Spinal cord injury full recovery. Spinal cord injuries: causes, signs, symptoms, treatment

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.

Damage spinal cord doctors consider sprain, compression, bruise 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 damage to soft tissues 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 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 has the same symptoms as adults: spinal shock, swelling, breathing problems, problems with functioning 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:

1. Limit the victim's movements, place him on a hard surface and secure the damaged area using available means.
2. Give pain medication if necessary.
3. 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 sensory, motor and reflex functions 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 both in longitudinal and cross sections, 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 for analysis cerebrospinal fluid, detecting 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 the postoperative period, a course of intensive therapy is carried out to prevent side effects. 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 if the cervical spine is damaged or orthopedic corset when treating the thoracic or lumbar regions.

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 of inflammatory phenomena, antibiotics are taken wide range actions.

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 for recovery motor activity, prevention of bedsores and pelvic organ disorders. 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 active ingredients in tissues and cells.

For paralysis and paresis lower limbs Hydrogalvanic baths, underwater shower massage, and mud applications are used. Mud therapy can be replaced with ozokerite or paraffin.

For 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, and 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.

The fast pace of life makes us rush somewhere, hurry, run without looking back. But if you have an unfortunate fall, a sharp pain pierces your back. A disappointing diagnosis from the doctor’s lips interrupts the endless rush. Spinal cord injury is a scary word, but is it a death sentence?

What is a spinal cord injury?

The human spinal cord is reliably protected. It is covered by a strong bone frame of the spine, while being abundantly supplied with nutrients through the vascular network. Influenced various factors- external or internal - the activity of this stable system may be disrupted. All changes that develop after damage to the spinal substance, surrounding membranes, nerves and blood vessels are collectively known as “spinal cord injury.”

A spinal cord injury may be called spinal or, in the Latinized manner, spinal. There are also the terms “spinal cord injury” and “traumatic spinal cord disease.” If the first concept refers, first of all, to changes that arose at the time of damage, then the second describes the entire complex of developed pathologies, including secondary ones.

A similar pathology can affect any of the parts of the spine in which the spinal canal with the spinal cord passes:

• cervical;
• chest;
• lumbar.

The spinal cord is at risk of injury at any point

Classification of spinal injuries

There are several principles for classifying spinal cord injuries. Depending on the nature of the damage, they are:

• closed - not affecting soft tissues located nearby;
• open:
  • without penetration into the spinal canal;
  • penetrating:
    • tangents;
    • blind;
    • end-to-end.

The factors that provoked the damage are of considerable importance in further therapy.. According to their nature and impact, the following categories of injuries are distinguished:

• isolated, caused by point mechanical influence;
• combined, accompanied by damage to other tissues of the body;
• combined, arising under the influence of toxic, thermal, wave factors.

Depending on the nature of the damage, treatment tactics are chosen

Nosological classification is based on a detailed description of the affected tissues, types of damage and characteristic symptoms. Its system indicates the following types of damage:

• injuries to supporting and protective components:
  • spinal dislocation;
  • vertebral fracture;
  • fracture dislocation;
  • ligament rupture;
  • spinal bruise;
• injuries to nerve components:
  • spinal cord contusion;
  • shake;
  • contusion;
  • compression (squeezing);
    • acute - occurs in a short time;
    • subacute - forms over several days or weeks;
    • chronic - develops over months or years;
  • rupture (break) of the brain;
  • hemorrhage:
    • into the brain tissue (hematomyelia);
    • between shells;
  • damage to large vessels (traumatic infarction);
  • nerve root injuries:
    • pinching;
    • gap;
    • injury.

Causes and development factors

The causes of spinal cord injuries can be divided into three categories:

• traumatic - various mechanical impacts that provoke tissue destruction:
  • fractures;
  • dislocations;
  • hemorrhages;
  • bruises;
  • squeezing;
  • concussions;
• pathological - changes in tissues caused by painful conditions:
  • tumors;
  • infectious diseases;
  • circulatory disorders;
• congenital anomalies intrauterine development and hereditary pathologies.

Traumatic injuries are the most common category, occurring in 30–50 cases per 1 million inhabitants. The majority of injuries occur among able-bodied men aged 20–45 years.

Tumor changes are a common cause of pathological lesions of the spinal cord

Characteristic symptoms and signs of damage to various parts of the spinal cord

Symptoms of a spinal cord injury do not develop overnight; they change over time. Primary manifestations are associated with the destruction of a part nerve cells at the time of injury. Subsequent mass mortality can occur for a number of reasons:

• self-destruction (apoptosis) of damaged tissues;
• oxygen starvation;
• nutritional deficiencies;
• accumulation of toxic breakdown products.

Increasing changes divide the course of the disease into five periods:

1. Acute - up to 3 days after injury.
2. Early - up to 3 weeks.
3. Intermediate - up to 3 months
4. Late - several years after the injury.
5. Residual - long-term consequences.

IN initial periods symptoms are shifted to the side neurological symptoms(paralysis, loss of sensitivity), in the final stages - towards organic changes (dystrophy, tissue necrosis). Exceptions are concussions, which are characterized by a rapid course, and sluggish chronic diseases. The cause, location and severity of the injury have a direct impact on the range of likely symptoms.

Loss of sensation and motor activity directly depends on the location of the injury

Table: symptoms of spinal cord injuries

Type of damage	Spine department
	Cervical	Chest	Lumbar
Spinal nerve root injuries	sharp pain in the area: back of the head shoulder blades; numbness of the skin and muscles; impaired hand motor skills.	pain in the back and intercostal space, aggravated by sudden movements; stabbing pain radiating to the heart.	sharp pain (sciatica) in the lower back, buttocks, thighs; numbness and weakness in the limbs; in men - sexual dysfunction; Loss of control over urination and defecation.
Spinal cord contusion	swelling in the neck area; loss of sensation in the neck, shoulders and arms; weakened motor skills of the neck and arms; at severe injury- visual impairment and auditory perception, weakening of memory.	swelling and numbness at the point of injury; pain: in back; in heart; dysfunction: digestive; urinary; respiratory.	slight numbness at the site of injury; pain when standing or sitting; numbness and atrophy of the lower extremities.
Shake	General symptoms: loss of sensitivity at the site of injury; manifestations occur immediately after the moment of injury and last from several hours to several days.
	weakness and mild paralysis of the arms	difficulty breathing	mild paralysis of the legs; urinary disturbance.
Squeezing	discomfort in the area of ​​injury: loss of sensation; pain; burning - in chronic conditions; muscle weakness (paresis); spasms; paralysis.
Contusion	recurring muscle weakness; temporary paralysis; impaired reflexes; manifestations of spinal shock: system anomalies: increase or decrease in body temperature; excessive sweating; disturbances in the functioning of internal organs, including the heart; hypertension; bradycardia. Signs reach their maximum severity a few hours after the injury.
Fracture	spasms of the neck muscles; difficulty turning the head; limited mobility and sensitivity of the body below the neck; paresis; paralysis; spinal shock.	pain: at the point of injury; encircling; in a stomach; when moving; violation: digestion; urination; loss of sensation and motor activity of the lower extremities; spinal shock.
Dislocation	the neck is unnaturally tilted; pain: head; at the point of injury; weakness; dizziness; loss of sensation; paralysis.	pain radiating to the intercostal space; paraplegia; paresis; violation: digestion; respiratory functions.	pain radiating to the legs, buttocks, abdomen; paresis or paralysis of the muscles of the lower extremities; loss of sensation in the lower body.
Complete spinal cord interruption	Rare pathology. Signs: severe pain at the site of injury; complete irreversible loss of sensation and motor activity in the part of the body located below the break point.

Diagnosis of spinal cord injuries

Diagnosis of spinal cord injuries begins with clarifying the circumstances of the incident. During the interview of the victim or witnesses, primary neurological symptoms are established:

• motor activity in the first minutes after injury;
• manifestations of spinal shock;
• paralysis.

After delivery to the hospital, a detailed external examination with palpation is performed. At this stage, the patient's complaints are described:

• intensity and location of pain;
• memory and perception disorders;
• change in skin sensitivity.

Palpation reveals bone displacement, tissue swelling, unnatural muscle tension, and various deformities. Neurological examination reveals changes in reflexes.

For accurate diagnosis, it is necessary to use instrumental techniques. These include:

• computed tomography (CT);
• magnetic resonance imaging (MRI);
• spondylography is an X-ray examination of bone tissue. Performed in various projections:
  • front;
  • side;
  • oblique;
  • through an open mouth;
• myelography - radiography using a contrast agent. Varieties:
  • ascending;
  • descending
  • CT myelography;
• study of somatosensory evoked potentials (SSEP) - allows you to measure the conductivity of nervous tissue;
• vertebral angiography - a technique for studying the blood vessels that supply brain tissue;
• Electroneuromyography is a method that allows you to assess the condition of muscles and nerve endings:
  • superficial;
  • needle-shaped;
• Lumbar puncture with liquorodynamic tests is a method for studying the composition of cerebrospinal fluid.

The MRI method allows you to quickly identify changes in organs and tissues

The diagnostic techniques used make it possible to differentiate different types of spinal cord injuries from each other, depending on their severity and causes. The obtained result directly affects the tactics of further therapy.

Treatment

Considering the exceptional threat of spinal cord injuries to human life, all measures to save the victim are strictly regulated. Therapeutic measures are carried out through efforts medical personnel. Faces without special education can provide only the necessary first aid and only with clear information about the actions being performed.

First aid

Even with a slight suspicion of a spinal cord injury, first aid is provided as carefully as in the case of a proven fact of injury. In a worst-case scenario, the greatest risk to the victim is the fragments of the destroyed vertebrae. Shifting in motion, bone fragments can irreversibly damage the spinal cord and the vessels that supply it. To prevent such an outcome, the victim’s spine must be immobilized (immobilized). All actions must be performed by a group of 3-5 people acting carefully and synchronously. The patient should be placed on the stretcher quickly but smoothly, without sudden jerks, lifting only a few centimeters above the surface.

It should be noted that the stretcher for transporting the victim is placed under him. Carrying a non-immobilized patient even short distances is strictly prohibited.

The method of immobilization depends on the point of injury. A person with injuries in the cervical region is placed face up on a stretcher, after first fixing his neck using:

• a circle of soft fabric or cotton wool;
• Elansky tires;
• Kendrick tires;
• Shants collar.

Injuries to the thoracic or lumbar regions require transportation of the victim on a board or rigid stretcher. In this case, the body should be in a lying position on its stomach, with a thick cushion placed under the head and shoulders.

A person with a damaged spine can be transported in a lying position: on his stomach (a) and on his back (b)

If spinal shock develops, it may be necessary to normalize cardiac activity with atropine or dopamine. Severe pain syndrome requires the administration of analgesics (Ketanov, Promedol, Fentanyl). Saline solutions and their derivatives (Hemodez, Reopoliglyukin) are used for heavy bleeding. Broad-spectrum antibiotics (Ampicillin, Streptomycin, Ceftriaxone) are necessary to prevent infection.

If necessary, to save the life of the victim at the scene of the incident, the following may be carried out:

• cleaning the oral cavity from foreign bodies;
• artificial ventilation;
• indirect cardiac massage.

After emergency treatment, the patient should be immediately transported to the nearest neurosurgical facility. It is strictly prohibited:

• transport the victim in a sitting or lying position;
• influence the site of injury in any way.

Treatment in a hospital for bruises, concussions and other types of injuries

The range of treatment measures depends on the nature and severity of the injury. Minor injuries - bruises and concussions - require only drug therapy. Other types of injuries are treated in combination. In some situations that threaten irreversible changes in the spinal cord tissue, emergency surgical intervention is required - no later than 8 hours after the injury. Such cases include:

• spinal canal deformity;
• spinal cord compression;
• compression of the main vessel;
• hematomyelia.

It should be taken into account that extensive internal injuries can pose a threat to the patient's life during the operation. Therefore, in the presence of the following pathologies, immediate surgical intervention is contraindicated:

• anemia;
• internal bleeding;
• fat embolism;
• failure:
  • hepatic;
  • renal;
  • cardiovascular;
• peritonitis;
• penetrating chest trauma;
• severe skull injury;
• shock:
  • hemorrhagic;
  • traumatic.

Drug therapy

Drug treatment continues the tactics begun during first aid: combating pain syndrome, infections, cardiovascular manifestations. In addition, measures are being taken to preserve the damaged brain tissue.

1. Methylprednisolone increases metabolism in nerve cells and enhances microcirculation processes.
2. Seduxen and Relanium reduce the sensitivity of affected tissues to oxygen starvation.
3. Magnesium sulfate allows you to control the calcium balance, therefore normalizing the passage of nerve impulses.
4. Vitamin E functions as an antioxidant.
5. Anticoagulants (Fraxiparin) are prescribed to prevent thrombosis, the risk of which increases with prolonged immobility of the limbs due to spinal injuries.
6. Muscle relaxants (Baclofen. Mydocalm) relieve muscle spasms.

Photo gallery of medicines

Baclofen relieves muscle spasms Vitamin E is a powerful antioxidant Methylprednisolone enhances microcirculation processes Seduxen reduces the sensitivity of affected tissues to oxygen starvation Magnesium sulfate normalizes the passage of nerve impulses Fraxiparine is prescribed for the prevention of thrombosis

Decompression for spinal cord compression

Most often, the greatest threat to the victim is not direct damage to the spinal cord, but its compression by surrounding tissues. This phenomenon - compression - occurs at the time of injury, intensifying further due to pathological changes.Reducing pressure on the spinal cord (decompression) is the primary goal of therapy. In 80% of cases, skeletal traction is successfully used for this.

Fixation with traction reduces pressure on the spine

Surgical decompression is performed through direct access to the spine:

• anterior (pretracheal) – in case of injury to the cervical spine;
• anterolateral (retroperitoneal) – in case of damage to the lumbar vertebrae;
• lateral;
• rear

Vertebrae may be subject to:

• reposition - comparison of bone fragments;
• cornorectomy - removal of the vertebral body;
• laminectomy - removal of the arch or processes;
• discectomy - removal of intervertebral discs.

At the same time, normal innervation and blood supply to the affected area are restored. Once this is complete, the spine is stabilized with an autologous bone graft or metal implant. The wound is closed, the damaged area is fixed motionless.

Metal implants stabilize the spine after surgery

Video: surgery for a spinal fracture

Rehabilitation

The rehabilitation period after a spinal cord injury can last from several weeks to two years, depending on the extent of the damage. For successful recovery, it is necessary to maintain the relative integrity of the spinal cord - if it is completely interrupted, the regeneration process is impossible. In other cases, nerve cell growth occurs at a rate of about 1 mm per day. Rehabilitation procedures pursue the following goals:

• increased blood microcirculation in damaged areas;
• facilitating the delivery of medications to areas of regeneration;
• stimulation of cell division;
• preventing muscle dystrophy;
• improvement of the patient’s psycho-emotional state.

Proper nutrition

The basis of rehabilitation is a stable regime and proper nutrition. The patient's diet should include:

• chondroprotectors (jelly, sea fish);
• protein products (meat, liver, eggs);
• vegetable fats (olive oil);
• fermented milk products (kefir, cottage cheese);
• vitamins:
  • A (carrots, pumpkin, spinach);
  • B (meat, milk, eggs);
  • C (citrus fruits, rose hips);
  • D (seafood, kefir, cheese).

Exercise therapy and massage

Therapeutic exercise and massage are aimed at relieving spasms, improving muscle trophism, activating tissue metabolism and increasing spinal mobility.

Exercises should be started by the patient when his condition is stable, immediately after the removal of restrictive structures (plaster, bandages, skeletal traction). Preliminary radiography of the damaged spine is a prerequisite for this stage.

Loads during exercise therapy increase in stages: the first two weeks are characterized by minimal effort, the next four are increased, during the last two the exercises are performed while standing.

An example complex is:

Massage is ancient and effective method rehabilitation for back injuries. Given the sensitivity of a weakened spine, such mechanical manipulations should be performed by a person with knowledge and experience in the field of manual therapy.

Other physiotherapy techniques for recovery after injury

In addition, a variety of physiotherapeutic techniques are widely used for the rehabilitation of the victim:

• hydrokinesitherapy - gymnastics in an aquatic environment;
• acupuncture - a combination of acupuncture techniques with exposure to weak electrical impulses;
• iontophoresis and electrophoresis - methods of delivering drugs to tissues directly through the skin;
• mechanotherapy - rehabilitation methods involving the use of simulators;
• electrical neurostimulation - restoration of nerve conduction using weak electrical impulses.

The aquatic environment creates supportive conditions for the damaged spine, thereby accelerating rehabilitation

The psychological discomfort that arises in the victim due to forced immobility and isolation is helped to overcome by an occupational therapist - a specialist who combines the features of a rehabilitation therapist, psychologist and teacher. It is his participation that can restore lost hope and good spirits to the patient, which in itself significantly speeds up recovery.

Video: Dr. Bubnovsky about rehabilitation after spinal cord injuries

Treatment prognosis and possible complications

The prognosis of treatment depends entirely on the extent of the damage. Minor injuries do not affect many cells. Lost nerve circuits are quickly compensated by loose connections, so that their restoration occurs quickly and without consequences. Extensive organic damage is life-threatening to the victim from the first moment of its existence, and the prognosis for their treatment is ambiguous or completely disappointing.

The risk of complications increases greatly without the necessary assistance medical care as soon as possible.

Extensive damage to the spinal cord threatens many consequences:

• disruption of nerve fiber conduction due to rupture or hemorrhage (hematomyelia):
  • spinal shock;
  • violation of thermoregulation;
  • excessive sweating;
  • loss of sensation;
  • paresis;
  • paralysis;
  • necrosis;
  • trophic ulcers;
  • hemorrhagic cystitis;
  • hard tissue swelling;
  • sexual dysfunction;
  • muscle atrophy;
• spinal cord infection:
  • epiduritis;
  • meningomyelitis;
  • arachnoiditis;
  • abscess.

Prevention

There are no specific measures to prevent spinal cord injuries. You can simply limit yourself to taking good care of your body, maintaining it in proper physical shape, avoiding excessive physical exertion, shocks, concussions, and collisions. Routine examinations by a therapist will help identify hidden pathologies that threaten your back health.

Thank you

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!

Spinal injuries: prevalence, causes and consequences

Prevalence of spinal injuries

According to various authors, spinal injuries account for 2 to 12% of cases of traumatic lesions of the musculoskeletal system.
The average portrait of the victim: a man under 45 years old. In old age spinal injuries are observed with equal frequency in both men and women.

The prognosis for spinal injuries combined with spinal cord damage is always very serious. Disability in such cases is 80-95% (according to various sources). A third of patients with spinal cord injuries die.

Damage to the spinal cord is especially dangerous due to injuries to the cervical spine. Often such victims die at the scene from respiratory and circulatory arrest. The death of patients in a more distant period after injury is caused by hypostatic pneumonia due to impaired ventilation, urological problems and bedsores with transition to a septic state (blood poisoning).

Injuries to the spinal column and spinal cord in children, including birth trauma to the spine, are more amenable to treatment and rehabilitation due to the greater adaptive capabilities of the child’s body.

It should be noted that the consequences of spinal injuries are largely determined by the period of time from injury to the onset of complex treatment. In addition, very often ineptly provided first aid significantly aggravates the victim’s condition.

Treatment of spinal injuries is complex and lengthy, often requiring the participation of several specialists (traumatologist, neurosurgeon, rehabilitation specialist). Therefore, in many countries, patients with serious injuries to the spinal column are concentrated in specialized centers.

Anatomical structure of the spine and spinal cord

Anatomy of the spinal column

The spine consists of 31-34 vertebrae. Of these, 24 vertebrae are connected freely (seven cervical, twelve thoracic and five lumbar), and the rest are fused into two bones: the sacrum and the rudiment of the tail in humans - the coccyx.

Each vertebra consists of a body located anteriorly and an arch that limits the vertebral foramen posteriorly. The free vertebrae, with the exception of the first two, have seven processes: spinous, transverse (2), upper articular (2) and lower articular (2).
The articular processes of adjacent free vertebrae are connected in joints that have strong capsules, so that the spinal column is an elastic, movable joint.

The vertebral bodies are connected into a single whole by elastic fibrous discs. Each disc consists of an annulus fibrosus, within which is located the nucleus pulposus. This design:
1) ensures mobility of the spine;
2) absorbs shocks and loads;
3) stabilizes the spinal column as a whole.

The intervertebral disc is devoid of blood vessels, nutrients and oxygen is supplied by diffusion from neighboring vertebrae. Therefore, all restoration processes occur here too slowly, so that with age a degenerative disease develops - osteochondrosis.

Additionally, the vertebrae are connected by ligaments: longitudinal – anterior and posterior, interspinal or “yellow”, interspinous and supraspinous.

The first (atlas) and second (axial) cervical vertebrae are not similar to the others. They have been modified as a result of human upright walking and provide connection between the head and the spinal column.

Atlas does not have a body, but consists of a pair of massive lateral surfaces and two arches with upper and lower articular surfaces. The upper articular surfaces articulate with the condyles of the occipital bone and provide flexion and extension of the head, while the lower ones face the axial vertebra.

Between the lateral surfaces of the atlas there is a transverse ligament, in front of which there is a medulla, and posteriorly the process of the axial vertebra, called the tooth. The head, together with the atlas, rotates around the tooth, and the maximum angle of rotation in any direction reaches 90 degrees.

Anatomy of the spinal cord

Located inside the spinal column, the spinal cord is covered with three membranes, which are a continuation of the membranes of the brain: hard, arachnoid and soft. Downwards it narrows, forming a medullary cone, which at the level of the second lumbar vertebra passes into the terminal filum, surrounded by the roots of the lower spinal nerves (this bundle is called the cauda equina).

Normally, between the spinal canal and its contents there is a reserve space that allows you to painlessly tolerate natural movements of the spine and minor traumatic displacements of the vertebrae.

The spinal cord in the cervical and lumbosacral regions has two thickenings, which are caused by the accumulation of nerve cells to innervate the upper and lower extremities.

The spinal cord is supplied with blood by its own arteries (one anterior and two posterior spinal arteries), which send small branches deep into the brain substance. It has been established that some areas are supplied from several branches at once, while others have only one supply branch. This network is fed by the radicular arteries, which are variable and absent in some segments; at the same time, sometimes one radicular artery supplies several segments at once.

For deforming injury blood vessels they are bent, compressed, overstretched, their internal lining is often damaged, resulting in the formation of thrombosis, which leads to secondary circulatory disorders.

It has been clinically proven that spinal cord lesions are often associated not with a direct traumatic factor (mechanical trauma, compression by vertebral fragments, etc.), but with blood supply disorders. Moreover, in some cases, due to the peculiarities of blood circulation, secondary lesions can cover quite large areas beyond the influence of the traumatic factor.

Therefore, in the treatment of spinal injuries complicated by damage to the spinal cord, prompt elimination of the deformity and restoration of normal blood supply are indicated.

Classification of spinal injuries

Spinal injuries are divided into closed (without damage to the skin and tissues covering the vertebra) and open (gunshot wounds, bayonet wounds, etc.).
Topographically distinguish injuries different departments spine: cervical, thoracic and lumbar.

Based on the nature of the damage, the following are distinguished:

• bruises;
• distortions (tears or ruptures of ligaments and bursae of vertebral joints without displacement);
• fractures of the spinous processes;
• transverse process fractures;
• vertebral arch fractures;
• vertebral body fractures;
• subluxations and dislocations of the vertebrae;
• fracture-dislocations of the vertebrae;
• traumatic spondylolisthesis (gradual anterior displacement of the vertebra due to destruction of the ligamentous apparatus).

In addition, great clinical significance distinguishes between stable and unstable injuries.
Unstable spinal injury is a condition in which the resulting deformity may worsen in the future.

Unstable injuries occur with combined damage to the posterior and anterior parts of the spine, which often occurs with a flexion-rotation mechanism of injury. Unstable injuries include dislocations, subluxations, fracture-dislocations, spondylolisthesis, and shear and sprain injuries.

Clinically important is the division of all spinal injuries into uncomplicated (without damage to the spinal cord) and complicated.

There is the following classification of spinal cord injuries:
1. Reversible functional impairment (concussion).
2. Irreversible damage (bruise or concussion).
3. Spinal cord compression syndrome (can be caused by splinters and fragments of parts of the vertebrae, fragments of ligaments, nucleus pulposus, hematoma, edema and swelling of tissue, as well as several of these factors).

Symptoms of spinal injuries

Symptoms of Stable Spinal Injuries

Stable spinal injuries include contusion, distortion (rupture of ligaments without displacement), fractures of the spinous and transverse processes, and whiplash injuries.

When a spinal bruise occurs, victims complain of diffuse pain at the site of injury. During the examination, swelling and hemorrhage are detected, movements are slightly limited.
Distortions usually occur during sudden lifting of heavy objects. They are characterized by acute pain, severe limitation of movements, pain when pressing on the spinous and transverse processes. Sometimes the phenomena of radiculitis are added.

Fractures of the spinous processes are not often diagnosed. They arise both as a result of the direct application of force and as a result of strong muscle contraction. The main signs of spinous process fractures are: sharp pain on palpation; sometimes you can feel the mobility of the damaged process.

Fractures of the transverse processes are caused by the same reasons, but are more common.
They are characterized by the following symptoms:
Payra's symptom: localized pain in the paravertebral region, increasing when turning in the opposite direction.

Symptom of a stuck heel: when lying on the back, the patient cannot lift the straightened leg from the bed on the affected side.

In addition, diffuse pain is observed at the site of injury, sometimes accompanied by radiculitis symptoms.

Whiplash injuries, which are common in intravehicular accidents, are usually classified as stable spinal injuries. However, quite often they have severe neurological symptoms. Spinal cord lesions are caused by both direct contusion during injury and circulatory disorders.

The extent of damage depends on age. In older people, due to age-related changes in the spinal canal (osteophytes, osteochondrosis), the spinal cord is more severely injured.

Signs of mid- and lower-cervical spine injuries

Injuries to the middle and lower cervical vertebrae occur in car accidents (60%), diving (12%) and falls from a height (28%). Currently, injuries to these departments account for up to 30% of all spinal injuries, a third of them occur with lesions of the spinal cord.

Dislocations, subluxations and fracture-dislocations occur quite often due to the special mobility of the lower cervical spine, and are classified into tipping and sliding. The former are characterized by pronounced kyphosis (convexity posteriorly) and widening of the interspinous space due to rupture of the supraspinous, interspinous, interspinal and posterior longitudinal ligaments. With sliding injuries, a bayonet-shaped deformity of the spine and fractures of the articular processes are observed. The victims are bothered by severe pain and a forced position of the neck (the patient supports his head with his hands). Spinal cord injuries are common, the severity of which largely determines the prognosis.

Isolated fractures of the third to seventh cervical vertebrae are diagnosed quite rarely. Characteristic sign: pain in a damaged vertebra with dynamic load on the patient’s head (pressure on the top of the head).

Symptoms of thoracic and lumbar spine injuries

Injuries of the thoracic and lumbar spine are characterized by fractures and fracture-dislocations; isolated dislocations occur only in the lumbar region, and then extremely rarely, due to limited mobility.

There are many classifications of injuries to the thoracic and lumbar spine, but they are all complex and cumbersome. The simplest is clinical.

According to the degree of damage, which depends on the magnitude of the applied force directed at an angle to the axis of the spine, the following are distinguished:

• wedge-shaped fractures (the shell of the vertebral body and part of the substance are damaged, so that the vertebra takes a wedge-shaped shape; such fractures are mostly stable and subject to conservative treatment);
• wedge-comminuted (the entire thickness of the vertebral body and the upper closure is damaged, so that the process affects the intervertebral disc; the injury is unstable, and in some cases requires surgical intervention; may be complicated by damage to the spinal cord);
• fracture-dislocations (destruction of the vertebral body, multiple damage to the ligamentous apparatus, destruction of the fibrous ring of the intervertebral disc; the injury is unstable and requires immediate surgical intervention; as a rule, such lesions are complicated by damage to the spinal cord).

Separately, we should highlight compression fractures that occur as a result of load along the axis of the spine (when falling on the legs, compression fractures occur in the lower thoracic and lumbar regions, and when falling on the head - in the upper thoracic). With such fractures, a vertical crack forms in the vertebral body. The severity of the lesion and treatment tactics will depend on the degree of divergence of the fragments.

Fractures and fracture-dislocations of the thoracic and lumbar regions have the following symptoms: increased pain in the fracture zone with dynamic load along the axis, as well as when tapping on the spinous processes. The protective tension of the rectus dorsi muscles (muscle ridges located on the sides of the spine) and abdomen is expressed. The latter circumstance requires differential diagnosis with damage to internal organs.

Signs of spinal cord damage

Movement disorders

Motor disorders in spinal cord injuries, as a rule, are symmetrical. Exceptions include puncture wounds and cauda equina injuries.

Severe lesions of the spinal cord lead to a lack of movement in the limbs immediately after the injury. The first signs of restoration of active movements in such cases can be detected no earlier than a month later.

Motor disorders depend on the level of damage. The critical level is the fourth cervical vertebra. Paralysis of the diaphragm, which develops with lesions of the upper and middle cervical areas of the spinal cord, leads to respiratory arrest and death of the patient. Damage to the spinal cord in the lower cervical and thoracic segments leads to paralysis of the intercostal muscles and breathing problems.

Sensory disorders

Damage to the spinal cord is characterized by disturbances of all types of sensitivity. These disorders are both quantitative (decreased sensitivity up to complete anesthesia) and qualitative in nature (numbness, crawling sensation, etc.).

The degree of severity, nature and topography of sensitivity impairment is important diagnostic value, as it indicates the location and severity of the spinal cord injury.

It is necessary to pay attention to the dynamics of violations. A gradual increase in signs of sensory impairment and motor disorders is characteristic of compression of the spinal cord by bone fragments, fragments of ligaments, hematoma, a shifting vertebra, as well as circulatory disorders due to compression of blood vessels. Such conditions are an indication for surgical intervention.

Visceral-vegetative disorders

Regardless of the location of the damage, visceral-vegetative disorders manifest themselves primarily in disturbances in the functioning of the pelvic organs (retention of stool and urination). In addition, with high damage, there is a mismatch in the activity of the digestive tract organs: increased excretion gastric juice and pancreatic enzymes while reducing the secretion of intestinal juice enzymes.

The speed of blood flow in tissues is sharply reduced, especially in areas with reduced sensitivity, microlymph drainage is impaired, and the phagocytic ability of blood neutrophils is reduced. All this contributes to the rapid formation of bedsores that are difficult to treat.

Complete rupture of the spinal cord often manifests itself in the formation of extensive bedsores, ulceration gastrointestinal tract with massive bleeding.

Treatment of spine and spinal cord injuries

Basic principles of treatment of spinal cord and spinal cord injuries: timeliness and adequacy of first aid, compliance with all rules when transporting victims to a specialized department, long-term treatment with the participation of several specialists and subsequent repeated rehabilitation courses.

When providing first aid, much depends on the timely diagnosis of injury. You should always remember that in the event of car accidents, falls from a height, building collapses, etc., it is necessary to take into account the possibility of damage to the spinal column.

When transporting victims with spinal injuries, all precautions must be taken so as not to worsen the damage. Such patients should not be transported in a sitting position. The victim is placed on a shield. In this case, an inflatable mattress is used to prevent bedsores. If the cervical spine is affected, the head is additionally immobilized using special devices (splints, head collar, etc.) or improvised means (sandbags).

If a soft stretcher is used to transport a patient with a spinal injury, the victim should be placed on his stomach, and a thin pillow should be placed under the chest for additional extension of the spine.

Depending on the type of spinal injury, treatment at the hospital stage can be conservative or surgical.

For relatively mild, stable spinal injuries (distortions, whiplash injuries, etc.), bed rest, massage, and thermal procedures are indicated.

In more severe cases, conservative treatment consists of closed correction of deformities (simultaneous reduction or traction) followed by immobilization (special collars and corsets).

Open surgical removal of the deformity relieves compression of the spinal cord and helps restore normal blood circulation to the affected area. Therefore, increasing symptoms of spinal cord damage, indicating its compression, are always an indication for urgent surgical intervention.

Surgical methods are also used in cases where conservative treatment is ineffective. Such operations are aimed at reconstructing damaged segments of the spine. In the postoperative period, immobilization is used, and if indicated, traction is used.

Victims with signs of spinal cord injury are hospitalized in the intensive care unit. In the future, such patients are supervised by a traumatologist, neurosurgeon and rehabilitation specialist.

Rehabilitation after spinal and spinal cord injuries

Recovery from spinal injuries is a rather lengthy process.
For spinal injuries not complicated by damage to the spinal cord, exercise therapy is indicated from the first days of the injury: first it consists of breathing exercises, and from the second week, limb movements are allowed. The exercises are gradually made more difficult, focusing on the general condition of the patient. In addition to exercise therapy, massage and thermal procedures are successfully used for uncomplicated spinal injuries.

Rehabilitation for spinal cord injuries is supplemented by electrical pulse therapy and acupuncture. Drug treatment includes a number of drugs that enhance regeneration processes in nervous tissue (methyluracil), improve blood circulation (Cavinton) and intracellular metabolic processes (nootropil).

To improve metabolism and speed up recovery after injury, anabolic hormones and tissue therapy (vitreous body, etc.) are also prescribed.

Today, new neurosurgical methods are being developed (transplantation of embryonic tissues), methods of performing operations that reconstruct the affected segment are being improved, clinical trials new medicines.

The difficulties of treatment and rehabilitation after spinal injuries are associated with the emergence of a new branch of medicine - vertebrology. The development of the region is of great social importance, since, according to statistics, spinal injuries lead to disability for the most active part of the population.

There are contraindications. Before use, you should consult a specialist.

Causes emergency conditions with spinal lesions they can be traumatic or non-traumatic.

TO non-traumatic reasons include:

• Medullary processes:
  • inflammation of the spinal cord: myelitis, viral and autoimmune
  • medullary tumors (gliomas, ependymomas, sarcomas, lipomas, lymphomas, “drip” metastases); paraneoplastic myelopathies (eg, bronchial carcinoma and Hodgkin's disease)
  • radiation myelopathy in the form of acute, from incomplete to complete, symptoms of damage at a certain level of the spinal cord at radiation doses of 20 Gy with a latency from several weeks to months and years
  • vascular spinal syndromes: spinal ischemia (eg, after aortic surgery or aortic dissection), vasculitis, embolism (eg, decompression sickness), vascular compression (eg, due to mass effect) and spinal arteriovenous malformations, angiomas, cavernomas or dural fistulas ( with venous stagnation and congestive ischemia or hemorrhage)
  • metabolic myelopathy (with acute and subacute course); funicular myelosis with vitamin B12 deficiency; hepatic myelopathy in liver failure
• Extramedullary processes:
  • purulent (bacterial) spondylodiscitis, tuberculous spondylitis (Pott's disease), mycotic spondylitis, epi- or subdural abscess;
  • chronic inflammatory rheumatic diseases of the spine, such as rheumatoid arthritis, seronegative spondyloarthropathy (ankylosing spondylitis), psoriatic arthropathy, enteropathic arthropathy, reactive spondyloarthropathy, Reiter's disease;
  • extramedullary tumors (neurinomas, meningiomas, angiomas, sarcomas) and metastases (for example, bronchial cancer, multiple myeloma [plasmocytoma]);
  • spinal subdural and epidural hemorrhages due to bleeding disorders (anticoagulation!), condition after injury, lumbar puncture, epidural catheter and vascular malformations;
  • degenerative diseases such as osteoporotic fractures of the spine, spinal canal stenosis, herniated intervertebral discs.

TO traumatic reasons include:

• Contusions, spinal cord injuries
• Traumatic hemorrhages
• Vertebral body fracture/dislocation

Non-traumatic spinal cord injuries

Spinal cord inflammation/infection

Frequent causes of acute myelitis are, first of all, multiple sclerosis and viral inflammation; however, in more than 50% of cases, pathogens are not detected.

Risk factors for spinal infection are:

• Immunosuppression (HIV, immunosuppressive drug therapy)
• Diabetes
• Alcohol and drug abuse
• Injuries
• Chronic liver and kidney diseases.

Against the background of systemic infection (sepsis, endocarditis), especially in the above risk groups, additional spinal manifestations of infection may also be observed.

Spinal ischemia

Spinal ischemia, compared to cerebral ischemia, is rare. In this regard, a beneficial effect is primarily due to good collateralization of the blood flow of the spinal cord.

The causes of spinal ischemia are considered:

• Arteriosclerosis
• Aortic aneurysm
• Surgeries on the aorta
• Arterial hypotension
• Vertebral artery occlusion/dissection
• Vasculitis
• Collagenosis
• Embolic vascular occlusion (eg, decompression sickness in divers)
• Spinal space-occupying processes (intervertebral discs, tumor, abscess) with vascular compression.

In addition, there are also idiopathic spinal ischemia.

Spinal cord tumors

According to anatomical location, spinal tumors/mass processes are divided into:

• Vertebral or extradural tumors (eg, metastases, lymphomas, multiple myeloma, schwannomas)
• Spinal cord tumors (spinal astrocytoma, ependymoma, intradural metastases, hydromyelia/syringomyelia, spinal arachnoid cysts).

Hemorrhage and vascular malformations

Depending on the compartments there are:

• Epidural hematoma
• Subdural hematoma
• Spinal subarachnoid hemorrhage
• Hematomyelia.

Spinal hemorrhages are rare.

The reasons are:

• Diagnostic/therapeutic measures such as lumbar puncture or epidural catheter
• Oral anticoagulation
• Bleeding disorders
• Malformations of spinal vessels
• Injuries
• Tumors
• Vasculitis
• Manual therapy
• Rarely, aneurysms in the cervical spine (vertebral artery)

Vascular malformations include:

• Dural arteriovenous fistulas
• Arteriovenous malformations
• Cavernous malformations and
• Spinal angiomas.

Symptoms and signs of non-traumatic spinal cord injuries

The clinical picture in spinal emergencies depends mainly on the underlying etiopathogenesis and location of the lesion. Such conditions usually manifest as acute or subacute neurological deficits, which include:

• Sensitization disorders (hypoesthesia, par- and dysesthesia, hyperpathia) are usually caudal to the spinal cord injury
• Motor deficits
• Autonomic disorders.

The symptoms of prolapse can be lateralized, but also manifest themselves in the form of acute symptoms of transverse spinal cord lesions.

Ascending myelitis may result in brainstem involvement with cranial nerve loss and dative failure, which clinically may correspond to the pattern of Landry's palsy (=ascending flaccid paralysis).

Back pain, often pulling, stabbing or dull, are felt primarily during extramedullary inflammatory processes.

For local inflammation fever may initially be absent and develops only after hematogenous dissemination.

Spinal tumors at first they are often accompanied by back pain, which intensifies with percussion of the spine or with exercise; neurological deficits do not necessarily have to be present. Radicular pain can occur when nerve roots are damaged.

Symptoms spinal ischemia develops over a period of minutes to hours and usually covers the basin of the vessel:

• Anterior spinal artery syndrome: often radicular or encircling pain, flaccid tetra- or paraparesis, lack of pain and temperature sensitivity while maintaining vibration sensitivity and joint-muscular sensation
• Sulcocommissural artery syndrome
• Posterior spinal artery syndrome: loss of proprioception with ataxia when standing and walking, sometimes paresis, bladder dysfunction.

Spinal hemorrhages characterized by acute - often unilateral or radicular - back pain, usually with incomplete symptoms of transverse spinal cord lesions.

Due to malformations of spinal vessels Slowly progressive symptoms of transverse spinal cord lesions often develop, sometimes fluctuating or paroxysmal.

At metabolic disorders It is necessary, first of all, to remember about vitamin B12 deficiency with the picture of funicular myelosis. It often occurs in patients with pernicious anemia (eg, Crohn's disease, celiac disease, malnutrition, strict vegetarian diet) and slowly progressive motor deficits, such as spastic paraparesis and gait disturbances, and sensory loss (paresthesia, decreased vibration sensitivity). ). Additionally, cognitive functions usually deteriorate (confusion, psychomotor retardation, depression, psychotic behavior). Rarely, in case of liver dysfunction (mainly in patients with portosystemic shunt), hepatic myelopathy develops with damage to the pyramidal tracts.

Polio classically occurs in several stages and begins with fever, followed by a meningitis stage until the development of the paralytic stage.

Spinal syphilis with tabes spinal cord (myelitis of the posterior/lateral cord of the spinal cord) as late stage Neurosyphilis is accompanied by progressive paralysis, sensory disturbances, stabbing or cutting pain, loss of reflexes and bladder dysfunction.

Myelitis due to tick-borne encephalitis often associated with “severe transverse symptoms” with lesions upper limbs, cranial nerves and diaphragm and has a poor prognosis.

Neuromyelitis optica(Devick's syndrome) is an autoimmune disease that predominantly affects young women. It is characterized by signs of acute (transverse) myelitis and optic neuritis.

Radiation myelopathy develops after irradiation, usually with a latency of several weeks to months and can manifest itself as acute spinal symptoms (paresis, sensory disturbances). The diagnosis is indicated by medical history, including the size of the radiation field.

Diagnosis of non-traumatic spinal cord injuries

Clinical examination

The localization of damage is determined by examining sensory dermatomes, myotomes and stretch reflexes of skeletal muscles. The study of vibration sensitivity, including the spinous processes, helps in determining the level of localization.

Autonomic disorders can be determined, for example, through the tone of the anal sphincter and impaired bladder emptying with the formation of residual urine or incontinence. Limited inflammation of the spine and adjacent structures is often accompanied by pain when tapping and squeezing.

Symptoms of spinal inflammation can initially be completely nonspecific, which significantly complicates and slows down diagnosis.

Difficulties arise in differentiating pathogen-caused and parainfectious myelitis. In the latter case, an asymptomatic interval between the previous infection and myelitis is often described.

Visualization

If a spinal process is suspected, the method of choice is MRI in at least two projections (sagittal + 33 axial).

Spinal ischemia, inflammatory foci, metabolic changes and tumors are especially well visualized on T2-weighted images. Inflammatory or edematous changes, as well as tumors, are well imaged in STIR sequences. After the administration of a contrast agent, blooming inflammatory foci and tumors are usually well differentiated in T1 sequences (sometimes subtraction of the original T1 from T1 after the administration of a contrast agent for more accurate delineation of contrast). If osseous involvement is suspected, T2 or STIR sequences with fat saturation, or T1 after administration of a contrast agent, are appropriate for better differentiation.

Spinal hemorrhages can be recognized on CT for emergency diagnosis. The method of choice for better anatomical and etiological classification, however, is MRI. Hemorrhages appear differently on MRI depending on their stage (< 24 часов, 1-3 дня и >3 days). If there are contraindications to MRI, then a CT scan of the spine with contrast is performed to assess bone damage and clarify the issue of significant mass effects in extramedullary inflammatory processes.

To minimize the radiation dose received by the patient, it is advisable to determine the level of damage based on clinical picture.

In rare cases (functional imaging, intradural space-occupying processes with bone involvement), it is advisable to perform myelography with postmyelographic computed tomography.

Degenerative changes, fractures and osteolysis of the vertebral bodies can often be recognized on a regular x-ray.

CSF examination

An important role is played by cytological, chemical, bacteriological and immunological analysis of cerebrospinal fluid.

Bacterial inflammation usually accompanied by a marked increase in cell number (> 1000 cells) and total protein. If you suspect bacterial infection it is necessary to strive to isolate the pathogen by inoculating the cerebrospinal fluid for flora or PCR method. If there are signs of systemic inflammation, the bacterial pathogen is detected by blood culture.

At viral inflammations Apart from a slight to moderate increase in number (usually 500 to a maximum of 1000 cells), there is usually only a slight increase in protein levels. On viral infection may indicate the detection of specific antibodies (IgG and IgM) in the cerebrospinal fluid. The formation of antibodies in the cerebrospinal fluid can be reliably confirmed by determining the specific antibody avidity index (AI). An index >1.5 is suspicious, and values ​​>2 indicate the formation of antibodies in the central nervous system.
Antigen detection by PCR is a fast and reliable method. This method can, in particular, provide important information in the early phase of infection, when the humoral immune response is still insufficient. In autoimmune inflammation, slight pleocytosis is observed (< 100 клеток), а также нарушения гематоэнцефалического барьера и повышение уровня белков

In multiple sclerosis, oligoclonal bands are found in the cerebrospinal fluid in more than 80% of patients. Neuromyelitis optica is associated with the presence of specific antibodies to aquaporin 4 in the serum in more than 70% of patients.

Other diagnostic measures

Routine laboratory diagnostics, complete blood count and C-reactive protein do not always help in the case of isolated inflammatory spinal processes, and often in the initial phase no anomalies are detected in the tests, or only minor changes are present. However, an increase in the level of C-reactive protein in bacterial spinal inflammation is a nonspecific sign that should lead to a detailed diagnosis.

Pathogens are identified by bacterial blood culture, sometimes by biopsy (CT-guided puncture for abscess or discitis) or intraoperative sampling.

Electrophysiological studies serve to diagnose functional damage nervous system and, above all, to assess the prognosis.

Differential diagnosis

Attention: this phenomenon in the cerebrospinal fluid can occur during “cerebrospinal fluid blockade” (in the absence of cerebrospinal fluid flow as a result of mechanical displacement of the spinal canal).

Differential diagnosis of non-traumatic spinal injuries includes:

• Acute polyradiculitis (Guillain-Barré syndrome): acute “ascending” sensorimotor deficits; It is usually possible to differentiate myelitis on the basis of typical cell-protein dissociation in the cerebrospinal fluid with an increase in total protein while maintaining a normal number of cells.
• Hyper- or hypokalemic paralysis;
• Syndromes with polyneuropathy: chronic inflammatory demyelinating polyneuropathy with acute deterioration, borreliosis, HIV infection, CMV infection;
• Myopathic syndromes (myasthenia gravis, dyskalemic paralysis, rhabdomyolysis, myositis, hypothyroidism): usually an increase in creatine kinase, and in dynamics there is a typical picture on the EMG;
• Parasagittal cortical syndrome (eg, falx cerebri tumor);
• Psychogenic symptoms of transverse spinal cord lesions.

Complications of emergency conditions with spinal lesions

• Long-term sensorimotor deficits (paraparesis/paraplegia) with increased risk
  • deep vein thrombosis (prevention of thrombosis)
  • contractures
  • spasticity
  • bedsores
• With high cervical injuries, there is a risk of respiratory disorders - increased risk of pneumonia, atelectasis
• Autonomic dysreflexia
• Impaired bladder function, increased risk of urinary tract infections up to urosepsis
• Bowel dysfunction - risk of excessive bloating, paralytic ileus
• Temperature regulation disorders in the case of lesions located at the level of 9-10 thoracic vertebrae with a risk of hyperthermia
• Increased risk of orthostatic hypotension

Treatment of non-traumatic spinal cord injuries

Spinal cord inflammation

In addition to specific therapy directed against the pathogen, general measures should first be carried out, such as installation urinary catheter for bladder emptying disorders, prevention of thrombosis, changing the patient's position, timely mobilization, physiotherapy and pain therapy.

General therapy: drug therapy depends mainly on the etiopathogenesis of the spinal lesion or on the causative agent. Often in the initial phase it is not possible to unambiguously establish the etiology or isolate pathogens, so the choice of drugs is carried out empirically, depending on the clinical course and results laboratory diagnostics and studies of cerebrospinal fluid, as well as on the expected spectrum of pathogens.

Initially, broad combination antibiotic therapy should be carried out using an antibiotic acting on the central nervous system.

In principle, antibiotics or virostatic agents should be used purposefully.

The choice of drugs depends on the results of a study of bacteriological cultures of blood and cerebrospinal fluid or cerebrospinal fluid punctures (an angiogram is required!), as well as on the results of serological or immunological studies. In the case of a subacute or chronic course of the disease, if the clinical situation allows it, a targeted diagnosis should first be carried out, if possible, with isolation of the pathogen, and, if necessary, a differential diagnosis.

In case of bacterial abscesses, in addition to antibiotic therapy (if this is possible from an anatomical and functional point of view), the possibility should be discussed and an individual decision made on neurosurgical sanitation of the lesion.

Specific therapy:

• idiopathic acute transverse myelitis. There are no randomized, placebo-controlled studies that clearly support the use of cortisone therapy. By analogy with the treatment of other inflammatory diseases and based on clinical experience, 3-5 days of intravenous cortisone therapy with methylprednisolone at a dose of 500-1000 mg is often carried out. Patients with severe clinical conditions may also benefit from more aggressive cyclophosphamide therapy and plasmapheresis.
• myelitis associated with herpes simplex and herpetic herpes zoster: acyclovir.
• CMV infections: ganciclovir. In rare cases of intolerance to acyclovir due to infections with HSV, varicella-zoster virus or CMV, foscarnet can also be used.
• neuroborreliosis: 2-3 weeks of antibiosis with ceftriaxone (1x2 g/day intravenously) or cefotaxime (3x2 g/day intravenously).
• neurosyphilis: penicillin G or ceftriaxone 2-4 g/day intravenously (duration of therapy depends on the stage of the disease).
• tuberculosis: multi-month four-component combination therapy rifampicin, isoniazid, ethambutol and pyrazinamide.
• spinal abscesses with progressive neurological loss (for example, a myelopathic signal on MRI) or pronounced signs of a space-occupying process require urgent surgical intervention.
• Spondylitis and spondylodiscitis are often treated conservatively with immobilization and (if possible, targeted) antibiotic therapy for a minimum of 2-4 weeks. Antibiotics that are effective against the central nervous system for Gram-positive pathogens include, for example, fosfomycin, ceftriaxone, cefotaxime, meropenem and linezolid. In the case of tuberculous osteomyelitis, multi-month anti-tuberculosis combination therapy is indicated. If there is no effect or severe symptoms, first
  In total, bone destruction with signs of instability and/or depression of the spinal cord may require surgical sanitation with removal of the intervertebral disc and subsequent stabilization. Surgical measures should be discussed primarily for compression of neural structures.
• - neurosarcoidosis, neuro-Behçet, lupus erythematosus: immunosuppressive therapy; Depending on the severity of the disease, cortisone and, mainly with long-term therapy, also methotrexate, azathioprine, cyclosporine and cyclophosphamide are used.

Spinal ischemia

Therapeutic options for spinal ischemia are limited. There are no evidence-based medicine recommendations. The priority is to restore or improve spinal circulation to prevent further damage. Accordingly, it is necessary, as far as possible, to therapeutically influence the underlying causes of spinal ischemia.

In case of vascular occlusion, blood clotting (anticoagulation, heparinization) should be taken into account. The use of cortisone is not recommended due to potential side effects.

In the initial phase, the basis of therapy is control and stabilization of vital important functions, as well as the prevention of complications (infections, bedsores, contractures, etc.). In the future, neurorehabilitation measures are indicated.

Tumors

In the case of isolated space-occupying processes with spinal cord compression, urgent surgical decompression is necessary. The longer the spinal cord injury is present or continues (>24 hours), the worse the chances of recovery. In case of radiosensitive tumors or metastases, the possibility of irradiation is considered.

Other therapeutic options, depending on the type of tumor, its extent and clinical symptoms, include conservative therapy, irradiation (including gamma knife), chemotherapy, thermocoagulation, embolization, vertebroplasty, and if there are signs of instability, various stabilization measures. Therapeutic approaches should be discussed interdisciplinaryly, together with neurologists, neurosurgeons/trauma surgeons/orthopedic oncologists (radiation therapy specialists).

For spinal mass lesions with edema, cortisone is used (eg hydrocortisone 100 mg per day, according to the standards of the German Society of Neurology 2008, alternatively dexamethasone, eg 3 x 4-8 mg/day). The duration of treatment depends on the clinical course and/or changes in imaging findings.

Spinal hemorrhages

Depending on the clinical course and extensive nature of the process, sub- or epidural spinal hemorrhage may require surgical intervention (often decompressive laminectomy with blood aspiration).

For small hemorrhages without signs of mass effect and with minor symptoms, a conservative wait-and-see approach with monitoring the dynamics of the process is initially justified.

Spinal vascular malformations respond well to endovascular therapy (embolization). First of all, type I arteriovenous malformations (= fistulas) can often be “clogged.” Other arteriovenous malformations cannot always be occluded, but their size can often be reduced.

Prognosis for non-traumatic spinal cord injuries

Prognostically unfavorable factors for inflammatory spinal cord injuries include:

• Initially rapidly progressive course
• Duration of neurological loss more than three months
• Detection of protein 14-3-3 in the cerebrospinal fluid as a sign of neuronal damage
• Abnormal motor and sensory evoked potentials, as well as signs of denervation on the EMG.

Approximately 30-50% of patients with acute transverse myelitis have a poor outcome with residual severe disability, while the prognosis in the case of multiple sclerosis better than in patients with other causes of transverse spinal cord syndrome.

The prognosis of spondylitis/spondylodiscitis and spinal abscesses depends on the size and duration of damage to neural structures. Decisive factor is therefore timely diagnosis and therapy.

The prognosis of spinal ischemia, due to limited therapeutic options, is poor. Most patients have persistent neurological deficits, depending primarily on the type of primary lesion.

The prognosis for spinal space-occupying processes depends on the type of tumor, its prevalence, the extent and duration of damage to neural structures and the possibilities or effect of therapy.

The prognosis of spinal hemorrhages is determined mainly by the severity and duration of neurological deficits. With minor hemorrhages and conservative tactics, the prognosis in most cases can be favorable.

Traumatic spinal cord injury

Spinal injuries occur as a result of high-energy force. TO usual reasons relate:

• High speed accident
• Fall from high altitude And
• Direct force.

Depending on the mechanism of the accident, axial forces can lead to compression fractures of one or more vertebrae, as well as flexion-extension injuries of the spine with distraction and rotation components.

Up to 15-20% of patients with severe traumatic brain injury have associated cervical spine injuries. Approximately 15-30% of patients with polytrauma have spinal injuries. It is fundamentally recognized to distinguish the anterior, middle and posterior column or column in the spine ( three-column model Denis), and the anterior and middle columns of the spine include the vertebral bodies, and the posterior columns include their dorsal segments.

A detailed description of the type of injury, reflecting functional and prognostic criteria, is classification of injuries of the thoracic and lumbar spine, according to which spinal injuries are divided into three main types A, B and C, where each category includes three further subtypes and three subgroups. Instability increases in the direction from type A to type C and within the corresponding subgroups (from 1st to 3rd).

For upper cervical spine injuries, due to anatomical and biomechanical features, there is separate classification.

In addition to fractures, the following injuries occur with spinal injuries:

• Hemorrhages in the spinal cord
• Contusions and swelling of the spinal cord
• Spinal cord ischemia (due to compression or rupture of arteries)
• Ruptures and displacements of intervertebral discs.

Symptoms and signs of traumatic spinal cord injuries

In addition to the medical history (primarily the mechanism of the accident), the clinical picture plays a decisive role in further diagnostic and therapeutic measures. The following are the main clinical aspects traumatic spinal injuries:

• Pain in the area of ​​the fracture when tapping, squeezing, or moving
• Stable fractures are usually less painful; unstable fractures often cause more severe pain with limited movement
• Hematoma at the fracture site
• Spinal deformity (eg, hyperkyphosis)
• Neurological loss: radicular pain and/or sensory disturbances, symptoms of incomplete or complete transverse lesion of the spinal cord, dysfunction of the bladder and rectum in men, sometimes priapism.
• Respiratory failure in high cervical paralysis (C Z-5 innervates the diaphragm).
• Prolapse of the brain stem/cranial nerves with atlanto-occipital dislocations.
• Rarely, traumatic injuries to the vertebral or basilar arteries.
• Spinal shock: transient loss of function at the level of spinal cord injury with loss of reflexes, loss of sensorimotor functions.
• Neurogenic shock: develops mainly with injuries to the cervical and thoracic spine in the form of a triad: hypotension, bradycardia and hypothermia.
• Autonomic dysreflexia in the case of lesions within T6; as a result of the action of various nociceptive stimuli (for example, tactile irritation) below the level of the lesion, an excessive sympathetic reaction with vasoconstriction and a rise in systolic pressure up to 300 mm Hg, as well as a decrease in peripheral circulation (pallor of the skin) can develop. Above the level of the lesion in the spinal cord, compensatory vasodilation develops (redness of the skin and sweating). Due to crises of blood pressure and vasoconstriction - with the risk of cerebral hemorrhage, cerebral and myocardial infarction, arrhythmias up to cardiac arrest - autonomic dysreflexia is a serious complication.
• Brown-Séquard syndrome: usually a hemilateral spinal cord lesion with ipsilateral paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensations.
• Conus medullary syndrome: damage to the sacral spinal cord and lumbar nerve roots with areflexia of the bladder, bowel and lower extremities with sometimes persisting reflexes at the sacral level (for example, bulbocavernosus reflex).
• Cauda equina syndrome: damage to the lumbosacral nerve roots with areflexia of the bladder, bowel and lower extremities.

Diagnosis of traumatic spinal cord injuries

To determine the level and severity of spinal cord injury, the classification developed by the American Spinal Injury Association can be used.

Every patient with neurological deficits due to trauma requires adequate and timely initial diagnostic imaging. In patients with moderate to severe traumatic brain injury, the cervical spine including the upper thoracic spine should be examined.

For mild to moderate injuries (without neurological deficit), the following signs indicate the need for timely imaging:

• Variable state of consciousness
• Intoxication
• Pain in the spine
• Distraction injury.

The patient's advanced age and significant past or concomitant diseases, as well as the mechanism of the accident, play an important role in the decision to perform imaging.

Patients with a minor mechanism of injury and a low risk of injury often do not need hardware diagnostics, or only conventional radiography is sufficient (if indicated, additional functional radiography). Once the likelihood of spinal injury is determined based on risk factors and the course of the injury, it should be considered more high sensitivity, first perform a CT scan of the spine.

In case of possible vascular damage, CT angiography is additionally required.

MRI is inferior to CT in the emergency diagnosis of spinal injury, since it allows only limited assessment of the extent of bone damage. However, with neurological deficits and mixed results A CT scan should be performed and, in case of emergency diagnosis, an additional MRI should be performed.

MRI is indicated primarily in the acute phase and to monitor the dynamics of neural damage. In addition, the ligamentous and muscular components of the injury and, if necessary, the lesions within these components can be better assessed.

During visualization, it is necessary to obtain answers to the following questions:

• Is there any trauma at all?
• If yes, what type (fracture, dislocation, hemorrhage, compression of the brain, lesions in the ligaments)?
• Is there an unstable situation?
• Is surgery required?
• Daffner recommends that spinal injury be assessed using the following procedure:
• Alignment and anatomical abnormalities: anterior and posterior margins of vertebral bodies in the sagittal plane, spinolaminar line, lateral masses, interspinal and interspinous distances;
• Bone - violation of bone integrity: bone rupture/fracture line, compression of vertebral bodies, “bone spurs”, displaced bone fragments;
• Cartilage-anomalies of the cartilage/articular cavity: increased distances between small vertebral joints (> 2 mm), interspinal and interspinous distances, expansion of the intervertebral space;
• Soft tissue - soft tissue abnormalities: hemorrhages extending into the retrotracheal (< 22 мм) и ретрофарингеальное пространство (>7 mm), paravertebral hematomas.

In case of severe spinal injuries, a search for other injuries (skull, chest, abdomen, blood vessels, extremities) should always be carried out.

Laboratory diagnostics includes a hemogram, coagulogram, determination of electrolyte levels and kidney function indicators.

For neurological loss in the subacute phase must be carried out additional electrophysiological diagnostics to assess the extent of functional damage.

Complications of spine and spinal cord injuries

• Spinal instability with secondary spinal cord injuries
• Spinal cord injuries (myelopathy) due to compression, contusion with various types of prolapses:
• - complete transverse paralysis (depending on the level of tetra- or paraplegia and corresponding sensory deficits)
• incomplete transverse paralysis (paraparesis, tetraparesis, sensory deficits)
• With high cervical transverse lesions - respiratory failure
• Cardiovascular complications:
• orthostatic hypotension (most pronounced in the initial phase, improvement over time)
• loss/weakening of daily blood pressure fluctuations
• violations heart rate(in the case of lesions above T6, bradycardia is predominant as a result of loss of sympathetic innervation and dominance of vagus nerve stimulation)
• Deep vein thrombosis and pulmonary embolism
• Long-term complications of transverse paralysis:
• areflexia (diagnosis=combination of arterial hypertension and vasoconstriction below the level of injury)
• post-traumatic syringomyelia: symptoms often last months or several years with neurological pain above the level of the lesion, as well as increasing neurological deficits and spasticity, deterioration of bladder and rectal function (diagnosis is established using MRI)
• heterotopic ossification = neurogenically caused perarticular ossification below the level of the lesion
• spasticity
• painful contractures
• bedsores
• chronic pain
• urinary disorders with increased rates of urinary tract/kidney infections
• increased risk of infections (pneumonia, sepsis)
• impaired intestinal motility and bowel movements
• psychological and psychiatric problems: stress disorder, depression

Treatment of traumatic spinal cord injuries

Depending on the scale of neurological damage and associated immobility, great importance is attached to conservative, preventive and rehabilitation measures:

• Intensive medical monitoring, especially in the initial phase, to maintain normal cardiovascular and pulmonary functions;
• For arterial hypotension, attempt therapy by adequate fluid replacement; in the initial phase, according to indications, the appointment of vasopressors;
• Prevention of bedsores, thrombosis and pneumonia;
• Depending on the stability and course of the disease, early implementation of mobilization and physiotherapeutic measures.

Caution: Autonomic impairments (orthostatic hypotension, autonomic dysreflexia) make mobilization significantly more difficult.

The indication for surgical intervention (decompression, stabilization) depends, first of all, on the type of injury. In addition to eliminating possible myelocompression, surgical intervention is necessary in unstable situations (types B and C injuries).

Surgical intervention requires the appropriate competence of neurosurgeons, trauma surgeons and orthopedists.

In case of severe traumatic compression of the spinal cord with neurological symptoms, urgent surgical decompression is indicated (within the first 8-12 hours). In the absence of neurological loss or in case of inoperability, depending on the type of injury, the possibility of conservative (non-invasive) treatment tactics is individually considered, for example, using a HALO head fixator for injuries of the cervical spine.

The use of methylprednisolone for spinal injury remains controversial. Despite scientific indications of an effect in the case of early onset, critics note, first of all, side effects(eg, increased incidence of pneumonia and sepsis) and possible associated injuries (eg, traumatic brain injury, CRASH study). If spinal cord swelling (or expected swelling) occurs, methylprednisolone (eg, Urbason) may be prescribed. As a bolus, 30 mg/kg body weight is prescribed intravenously, followed by a long-term infusion. If administration is carried out within the first three hours after injury, long-term infusion is carried out within 24 hours, if started between 3 and 8 hours after injury, within 48 hours.

Therapy for autonomic dysreflexia consists primarily of eliminating the provoking stimulus. For example, a blocked urinary catheter causing bladder distension, skin inflammation, rectal distension. In case of persistent arterial hypertension, despite the elimination of provoking irritants, medications are used to lower blood pressure, for example nifedipine, nitrates or captopril.

Prognosis for traumatic spinal cord injuries

The prognosis depends mainly on the location of the injury, its severity and type (polysegmental or monosegmental), as well as on the primary neurological status. In addition to the clinical picture, MRI is required to clarify morphological damage, and additionally electrophysiological diagnostics (sensory and motor evoked potentials, EMG) are required to identify functional lesions. Depending on the primary damage, complete loss of functions, partial loss of motor and sensory functions, but also their complete restoration. The prognosis for severe intramedullary hemorrhage, swelling and compression of the spinal cord is poor.

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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 spinal cord injuries without damage to 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 sensitivity 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 methods studies, including assessment of the patency of the subarachnoid space during lumbar puncture with performing liquorodynamic 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. The timing of it is closed injuries spine:

• 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.

Vertebral fractures without damage to the spinal cord are treated either conservatively: lumbar and thoracic - by traction with straps axillary areas on a bed with a shield, using rollers to reposition the vertebrae in bed; cervical spine - 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: repositioning of the vertebrae, removal of bone fragments and fixation of the spine with metal structures is performed.

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. At the same time, tendon reflexes are lost and muscle tone, sensitivity and function of the pelvic organs are impaired (acute retention type). The state of spinal shock lasts 2–4 weeks and is supported 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 early period occurs most often as a result of pressure on the substance of the brain 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 foreign body. The syndrome is expressed by a combination of 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 activity disturbances of cardio-vascular 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 collarbone, 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 to the lumbar 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