks |
| 14 | 82 | Fall from height | 14 | C5 | A | Complete | C2-C6 | – |
| 15 | 50 | Fall against an obstacle | 15 | C5 | D | Central | C3-C6 | – |
| 16 | 32 | Diving accident | 15 | C4 | A | Complete | C3-C7 | D1 |
| 17 | 54 | Fall from height | 15 | C5 | D | Brown Sequard | C4-C6 | – |
| 18 | 59 | Fall from roof | 3 | C4 | A | Complete | C4-C6 | D1 |
| 19 | 52 | Tractor accident | 15 | C4 | D | Brown Sequard | C4-C6 | D5 |
| 20 | 86 | Fall from height | 15 | C4 | C | Central | C3-C4 | D1 |
The main cause of the accident was a fall (13 patients, 65%). The nine patients aged over 60 had fallen, seven of them from a height comparable to theirs. The other causes of medullary traumatism were three traffic collisions, two swimming accidents and one frontal impact on a glass door.
On admission, five patients presented with complete tetraplegia (25%), and fifteen with incomplete tetraplegia (75%): nine were grade AIS D (45%), four AIS C, and two AIS B. Half of the patients presented with a centromedullary syndrome. The neurological level was principally C4 (12 cases, 60%) and C5 (5 cases, 25%). The mean initial AMS score was 44.9 ± 35.2 points. The mean initial ASS score was 64.95 ± 39.75 points. Sixteen patients had an isolated medullary lesion (80%), and four of them had associated facial traumatism and/or shoulder dislocation.
On X-rays, the Torg ratio averaged 0.65 ± 0.1 and the medullary canal ratio averaged 0.67 ± 0.0, with no correlation between the two measurement tools ( p = 0.37). Sixteen patients had a multistage CSS (80%). The most affected vertebral segment was (17 patients). CSS originated with cervical arthrosis in 17 patients and in congenital CSS with 3 patients. Three patients had an associated cervical disc herniation. An intramedullary hypersignal was found in 17 patients (85%) on T2-weighted sequences, thereby suggesting medullary oedema.
Twenty patients were evaluated on admission, 19 a week afterwards, 18 a month afterwards, and 16 six months and one year after the accident. As regards the subjects not seen again, one disappeared from view (case 5), and three died of acute respiratory distress syndrome (ARDS). Two patients aged 77 and 82 years (cases 11 and 14) died during the first month, and a patient aged 49 years (case 6) died during the eleventh month. The three deceased patients all had complete tetraplegia, with a neurological level of C3 (two cases) and C5 (one case). The mortality rate rose significantly with complete tetraplegia ( p = 0.008), but did not rise significantly with age ( p = 0.53).
1.3.2
Neurological evolution
The AMS rose by 20.9 ± 22.5 points in the year following admission, with a motor recovery rate of 49.5%. The AMS increased the most from a week to a month (7.8 points or 37.2% of overall recovery), and from one to six months (5.6 points or 26.5% of overall recovery) following admission ( Table 2 ). The patients aged under 60 years had a tendency to recover less (17.5 ± 25.5 points) than those aged over 60 years (27.0 ± 16.7 points, p = 0.43).
| D0 | D8 | D30 | D180 | D365 | D365-D0 | |
|---|---|---|---|---|---|---|
| ASIA motor score | ||||||
| Mean (points) | 49 | 51 | 59 | 65 | 70 | 21 |
| Recovery percentage D n –D n−1 (%) | 0 | 12 | 37 | 26 | 24 | 100 |
| ASIA sensory light touch score | ||||||
| Mean (points) | 74 | 84 | 85 | 89.5 | 80 | 15.8 |
| Recovery percentage D n –D n−1 (%) | 0 | 65.5 | 7 | 26 | 1 | 100 |
| ASIA sensory pinprick score | ||||||
| Mean (points) | 68 | 80 | 84 | 90 | 90 | 22.1 |
| Recovery percentage D n –D n−1 (%) | 0 | 54.5 | 18 | 27 | 0.5 | 100 |
| FIM score | ||||||
| Mean (points) | 60.5 | 73 | 84 | 85 | 24.1 | |
| Recovery percentage D n –D n−1 (%) | 0 | 51 | 45 | 4 | 100.0 |
The total ASS rose by 19.0 ± 7.8 points in the year following admission, with a sensory recovery rate of 46.2%. The total ASS increased the most in the week following admission (an average of 11.2 points or 59.0% of overall recovery), and from one to six months (5.1 points or 26.7%). The patients aged under 60 years had a tendency to recover less (7.5 ± 31.2 points) than those aged over 60 years (36.7 ± 34.9 points, p = 0.14).
As regards the five grade AIS A patients, 80% remained at that level, including the three deceased patients and one patient after a year of follow-up. All the initially AIS B patients, three quarters of the initially AIS C patients and one third of the initially AIS D patients moved up on the scale by one grade ( Table 3 ).
| D365 | |||||||
|---|---|---|---|---|---|---|---|
| A | B | C | D | E | Deaths | Lost to follow-up | |
| D0 | |||||||
| A | 1 | 1 | 3 (A) | 0 | |||
| B | 0 | 2 | 0 | 0 | |||
| C | 1 | 3 | 0 | 0 | |||
| D | 1 | 4 | 3 | 0 | 1 (D) | ||
| E | 0 | 0 | 0 |
1.3.3
Functional evolution
The FIM score rose by 24.1 ± 20.2 points a week to a year following the accident, with a functional recovery rate of 36.8%. The FIM score rose the most a week to a month (an average of 12.2 points, or 50.6% of overall recovery), and one to six months following the trauma (10.9 points, 45.2%) ( Table 2 ). The patients aged under 60 years had a tendency to recover more (28.9 ± 24.5 points) than those aged over 60 years (16.0 ± 4.3 points, p = 0.263).
On admission, three quarters of the patients did not walk; a year later, this figure stood at 56%. While all the subjects initially presented with manual dysfunction, within one year three of them had fully recovered.
Initially, an indwelling urinary catheter was put into place in fifteen patients so as to prevent urinary retention or, in four cases, because of confirmed urinary retention. One year later, 11 patients still presented with urinary disorders; eight had urinary retention necessitating probes (five permanent catheterisms and three intermittent catheterisms), and three had neurogenic incontinence.
1.3.4
Clinical evolution according to surgical management
Twelve patients were operated (60%). They were aged 57.1 ± 16.8 years (extremes 32–86), while non-operated patients had mean ages of 69.2 ± 14.6 years (extremes 50–90) ( p = 0.10). Nine patients underwent first an anterior approach, and then an intervention associating discectomy and/or corpectomy, bone graft and osteosynthesis. The initial anterior approach was justified by the extension of the cervical canal stenosis on at least three levels and/or the existence of compression by disc hernia. For two patients, a posterior approach was preferred and carried out by laminectomy or laminoplasty. This approach was used when decompression had occurred on at least three levels. Six subjects had early surgery within a month, including five during the first 24 hours. Half of them had complete tetraplegia. Early surgery was decided upon when clinical and/or radiological instability was described: that is to say initial neurological and/or respiratory and/or cardiovascular clinical aggravation; radiological instability criteria such as serious sprain, herniated or ruptured disc, osteophyte fracture. Six patients, all of them incomplete tetraplegiacs, underwent late decompression surgery 14 weeks on the average after the accident (extremes 8–24 weeks). Indications for late surgery were recurrence prevention in five cases and aggravation with progressive neurological deterioration in one case.
As regards the operated patients, 11 were assessed a year after the accident. Patient 6, who had undergone early surgery, died in the 11th month. On an overall basis, the AMS rose 23.2 ± 25.4 points in the operated group (19.0 ± 31.9 in the early surgery group and 26.7 ± 21.2 in the late surgery group, p = 0.93), and increased by 16.0 ± 18.6 points in the non-operated group ( p = 0.37). The FIM score rose 26.7 ± 21.9 points in the operated group and increased by 18.2 ± 16.0 points in the non-operated group ( p = 0.51). Nine patients were admitted to a rehabilitation center. The average age of the group was lower (54.1 ± 12.2 vs. 67.4 ± 18.2 years p = 0.13).
1.3.5
Complications
Medical complications are presented in Table 4 . Five patients required intubation with ventilatory assistance on arrival in the emergency ward; in four cases, the intubation was necessitated by a lesional level equal to or higher than C4. Five patients suffered from pneumopathy, three from autonomic dysreflexia, and one from deep venous thrombosis during the early follow-up.
| Complications | Day | Age (years) | Initial tetraplegia | Surgery | ||||
|---|---|---|---|---|---|---|---|---|
| < D30 (%) | > D30 (%) | ≤ 50 (%) | > 50 (%) | Complete (%) | Incomplete (%) | Op (%) | Non-Op (%) | |
| Cardiovascular | 30 a | 20 a | 17 | 43 | 80 | 20 | 33 | 38 |
| Respiratory | 55 a | 25 a | 50 | 57 | 100 | 40 | 58 | 50 |
| Urinary disorders | 90 a | 70 a | 83 | 100 | 100 | 93 | 100 | 88 |
| Digestive disorders | 80 a | 70 a | 83 | 86 | 100 | 80 | 92 | 75 |
| Bedsores | 25 a | 45 a | 33 | 64 | 60 | 53 | 50 | 63 |
| Spasticity | 30 a | 80 a | 83 | 86 | 60 | 93 | 92 | 75 |
| Pain | 70 a | 80 a | 100 | 79 | 60 | 93 | 100 | 63 |
| Infections | 35 a | 45 a | 67 | 50 | 60 | 53 | 58 | 50 |
| Orthopedic | 5 a | 40 a | 33 | 50 | 60 | 40 | 50 | 38 |
| Syringomyelia | 0 a | 5 a | 17 | 0 | 20 | 0 | 8 | 0 |
Thirteen patients (65%) presented with neuropathic pain at the initial examination and 17 (85%) during follow-up. Allodynia and/or dysesthesia were present in the upper limbs of 13 patients, and in the lower limbs of four patients. While the pain was most often treated by simple antalgics from pain level I to level III, such treatments lacked effectiveness because they were not specific to neurogenic pain. Spasticity justifying a specific medical treatment affected 17 patients during the follow-up, 12 for hypertonia predominating in the upper limbs, and 15 in the lower limbs.
As concerns occurrence of cardiovascular, respiratory, orthopedic or infectious disorders, pain, bedsores and spasticity, there was no significant difference between the patients of over and under 60 years of age, or between the patients operated early and the others.
1.4
Discussion
Radiographic criteria for measurement of the cervical canal remain controversial . CSS is classically defined by anteroposterior cervical spinal canal diameter of less than 12 mm on lateral radiographs of the cervical spinal cord . However, there exist significant differences in the dimensions of the cervical canal according to vertebral level, gender, ethnic origin, morphotype, overall patient bone mass, and source-to-image distance with regard to standard radiography . The Torg ratio, described in 1986 by Torg, eliminates the need for an amplification coefficient . We consequently used this tool , which nonetheless appears to vary according to ethnic origin and gender, and may possibly yield false positives . That is why we concurrently used the medullary canal ratio (MCR), which has the advantage of being able to assess protected perimedullary space. Taylor states that in hyperextension trauma, anteroposterior diameter is diminished by 30%, with a risk of medullary contusion if the spinal cord occupies more than two thirds of the canal . That is why a MCR higher than 0.65 suggests CSS. In our study, we have not found any correlation between the Torg ratio and the medullary canal ratio.
An important element in our study is the average age (62 years) of its population. Using the National Spinal Cord Injury Database of the United States as a reference, we learn that the frequency of medullary injuries in people aged over 60 has risen from 4.8% before 1980 to 12.1% since 2000 . The more frequent occurrence of traumatic spinal cord injury (TSCI) in elderly subjects may be explained by a heightened life expectancy entailing more pronounced degenerative processes with a weakened cervical spine. Our results confirm that the fact that the most frequent CSS mechanism in subjects with medullary injuries is cervical arthrosis (85%). More often than not, tetraplegia associated with CSS results from minimal traumas . In our study, for example, the one cause of traumatism in patients aged over 60 was a fall, generally from a height comparable to theirs (70%). Moreover, the proportion of incomplete tetraplegia (75%) appears higher in our study than in the overall cervical TSCI population (50%) . This may be due to the fact that falls in elderly subject usually entail incomplete tetraplegia with centromedullary syndrome (67%), as has been underlined by Waters et al. .
As regards recovery prognostic indicators, earlier studies have underscored the importance of the initially complete or incomplete nature of the tetraplegia , particularly preservation of sensitivity to a pinprick below the lesion . In our series, three out of five patients with initial complete tetraplegia died. The risk of death is significantly higher in cases of complete tetraplegia but is not significantly associated with age ( p = 0.53). However, two patients who died during treatment were 77 and 82 years old (cases 11 and 14), a result suggesting that complete tetraplegia in an elderly population is a risk factor for mortality in the early post-traumatic phase.
Our results show that the main phase of neurological and functional recovery in incomplete tetraplegic patients takes place during the first six months: 76% for motor recovery, 98% for sensory recovery and 95% for functional recovery; our figures corroborate those reported in previous studies . Incomplete tetraplegic patients presenting with either a centromedullary syndrome of a Brown-Sequard syndrome would appear to have a better prognosis ; as regards our work, the limited number of subjects does not allow us to draw conclusions. After one year of follow-up, 69% of our patients could not wall or walk with technical assistance, 81% had partial or total grip weakness, and 69% suffered from urinary disorder that frequently necessitated urinary catheterization. According to the study by Waters et al. , 84% could not ambulate unassisted and 74% were subject to urinary disorders. Gripping difficulties were not studied by the author.
The possible neurological and functional benefits of decompression surgery and stabilization remain controversial . In our study, early surgery did not improve neurological and functional recovery, nor was it associated with fewer medical complications or shorter hospital stays. Moreover, the literature does not contain proofs warranting encouragement of routine early surgery in patients presenting TSCI associated with CSS but without vertebral fracture. In addition, potential perioperative complications need to be taken into account, particularly in an elderly population. Nor does the methodology employed in our study allow us to demonstrate the potential benefits of late or fairly late decompression surgery; only a long-term comparative study would be likely to conclusively show the interest of late surgery to prevent recurrence or neurological aggravation.
In our study, the most frequent complication was neuropathic pain, which was reported in 85% of the subjects, principally in the upper limbs (76%). Identification of the neuropathic pain remains a priority in early administration of suitable specific treatments . In fact, 90% of the patients developed spasticity in the upper and/or lower limbs necessitating a specific treatment. Dvorak reports that the development of spasticity exerts a negative influence on the functional evolution of patients with a post-traumatic centromedullary syndrome .
Our study is limited by the low number of subjects and the lack of a control group. It does not allow for any generalizing, particularly as regards identification of recovery prognostic indicators. It nonetheless pinpoints a few elements, especially with regard to the elderly population, which suggest a need for earlier and more specifically designed hospital care and rehabilitation. With this in mind, close attention should be paid to comorbidities, the cause of tetraplegia, mortality in cases of complete tetraplegia, the impact of surgery, and expected recovery.
1.5
Conclusion
Few studies have been devoted to post-traumatic medullary injuries associated with spinal stenosis. Our prospective study deals with the characteristics of and care for that population; it uses as supports the standardized and repeated neurological and functional assessments carried out during the first year following the trauma. Even though it is necessarily limited, our study suggests that an association of complete tetraplegia with advanced age provides a predictive factor for death in the early post-traumatic phase. As concerns incomplete tetraplegics, most of their neurological and functional recovery is observed over the course of the first six months. No argument advising early surgical intervention in this population will be found in our study.
1.6
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
2
Version française
2.1
Introduction
En 2000, l’incidence des traumatismes vertébromédullaires (TVM) en France est de 19,4 personnes de plus de 15 ans par million d’habitants, soit 934 nouveaux cas par an .
Le plus souvent associé à une fracture vertébrale, le TVM peut aussi entraîner une lésion médullaire sans atteinte osseuse, particulièrement lorsqu’un canal cervical étroit (CCE) préexiste . La moitié des personnes de plus de 50 ans et 75 % au-delà de 65 ans ont un canal cervical étroit, ce qui représente le facteur de risque le plus fréquent pour un traumatisme médullaire cervical dans la population adulte . Par ailleurs, la moelle cervicale est plus vulnérable car moins bien vascularisée, en particulier dans la population âgée.
Le CCE est classiquement défini par le Torg ratio, qui correspond, sur des radiographies standard de profil, au quotient entre le diamètre antéropostérieur du canal rachidien et le diamètre antéropostérieur du corps vertébral en son milieu . Un Torg ratio inférieur ou égal à 0,8 indique un canal cervical étroit, avec une sensibilité de 93 % . Le rapport médullocanalaire (RMC) utilisé par Berge et al. est défini à l’IRM en séquences T2 par le quotient entre le diamètre antéropostérieur de la moelle épinière mesuré au niveau du disque intervertébral et le diamètre antéropostérieur du canal vertébral mesuré à mi-hauteur du corps vertébral . Un RMC supérieur à 0,65 évoque un CCE .
Le tableau clinique le plus fréquent dans les TVM sur CCE, d’après l’étude de Pascal-Mousselard et al., est principalement une tétraplégie incomplète de type syndrome central de Kahn et Schneider (62 % des patients), avec nette prédominance des stades ASIA Impairment Scale (AIS) C (72,4 %) .
Il n’existe pas de consensus de prise en charge de cette population, en particulier concernant l’indication et le délai d’un traitement chirurgical à visée décompressive et stabilisatrice. À la phase aiguë, les indications les plus fréquentes sont la présence de signes d’instabilité clinique et/ou radiologique. Les critères classiquement retenus en faveur d’une intervention chirurgicale à distance sont une aggravation ou une stagnation d’un état neurologique après une phase d’amélioration .
Les études semblent montrer que le traitement conservateur et la chirurgie donnent les mêmes résultats fonctionnels à deux ans, mais il est possible que la chirurgie précoce permette une récupération plus rapide, avec des complications secondaires moindres .
Notre étude prospective est une analyse descriptive des mécanismes, de l’impact de la chirurgie, et de l’évolution clinique et fonctionnelle sur un an de patients tétraplégiques dans les suites d’une décompensation d’un CCE sans notion de fracture. Il s’agit en particulier de préciser la prise en charge, afin d’insister sur certaines spécificités des patients blessés médullaires, notamment selon leurs caractéristiques démographiques et lésionnelles.
2.2
Patients et méthode
Nous exposons une étude descriptive prospective, avec une période d’inclusion de 16 mois, et un suivi d’un an. Les critères d’inclusion sont un TVM avec tableau neurologique aigu, c’est-à-dire déficit moteur et/ou sensitif et/ou troubles vésicosphinctériens, et à l’imagerie d’une part l’absence de fracture vertébrale, et d’autre part un CCE défini par un Torg ratio < 0,8 et un RMC > 0,65 ( Fig. 1 ). Les critères d’exclusion sont l’absence de troubles neurologiques aigus, l’absence de canal cervical étroit, la présence de fracture(s) rachidienne(s) cervicale(s) et/ou d’autre(s) fracture(s) rachidienne(s) sans respect du mur postérieur.
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Erratum to contents of no. 10 published in December 2010
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