INTRODUCTION
7.6 magnitude earthquake on 8th of October 2005 at Pakistan resulted in 73,338 deaths and 128,304 injured patients [1]. There
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Correspondence: Lt Col Muhammad Asad Qureshi, Consultant Orthopedic Surgeon, Combined Military Hospital, Rawalpindi.
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There is very little data available in the world literature on the surgical management of spinal injuries in earthquake victims [2,3]. Theoretically if unstable spinal injuries are not stabilized early, it can lead to long term disastrous complications and adds to load of admitted patients in the already compromised state of hospital beds after major disaster. After surgical stabilization of these unstable injuries, these patients can be mobilized early and incidence of serious complications can be reduced, nursing care can be facilitated and many patients can be discharged out of acute hospital beds. At the same time it needs specialized training and aptitude to operate on the complex spinal injury cases to reduce the complication rate and produce good results.
Aim of present paper is to document the data for spinal injury operations performed on these earthquake victims and to analyze the results.
PATIENTS AND METHODS
This quasi-experimental study carried out at the Orthopaedic and Spinal Surgery department of Combined Military Hospital (CMH) Rawalpindi in collaboration with the two other major army hospitals at Rawalpindi: Military Hospital (MH) and Armed Forces Institute of Rehabilitation
Medicine (AFIRM). Spinal operations were performed at operation theatres of CMH and MH. Study started after earthquake on 8th Oct 2005 and ended in Aug 2006.
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Table-1: Rank of patients (n=110).
Table-2: Cities of patients (n=110)>
Table-3: Diagnosis of patients (n=120).
Table-4: Region of spine involved (n=120).
Table-5: Asia impairment scale (Ais) (n=120)
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120 major spinal surgical operations were performed on 110 spinal injury patients out of over 250 spinal injury admissions at CMH, MH and AFIRM. 12 patients were received form other units for revision surgery, where primary surgery had failed. Rest of the patients was primary admissions in our unit.
Spinal injures were classified according to the Denis’s Classification system into four major categories [4]:
Compression fractures, burst fractures, seat-belt-type injuries, and fracture dislocations.
Neurological deficit was classified according to American Spinal Injuries Association (ASIA) impairment scale (AIS) into [5]:
Complete, sensory only, up to grade 3/5 power, power grade 4/5 and complete neurological recovery.
OUTCOME MEASURES
Four outcome measures were defined:
Correction of deformity in percentage: excellent > 75% post-operative correction of deformity, good 50-75% post-operative correction of deformity, fair 25-50% post-operative correction of deformity and poor < 25% post-operative correction of deformity. Back pain: mild easily ignorable pain, moderate pain controlled with occasional medication, severe pain requiring continuous medication and excruciating pain not controllable with any measures. Mobilization status of patient: bed, wheel chair assisted, wheel chair independent, walking assisted and walking independent. Change in AIS after surgery on last follow up.
After surgery and stabilization of general condition of patient, in few days time, most of the patients were transferred to AFIRM for rehabilitation. At times there was full bed
occupancy at AFIRM, leading to hold up of post-op cases at CMH and MH Rawalpindi.
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Table-6: Associated conditions (n=26).
Table-7: Types of operations (n=120).
Table-8: Implants used (n=105).
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STATISTICAL ANALYSIS
Record of all patients was kept in a custom built Microsoft Access Database, by the Spinal Surgeon. Data was analyzed using SPSS ver-10.0. Percentages were used to describe the data. Pearson Chi-Square test was applied to calculate the ‘p’ value for comparison of pre-op and post-op condition of patients.
RESULTS
120 major spinal surgical operations were performed on 110 spinal injury patients. 12 patients were received form other units for revision surgery, where primary surgery had failed. Rest of the patients was primary admissions in our units.
75% patients were civilians and 25% were army personnel and their families (table:1). Most of the patients were from districts Muzafarrabad and Bagh (table:2). Average age was 28 years, range 8-65 years (fig: 1). 56% (62) patients were females and 44% (48) were males. Most of the operations were performed during first ten weeks after earthquake (Fig:3).
Most common injury was fracture dislocation (57%) followed by burst fracture (30%) (table: 3). 55% injuries involved thoraco-lumbar junction (table: 4).
46% Patients had complete neurological deficit (AIS – A) while 54% had incomplete deficits (AIS – B, C, D, E) (table: 5). Most common associated injuries were fractures of tibia and fibula (table: 6).
Most commonly performed operation was open reduction of fractures followed by Pedicle Screw Fixation and bone grafting (fig: 4). As time passed by many injuries became fixed deformities necessitating complex operations like osteotomies and corpectomies (fig: 5, 6). Cervical spine injuries were quite rare in our series, probably most of the patients died at the spot and could not be evacuated after earthquake. Anterior Cervical spine Plating was done in one patient (fig: 7).
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Table-9: Re-Operations (n=10).
Table-10: Complications (n=38).
 Fig. 1: Age distribution of patients.
 Fig. 2: Sex distribution of patients.
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 Fig. 3: Weekly operations.
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Few patients required removal of spinal implants and various other type of spinal operations (table: 7). CD Horizon M8 pedicle screw and hook system (Medtronic, Sofamor Danek), MOSS Miami pedicle screw and hook system (DePuy, Johnson & Johnson) and Universal Spine System (Synthes) were the most common implant systems used in our surgeries (table: 8).
Only 34 spinal operations could be performed during first three weeks after earthquake (fig: 3) leading to start of formation of fixed spinal deformities in remaining patients. This led to more complex operations, requiring more time to perform, after first three weeks of injury. This was in part due to too many patients and too few people who could perform spinal surgeries. Later on many surgeries in fixed deformity patients were delayed due to formation of pressure sores or other complications due to prolonged bed rest. These patients were operated after healing of pressure sores or other infected foci. 12 cases were referred from other hospitals and units for re-do surgeries (table: 9).
Excellent (>75%) or good (50-75%) correction of deformity was achieved in 90% (107/120) of operations (fig: 9) this was calculated by measuring kyphotic angles and translations on pre-op and post-op x-rays. Correction of deformity was calculated relative to pre-op deformity in each patient individually.
92% patients had no or mild pain which could be easily ignored (fig: 10). This was
compared with pre-op severe pain in all patients.
 Fig. 4: Open reduction and short segment pedicle screw fixation of a burst fracture.
 Fig. 5: Corpectomy of a thoraco-lumbar burst fracture and anterior cage and screw rod fixation.
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At last follow-up 46% patients were walking independently and 51% were using wheel chair independently (fig: 11). Prior to surgery all patients were in bed.
Neurological improvement was analyzed using Pearson Chi-Square test and a highly significant improvement was noted (fig: 8): (p value < 0.001). Overall 45 patients showed 69 AIS improvements (1.5 AIS improvement per patient). Four patients had neurological deterioration to one level downwards.
There was one post operative death. This was in a patient with cervical spine injury who had associated chest injury. He was on ventilatory support and had severe chest infection, leading to ARDS and death. Other complications included pressure sores, neurogenic pains, wound infections, etc. (table: 10).
DISCUSSION
Surgical management of unstable spinal injuries is considered to be a superior method of treatment as compared to conservative method [6]. This has been proved in our series of cases as well. If we did not operate on these patients, they would have occupied our acute beds and would have hampered admission of other acute cases.
Method of fixation of unstable spinal fractures has also improved remarkably over the last few decades [7]. Modern gold standard fixation method for unstable thoraco-lumbar spinal injuries is pedicle screw fixation [8]. This gives three column fixation and very good hold to achieve and maintain surgical correction. It has been shown that short segment fixation (one level above and below) has comparable results to long segment fixation in most of the cases. However, if complex deformities are reduced than at least two segments above and below should be stabilized [9]. This has held true in our series as well.
In some thoraco-lumbar burst fractures, if surgery is delayed more than two weeks, or in acute burst fractures which have torn posterior longitudinal ligament, it is not possible to reduce them posteriorly by ligamento-taxis. These cases require corpectomy and anterior decompression and fixation. However if there is persistent
instability after anterior fixation, posterior fixation may be added, as a second stage procedure at same time or later on depending on circumstances. In burst fractures where only posterior surgery is contemplated and a large defect results in anterior column after posterior fixation, anterior augmentation with bone graft is required as well [10].
 Fig. 6: Posterior total vertebrectomy in a malunited thoracic dislocation. reconstruction with long segment pedicle screw fixation.
 Fig. 7: Anterior cervical spine plating for a facet dislocation with disc prolapse.
 Fig. 8: Change in AIS after.
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In cervical spine burst fractures, primary anterior surgery, by doing corpectomy and plate reconstruction is a gold standard procedure [11]. For pure dislocations of cervical spine without disc prolapse posterior surgery by lateral mass plating is biomechanially a superior procedure as compared to inster-spinous wiring [12]. If there is a disc prolapse in addition to a dislocation than anterior surgery should be performed first (discectomy, bone grafting and plating). If this stabilizes spine adequately posterior surgery may be omitted, however if good stability is not achieved than lateral mass plating should be added posteriorly [13].
Regarding timing of surgery after spinal injury; it has been shown that early surgery carries good results [14]. This is true in ideal circumstances. In our setup there are very few people who can do this type of surgery and after a major disaster it is not possible to operate on all the patients at the same time. This shows the needs for development of the specialty of Spinal Surgery in our country. Further more after surgery these patients need rehabilitation. If there are no facilities for rehabilitation than continuum of care can not be established and surgery should not be performed [15]. This also highlights the association between spinal surgery and rehabilitation and need for development of specialty of rehabilitation medicine in our set up.
There is sparse data in world literature on spinal injury patients after earthquake. Present earthquake resulted in more than 600 spinal injuries. Maximum number of spinal injuries reported in literature prior to this was 140 spinal fractures in 1995 Great Hanshin Earthquake of the Kobe-Osaka area of Japan [16].
Chen [17] reports 86% correction of post traumatic kyphosis, in our cases 90% patients had excellent or good correction of pre-op deformity. Olumide [18] showed overall 0.72
Frankel grade improvement in in-complete deficit patients, while Nadeem [19] showed 0.9 Frankel grade improvement per patient in a study of 79 patients. Our study has shown 1.5 AIS (equivalent to Frankel grade) improvement per patient. It is important to note that in study of Nadeem 58% patients were in Frankel grade A while in our series only 46% patients were in AIS-A.
 Fig. 9: Correction of deformity.
 Fig. 10: Pain on last followup.
 Fig. 11: Mobility on last followup.
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CONCLUSION
Spinal stabilization should be carried out early in cases of unstable spinal trauma by well trained personnel and in a setup where facilities for proper rehabilitation are available post-operatively. This has given better results in a major disaster like 8th October 2005 earthquake as well as peace.