4.10. DISCUSSION ON BONE HEALING
Bone healing is the goal of treatment, bone healing is also the standard for evaluating treatment results. Because bone fusion devices only create temporary stability, the device cannot withstand force forever. On the contrary, bone healing creates long-term stability, avoids secondary displacement, avoids further nerve damage and avoids chronic neck pain. In this study, bone healing results were evaluated according to the Bridwell classification (mentioned in section 2.2.8.3).
The results of bone healing variables recorded at 3 - 6 months included: bone healing level I was 4.4%, bone healing level II was 95.6%. Bone healing results at the final examination: bone healing level I was 82%, bone healing level II was 18% . Thus, the bone healing rate was 100% (Chart 3.17 in chapter 3), with no cases of pseudoarthrosis.
The bone union rate of the improved Bohlman procedure was 100%, which was equal to the bone union rate of the Bohlman procedure [13].
Comparing the bone union rate with other surgical methods, the bone union rate of the modified Bohlman surgery has equal results. For example, Omar [92] with 52 patients with low CSC dislocation fractures, combined with the spinous process bone with steel thread and Kirschner needle, the bone union result was 100%. Bohlman [41] in a study of 300 patients with 229 patients reported the results: 100% bone union for 62 non-paralyzed cases, and 99.98% for 167 paralyzed patients. Roger [103] had 96% bone union. Mc.Afee
[85] reported 60 patients with posterior fusion, 100% bone union. Anderson [28] reported 30 patients with posterior fusion, 100% bone union.
Figure 3.19 (Chapter 3 - Bone healing progression) shows that: at 3 - 6 months after surgery, 4.4% of patients had level I bone healing and the remaining 95.6% of patients had level II bone healing. Meanwhile, at the last follow-up visit, level I bone healing was 82%, level II bone healing was 18%. Thus, the level I bone healing rate at the two follow-up visits: 3 - 6 months after surgery and at the last follow-up visit was completely different and this difference was statistically significant (p < 0.01).
4.11. CHRONIC NECK PAIN PROBLEM
Chronic neck pain is not as dangerous as a prosthetic joint, but it makes the patient uncomfortable, irritable, depressed, and mentally stagnant. Patients have to take medication for a long time and of course their quality of life is poor.
Chronic neck pain indicates CSC instability or damage to the C2 - C3 - C4 radicular branches , or more rarely, arachnoiditis [43], [51], [105]. Chronic neck pain usually subsides and disappears as the bones heal.
10
4
6
8
We assessed pain status using the VAS visual acuity scale [80], [84], (refer to section 2.3.9.3), recorded at the following times: before surgery, after surgery, 3 - 6 months after surgery, and the final visit after 6 months (Chart 4.23).
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Figure 4.23: Average pain score of patients over time
Before surgery, the study sample had an average pain score of 6.1 ± 1.3. After surgery, this value decreased to 0.6 ± 1.0 points and continued to decrease to 0.1 ± 0.4 points at the final visit. The differences between the above values were all statistically significant (p < 0.01).
Thus, in the study group of 66 patients, with an average follow-up time of 30 months, before surgery, patients had a lot of pain (VAS = 6.1 ± 1.3). After surgery, the pain condition improved.
Significant improvement (VAS = 0.6 ± 1.0), gradually in subsequent follow-up visits, the patient's pain was completely gone (VAS = 0.1 ± 0.4).
Compared with the previous study, author VVSi applied Bohlman surgery to treat 38 patients with CSC C3-C7 fractures. The study results showed that 3 patients had chronic neck pain, accounting for 8%. Thus, in terms of chronic neck pain, the modified Bohlman surgery was better than the Bohlman surgery. This difference was statistically significant (P = 0.02).
In the study of 52 cases of low CSC fractures treated with surgical compression of steel sutures and Kirschner needles of the spinous process by Omar, there were no cases of chronic neck pain. In addition, with the results of the study of 25 patients who underwent Norton posterior fusion surgery, there were no cases of chronic neck pain [91]. Thus, the problem of chronic neck pain in our study is similar to the research results of some foreign authors (studies by domestic authors did not mention this issue).
4.12. SURGERY TIME
The surgical time is calculated from the time the skin is incised until the skin is closed. This is a criterion to assess the relative complexity of the surgery, because this criterion is also affected by the skill, cooperation in the team, equipment and instruments, etc. Indeed, while conducting this study, we found that the later the surgeries, the shorter the surgical time (Table 4.34).
Table 4.34: Surgical time (from skin incision to completion of skin suture).
Time (minutes)
75' 80' 90' 105' 120' | |
Frequency | 2 15 29 16 4 |
Total | 66 patients |
+ Fastest surgery is 1 hour 15 minutes: 02 patients
+ Longest surgery was 120 minutes: 04 patients
Average surgery time: 92.7 minutes (75-120 minutes)
In the specialized thesis II (2000) of the same author VVSi [13], 38 cases of CSC C3-C7 dislocation and fracture were studied and treated by the Bohlman method. The average surgical time was 107 minutes (75-165 minutes). When compared with the average surgical time of the modified Bohlman surgery, there was a statistically significant difference (p < 0.01).
In the 2005 CKII thesis, author Truong Thiet Dung studied 86 cases of low CSC fractures. The author performed anterior surgery and screw placement on the vertebral body in 18 cases, with an average surgical time of 116.50 minutes (80 - 180 minutes). Posterior surgery and lateral mass screw placement on 68 cases, with an average surgical time of 115.15 minutes (60 - 180 minutes).
The average operative time in our study and the average operative time in the study of author Truong Thiet Dung (presented in chart 4.24) have a statistically significant difference. Specifically: P = 0.0002 compared with lateral mass screw fixation, P = 0.0004 compared with anterior vertebral body screw fixation.
140'
120'
107
115
116
100'
92
80'
60'
40'
20'
0'
Improved Bohlman
Bohlman
anterior splint
average surgery time
Figure 4.24: Comparison of average surgical time of 4 surgical methods:
- Improved Bohlman: 92 minutes.
- Bohlman: 107 minutes.
- Joint plate and screw: 115 minutes.
- Vertebral body screw-plate: 116 minutes.
4.13. AMOUNT OF BLOOD LOSS
Blood loss was not the objective of the study, but it reflects the complexity of the surgery. In our study group, the average blood loss per surgery was 170 (100-300 ml). No case required blood transfusion. This also reflects the simplicity of the surgery.
Compared with the amount of blood loss in Bohlman surgery of VV Si (2000) [14], the average amount of blood loss in Bohlman surgery was 197ml. This difference was statistically significant with P < 0.02.
In the study of TT Dung, the author performed posterior surgery on 68 cases and none of them required blood transfusion [6].
4.14. COMPLICATIONS
Many authors agree that the posterior approach is safer, especially the combination of the spinous process is the safest [26], [46]. The reason is that there are no important organs in the back of the neck. Moreover, the steel thread only penetrates the spinous process base bone outside the spinal canal.
In general, complications can be divided into 3 types: technical complications (due to the surgeon), complications due to surgical method, and complications due to the nature of the disease.
Table 3.23 (chapter 3) shows that the group of complications due to technique or surgeon includes: surgical site infection, dural tear, wrong site surgery (this group is very rare nowadays, not mentioned much in medical literature). Only surgical site infection accounts for a rate of 0% - 2.9% depending on the author. The infection in our study was 3% (2/66 patients).
The infection rate in the modified Bohlman procedure was 3% and the infection rate in the Bohlman procedure was 10.5%. Thus, the modified Bohlman had more than 3 times less infection.
Compared with other authors, Anderson PA [28] with 30 patients who underwent posterior fusion and bone fixation with AO plate reported an infection rate of 3.33% (1/30). Gordon J. Petrie [68] performed posterior bone fixation for 105 patients with CSC fractures, the rate
Infection rate 2.9% (3/105). Author Nguyen Thiet Dung [6] with 2 research groups including 18 cases of anterior surgery with bone grafting and interbody fusion had an infection rate of 5.55%. In 68 cases of posterior surgery with lateral mass screw, there was also 1 case of infection, the rate was 1.47%. Other authors such as Bohlman, Omar reported an infection rate of 0%.
Thus, the infection rate in the modified Bohlman procedure is acceptable.
Regarding dural tear and wrong site surgery complications, there were none in our study group, but in the Bohlman surgery study there was 1 case of dural tear and 1 case of wrong site surgery.
Group of complications due to surgical methods, including:
- Suture rupture: in the improved Bohlman surgery, there was no case of suture rupture. However, in the Bohlman surgery, we encountered 1 case of suture rupture and 2 cases of suture expansion, causing 2 out of 3 patients to have secondary displacement, but no nerve damage and good bone healing.
Compared with other authors: Roger reported 50 cases with 3 cases of suture rupture and 1 case of displacement; Bohlman also had 2 cases of suture rupture; meanwhile, Omar and Whitehill did not.
- Neck muscle atrophy: there were two cases of neck muscle atrophy (Patient No. 52: Nguyen Thi Kim Y. and Patient No. 55: Truong Van Th.). These two patients were paralyzed and did not practice neck exercises as instructed. They were found to have atrophied neck muscles on both sides 3 months after surgery. The patients were instructed to practice seriously. At the next follow-up visit (6 months after surgery), they showed very good recovery. The two muscle groups grew larger, forming a groove between them, and the movements of bending, extending, rotating, and tilting were almost normal, without neck pain.
There were no cases of chronic neck pain in the study group, which contributes to the effectiveness of the treatment.
- Severe paralysis after surgery, the case of severe paralysis after surgery of patient Truong Van Th. (this case is discussed in illustrative case number 4).
Complications of spinal cord injury are complications due to paralysis and prolonged lying down, these complications are very common. This is also the cause of the patient's gradual wasting leading to death. Limiting this complication is relatively difficult, because it requires a coordinated effort between medical staff, patients and their families to regularly exercise the patient according to a pre-existing exercise program.
- Regarding mortality: there were no cases in this study. Compared with 38 patients who underwent Bohlman surgery in 2000, there was 1 case of death due to respiratory failure and gastrointestinal bleeding.
Research results of Nguyen Thiet Dung in 2005 at the Department of Neurosurgery, Cho Ray Hospital [6], there were 2 patients who died, accounting for 2.32%.
Le Ngoc Dung [5], Department of Neurosurgery, Da Nang Hospital (1980-1990), treated 37 patients with CSC injuries. Of which, Roy-Camille surgery was performed on 2 patients, resulting in 1 patient's death.
Ha Kim Trung [21], Department of Surgery, Hanoi Medical University (1996), operated on 6 patients with low CSC fractures, 3 patients recovered, no deaths.
Daniel R. Ripa [55] treated 92 patients with CSC injuries using anterior decompression-bone grafting-plate and screws.
Results: 04 deaths (mortality rate: 4.34%):
_ 01 patient died of gastrointestinal bleeding.
_ 03 patients died of respiratory failure.
Bohlman [40] had 37 quadriplegic patients treated with Corticosteroids, 17 of whom died due to gastrointestinal bleeding. For quadriplegic patients, there is often a condition of increased gastric secretion, decreased gastric contractions, and intestinal paralysis causing stasis. These causes cause gastrointestinal bleeding in 9% [98].
Comment: In the study of mortality complications, few authors mentioned the cause of death, most authors only mentioned the mortality rate. Therefore, it is difficult to discuss mortality. However, with the research results in our specialized thesis II and the results of Daniel R. Ripa (1991), of Bohlman (1979), we temporarily conclude
It is concluded that fatal complications in low CSC trauma are mostly due to respiratory failure and/or gastrointestinal bleeding.
4.15. COST OF BONE FUSION FOR PT. BOHLMAN IMPROVED
The improved Bohlman surgery uses only one steel thread to KHX the spinous process and fix the graft bone. The 0.6 or 0.7mm thread costs 100,000 VND. Meanwhile, if using 1 plate + 4 screws + 1 cage for anterior surgery, it will cost up to 16,500,000 VND. Or posterior surgery with 2 vertical bars + 2 lateral screws will also cost up to 15,500,000 VND.
Thus, Bohlman's improvement will save over 15,000,000 VND for each surgical case.