Ischemické poškození míchy následkem tupého poranění hrudníku – kazuistika

Souhrn

Autoři prezentují kazuistiku pacienta, který utrpěl tupé poranění hrudníku. V klinickém obraze dominovala paraplegie dolních končetin. Vzhledem k oslabenému dýchání na pravé straně byla okamžitě provedena hrudní drenáž. Pro známky oběhové nestability a jednorázový odpad krve z hrudního drénu byla indikována urgentní torakotomie bez dalších vyšetření jako CT či MRI. Zdrojem krvácení do pravé pohrudniční dutiny byla ruptura Adamkiewiczovy arterie, která byla ošetřena. Pooperačně provedené CT a MRI potvrdily míšní ischemii jako následek poranění.

Klíčová slova:
tupé poranění hrudníku – Adamkiewiczova arterie – míšní ischemie

_INTRODUCTION

Ischemic affection of spinal cord after the blunt chest trauma is a rare complication. We present a case report of a young man referred to traumacentrum of University Hospital in Hradec Kralove after accident during motocross race. He was unstable and urgent operation was needed. The cause of spinal cord ischemia and resulting paraplegia of both the lower extremities was ruptured artery of Adamkiewicz.

A young man crashed during the motocross race, in a high speed he left the coarse and collided with a tree by his back. Call for the Urgent medical help was sent at 16.35 h. Patient was conscious, GCS 15, and in the clinical picture paraplegia of the lower extremities dominated. The volume resuscitation had been started. 1000 ml of crystaloids and a bolus of Solumedrol 3 g i.v. were given. Patient was transported in the whole body vacuum mattress to the Traumacentre of the University Hospital in Hradec Kralove, Czech Republic. During the transport the patient’s circulation was stabile and he ventilated spontaneously. When admitted in 17.15 h the patient was still conscious, but circulation started to malfunction – blood pressure was gradually falling 100/80... 87/65, pulse rate 78/min., 02 saturation 85%.

During the clinical investigation we found markedly weakened breathing on the right side, lower extremities paraplegia with anaesthesia from the umbilicus caudally and hypotonia of the anal sphincter. In the local anaesthesia we introduced the chest drain via the right 5^th intercostal space in the medioaxillar line. It evacuated about 300 ml of blood. Drain was then connected with an active suction. In few following minutes another 800–900 ml of blood was drained away and patient still suffered from the circulation instability. During the emergency admission we performed ultrasound investigation of cavities with the confirmed presence of fluid in the right hemithorax and negative finding in the abdomen. The urinary catheter and nasogastric tube were introduced. We went on with the corticoids therapy, with volume resuscitation by crystaloids (2000 ml), and then we administered 2 units of erytrocyte concentrates 0 negative. Due to the clinical conditions after the thoracosurgeon had been consulted, we indicated the operation revision even without the CT investigation of spine, which would have represented the time delay. Before the operation was started (about 30 minutes after having been admitted) the total blood loss via the drain had reached about 1500 ml. During the operation other 1000 ml of blood was found in the right pleural cavity and the bleeding intercostal artery in the region of 9^th right rib broken at the paravertebral line. The bleeding was stopped by clips application. Because of a big paravertebral haematoma we also checked the anterior portion of vertebrae Th9 and Th10. As the principal source of bleeding there was found the vertebral artery, which was severed close to the branching from aorta. Bleeding was taken care of by clips and a stitch. After the operation the patient was sent to the ICU, where further supplementation of intravascular volume and arteficial ventilation went on.

The next day the patient was extubated and both CT and MR of spine were performed. The CT investigation revealed non-dislocated fracture of the 10^th rib paravertebrally and fractures of spinous prominences of vertebrae Th9 and Th10. The MRI did not prove any injury of intervertebral joints, discs or spinal duct deformity. STIR investigation and T2 sequence on the level of Th9 and Th10 showed a picture of spinal cord ischemia. Consulted neurosurgeon concluded that the ischemia of the spinal cord had been caused most probably by an injury of Adamkiewicz’s artery and recommended a conservative treatment. Corticoids and vitamin B12 were given, rehabilitation executed.

For the whole remaining period of time the patient was stabile and on the 12^th day he was transferred to the special spinal unit in Liberec, Czech Republic.

_DISCUSSION

Ischemic affection of spinal cord after the blunt chest trauma is a rare complication. In blunt cervical spine injuries we may meet the traumas of vertebral arteries, namely in cases of fasets dislocations or transforaminal fractures. The flexion-distraction type of movement is the most common mechanism. Frequency of these vascular complications varies from 20 up to 75% [1, 2, 3]. Neurological consequencies of such injuries are rather rare, mostly being visus disorders, dysfagia, tinitus but even the death may appear. In blunt chest traumas we can also find an injury of aorta. Fabian [4] prospectively documented in his multicentre study 274 patients with the blunt trauma of aorta. In 81% of cases they were the victims of the car crashes. Mortality reached 31% and complication rate (paraplegia) as a result of ischemic changes was 8.7%.

Their most common origin consists in iatrogenic injuries during the operations of thoraco-abdominal aorta. Paraparesis and paraplegia vary from 0.2% in the planned operations of abdominal aorta up to 40% in acute operations of the chest aorta [5, 6]. As the anatomical reason of ischemic changes there is considered to be the injury of a. radicularis anterior – Adamkiewicz artery (AA). This vessel has been named after the famous Polish pathologist Albert Adamkiewicz who was taken for a pioneer in the field of the spinal cord vascular supply. In 75% this AA branches from the lumbal or intercostal artery between the vertebras Th9 and Th12 on the left side [7]. At present the perioperative detection of AA (most frequently by MRI or angiography) became a standard procedure in the chest aorta operations, together with following of evoked potentials, drainage of cerebrospinal fluid and corticoids dosing.

In literature we found only one reference to the traumatic affection of AA [8]. In that case there was a man who underwent multiple stub wounds in the region of the back. Diagnosis was set by MRI. In this case of ours the vessel injury was revealed already during the operation, which was indicated because of the circulation instability, that means even prior to CT or MRI investigations. MRI investigation performed postoperatively in stabilized patient foreclosed traumatic changes of spinal duct and confirmed the ischemia.

Publishing this case report we would like to point out the proceeding according to the ATLS principles, which proved to be correct. The patients’ life was endangered by bleeding into the chest cavity and thus the urgent thoracotomy prior to the complete investigation of the suspected injury of spinal cord was justified thanks to the circulating instability of the patient and to the losses via chest drain. The delay in transport and spine CT would have threatened the patient with death. The treatment of the ischemic afflictions of the spinal cord is conservative one, prognosis far from being warranted.

MUDr. P. Lochman

Dolní 452

765 02 Otrokovice

e-mail: lochmpet@seznam.cz