Although methods for diagnosing and providing assistance for injuries of the spine and spinal cord were given back in the Egyptian papyri and the works of Hippocrates, for a long time spinal injury with neurological disorders was considered practically a death sentence. Back in the First World War, 80% of those wounded in the spine died within the first 2 weeks. Progress in the treatment of spinal cord injury (SCI), based on an improved understanding of its pathogenesis and the development of radically new treatment methods, began only during the Second World War and in the post-war years. Today, SCI remains a serious, but usually not fatal, type of injury, and a significant contribution to minimizing its consequences is made by timely and adequate provision of first, qualified and specialized medical care to the victims.
Traumatic injuries of the spine and spinal cord are much less common than TBI. In adults, the incidence of STS is 5 per 100 thousand population per year, in children it is even lower (less than 1 per 100 thousand population per year), but in children STS is more often associated with polytrauma and is more severe, with a worse prognosis. In Russia, approximately 80% of victims are men under 30 years of age. Since today the majority of victims even with severe STS survive, the number of people with the consequences of STS in the population of developed countries is approximately 90 per 100 thousand population (for Russia today this is approximately 130 thousand people, of which 13 thousand are with paraplegia or tetraplegia) . The social significance of the problem is difficult to overestimate.
The main cause of SMT is road traffic accidents (50% of cases). This is followed by sports injuries and those associated with active recreation (25%, of which 2/3 are injuries to the cervical spine and spinal cord received while diving in a shallow place). Approximately 10% are industrial injuries and those received as a result of illegal actions, and 5% are received from a fall from a height, in natural disasters, etc.
Most often the cervical spine is damaged (55%), less often - the thoracic (30%), even less often - the lumbosacral
Damage to the spinal cord and its roots occurs in approximately 20% of cases of SCI. Such injuries are called complicated.
Damage level(defeats) spinal cord assessed by the lower segment, in the dermatome of which sensitivity and at least minimal voluntary movements are preserved. Often, but not always, this level corresponds to the established level of spinal injury. When assessing the level of spinal cord damage, one should not rely on pathological reflexes (Babinsky, Rossolimo, Oppenheim, defensive and synkinesis); their reflex arc may pass below the level of complete spinal cord damage.
Highlight complete And incomplete spinal cord injury. With complete damage (group A on the Frankel scale, Table 12.1), there is no sensitivity and voluntary movements below the level of the lesion. Usually in such a situation the spinal cord is anatomically destroyed. With incomplete damage (groups B, C, D on the Frankel scale), disturbances in sensitivity and movement are expressed to a greater or lesser extent; group E corresponds to the norm.
Injuries to the spine and spinal cord are divided into open, in which the integrity of the skin and underlying soft tissues is compromised, and closed, in which these damages are absent. In peacetime, closed
Table 12.1. Spinal Cord Disability Rating Scale (Frankel)
Complete defeat | No voluntary movement or sensation below the level of the lesion |
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Only sensitivity is preserved | Below the level of the lesion there are no voluntary movements, sensitivity is preserved |
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Movements intact but non-functional | Below the level of the lesion there are voluntary movements, but without useful function. Sensitivity may or may not be preserved. |
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Movements are intact and functional | Useful voluntary movements below the level of the lesion are functional. Various sensitivity disorders |
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Normal motor function | Movements and sensitivity below the level of the lesion are preserved, pathological reflexes are possible |
Closed injuries of the spine and spinal cord
Spinal injuries. Closed spinal injuries occur under the influence of excessive flexion, extension, rotation and axial compression. In many cases, a combination of these mechanisms is observed (for example, with the so-called whiplash injury of the cervical spine, when flexion of the spine is followed by its extension).
As a result of the influence of these mechanical forces, various changes in the spine are possible:
Sprain and rupture of ligaments;
Damage to intervertebral discs;
Subluxations and dislocations of the vertebrae;
Vertebral fractures;
Fracture-dislocations.
The following types of vertebral fractures are distinguished:
Fractures of vertebral bodies (compression, comminuted, explosive);
Fractures of the posterior half ring;
Combined with simultaneous fracture of the bodies, arches, articular and transverse processes;
Isolated fractures of the transverse and spinous processes.
It is of fundamental importance to classify spinal injury as stable or unstable. The stability of the spine is understood as the ability of its structures to limit their mutual displacement so that under physiological loads it does not lead to damage or irritation of the spinal cord and its roots. Unstable spinal injuries are usually associated with rupture of ligaments, fibrous ring, multiple destruction of bone structures and are fraught with additional trauma to the spinal cord even with minor movements in the affected segment.
It is easier to understand the causes of spinal instability if we turn to the concept of Denis (Fig. 12.1), who identifies 3 support systems (pillars) of the spine: front the supporting complex (pillar) includes the anterior longitudinal ligament and anterior segment of the vertebral body; average the column unites the posterior longitudinal ligament and the posterior segment of the vertebral body; rear column - articular processes, arches with yellow ligaments and spinous processes with their ligamentous apparatus. Violation of the integrity of two of the mentioned supporting complexes (pillars), as a rule, leads to instability of the spine.
Rice. 12.1. Denis’s diagram: the anterior, middle and posterior supporting complexes (pillars) of the spine are highlighted; instability of the spinal segment develops when two of them are affected in any combination
Spinal cord injuries. Based on the type of spinal cord injury, it is classified as concussion, bruise, compression And violation of anatomical integrity(partial or complete rupture of the spinal cord); often these mechanisms are combined (for example, a bruise with vascular rupture and hemorrhage - hematomyelia, causing direct damage to the axons and cells of the spinal cord). The most severe form of local damage to the spinal cord is its complete anatomical break with diastasis of the ends at the site of damage.
The degree of damage to the spinal cord and its roots is of primary importance for the fate of the patient. This damage can occur both at the time of injury (which is incurable) and in the subsequent period, when prevention of secondary spinal cord injuries is potentially possible.
Currently, there are no methods to restore the function of anatomically damaged neurons and cells of the spinal cord. The goal of treating STS is to minimize secondary damage to the spinal cord and ensure optimal conditions to restore neurons and axons that find themselves in the zone of impaired blood supply - the “ischemic penumbra”.
A frequent and dangerous consequence of spinal cord injury is edema, caused both by an increase in tissue osmotic pressure during the destruction of cell membranes, and by disturbances in venous outflow due to compression of the spinal veins (hematomas, bone fragments, etc.) and their thrombosis. An increase in the volume of the spinal cord as a result of edema leads to an increase in local hypertension and a decrease in perfusion pressure, which, according to the principle of a vicious circle, leads to a further increase in edema, ischemia and can lead to irreversible damage to the entire diameter of the spinal cord.
In addition to the above morphological changes Functional disorders caused by disturbances at the cellular level are also possible. Such spinal cord dysfunctions regress, as a rule, within the first 24 hours after injury.
Clinical picture of spinal injury. The main manifestation of a spinal fracture is local pain, which increases significantly with load (standing up, bending and even turning in bed). Spinal damage may also be indicated by:
Abrasions and hematomas;
Swelling and local tenderness of soft tissues in the paravertebral region;
Pain on palpation of the spinous processes;
Different distances between the apices of the spinous processes, displacement of one or more of them anteriorly, posteriorly or to the side from the midline;
Angular change in the spinal axis (traumatic scoliosis, kyphosis or lordosis).
With a fracture of the lower thoracic and lumbar spine, even without damage to the spinal cord, intestinal paresis may develop due to a retroperitoneal hematoma (compressing the vessels and nerves of the mesentery).
Clinical picture of spinal cord damage in spinal injury
The clinical symptoms of a complicated spinal fracture are determined by a number of reasons, primarily the level and degree of damage to the spinal cord.
There are syndromes of complete and partial transverse spinal cord lesions.
At complete transverse spinal cord syndrome down from the level of the lesion, all voluntary movements are absent, flaccid paralysis is observed, deep and cutaneous reflexes are not evoked, all types of sensitivity are absent, control over the functions of the pelvic organs is lost (involuntary urination, defecation disorders, priapism); autonomic innervation suffers (sweating and temperature regulation are impaired). Over time, flaccid muscle paralysis can be replaced by spasticity, hyperreflexia, and automatisms in the functions of the pelvic organs are often formed.
Peculiarities clinical manifestations Spinal cord injuries depend on the level of injury. If the upper cervical part of the spinal cord is damaged (C I-IV at the level of the I-IV cervical vertebrae), tetraparesis or spastic tetraplegia develops with the loss of all types of sensitivity from the corresponding level. If there is concomitant damage to the brain stem, bulbar disorders (dysphagia, aphonia, respiratory and cardiovascular disorders) appear.
Damage to the cervical enlargement of the spinal cord (C V -Th I at the level of the V-VII cervical vertebrae) leads to peripheral paraparesis of the upper extremities and spastic paraplegia of the lower extremities. Conduction disorders of all types of sensitivity occur below the level of the lesion. There may be radicular pain in the arms. Damage to the ciliospinal center causes the appearance of Horner's symptom, decreased blood pressure, and slowed pulse.
Injury to the thoracic part of the spinal cord (Th II-XII at the level of I-IX thoracic vertebrae) leads to lower spastic paraplegia with the absence of all types of sensitivity, loss of abdominal reflexes: upper (Th VII-VIII), middle (Th IX-X) and lower (Th XI-XII).
If the lumbar thickening (L I S II at the level of the X-XII thoracic and I lumbar vertebrae) is damaged, peripheral paralysis occurs lower limbs, anesthesia of the perineum and legs down from the inguinal (pupart) ligament, the cremasteric reflex falls out.
In case of injury to the conus of the spinal cord (S III-V at the level of the I-II lumbar vertebrae), there is a “saddle-shaped” anesthesia in the perineal area.
Damage to the cauda equina is characterized by peripheral paralysis of the lower extremities, anesthesia of all types in the perineum and legs, and sharp radicular pain in them.
Spinal cord injuries at all levels are accompanied by disorders of urination, defecation and sexual function. With transverse damage to the spinal cord in the cervical and thoracic parts, dysfunction of the pelvic organs appears, such as the “hyper-reflex neurogenic bladder” syndrome. At first after the injury, urinary retention occurs, which can last for a very long time (months). The sensitivity of the bladder is lost. Then, as the segmental apparatus of the spinal cord disinhibits, urinary retention is replaced by spinal automaticity of urination. In this case, involuntary urination occurs when there is a slight accumulation of urine in the bladder.
When the conus of the spinal cord and the roots of the cauda equina are damaged, the segmental apparatus of the spinal cord suffers and the syndrome of “hyporeflex neurogenic bladder” develops: urinary retention with paradoxical phenomena is characteristic.
noi ischuria - the bladder is full, but when the pressure in it begins to exceed the resistance of the sphincters, part of the urine flows out passively, which creates the illusion of intact urinary function.
Defecation disorders in the form of stool retention or fecal incontinence usually develop in parallel with urination disorders.
Damage to the spinal cord in any part is accompanied by pressure sores that occur in areas with impaired innervation, where bony protrusions are located under the soft tissues (sacrum, iliac crests, heels). Bedsores develop especially early and quickly with severe (transverse) damage to the spinal cord at the level of the cervical and thoracic regions. Bedsores quickly become infected and cause the development of sepsis.
When determining the level of spinal cord damage, the relative position of the vertebrae and spinal segments must be taken into account. It is easier to compare the location of the spinal cord segments with the spinous processes of the vertebrae (with the exception of the lower thoracic). To determine the segment, add 2 to the vertebral number (so, at the level of the spinous process of the third thoracic vertebra, the fifth thoracic segment will be located).
This pattern disappears in the lower thoracic and upper lumbar regions, where at the level of Th XI-XII and L I there are 11 segments of the spinal cord (5 lumbar, 5 sacral and 1 coccygeal).
There are several syndromes partial defeat spinal cord.
Half spinal cord syndrome(BrownSequard syndrome) - paralysis of the limbs and impairment of deep types of sensitivity on the affected side with loss of pain and temperature sensitivity on the opposite side. It should be emphasized that this syndrome in its “pure” form is rare; its individual elements are usually identified.
Anterior spinal syndrome- bilateral paraplegia (or paraparesis) combined with decreased pain and temperature sensitivity. The reason for the development of this syndrome is a violation of blood flow in the anterior spinal artery, which is injured by a bone fragment or a prolapsed disc.
Central spinal cord syndrome(more often occurs with a sharp hyperextension of the spine) is characterized mainly by
paresis of the arms, weakness in the legs is less pronounced; Sensory disturbances of varying severity below the level of the lesion and urinary retention are noted.
In some cases, mainly with trauma accompanied by sharp flexion of the spine, it may develop dorsal cord syndrome- loss of deep types of sensitivity.
Damage to the spinal cord (especially when its diameter is completely damaged) is characterized by disturbances in the regulation of the functions of various internal organs: respiratory disorders with cervical damage, intestinal paresis, dysfunction of the pelvic organs, trophic disorders with the rapid development of bedsores.
IN acute stage injury, the development of “spinal shock” is possible - a decrease in blood pressure (usually not lower than 80 mm Hg) in the absence of signs of polytrauma and internal or external bleeding. The pathogenesis of spinal shock is explained by the loss sympathetic innervation below the site of injury while maintaining parasympathetic (causes bradycardia) and atony skeletal muscles below the level of damage (causes blood deposition in the venous bed with a decrease in circulating blood volume).
Clinical forms of spinal cord injury
Spinal concussion is very rare. It is characterized by damage to the spinal cord of a functional type in the absence of obvious structural damage. More often, paresthesia and sensory disturbances below the injury zone are observed, less often - paresis and paralysis, and dysfunction of the pelvic organs. Occasionally, clinical manifestations are severe, up to the picture of complete damage to the spinal cord; The differential diagnostic criterion is complete regression of symptoms within 24 hours.
The cerebrospinal fluid is not changed during a concussion of the spinal cord, the patency of the subarachnoid space is not impaired. Changes in the spinal cord are not detected by MRI.
Spinal cord contusion - the most common type of lesion in closed and non-penetrating spinal cord injuries. A bruise occurs when a vertebra is fractured with its displacement, prolapse of the inter-
vertebral disc, vertebral subluxation. When a spinal cord injury occurs, structural changes in the substance of the brain, roots, membranes, vessels (focal necrosis, softening, hemorrhages).
The nature of motor and sensory disorders is determined by the location and extent of the injury. As a result of a contusion of the spinal cord, paralysis, changes in sensitivity, dysfunction of the pelvic organs, and autonomic disorders develop. Trauma often leads to the appearance of not one, but several areas of injury. Secondary disorders of the spinal circulation can cause the development of foci of softening of the spinal cord several hours or even days after the injury.
Spinal cord contusions are often accompanied by subarachnoid hemorrhage. In this case, an admixture of blood is detected in the cerebrospinal fluid. The patency of the subarachnoid space is usually not impaired.
Depending on the severity of the injury, restoration of impaired functions occurs within 3-8 weeks. However, with severe bruises that cover the entire diameter of the spinal cord, the lost functions may not be restored.
Spinal cord compression occurs when a vertebrae is fractured with displacement of fragments or when there is a dislocation or herniation of an intervertebral disc. The clinical picture of spinal cord compression can develop immediately after injury or be dynamic (increasing with spinal movements) if it is unstable. As in other cases of SMT, symptoms are determined by the level of damage, as well as the severity of compression.
There are acute and chronic compression of the spinal cord. The latter mechanism occurs when the compressing agent (bone fragment, prolapsed disc, calcified epidural hematoma, etc.) persists in the post-traumatic period.
In some cases, with moderate compression, after the acute period of SMT has passed, a significant or complete regression of symptoms is possible, but their reappearance in the long term due to chronic trauma to the spinal cord and the development of a focus of myelopathy. There is a so-called hyperextension injury of the cervical spine
(whiplash injury) that occurs when
car accidents (rear impact with incorrectly installed or missing head restraints), diving, falling from a height. The mechanism of this spinal cord injury is a sharp hyperextension of the neck, exceeding the anatomical and functional capabilities of this section and leading to a sharp narrowing of the spinal canal with the development of short-term compression of the spinal cord. The morphological focus that forms in this case is similar to that of a bruise. Clinically, hyperextension injury is manifested by spinal cord lesion syndromes of varying severity - radicular, partial dysfunction of the spinal cord, complete transverse lesion, anterior spinal artery syndrome. Hemorrhage in the spinal cord. Most often, hemorrhage occurs when blood vessels rupture in the area of the central canal and posterior horns
Hematomyelia, if not combined with other forms of structural damage to the spinal cord, is characterized by a favorable prognosis. Neurological symptoms begin to regress after 7-10 days. Restoration of impaired functions may be complete, but more often certain neurological disorders remain.
Hemorrhage into the spaces surrounding the spinal cord can be either epidural or subarachnoid.
An epidural spinal hematoma, unlike an intracranial hematoma, usually occurs as a result of venous bleeding (from
venous plexuses surrounding the dura mater). Even if the source of bleeding is an artery passing through the periosteum or bone, its diameter is small and the bleeding quickly stops. Accordingly, spinal epidural hematomas rarely reach large sizes and do not cause severe compression of the spinal cord. The exception is hematomas caused by damage to the vertebral artery during a fracture of the cervical spine; such victims usually die from circulatory disorders in the brain stem. In general, epidural spinal hematomas are rare.
The source of a subdural spinal hematoma can be both the vessels of the dura mater and spinal cord, and the epidural vessels located at the site of traumatic damage to the dura mater. Subdural spinal hematomas are also rare; usually bleeding inside the dural sac is not limited and is called spinal subarachnoid hemorrhage.
Clinical manifestations. Epidural hematomas are characterized by an asymptomatic interval. Then, a few hours after the injury, radicular pain appears with varying irradiation depending on the location of the hematoma. Later, symptoms of transverse compression of the spinal cord develop and begin to increase.
The clinical picture of intrathecal (subarachnoid) hemorrhage in spinal cord injury is characterized by acute or gradual development of symptoms of irritation of the membranes and spinal roots, including those located above the site of injury. Intense pain in the back and limbs, stiffness of the neck muscles, and Kernig's and Brudzinski's symptoms appear. Very often they are accompanied by paresis of the limbs, sensory conduction disturbances and pelvic disorders due to damage or compression of the spinal cord by gushing blood. The diagnosis of hemorrhachis is verified by lumbar puncture: the cerebrospinal fluid is intensely stained with blood or xanthochromic. The course of hemorrhachis is regressive, often occurs full recovery. However, hemorrhage in the cauda equina area can be complicated by the development of an adhesive process with severe neurological disorders.
Anatomical spinal cord injury occurs at the time of injury or secondary spinal cord injury
a wounding object, bone fragments, or when it is overstretched and ruptured. This is the most severe type of SMT, since restoration of anatomically damaged spinal cord structures never occurs. Occasionally, anatomical damage is partial, and Brown-Séquard syndrome or another of those described above develops, but more often such damage is complete. Symptoms are determined by the nature and level of the lesion.
Objective diagnosis
Radiography. Direct radiological signs of a spinal fracture include disturbances in the structure of the bodies, arches and processes of the vertebrae (discontinuity of the external bone plate, the presence of bone fragments, a decrease in the height of the vertebral body, its wedge-shaped deformation, etc.).
Indirect radiological signs of SMT - narrowing or absence, less often - widening of the intervertebral space, smoothing or deepening of natural lordoses and kyphosis, the appearance of scoliosis, changes in the axis of the spine (pathological displacement of one vertebra relative to another), changes in the course of the ribs due to trauma to the thoracic region, as well as poor visualization spinal structures in the area of interest even with targeted images (caused by paravertebral hematoma and soft tissue edema).
X-ray examination makes it possible to detect bone-destructive changes and metal foreign bodies with sufficient reliability, but provides only indirect, unreliable information about the state of the ligamentous apparatus of the spine and intervertebral discs, hematomas and other factors of spinal cord compression.
To identify the condition of the spinal cord and its roots, as well as to assess the patency of the spinal subarachnoid space, previously myelography- X-ray examination spine after injection into the subarachnoid space of the lumbar or occipital cistern of a radiopaque substance that contoured the spinal cord and its roots. Were suggested different drugs(air, oil and aqueous solutions of iodine salts), the best in terms of tolerability and quality of contrast were nonionic water-based
suitable radiopaque agents. With the advent of CT and MRI, myelography is practically not used.
CT- the main method for diagnosing the condition of the bone structures of the spine. Unlike spondylography, CT is good at detecting fractures of the arches, articular and spinous processes, as well as linear fractures of the vertebral bodies, which do not lead to a decrease in their height. However, before a CT scan, X-ray or MRI of the spine is mandatory, since it allows you to establish “areas of interest” in advance and thereby significantly reduce the radiation dose. Three-dimensional reconstruction of spinal structures obtained from spiral CT helps plan surgical intervention. CT angiography provides visualization of the internal carotid and vertebral arteries, which can be damaged by trauma to the cervical spine. CT can be performed if there is metal in the wound foreign bodies. The disadvantage of CT is unsatisfactory visualization of the spinal cord and its roots; some assistance in this may be provided by the introduction of a radiopaque substance into the subarachnoid space of the spinal cord (computed myelography).
MRI- the most informative method for diagnosing SMT. It allows you to assess the condition of the spinal cord and its roots, the patency of the spinal subarachnoid space and the degree of compression of the spinal cord. MRI clearly visualizes intervertebral discs and other soft tissues, including pathological ones, and obvious bone changes. If necessary, MRI can be supplemented with CT.
The functional state of the spinal cord can be assessed using electrophysiological methods- studies of somatosensory evoked potentials, etc.
Algorithm for providing medical care for spinal cord injury
1. At the scene of injury, as with TBI, the DrABC algorithm works (Danger remove, Air, Breathing, Circulation). That is, the victim must be moved from the place of maximum danger, ensure patency respiratory tract, mechanical ventilation for breathing problems or in patients in stupor and coma and maintaining adequate hemodynamics.
Rice. 12.2. Philadelphia collar; Various modifications are possible (a, b)
If the victim is unconscious and complains of pain in the neck or weakness and/or numbness in the limbs, external immobilization of the cervical spine with a Philadelphia collar (included in the set of external ambulance orthoses) is necessary - Fig. 12.2. The trachea can be intubated in such a patient after applying the specified external cervical orthosis. If there is a suspicion of injury to the thoracic or lumbar sacral regions There is no special immobilization of the spine; the patient is carefully placed on a stretcher and, if necessary, fixed to it.
The main thing at this stage is to ensure arterial normotension and normal arterial blood oxygen saturation, which, as with TBI, prevents the development of secondary consequences of TBI. If there are external and/or internal damage among other things, compensation for blood loss is necessary.
There is no specific drug treatment for STS. Glucocorticoids may inhibit lipid peroxidation at the site of injury and may reduce secondary spinal cord injury to some extent. There are recommendations for the administration of high doses of methylprednisolone (30 mg per 1 kg of body weight as a bolus in the first 3 hours after SMT, then 5.4 mg per 1 kg of body weight per hour for 23 hours); The effectiveness of this regimen has not yet been confirmed in independent studies. Other previously proposed drugs (“nootropic”, “vascular”, “metabolic”) are ineffective.
2. Inpatient (hospital) stage of medical care. Assessment of the condition of the spine is necessary in all victims with TBI of any severity, in victims with neurological symptoms that appeared after the injury (impaired sensitivity, movements, sphincter function, priapism), in persons with multiple injuries to the skeletal bones, as well as in cases of complaints of back pain in the absence of noticeable damage and neurological deficits.
Victims with clinical manifestations or a high risk of STS (see below) must undergo one or more objective neuroimaging studies.
Algorithm of actions in the emergency room. First of all, the severity of the patient’s condition is assessed using the GCS, hemodynamic parameters, pulmonary ventilation are determined and, if necessary, taken emergency measures for their correction. At the same time, the presence and nature of associated injuries are assessed internal organs, limbs, identify signs of combined damage (thermal, radiation, etc.) and determine the order of therapeutic and diagnostic measures.
All patients with clinical signs of SMT or in an unconscious state must have a permanent urinary catheter and nasogastric tube installed.
The general rule is to eliminate the most life-threatening factor a. However, even if SMT is not leading in the severity of the patient’s condition or is only suspected, all diagnostic and therapeutic measures should be carried out with maximum immobilization of the spine.
In victims with mild TBI (15 GCS points) in the absence of complaints and neurological symptoms, assessing the condition of the spine using physical methods is sufficient. Obviously, in such victims the likelihood of SMT is extremely low, and the patient can be released under the supervision of a family doctor. Neuroimaging studies are usually not performed in these cases.
In the absence of signs of TBI or SCI, but with multiple bone injuries, a thorough neurological and physical assessment of the condition of the spinal cord and spine is necessary. In such a situation, even in the absence of clinical signs of STS, radiography of the cervical spine is advisable, and in patients in serious condition, of the entire spine.
Radiography is performed by most victims (only with closed SMT and, accordingly, confidence in the absence of metallic foreign bodies in the patient’s body, is it possible to refuse radiography in favor of MRI).
In patients with impaired consciousness, radiography of the cervical spine is required in at least a lateral projection
Rice. 12.3. Compression fracture of the VII cervical vertebra with retrolisthesis (“diver’s fracture”); spondylogram, lateral projection: a - before stabilization; b - after it
(Fig. 12.3); For other victims with complaints of back pain or neurological symptoms, radiography of the presumably damaged part of the spine is performed in 2 projections. In addition to radiography in standard projections, if necessary, radiography is performed in special settings (for example, if there is a suspicion of injury to the 1st and 2nd cervical vertebrae, pictures through the mouth).
When identifying radiological signs spinal injuries (direct or indirect), the diagnosis is verified using MRI or CT (Fig. 12.4). As already mentioned, with closed SMT, it is possible to abandon radiography in favor of MRI.
Rice. 12.4. Fracture of the odontoid process of the II cervical vertebra: a - MRI; b - CT; due to the loss of the supporting function of the odontoid process as a result of a fracture, the first cervical vertebra is displaced anteriorly, the spinal canal is sharply narrowed
Evaluation functional state spinal cord examination using electrophysiological methods is usually performed in a hospital on a routine basis.
Algorithm of actions in the hospital. After the diagnosis of STS and associated injuries is established, the patient is hospitalized in the department according to the profile of the main (most life-threatening) pathology. From the first hours of SMT with spinal cord injury, complications are prevented, the main of which are bedsores, urinary tract infections, deep vein thrombosis of the legs and pelvis, intestinal paresis and constipation, gastric bleeding, pneumonia and contractures.
Measures to prevent bedsores include the use of an anti-bedsore mattress, hygienic skin care, frequent changes in the patient’s position in bed and, in the absence of spinal instability, early (after 1-2 days) activation of the victim.
Urinary infection develops in almost all patients with spinal cord injury, and the “trigger” is the resulting acute urinary retention, leading to overstretching of the bladder, ureters and renal pelvis, circulatory disorders in their walls and retrograde spread of infection due to vesicoureteral reflux . Therefore, it is possible that such patients undergo catheterization of the bladder earlier with preliminary introduction into the urethra of a solution or gel of an antiseptic and anesthetic (usually chlorhexidine with lidocaine); If possible, the permanent catheter is removed after a few days and periodic catheterization of the bladder is performed (once every 4-6 hours; to prevent overdistension of the bladder, the volume of urine should not exceed 500 ml).
Deep vein thrombosis of the legs and pelvis develops in 40% of patients with spinal cord injury and often occurs without clinical manifestations, but in 5% of cases it leads to pulmonary embolism. The greatest risk of deep vein thrombosis is in the first 2 weeks after injury with a maximum on the 7-10th day. Prevention consists of the use of periodic pneumatic compression of the legs and/or stockings with graduated compression, passive exercises and early activation (for stable or surgically stabilized spinal injuries);
in the absence of contraindications, low molecular weight heparin preparations are prescribed.
Intestinal paresis develops in the majority of victims with STS and can be caused by both central and peripheral mechanisms (compression of the mesentery with vessels and nerves passing through it by a retroperitoneal hematoma that occurs during a fracture of the lumbar and sometimes thoracic spine). Therefore, on the first day, such victims are fed parenterally and then gradually increase the amount of food with sufficient fiber content; If necessary, laxatives are prescribed.
In many patients, on the 1st day after SMT, erosions of the mucous membrane of the stomach and duodenum occur, leading to gastric bleeding in 2-3% of cases. Therefore, victims are given a nasogastric tube and H2 blockers (ranitidine, famotidine) are prescribed; taking them during the first 7-10 days reduces the risk stomach bleeding up to 1%.
Violations of pulmonary ventilation are caused by impaired innervation of the intercostal muscles, pain with concomitant rib fractures and immobilization with development stagnation in the posterior regions of the lungs. Prevention consists of breathing exercises, anesthesia for rib fractures, and early activation of the patient. In case of injury to the cervical spine, there is a need for periodic sanitation of the upper respiratory tract, sometimes using a bronchoscope. Mechanical ventilation is carried out with a periodic increase in end-expiratory pressure; if long-term mechanical ventilation is necessary, a tracheostomy is performed.
Prevention of contractures begins on the 1st day after SMT and consists of active and passive gymnastics at least 2 times a day; to prevent contractures in ankle joints the feet are fixed in a flexed position using pillows or external orthoses.
It should be borne in mind that even if immediately after the injury the clinical picture of complete spinal cord damage is determined, in 2-3% of victims, a greater or lesser recovery of impaired functions is observed after a few hours. If the clinical picture of complete spinal cord injury persists after 24 hours from the moment of SMT, the chances of further neurological improvement are extremely low.
Until the nature of the lesion is clarified and an adequate treatment method is selected, external immobilization is maintained. Algorithm for the treatment of spinal cord injury
The treatment algorithm for STS is determined by the nature of the damage to the spine (stable or unstable) and spinal cord (complete or incomplete).
For stable damage indications for urgent surgery rarely arise, only when there is compression of the spinal cord or spinal root. Limiting the load on the affected segment is usually sufficient. To do this, in case of damage to the cervical spine, external orthoses (“head holders”) are used; in case of stable fractures of the thoracic and lumbar spine, various corsets are used or simply prohibit lifting heavy objects, bending, and sudden movements for 2-3 months. With concomitant osteoporosis, calcium supplements with ergocalceferol and, if necessary, synthetic calcitonin are prescribed to accelerate fracture healing.
For unstable damage immobilization is necessary - external (using external devices) or internal, carried out during surgery. It should be noted that even with complete damage to the spinal cord and instability of the spine, its stabilization is necessary - this improves the possibilities of rehabilitation.
Treatment of complicated spinal fractures
The main goals that are pursued when providing care to patients with a complicated spinal fracture are the elimination of compression of the spinal cord and its roots and the stabilization of the spine.
Depending on the nature of the injury, this goal can be achieved in different ways:
Surgical method;
Using external immobilization and reposition of the spine (traction, cervical collars, corsets, special fixing devices).
Spinal immobilization prevents possible dislocation of the vertebrae and additional damage to the spinal cord, creates conditions for eliminating existing spinal deformation and fusion of damaged tissues in a position close to normal.
One of the main methods of immobilizing the spine and eliminating its deformation is traction, which is most effective for cervical trauma.
Traction is carried out using a special device consisting of a bracket fixed to the skull and a system of blocks that perform traction (Fig. 12.5).
The Crutchfield clamp is fixed to the parietal tuberosities with two screws with sharp ends. Traction using weights is carried out along the axis of the spine. At the beginning of traction, a small load is usually installed (3-4 kg), gradually increasing it to 8-12 kg (in some cases - more). Changes in spinal deformation under the influence of traction are monitored by repeated radiography.
The disadvantage of traction is the need for the victim to stay in bed for a long time, which significantly increases the risk of developing bedsores and thromboembolic complications. Therefore, recently, implantable or external immobilizing devices that do not interfere with the early activation of the patient have become increasingly widespread.
In case of damage to the cervical spine, immobilization of the spine can be carried out using a device consisting of a special corset such as a vest, a metal hoop rigidly fixed to the patient’s head, and rods connecting
Rice. 12.5. Skeletal traction for a fracture of the cervical spine using a Crutchfield clamp
wearing a hoop with a vest (halo fixation, halo vest- rice. 12.6). In cases where complete immobilization is not required for injuries to the cervical spine, semi-soft and hard collars are used. Corsets of a special design are also used for fractures of the thoracic and lumbar spine.
When using external immobilization methods (traction, corsets), it is required long time(months) to eliminate spinal deformity and heal damaged structures in the required position.
In many cases, this method of treatment is unacceptable: first of all, if it is necessary to immediately eliminate compression of the spinal cord. Then there is a need for surgical intervention.
The purpose of the operation is to eliminate compression of the spinal cord, correct spinal deformity and reliably stabilize it.
Surgery. Apply different kinds operations: with an approach to the spinal cord from behind through laminectomy, from the side or from the front with resection of the vertebral bodies. To stabilize the spine, a variety of metal plates, bone screws, and occasionally wire are used. Resected vertebral fragments are replaced with bone fragments taken from the patient's ilium or tibia, special metal and polymethyl methacrylate prostheses. You should know that stabilizing systems provide only temporary immobilization of the damaged part of the spine for up to 4-6 months, after which, due to osteoporosis around the screws embedded in the bone, their supporting function is lost. Therefore, implantation of a stabilizing system is necessarily combined with the creation of conditions for the formation of bone fusions between the above and underlying vertebrae - spinal fusion.
Indications for surgery for spinal and spinal cord injuries
When determining surgical indications, it is necessary to take into account that the most dangerous spinal cord injuries
Rice. 12.6. Halofixation system
occur immediately at the time of injury and many of these injuries are irreversible. So, if a victim immediately after an injury has a clinical picture of a complete transverse lesion of the spinal cord, then there is practically no hope that an urgent operation can change the situation. In this regard, many surgeons consider surgical intervention in these cases to be unjustified.
However, if there are symptoms of a complete break in the spinal cord roots, despite the severity of the damage, surgery is justified primarily due to the fact that it is possible to restore conductivity along the damaged roots, and if they are ruptured, which is rare, a positive result can be obtained with microsurgical suturing ends of damaged roots.
If there are at least the slightest signs preservation of some of the functions of the spinal cord (slight movement of fingers, the ability to determine a change in the position of a limb, perception of strong pain stimuli) and at the same time there are signs of compression of the spinal cord (presence of a block, displacement of the vertebrae, bone fragments in the spinal canal, etc.), surgery is indicated.
IN late period injury, surgery is justified if compression of the spinal cord persists and the symptoms of its damage progress.
The operation is also indicated for severe deformation and instability of the spine, even with complete transverse damage to the spinal cord. The purpose of the operation in this case is to normalize the supporting function of the spine, which is important condition more successful rehabilitation of the patient.
The choice of the most adequate treatment method - traction, external fixation, surgery, a combination of these methods is largely determined by the location and nature of the injury.
In this regard, it is advisable to separately consider the most typical types of injury to the spine and spinal cord.
Cervical spine injury
The cervical region of the spine is the most susceptible to damage and the most vulnerable. Cervical injuries are especially common in children, which can be explained by weakness of the neck muscles, significant extensibility of the ligaments, and large head size.
It should be noted that injury to the cervical vertebrae is more often than other parts of the spine accompanied by damage to the spinal cord (up to 40% of cases).
Damage to the cervical vertebrae leads to the most severe complications and more often than with injury to other parts of the spine, to the death of the patient: 25-40% of victims with injury localized at the level of the 3 upper cervical vertebrae die at the scene.
Due to the unique structure and functional significance of the 1st and 2nd cervical vertebrae, their damage should be considered separately.
The first cervical vertebra (atlas) can be damaged alone or together with the second vertebra (40% of cases). Most often, as a result of injury, the ring of the atlas ruptures in its different parts. The most severe type of SMT is atlanto-occipital dislocation - displacement of the skull relative to the first cervical vertebra. In this case, the area of transition of the medulla oblongata into the spinal cord is injured. The frequency of this type of SMT is less than 1%, mortality is 99%.
When the second cervical vertebra is damaged (epistrophy), a fracture and displacement of the odontoid process usually occur. A peculiar fracture of the second vertebra at the level of the articular processes is observed in hanged people (“hangman’s fracture”).
The C V -Th I vertebrae account for over 70% of injuries - fractures and fracture dislocations with accompanying severe, often irreversible damage to the spinal cord.
For fractures of the first cervical vertebra, traction by rigid external stabilization using halo fixation is usually successfully used. For combined fractures of the 1st and 2nd cervical vertebrae, in addition to these methods, surgical stabilization of the vertebrae is used, which can be achieved by tightening the arches and spinous processes of the first 3 vertebrae with wire or fixing them with screws in the area of the articular processes. Fixing systems have been developed that allow maintaining a certain range of movements in the cervical spine.
In some cases, to eliminate compression of the spinal cord and medulla oblongata by the broken odontoid process of the second cervical vertebra, anterior access through the oral cavity can be used.
Surgical fixation is indicated for fracture-dislocations of the C In -Th r vertebrae. Depending on the characteristics of the damage, it can be performed using various implanted systems. In case of anterior compression of the spinal cord by fragments of a crushed vertebra, prolapsed disc, or hematoma, it is advisable to use an anterior approach with resection of the affected vertebral body and stabilization of the spine with a metal plate fixed to the vertebral bodies, with the installation of a bone graft in place of the removed vertebra.
Trauma to the thoracic and lumbar spine
Injuries to the thoracic and lumbar spine often result in compression fractures. More often, these fractures are not accompanied by spinal instability and do not require surgical intervention.
With comminuted fractures, compression of the spinal cord and its roots is possible.
In this case, indications for surgery may arise. To eliminate compression and stabilize the spine, complex lateral and anterolateral approaches, including transpleural ones, are sometimes required.
Conservative treatment of patients with consequences of spinal cord injury
Special devices have been developed that allow victims, even with severe neurological disorders, to perform
take on socially useful functions and serve yourself. Even with tetraplegia, it is possible to use tongue-activated manipulators, voice-controlled computers, etc. The most important role The help of a psychologist and social rehabilitation play a role - training in a new, accessible profession.
Methods of conservative and surgical treatment of the consequences of SMT are auxiliary, but sometimes essential.
One of the common consequences of spinal cord injury is a sharp increase in tone in the muscles of the legs and torso, which often complicates rehabilitation treatment.
To eliminate muscle spasticity, medications are prescribed that reduce muscle tone(baclofen, etc.). At severe forms spasticity, baclofen is injected into the spinal subarachnoid space using implantable programmable pumps (see Chapter 14 “Functional Neurosurgery”). Surgical interventions described in the same section are also used.
In case of persistent pain syndromes, which more often occur with damage to the roots and the development of adhesions, there may be indications for pain interventions, also described in Chapter 14 “Functional Neurosurgery”.
The effectiveness of many drugs previously used to treat SMT (and TBI) - “nootropic”, “vasodilator”, “rheological”, “metabolic”, “neurotransmitter” - has been called into question by the results of independent studies.
Open injuries to the spine and spinal cord
In peacetime, open wounds with penetration of a wounding object into the cavity of the spinal canal are rare, mainly in criminal SMT. The frequency of such injuries increases significantly during military operations and anti-terrorist operations.
The incidence of military injuries to the spine approximately corresponds to the length of each section and is 25% for the cervical spine, 55% for the thoracic spine and 20% for the lumbar, sacral and coccygeal spine.
Features of mine-explosive and gunshot injuries of the spine and spinal cord are:
Open and often penetrating nature of the wounds;
High frequency and severity of damage to the spinal cord and its roots, caused by the high energy of the traumatic agent (causing a shock wave and cavitation);
Long pre-hospital stage of medical care;
High frequency of combined injuries (multiple wounds, fractures, dislocations, bruises, etc.);
High frequency of combined (with burns, compression, potentially radiation and chemical damage) injuries.
The principles of first aid are the same as for any type of injury (DrABC). A special feature is attention to preventing secondary infection of the wound by antiseptic treatment of its edges and applying an aseptic dressing; if there is moderate bleeding, the wound should be packed with a hemostatic sponge containing gentamicin (and then applied with an aseptic dressing).
Transportation of the wounded is carried out according to the same principles. Cervical immobilization is necessary but performed whenever possible. In the absence of a stretcher, it is better to carry a wounded person with suspected STS on a board made of boards, etc.
At the stage of qualified care, anti-shock measures are carried out (if they are not started earlier), bleeding stop, external immobilization of the damaged part of the spine, primary surgical treatment of the wound, administration of tetanus toxoid, catheterization of the bladder, installation nasogastric tube. The damage leading in the clinical picture is determined and prompt transportation of the wounded person to the appropriate specialized or multidisciplinary medical institution (hospital or civilian hospital) is ensured. Immobilization of the spine during transportation is mandatory.
At the stage of specialized medical care provided at a certain distance from the war zone, an algorithm for diagnostic and therapeutic measures during SMT is similar to that in peacetime. Peculiarities:
Even if MRI is available, preliminary radiography is required to identify metallic foreign bodies;
The use of glucocorticoids (methylprednisolone or others) is contraindicated;
High incidence of wound liquorrhea and infectious complications;
The rarity of spinal instability.
It should be borne in mind that unnecessarily extensive surgical interventions with resection of bone structures, especially those performed before the stage of specialized medical care, significantly increase the incidence of spinal instability.
Indications for surgery for wartime STS
Tissue damage (primary surgical treatment of the wound is required, in the absence of liquorrhea it is carried out according to the usual principles).
Massive tissue damage with crush areas and hematomas. Excision and closed external drainage are performed to reduce the risk of infectious complications.
Wound liquorrhea. It sharply, approximately 10 times, increases the risk of meningitis with the development of a cicatricial adhesive process, often leading to disability and sometimes death of the victim. To relieve liquorrhea, a wound revision is performed with detection and suturing of the dura mater defect (if it is impossible to match the edges, a graft from local tissues is sutured into the dura mater defect) and careful layer-by-layer suturing of the wound (preferably with absorbable polyvinyl alcohol sutures). Sutures on the dura mater can be strengthened with fibrin-thrombin compositions.
Epidural hematoma. In the absence of the possibility of objective diagnosis, the likelihood of developing an epidural hematoma is indicated by the increase in local neurological symptoms that began several hours after the injury. The operation significantly improves the prognosis.
Compression of the nerve root(s) by a wounding agent or hematoma, bone, cartilage fragments, etc. It manifests itself as pain in the area of innervation of the root and motor disturbances. The operation is indicated even with the assumption of complete anatomical damage, because the ends of the roots can sometimes be compared and sutured; in any case, decompression usually leads to the disappearance of pain.
Damage to the roots of the cauda equina. To decide on surgery in this case, it is desirable to verify the nature of the damage using CT or MRI, but even in the case of an anatomical break, microsurgical suturing of the roots can be beneficial; The greatest difficulty is in identifying the ends of the torn roots, which is problematic even in peaceful conditions.
Damage to blood vessels (vertebral or carotid arteries) is an absolute indication for surgery, during which it is possible to remove the accompanying epidural hematoma.
The presence of a copper-jacketed bullet in the spinal canal. Copper causes an intense local reaction with the development of a scar-adhesive process. It should be understood that the type of bullet can be established in case of criminal wounds in peacetime during operational search activities; during hostilities this is very problematic.
Spinal instability. As mentioned, it is rare with gunshot and mine-explosive wounds; If there is instability of the spine, its stabilization is required. In cases of open wounds, external stabilization (halo-fixation or other) is preferable, since implantation of a stabilizing system and bone grafts significantly increases the risk of infectious complications.
Compression of the spinal cord with the clinical picture of incomplete damage. As already mentioned, due to the high energy of the traumatic agent, even anatomically incomplete spinal cord damage in these situations is usually severe, and the prognosis for recovery is unfavorable. However, if there is at least minimal preservation of neurological function below the level of compression, decompressive surgery is sometimes beneficial.
To prevent infectious complications in case of penetrating wounds, reserve antibiotics are immediately prescribed - imopenem or meropenem with metrogyl, and tetanus toxoid is necessarily administered (if not previously administered), if there is a suspicion of anaerobic infection hyperbaric oxygen therapy is performed.
Indications for surgical treatment in the long-term period of gunshot and mine blast wounds are:
Pain syndromes - in order to eliminate them, devices are implanted for delivering painkillers to the central nervous system or systems for analgesic neurostimulation (see section “Functional neurosurgery”).
Spasticity - the same treatment methods are used as for closed SMT.
Migration of a traumatic agent with the development of neurological symptoms (rare).
Spinal instability. More often it is caused by inadequate primary surgical intervention (laminectomy with resection of the articular processes). Requires surgical stabilization.
Lead intoxication (plumbism). A very rare condition caused by the absorption of lead from a bullet located in the intervertebral disc. Lead bullets encapsulated anywhere outside the joints do not cause lead toxicity. Manifested by anemia, neuropathy (motor and/or sensory), intestinal colic. The operation involves removing the bullet; usually performed under X-ray television control. To accelerate the removal of lead residues from the body, calcium trisodium pentetate is used in a high dose (1.0-2.0 g intravenously slowly every other day, a total of 10 to 20 injections).
Rehabilitation of victims does not differ from that for other types of SMT. Psychological rehabilitation for wartime STS is less complex (due to obvious motivation), but physical rehabilitation tends to be a more significant challenge due to the greater severity of the neurological deficit.
Of great importance for psychological and social adaptation people with consequences of SMT of any origin have public opinion and government policy to help people with disabilities. Similar programs have now achieved great success in developed countries.
Spinal cord injury is damage due to injury or disease to any part of the spinal cord or nerves of the spinal canal. These injuries often cause impairment or loss of motor or sensory function.
Many scientists do not give up the idea that spinal cord damage will one day be completely reversible. Therefore, research in this area is being conducted all over the world. At the same time, treatment and rehabilitation programs that exist today allow many patients to once again become active members of society.
The ability to control the limbs of the body after a spinal cord injury depends on two factors: the location of the injury (part of the spinal cord) and the severity of the injury. If the spinal cord is seriously damaged, destroying the pathways that connect several parts of the spinal cord together, then the consequences of spinal injury are catastrophic.
The severity of injury is divided into:
Complete damage
Such an injury leads to loss of sensitivity and motor functions of all organs and parts of the body located below the level of injury.
Incomplete damage
With an incomplete spinal cord injury, the organs and limbs located below the injury site retain partial motor activity.
Also, spinal cord injuries can lead to tetraplegia (aka quadriplegia) - impairment or loss of the functions of the arms, torso, legs and functions of the pelvic organs.
Paraplegia is complete paralysis or paralysis affecting part of the torso, legs and pelvis.
- Your doctor will perform a series of tests to determine the neurological level of damage and the severity of the injury.
- Signs and symptoms of spinal cord injury (may manifest as several or one of the following):
- loss of motor functions,
- loss of sensation, including the ability to sense heat, cold, or touch.
- loss of bowel and bladder control
- increased muscle tone or uncontrollable spasms
- sexual dysfunction and infertility
- pain or tingling caused by damage to the nerve fibers of the spinal cord
- difficulty breathing, cough.
The first signs of a spinal cord injury:
- Severe back pain or pressure in the neck and head
- Weakness, incoordination, or paralysis in any part of the body
- Numbness, tingling, or loss of sensation in the hands, fingers, feet, or toes
- Loss of bowel or bladder control
- Difficulty walking and maintaining balance
- Respiratory problems
When to see a doctor
Anyone who suffers a serious head or neck injury should seek immediate medical attention. Doctors will also evaluate possible spinal cord damage. Whenever a spinal cord injury is suspected, doctors must perform all appropriate medical procedures until proven otherwise, this is important because:
- A serious spinal injury is not always immediately obvious. If it is not recognized in time, it can lead to more serious consequences.
- Numbness or paralysis may also not appear immediately, without timely diagnosis the situation may be made worse by prolonged internal bleeding and swelling in or around the spinal cord.
- The time elapsed after the injury and medical care directly affects possible complications and subsequent rehabilitation of the patient.
How to behave with a person who has just been injured:
- Call 1719 or the nearest hospital ambulance service.
- Place towels on both sides of your head and neck to keep them stationary and wait for emergency help.
- Provide first aid to the victim: take measures to stop the bleeding and provide comfort to the victim as much as possible, but without moving the neck or head.
Spinal cord injury may result from damage to the vertebrae, ligaments, or discs of the spine. Traumatic spinal cord injury may involve a sudden blow to the spine that fractures, dislocates, or compresses the vertebrae. Spinal cord injury can also be caused by a gunshot or knife wound. Complications usually occur within days or weeks after the injury due to bleeding, swelling, inflammation, and fluid accumulation in and around the spinal cord.
Non-traumatic spinal cord injury is also possible due to a number of diseases: arthritis, cancer, inflammation, infection or spinal disc degeneration.
Your Brain and Central Nervous System
The central nervous system consists of the brain and spinal cord. The spinal cord, made up of soft tissue surrounded by bones (vertebrae), runs down from the base of the brain, made up of nerve cells and their processes, and ends slightly above the waist. Below this area there is a bundle of nerve endings called the cauda equina.
The nerve branches of the spinal cord are responsible for communication between the brain and the body. Motor neurons transmit signals from the brain to control muscle movement. Sensory areas carry signals from body parts to the brain to convey information about heat, cold, pressure, pain, and limb position.
Damage to nerve fibers
Regardless of the cause of spinal cord injury, the nerve fibers passing through the injured area may also be affected. This leads to deterioration in the functioning of the muscles and nerves located below the site of injury. Damage to the thoracic or lumbar region can affect the functioning of the muscles of the trunk, legs and internal organs (bladder and bowel control, sexual function). And neck injuries can affect arm movement and even the ability to breathe.
Common Causes of Spinal Cord Injury
The most common causes of spinal cord injury in the United States are:
Road traffic accidents. Automobile and motorcycle accidents are the leading cause of spinal cord injury, accounting for more than 40% annually.
Falls.
Spinal cord injuries in older adults (over 65 years of age) are usually associated with falls. In general, statistics assign ¼ of all cases to this reason. Acts of violence. 15% of spinal cord injuries are caused by violence (including gunshots and knife wounds). Data
National Institute neurological disorders and stroke. Sports injuries. Professional sport carries many dangers, as does
active recreation
, for example, shallow water diving. 8% of back injuries fall under this heading.
Alcohol. Every fourth injury is, in one way or another, related to alcohol use.
Diseases.
Age. As a rule, injuries occur at the most active age - from 16 to 30 years. The main reason injuries at this age remain accidents on the road.
Love of risk and extreme sports. Which is logical, but the main thing is that athletes and amateurs are the first to get injured when safety precautions are violated.
Diseases of bones and joints. When chronic arthritis or osteoporosis, even a minor back injury can be fatal for the patient.
After spinal cord injuries, patients face a large number unpleasant consequences that can radically change their lives. When such a serious injury occurs, a team of specialists, including neurosurgeons, neurologists and doctors from a rehabilitation center, comes to the aid of the patient.
Specialists of the Rehabilitation Center will offer a number of methods for monitoring vital processes (bladder and intestinal function). They will develop a special diet to improve organ function, which will help avoid future formation of kidney stones, urinary tract and kidney infections, obesity, diabetes mellitus etc. Under the supervision of experienced physiotherapists, a physical exercise program will be developed to improve the patient's muscle tone. You will receive detailed recommendations on skin care to avoid bedsores and maintain the functioning of the cardiovascular and respiratory systems. Specialists in urology and infertility treatment may also be involved if necessary. Doctors will teach you how to deal with pain and depression. We are able to offer A complex approach to completely stabilize the patient's condition.
Medical Research:
Radiography.
This is where it makes sense to start the research. The images give a general picture of the situation, allow you to assess the deformation of the spine, detect fractures, dislocations of vertebral bodies and processes, and clarify the level of damage. Computed tomography (CT).
A CT scan provides more detailed information about the damaged area. During the scan, the doctor takes a series of cross-sectional images and provides a detailed examination of the walls of the spinal canal, its membranes and nerve roots. Magnetic resonance imaging (MRI).
A few days after the injury, when the swelling has subsided, the doctor may perform a neurological examination to determine the severity of the injury. It includes testing muscle strength and sensory sensitivity.
Unfortunately, spinal cord damage cannot be completely cured. But ongoing research is providing doctors with more and more new tools and techniques to treat patients that can promote the regeneration of nerve cells and improve nerve function. At the same time, we should not forget about the work that is being done in the field of maintaining an active life for patients after injury, expanding opportunities and improving the quality of life of people with disabilities.
Providing emergency medical care
Providing prompt first aid is critical to minimizing the consequences after any head or neck injury. Likewise, treatment of a spinal cord injury often begins at the scene of the accident.
Upon arrival, the emergency medical team should immobilize the spine as gently and quickly as possible using a rigid cervical collar and a special stretcher to transport the victim to the hospital.
When a spinal cord injury occurs, the patient is taken to the department intensive care. The patient may also be taken to a regional spinal cord injury center where a team of neurosurgeons, orthopedic surgeons, psychologists, nurses, therapists and social workers is always on duty.
Medicines. Methylprednisolone (Medrol) is used in cases of acute spinal cord injury. When treated with Methylprednisolone within the first eight hours after injury, there is a chance of obtaining a moderate improvement in the patient's condition. This drug reduces damage to nerve cells and relieves inflammation of tissues around the site of injury. However, it is not a cure for the spinal cord injury itself.
Immobilization. Stabilization of the injured spine during transport is extremely important. To do this, the team has special devices in its arsenal to hold the spine and neck motionless.
Surgical intervention. Often, doctors are forced to resort to surgery to remove bone fragments, foreign objects, herniated discs, or fix vertebral fractures. Surgery may also be needed to stabilize the spine to prevent pain or bone deformity in the future.
Hospitalization period
Once the patient has been stabilized and initial treatment has been provided, staff begin working to prevent complications and related problems. This may be a deterioration in the patient’s physical condition, muscle contracture, bedsores, bowel and bladder dysfunction, respiratory infections and blood clots.
The length of hospital stay depends on the severity of the injury and the pace of recovery. After discharge, the patient is sent to the rehabilitation department.
Rehabilitation. Work with the patient can begin in the early stages of recovery. The team may include physiotherapists, occupational therapists, specially trained nurses, a psychologist, a social worker, a dietician and a supervising physician.
At the initial stages of rehabilitation, doctors usually work to preserve and strengthen muscle function, using fine motor skills and teaching adaptive behavior in everyday activities. Patients receive advice on the consequences of injuries and the prevention of complications. You will be given recommendations on how you can improve your quality of life under current conditions. Patients are taught new skills, including the use of special equipment and technologies, which make it possible not to depend on outside help. Having mastered them, you can find a new hobby, participate in social and sporting events, return to school or the workplace.
Drug treatment. The patient may be prescribed medications to control the effects of a spinal cord injury. These include medications to control pain and muscle spasms, as well as medications to improve bladder control, bowel control, and sexual function.
New technologies. Today, for people with disabilities Modern means of transportation were invented to provide complete mobility for patients. For example, modern lightweight electric wheelchairs. Some of the latest models allow the patient to independently climb the stairs and lift the seated person to any required height.
Forecasts and recovery
Your doctor will not be able to predict the recovery of just an admitted patient. In case of recovery, if it can be achieved, it will take from 1 week to six months after the injury. For another group of patients, small improvements will come after a year of working on oneself or more time.
In the case of paralysis and subsequent disability, you need to find the strength to accept the situation and start a different life, adaptation to which will be difficult and frightening. A spinal cord injury will affect every aspect of life, whether it be daily activities, work or relationships.
Recovery from such an event takes time, but it is up to you to choose whether you will be happy in the current situation, and not the injury. Many people have gone through this and were able to find the strength to start a new one. full life. One of the main components of success is quality medical care and support from loved ones.
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Closed injuries of the spine and spinal cord are divided into three groups:
1) spinal injuries without dysfunction of the spinal cord;
2) spinal injuries accompanied by impaired conduction function of the spinal cord;
3) closed damage spinal cord without damaging the spine.
Damage to the spine occurs in the form of fractures of the bodies, arches, and processes; dislocations, fracture-dislocations; ligamentous ruptures, damage to intervertebral discs. Lesions of the spinal cord can be in the form of compression of the brain and its roots by an epidural hematoma or bone fragments, concussion or contusion of the medulla, rupture of the spinal cord and its roots, subarachnoid hemorrhage and hemorrhage into the medulla (hematomyelia).
Spinal cord contusion is characterized by dysfunction of the pathways and is manifested by paralysis and loss of sensation below the level of damage, retention of urination and defecation. All phenomena develop immediately after injury and last for 3-4 weeks. During this period, pneumonia, bedsores, ascending cystopyelonephritis and urosepsis may develop.
Spinal cord compression may be sharp (occurs at the time of injury), early (hours or days after injury) and late (months or years after injury).
Compressions are classified according to location: rear (broken vertebral arch, epidural hematoma, torn ligamentum flavum), front (body of a broken or displaced vertebra, prolapsed intervertebral disc), internal (cerebral edema, intracerebral hematoma, detritus in the softening area).
Compression may be with complete obstruction cerebrospinal fluid tracts and conduction functions of the spinal cord, with partial obstruction liquor-conducting pathways, and by the nature of development - acutely progressive and chronic.
Diagnosis of spinal cord compression syndrome is based on data from a neurological examination, survey spondylograms and special research methods, including assessment of the patency of the subarachnoid space during lumbar puncture with CSF tests, positive myelography with water-soluble contrast agents, or pneumomyelography. Spinal cord compression syndrome is characterized by a block of the subarachnoid space and an increase in neurological disorders. Ascending edema is especially dangerous in cases of cervical spinal cord injury.
When the spinal cord is compressed by the posterior structures of the vertebrae, decompressive laminectomy of 2–3 arches is used. Timing for its implementation in case of closed spinal injuries:
- emergency laminectomy - within the first 48 hours after injury;
- early laminectomy - the first week after injury;
- late laminectomy - 2-4 weeks.
When the anterior structures of the spinal cord are compressed by bone fragments displaced into the lumen of the spinal canal or damaged intervertebral discs, an operation is used - anterior decompression of the spinal cord (removal of bone fragments and damaged intervertebral discs using an anterior approach) followed by anterior corporedesis with a bone autograft.
Fractures of the vertebrae without damage to the spinal cord are treated either conservatively: lumbar and thoracic regions - by traction with straps on the axillary areas on a bed with a shield, using rollers to reposition the vertebrae in bed; cervical spine - by skeletal traction over the parietal tuberosities and zygomatic bones, or surgically, in order to restore the configuration of the spinal canal and stabilize the spine: vertebrae are repositioned, bone fragments are removed and the spine is fixed with metal structures.
For spinal cord injuries without damage to the spine, conservative treatment is performed.
Gunshot wounds of the spine and spinal cord are divided into:
- according to the type of wounding projectile - bullet and fragmentation;
- according to the nature of the wound channel - through, blind, tangential;
- in relation to the spinal canal - into penetrating, non-penetrating, paravertebral;
- by level - to the cervical, thoracic, lumbar, sacral regions; isolated, combined (with damage to other organs), multiple and combined injuries are also distinguished.
Penetrating spinal injuries are injuries in which mainly the bony ring of the spinal canal and the dura mater are destroyed.
In the acute period of spinal cord injury, spinal shock develops, manifested by inhibition of all functions of the spinal cord below the site of injury. In this case, tendon reflexes are lost, muscle tone decreases, sensitivity and function of the pelvic organs are disrupted (according to the type of acute retention). The state of spinal shock lasts 2–4 weeks and is maintained by foci of irritation of the spinal cord: foreign bodies (metal fragments, bone fragments, fragments of ligaments), areas of traumatic and circular necrosis.
The more severe the spinal cord injury, the later its reflex activity is restored. When assessing the degree of spinal cord damage, the following clinical syndromes are distinguished:
Syndrome of complete transverse destruction of the spinal cord; characterized by tetra- and paraplegia, tetra- and paraanesthesia, dysfunction of the pelvic organs, progressive development of bedsores, hemorrhagic cystitis, rapidly occurring cachexia, edema of the lower extremities;
Partial spinal cord injury syndrome - in the acute period is characterized by varying severity of symptoms - from preservation of movement in the limbs with a slight difference in reflexes, to paralysis with dysfunction of the pelvic organs. The upper limit of sensitivity disorders is usually unstable and can change depending on circulatory disorders, cerebral edema, etc.;
Spinal cord compression syndrome due to gunshot wounds - in the early period most often occurs due to pressure on the brain substance from a wounding projectile, bone fragments, displaced vertebrae, as well as due to the formation of subdural and epidural hematomas;
Perineural radicular position syndrome is observed with a blind wound of the spine in the cauda equina region with a subdural location of the foreign body. The syndrome is expressed by a combination pain and bladder disorders: in an upright position, pain in the perineum intensifies, and emptying the bladder is more difficult than in a lying position.
Injuries to the upper cervical spine and spinal cord are characterized by a severe condition with severe respiratory impairment (due to paralysis of the muscles of the neck and chest wall). Often such injuries are accompanied by stem symptoms: loss of consciousness, swallowing disorder and disturbances in the functioning of the cardiovascular system due to ascending edema.
Injuries to the lower cervical spine are accompanied by respiratory distress, high paralysis (tetraplegia), impaired sensitivity below the level of the clavicle and often Horner's symptom (narrowing of the pupil, palpebral fissure and some retraction of the eyeball).
When the thoracic spinal cord is damaged, paraplegia of the lower extremities, dysfunction of the pelvic organs and sensitivity disorder depending on the level of the lesion develop (the fifth thoracic segment corresponds to the level of the nipples, the seventh to the costal arch, the tenth to the line of the navel, the twelfth to the inguinal folds). Damage lumbar region spinal cord, segments of which are located at the level of the I X-XI thoracic vertebrae, is accompanied by paraplegia, dysfunction of the pelvic organs (like incontinence) and a disorder of sensitivity downward from the inguinal folds.
When the epiconus and roots of the initial section of the cauda equina are affected, flaccid paralysis of the muscles of the legs, feet, and buttocks occurs, and sensitivity disorders are detected on the skin of the lower extremities and in the perineal area.
Injuries of the lower lumbar and sacral spine are accompanied by damage to the roots of the cauda equina and are clinically characterized by flaccid paralysis of the lower extremities, radicular pain and urinary incontinence.
Instructions for military field surgery
The spinal cord is located in the spinal canal and is responsible for the functioning of the digestive, respiratory, reproductive, urinary and other important systems of the body. Any disturbances and damage to the spine and nervous tissue are fraught with disturbances in the functioning of organs and other pathological phenomena.
Doctors consider spinal cord injuries to be sprains, compression, contusions with intracerebral hemorrhage, ruptures or avulsions of one or more nerve roots, as well as infectious lesions and developmental abnormalities. In this article we will look at the symptoms, diagnosis and treatment of spinal and spinal cord injuries. You will learn how pre-hospital care and transportation of a victim with spinal cord injuries are performed.
Disturbances in the functioning of the spinal cord cause both independent diseases and spinal injuries. The causes of spinal cord injuries are divided into 2 large groups: traumatic and non-traumatic.
The following causes are considered traumatic:
Non-traumatic causes of spinal cord injuries:
- inflammatory processes: myelitis (viral or autoimmune);
- tumors: sarcoma, lipoma, lymphoma, glioma;
- radiation myelopathy;
- vascular spinal syndromes, vascular compression;
- myelopathies associated with metabolic disorders;
- purulent or bacterial infection: tuberculous, mycotic spondylitis;
- chronic rheumatic pathologies of the spine: rheumatoid, reactive arthritis, disease;
- degenerative changes in the spine: osteoporosis, spinal canal stenosis, .
Types of injuries
Spinal cord injuries are classified according to various criteria. There are open injuries with soft tissue damage and skin And closed injuries without external damage.
Types of spinal injuries:
- sprains or ruptures of spinal ligaments;
- vertebral fractures: compression, comminuted, marginal, explosive, vertical and horizontal;
- intervertebral disc injuries;
- dislocations, subluxations, fracture-dislocations;
- spondylolisthesis or displacement of the vertebrae.
Types of spinal cord injuries:
- injury;
- squeezing;
- partial or complete rupture.
Bruises and compression are usually associated with spinal injury: dislocation or fracture. When a bruise occurs, the integrity of the spinal tissue is disrupted, and hemorrhage and swelling of the brain tissue is observed, the extent of which will depend on the degree of damage.
Compression occurs when vertebral bodies are fractured. It can be partial or complete. Constriction is common in divers; Most often the lower cervical vertebrae are damaged.
The victim develops atrophic paralysis of the arms, paralysis of the legs, decreased sensitivity in the area below the level of the lesion, problems with the pelvic organs and bedsores appear in the sacral area.
Compression in the lumbosacral spine leads to paralysis of the legs, loss of sensation and dysfunction of the pelvic organs.
Symptoms
Signs of spinal cord injury depend on the type of injury and where it occurs.
Common signs of spinal cord problems:
Spinal cord injuries in newborns most often occur in the cervical or lumbar regions. The fact is that the baby’s spinal cord, in comparison with the spine and ligaments, is less extensible and is easily damaged by injuries without visible changes in the spine itself.
In some situations, even a complete rupture of the spinal cord occurs, although no changes will be visible on an x-ray.
Due to neck injury during childbirth, the baby will be in a state of anxiety. The neck may become curved, lengthened or shortened. The infant experiences the same symptoms as adults: spinal shock, swelling, breathing problems, disturbances in the functioning of internal organs, muscle atrophy, reflex and movement disorders.
First aid
The consequences of injuries will be less dangerous if first aid is provided correctly. The victim is laid flat on a hard surface and transported on a rigid board. If immobilization is not carried out, bone splinters and fragments will continue to compress the spinal cord, which can be fatal.
The injured person is carried exclusively on a hard surface. If damage to the cervical spine is suspected, the head is additionally fixed using a splint made from improvised means (fabric rollers are suitable).
Attention! Do not sit down or try to lift the victim to his feet. It is necessary to monitor breathing and pulse and, if necessary, carry out resuscitation measures.
Main rules:
- Limit the victim's movements, place him on a hard surface and secure the damaged area using available means.
- Give pain medication if necessary.
- Make sure the victim is conscious.
In a situation of severe injury, the spinal cord is switched off for some time, and a state of shock occurs. Spinal shock is accompanied by disruption of the sensory, motor and reflex functions of the spinal cord.
The disruption extends below the level of damage. During this period, it is impossible to determine a single reflex; only the heart and lungs work. They function autonomously; other organs and muscles also do not work.
While waiting for the shock to pass and the spinal cord to start working, the muscles are supported using electrical impulses to prevent atrophy.
Diagnostics
How to check a person's spinal cord after an injury? To determine the level of damage, an x-ray is taken (in at least 2 planes).
Computed and magnetic resonance imaging give the most detailed picture of the condition of the spine and spinal cord. Here you can see the spinal cord in both longitudinal and cross section, identify hernias, fragments, hemorrhages, damage to nerve roots and tumors.
Myelography carried out for the purpose of diagnosing nerve endings.
Vertebral angiography shows the condition of the blood vessels of the spine.
Lumbar puncture done to analyze cerebrospinal fluid to detect infection, blood, or foreign bodies in the spinal canal.
Treatment methods
Treatment for the spinal cord depends on the severity of the damage. If damaged mild degree the victim is prescribed bed rest, painkillers, anti-inflammatory and restorative drugs.
In case of violation of the integrity of the spine, compression of the spinal canal and severe injuries, surgery is necessary. It is produced to restore damaged tissue of the spine and spinal cord.
For serious injuries, emergency surgery is necessary. If you do not help the victim in time, irreversible consequences may occur 6-8 hours after the injury.
IN postoperative period To prevent side effects, a course of intensive therapy is carried out. In this process, the functioning of the cardiac system and breathing is restored, cerebral edema is eliminated and infectious lesions are prevented.
Orthopedic
Orthopedic treatment includes reduction of dislocations, fractures, traction and prolonged immobilization of the spine. The patient is recommended to wear a cervical collar for injuries to the cervical spine or an orthopedic corset for treatment of the thoracic or lumbar spine.
Conservative treatment involves the use of spinal traction. If the thoracic and lumbar spine are damaged, traction is carried out using loops, hanging the patient by the armpits.
Beds with a raised headboard are also used. When treating the cervical spine, a Gleason loop is used. This is a device in the form of a loop where a head with a cable and a counterweight is attached. Due to the counterweight, gradual stretching occurs.
Drug therapy includes taking anti-inflammatory and painkillers. Drugs are prescribed to restore blood circulation, strengthen the body and activate tissue regeneration processes.
If the victim experiences spinal shock, dopamine, atropine and significant doses of methylprednisolone are used. For pathological muscle stiffness, muscle relaxants are prescribed central action(). To prevent the development inflammatory phenomena take broad-spectrum antibiotics.
Rehabilitation
The rehabilitation period takes up to several months. After the integrity of the spinal cord is restored, training begins to restore physical activity.
The first week of therapeutic training begins with breathing exercises. In the second week, movements with arms and legs are included. Gradually, depending on the patient’s condition, the exercises become more complicated, the body is transferred to a vertical position from a horizontal one, and the range of movements and load are increased.
As you recover, massage is included in the rehabilitation process.
Physiotherapy carried out to restore motor activity, prevent bedsores and disorders of the pelvic organs. It promotes tissue regeneration in the area of injury and lymphatic drainage, improves blood circulation, cellular and tissue metabolism, reduces swelling and inflammatory processes.
For treatment, ultrasound, magnetic therapy, general ultraviolet irradiation, electrophoresis with lidase and novocaine, and phonophoresis are used.
Reference. Physiotherapy in combination with medications improves nutrition and absorption of active substances in tissues and cells.
For paralysis and paresis of the lower extremities, hydrogalvanic baths, underwater shower massage, and mud applications are used. Mud therapy can be replaced with ozokerite or paraffin.
At pain syndrome Balneotherapy, radon and pine baths, as well as vibration and whirlpool baths are used.
Along with physical therapy Hydrokinesitherapy and swimming in the pool are used.
Complications of spinal cord injury
Complications occur:
- in case of untimely provision of medical care;
- if the patient violates the discipline of treatment and rehabilitation;
- in case of neglect of doctor's recommendations;
- as a result of the development of infectious and inflammatory side processes.
A slight bruise, local hemorrhage in the tissues of the spinal cord, compression or concussion does not cause serious consequences; the victim makes a full recovery.
In severe cases - with extensive bleeding, spinal fractures, severe bruises and compression - bedsores, cystitis, pyelonephritis appear.
If the pathology takes chronic form, paresis and paralysis develop. In case of an unfavorable outcome, the person completely loses motor functions. Such patients require constant care.
Conclusion
Any damage to the spinal cord is fraught with serious problems. Untimely treatment, neglect of the condition of your spine and medical recommendations can lead to disastrous results.
