Clinical picture of traumatic disease of the spinal cord.

In this case, the traumatic effect is not only in the place of application of force. Disturbances in the circulation of blood, lymph and cerebrospinal fluid, thrombosis and hematoma cover extensive segments above and below from immediate place damage, which provokes peripheral functional loss of sensitivity and disorders of motor reflexes.

Stages of development of traumatic disease

Conventionally, there are several stages in the development of a traumatic disease. spinal cord:

acute stage. Lasts approximately 2-3 days characteristic features spinal shock (with complete paresis or paralysis, loss of sensation, sharp decline muscle tone). Recovery of motor abilities is possible immediately after recovery from spinal shock.

Early stage. Lasts up to 3 weeks. Reflex excitability is restored, which turns into hyperflection, activity increases muscle fibers clonic twitches or convulsions occur.

The intermediate stage is observed up to 3 months. There is a predominance of flexion or extensor reflexes of the muscles of the limbs, hypertrophy (spasticity) or hypotrophy of some muscle fibers appears, contractures in the joints are formed. Correct reflexes are formed Bladder, with little physical activity, bedsores may occur.

The late stage lasts up to 1 year. At this time, all possible neurological and reflex reactions are restored (later recovery is almost impossible) and a unidirectional change in the patient's health status (gradual improvement or deterioration) is observed.

The residual or rehabilitation stage occurs approximately one year after receiving traumatic injury. All pass possible consequences and residual effects, formed new level neurological reflexes and conditions that remain for life. Possible aggravation of symptoms due to the activation of cicatricial processes, the formation of cysts, adhesions of the membranes or the spinal cord itself, necrosis of some areas.

A few years after brain injury, secondary spinal stenosis (persistent narrowing of the spinal canal), protrusions, or hernias may form. intervertebral discs, instability of the vertebrae and associated compression of the spinal cord or nerve roots, curvature of the spinal column (kyphosis, scoliosis), etc.

Diagnosis of the disease and surgical treatment

The main task of the traumatologist after the admission of a patient with a spinal cord injury is to quickly and accurately establish the diagnosis. The possibility of further recovery of neurological reactions will depend on the promptness of the first aid provided.

Examination of the patient begins with a series of radiographic images, a consultation with a neurosurgeon and a neurologist. For more reliable information about the resulting damage, CT or MRI diagnostics are performed, as well as myelography with a contrast agent.

If a patient has traumatic splinters or compression of the spinal cord, surgery should be performed immediately. Surgical intervention carried out more than three days after brain damage is often ineffective, since pathological changes already irreversible.

All actions of surgeons are carried out using an optical microscope and special instruments. But even using the most modern technologies and tools does not guarantee full recovery and deliverance of the patient from disability.

The main efforts during the operation are aimed at: elimination of compression of the spinal cord and nerve roots, removal of hematomas, hemorrhages and adhesions, restoration of normal blood circulation and liquorodynamics, stability of the spinal column.

Treatment of traumatic disease of the spinal cord

The main difficulty in the treatment of traumatic diseases of the spinal cord is that nerve cells are not restored and the transmission of impulses (excitation) from the proximal sections of the central nervous system to the peripheral motor departments passes through the zone of damage. Thus, the signals simply do not reach the corresponding reflex areas.

With partial damage to the membranes of the brain or nerve roots, when some conductive fibers are preserved, additional interneurons are activated and new reflex connections are formed to replace the lost ones. New fibers fully or at least partially support functionality body at the same level. In some cases, the restoration of motor ability is due to long-term physical training.

At complete break brain, the passage of impulses is possible along extramedullary pathways, but motor functions are not always restored. In addition, recovery from spinal injuries is quite slow, a long stay in a passive state, as it were, turns off some nerve circuits, although they are in normal working condition (by analogy with muscle atrophy, if they long time do not use). Physical exercise for special simulators it is possible to save or restore the activity of paralyzed limbs.

Enhanced drug treatment is used in the acute period immediately after the patient has suffered an injury or surgical intervention. Basically, these are painkillers, substances that relieve inflammation and stimulate the restoration of nervous activity.

Classes begin immediately in the recovery room breathing exercises. Complexes of special physical therapy, light massage, passive and passive-active exercises to preserve muscle reflexes are added immediately after the patient recovers from spinal shock in the early period.

Active rehabilitation activities, locomotor training in the prone position and in special suspension systems, verticalization in suspension systems and water are prescribed by the attending physician in the early period from 2-4 weeks of treatment.

Numerous experiments and studies have shown that the effect on muscle tissue by passive or active actions, massages, functional electrical stimulation, wave methods, leads to the disinhibition of the activity of "dormant" motor neurons, promotes the regeneration of new nerve fibers in the area of injury and adjacent areas. Conversely, hypokinesia ( complete absence physical activity) leads to muscular dystrophy and loss of neurological reflexes.

After stabilization of the patient's condition and completion inpatient treatment rehabilitation courses are prescribed by the attending physician. The number of procedures depends on the degree of damage and the level of brain damage, the general mood of the patient, his physical abilities, the desire to fight the disease and self-discipline in the implementation of individual training sessions.

The main principle in the use of physical exercises is: sequential movement from simple actions to more complex ones, a smooth increase in loads, systematic and continuous implementation of individual exercises. Teaching the function of maintaining balance, first in a sitting position, then standing with support (parallel bars, walkers, canes, crutches, etc.), moving in space, moving with obstacles (on steps).

Good results in the treatment of traumatic disease of the spinal cord are shown by the parallel use manual therapy. Acupuncture, acupuncture, massage biologically active points on the soles of the feet and palms, auricles, the use of applicators and other physiotherapy procedures improve blood circulation and lymph flow, help to raise the general tone of the patient's body, improve mood and add vitality in the fight against disease.

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Traumatic disease of the spinal cord

Spinal cord injury is one of the most severe types of injuries, which in many cases cause death, long-term disability, and permanent severe disability.

Prevalence. In the general structure of peacetime injuries, spinal cord injury is up to 4%; among patients with trauma of the nervous system - up to 10%. According to A. V. Baskov (2002), on average, 19 to 25% of patients with acute spinal cord injury die; the highest mortality rate is observed in injuries cervical spinal cord.

According to the European International Medical Society, in Europe with a population of 415.7 million people, the average incidence of spinal cord injury ranges from 8 to 60 cases per 1 million inhabitants.

Disability due to spinal cord injury is established in 75–90% of cases; at the same time, disabled disabled people who need outside care (groups I and II) predominate.

In peacetime, among spinal cord injuries, closed damage spine and spinal cord as a result of car accidents, falls from a height, diving. According to O. G. Kogan (1975), in 40–60% of cases, spinal cord injury is accompanied by damage various structures spine (vertebral bodies, arches, processes, ligamentous apparatus). Up to 60% of all spinal cord injuries occur in the lower thoracic and lumbar regions; cervical spine injuries account for 27–30% of spinal injuries (I. V. Voronovich et al., 1998).

Classification (according to E. I. Babichenko, 1979). According to this classification, there are the following types injuries.

Concussion of the spinal cord characterized by the appearance in it of mostly reversible functional changes, which in acute period injuries are manifested only by segmental disorders and should completely disappear in the coming days and hours, or no later than 5–7 days from the moment of injury.

spinal cord injury mild degree accompanied by the appearance in it, along with functional, minor morphological changes, which can be clinically manifested as segmental disorders, and a syndrome of partial conduction disturbance. These neurological symptoms persist for more than 7 days, gradually leveling off over the next month, and end in significant, but not always full recovery spinal cord functions.

spinal cord injury medium degree It is characterized by its partial damage and neurologically manifests itself as a syndrome of partial or complete conduction disturbance. In the future, there is a slow (within 2-3 months), partial recovery of the functions of the spinal cord.

Severe spinal cord injury occurs with a morphological violation of its anatomical integrity and manifests itself as a syndrome of complete conduction disturbance. In the future, in the absence of a break, there may be partial recovery.

Compressed spinal cord (compression) most often accompanied by moderate or severe contusion with corresponding neurological symptoms in the form of partial or complete conduction disturbance. The outcome is favorable if decompression is performed in a timely manner, in the next few hours.

open injury accompanied by the same clinical manifestations as closed injuries spinal cord.

If concussion and contusion of the spinal cord are possible without damage to the spinal column itself, then compression, as a rule, is a consequence of the destruction of the vertebrae, violation of the integrity of the spinal column. The zone of structural damage to the spinal cord in vertebral fractures usually expands due to thrombosis of the spinal vessels, disorders of the circulation of cerebrospinal fluid, and tissue edema.

The spinal cord is a system of pathways ( white matter) and communicative structures of segmental innervation (gray matter), which provide motor activity of muscles, sensitivity and coordination of the main part of the body. If it is damaged or completely anatomically interrupted, starting from the level of injury, motor, sensory, trophic disorders develop, and the function of the pelvic organs is impaired. The severity of these manifestations depends on the severity of damage along the length and diameter, the level of damage to the spinal cord, and is also determined by the state of the hemodynamic system, respiration, neuropsychic sphere. Each of these consequences of spinal cord injury is severe form pathology, defined as traumatic disease of the spinal cord(TBSM) (G. V. Karepov, 1991).

TBSM periods. There are four periods during TBSM:

1) spicy, due to the development of spinal shock (up to 3-4 days);

2) early(up to 4 weeks), characterized by the formation of the main clinical manifestations spinal cord injury;

3) intermediate(up to a year), during which the true nature of the disorders and the possibility of functional recovery are revealed;

4) late, the duration of which can be indefinitely long.

The possibilities of rehabilitation are provided by mechanisms for the development of compensations and adaptation of the patient to the existing motor defect, solving the problems of preventing complications of the disease.

clinical picture. Depending on the localization of spinal cord injury, several clinical syndromes are distinguished, determined by the level of injury.

I. Syndrome of lesions of the spinal cord in the upper cervical region (level C1 - C4). It occurs in 3-5% of spinal injuries.

In the clinical picture, symmetrical spasticity of the flexors of the upper and lower extremities is usually observed, but the muscle tone of the legs is higher. The fingers of the hands are brought into a fist; extension of the forearms and support on the hands are sharply impaired; legs are brought to the stomach and bent at the knees. On most of the body - deep disorders of all types of sensitivity; disorders of pelvic functions are noted.

II. Syndrome of lesions of the spinal cord in the lower cervical region (level C5–C8). Occurs in 30-40% of cases.

In the clinical picture, mixed paralysis is observed: flaccid upper paraplegia or paraparesis with a decrease in the function of the fingers and hands while maintaining active movements in shoulder joints. AT lower limbs- central spastic paralysis or paraparesis with a predominance of flexor spasticity, which makes it difficult to maintain an upright posture and walk. The motor defect is accompanied by deep disorders of sensitivity and musculo-articular feeling of the segmental type, as well as a violation of the pelvic functions of the central type.

III . Syndrome of lesions of the upper thoracic spinal cord (level D,–D9).

Occurs in 10-15% of cases. In the clinical picture, there are: lower spastic paraplegia or paraparesis with high flexor tone; flaccid muscle paresis chest and deep paravertebral muscles in the area of injury; disorder of sensitivity and muscular-articular feeling of the segmental type. Pelvic functions are impaired by the type of delay.

IV. Syndrome of lesions of the lower thoracic spinal cord (level D10-D12 - lumbar enlargement of the spinal cord). It is observed in 30-40% of cases.

In the clinical picture, there are: lower flaccid paraplegia and paraparesis, with progressive muscle atrophy; disorders of all types of sensitivity below the level of trauma; pelvic dysfunction.

V. Defeat syndrome lumbar spinal cord (level Lj - Sj) - ponytail.

When the lumbar region is affected, the roots of the spinal cord suffer, so pain can be observed in the clinical picture, muscular atrophy due to flaccid paralysis. Disorders of function are noted pelvic organs peripheral type (true incontinence).

It is known that up to 55% of the descending motor pathways in the human body ends in the zone of the cervical enlargement, which provides a finely differentiated function. upper limbs. The size of motor units, i.e., groups of muscle fibers innervated by one motor neuron in the upper and lower extremities, is different. If in the muscles of the hands the motor unit consists of several tens, and in the muscles of the forearms and shoulder girdle - several hundred muscle fibers, then in the muscles of the legs the number of muscle fibers in one motor unit is up to 1.5–2 thousand. Since the muscles of the legs are innervated much worse ( only 25% of the fibers of the cortico-spinal tract end in the lumbar thickening) and the size of each motor unit is more significant, damage to the spinal cord at the level of the cervical region is manifested by deeper and more pronounced paresis in the lower extremities than in the upper ones.

In most cases, spinal cord injury captures all parts of the central nervous system and spinal shock occurs. Clinically, it is manifested by loss of consciousness, paralysis of the limbs and anesthesia below the level of injury, urinary retention, and respiratory distress. The phenomena of spinal shock can be observed for several hours or even days and require active medical measures.

Treatment. Indications for urgent neurosurgical operation are: compression of the spinal cord by a displaced vertebra or its fragments; hematoma; Availability foreign bodies. Currently, decompression of the spinal cord is accompanied by fixation of the damaged area of the spine with metal structures or autografts, which significantly reduces the time of consolidation and creates opportunities for early activation of the patient.

In postoperative and early recovery periods spinal injury are used medications aimed at stimulating regenerative and restorative processes in the spinal cord (lidase, ribonuclease, corticosteroids, vitamins, vasoactive drugs). Means of maintaining the cardiorespiratory system, preventing infectious complications (cordiamin, glucosides, antibiotics, antihistamines). To combat bedsores, tissues are treated with camphor-alcohol solutions, body parts are shifted; rubber circles are placed under the sacral region and heels, the position of the body is changed every 2-3 hours. To prevent infection urinary tract catheterization and washing of the bladder with solutions of antiuroseptics (furatsilin, furadonin) are carried out. To sanitize the intestines and stimulate peristalsis, cleansing enemas, laxatives, prozerin are used.

The mechanism of action of exercise with spinal cord injury is primarily to create an afferent flow to the segmental apparatus of the spinal cord in order to turn on nerve cells, which are in functional blocking due to inhibition caused by spinal shock. Violations motor functions resulting from spinal cord injury fast development dystrophic processes in all parts of the neuro-reflex apparatus and muscle tissues. Physical exercises performed passively, but with the participation of significant muscle groups, activate metabolic tissue processes contribute to the prevention of dystrophies and the development of joint contractures in patients with spinal cord injury.

Animal experiments have shown that transection of the spinal cord causes sharp violation structures and functions of interneurons and, to a much lesser extent, of motor motor neurons. Motor stimulation, especially started in the early stages, contributes to the normalization of the morphological picture of the neural apparatus and the restoration of reflex activity. Similar effect the effect of exercise on reflex activity of the segmental apparatus in spinal cord injury was also noted in humans. With partial damage to the substance of the brain, when some pathways are preserved, additional interneurons are switched on with the formation of new reflex connections to replace the lost ones, which ensure the maintenance of functions.

In view of the foregoing, along with the means of medical treatment and measures for the care of the patient, importance have exercise therapy and massage treatments.

Subject to strict bed rest, classes are carried out in the ward. Active and passive physical exercises are performed that contribute to the normalization of breathing and the prevention of joint contractures. Physiotherapeutic agents are also used: electrical stimulation of paretic muscles at rest, massotherapy, ultraviolet radiation.

After completion of fracture consolidation, expansion is possible motor mode. In the intermediate period, the patient is taught the elements of self-service, the development of movement using additional supports and orthopedic devices. AT late period TBSM, after discharge from the hospital, the patient, under the guidance of methodologists in specialized centers, masters walking, expands the possibilities of self-care or movement in a wheelchair, undergoes a course of psychocorrection, social and household adaptation.

Of great importance for patients with TSCI are the mechanisms of function compensation, which are based on the development of replacement movements and actions that are formed under the influence of prolonged training of muscle groups that have retained voluntary activity, but previously these actions did not provide. In cases of complete anatomical interruption of the spinal cord and the absence of any motor activity the patient becomes completely dependent on extraneous care. In these cases, exercise therapy remains the main means of maintaining the activity of the respiratory, cardiovascular, digestive and excretory systems through exercises performed passively.

Currently, while maintaining the motor activity of patients with spinal injury, subject to preventive measures average duration their lives exceed 15–20 years.

test questions and tasks

1. Tell us about the classification of spinal cord injuries.

2. Describe the clinical manifestations of traumatic spinal cord disease (TBSC).

3. Name the periods of TBSM and describe them.

4. What are the clinical manifestations of spinal cord injury in the cervical region?

5. What are the clinical manifestations of spinal cord injury in thoracic region?

6. What are the clinical manifestations of damage to the lumbar spinal cord?

7. Expand the mechanism of action of physical exercises in case of brain injury.

8. Tell us about the restoration of functions and means of rehabilitation in the late period of TBCI.

Spinal cord injury is a life-threatening condition requiring immediate medical attention. medical care. This pathology is called traumatic spinal cord disease (TBSC).

The spinal cord, being part of the nervous system, acts as the main coordinator of the work of all organs and muscles. It is through him that the brain receives signals from all over the body.

Each segment of the spinal cord is responsible for one or another organ, from which it receives reflexes and transmits them. This determines the severity of the pathology under consideration. These injuries have high mortality and disability.

The reasons why spinal pathologies occur can be grouped into 3 groups. The first includes malformations, which can be both acquired and congenital. They are associated with a violation of the structure of this organ. The second group includes various diseases of the spinal cord resulting from infection, hereditary predisposition or the occurrence of a tumor.

The third group includes various types of injuries that can be autonomous and combined with a fracture of the spine. This group of reasons includes:

Falling from height;
Auto accidents;
Household injuries.

Clinical manifestations of pathology are determined by the severity of the injury. Thus, complete and partial damage to the spinal cord is distinguished. With a complete lesion, all nerve impulses are blocked, and the victim does not have the opportunity to restore his motor activity and sensitivity. Partial defeat implies the possibility of conducting only a part of nerve impulses and due to this, some motor activity is preserved and there is a chance to restore it completely.

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Signs of spinal cord injury are:

Violation of motor activity;
Pain accompanied by a burning sensation;
Loss of sensation when touched;
No feeling of warmth or cold;
Difficulty in free breathing;
Active cough without relief;
Pain in the chest and heart;
Spontaneous urination or defecation.

In addition, experts identify such symptoms of spinal cord injury as loss of consciousness, unnatural position of the back or neck, pain that can be dull or sharp and felt throughout the spine.

Typology of injuries

Spinal cord injuries are classified according to the type and degree of destruction.

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Hematomyelia

Hematomyelia - in this case, hemorrhage occurs in the cavity of the spinal cord and the formation of a hematoma. Symptoms such as loss of pain and temperature sensitivity appear, which persist for 10 days, and then begin to regress. Properly organized treatment will restore lost and impaired functions. But at the same time neurological disorders the patient may remain.

Root damage

Damage to the roots of the spinal cord - they manifest themselves in the form of paralysis or paresis of the limbs, autonomic disorders, decreased sensitivity, and disruption of the pelvic organs. The general symptomatology depends on which part of the spine is affected. So, with the defeat of the collar zone, paralysis of the upper and lower extremities, difficulty breathing and loss of sensitivity occur.

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crush

Crush - this injury is characterized by a violation of the integrity of the spinal cord, it is torn. For a certain time, up to several months, symptoms of spinal shock may persist. Its result is paralysis of the limbs and a decrease in muscle tone, the disappearance of reflexes, both somatic and vegetative. Sensitivity is completely absent, the pelvic organs function uncontrollably (involuntary defecation and urination).

squeezing

Compression - such an injury most often occurs as a result of the action of fragments of the vertebrae, articular processes, foreign bodies, intervertebral discs, ligaments and tendons that damage the spinal cord. This leads to partial or complete loss of motor activity of the limbs.

Injury

A bruise - with this type of injury, paralysis or paresis of the limbs occurs, sensitivity is lost, muscles are weakened, and the functioning of the pelvic organs is disrupted. After carrying out therapeutic measures, these manifestations are eliminated completely or partially.

Shake

A concussion is a reversible disorder of the spinal cord, characterized by symptoms such as decreased muscle tone, partial or complete loss of sensation in those parts of the body corresponding to the level of damage. Such forms of manifestation last for a short time, after which the function of the spine is fully restored.

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Diagnostic methods

Spinal cord injuries can be different nature. Therefore, before starting therapeutic measures, it is necessary not only to establish the very fact of the injury, but also to determine the degree of its severity. This is in the competence of the neurosurgeon and neuropathologist. Today, medicine has sufficient means for a complete and reliable diagnosis of disorders that have occurred in connection with spinal cord injuries:

Computed and magnetic resonance imaging;
Spondylography;
Lumbar puncture;
contrast myelography.

Computed tomography is based on the action of X-ray radiation and makes it possible to identify gross structural changes and possible foci of hemorrhage. Magnetic resonance imaging to determine the formation of edema and hematomas, as well as damage to the intervertebral discs.

With the help of spondylography, it is possible to detect such features of the injury as fractures and dislocations of the vertebrae and arches, as well as the transverse spinous processes. Moreover, this diagnosis full information about the state of the intervertebral joints, whether there is a narrowing of the spinal canal, and if so, to what extent. Spondylography is performed in all cases of spinal cord injury and should be done in 2 projections.

This monograph presents current data on the pathogenetic and sanogenetic links of homeostasis in traumatic spinal cord disease. Provides information about the mechanisms of remodeling nervous tissue, organ (pulmonary) inflammatory response and mixed antagonistic response syndrome, developing in acute and early periods traumatic disease of the spinal cord and determining its severity. The monograph is intended for researchers, pathophysiologists, graduate students, neurosurgeons, students of faculties of advanced training and postgraduate training of specialists, residents, students of medical universities.

CHAPTER 1

Chapter 2. IMMUNOLOGICAL INDICATORS OF NERVOUS TISSUE AND INTERCELLULAR MATRIX REMODELING

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Books and textbooks on discipline Pathological physiology:

Gruzdeva Olga Viktorovna INSULIN RESISTANCE IN MYOCARDIAL INFARCTION: CLINICAL AND PATHOPHYSIOLOGICAL REGULARITIES, APPROACHES TO OPTIMIZATION OF EARLY DIAGNOSIS AND STATIN THERAPY - 2015
Ovsyannikov V.G. General pathology: pathological physiology: textbook / V.G. Ovsyannikov; GBOU VPO RostGMU of the Ministry of Health of Russia. - 4th ed. - Rostov n / D .: Publishing house of RostGMU, 2014. - Part I. General pathophysiology. - with. - year 2014
Gruzdeva Olga Viktorovna INSULIN RESISTANCE IN MYOCARDIAL INFARCTION: CLINICAL AND PATHOPHYSIOLOGICAL REGULARITIES, APPROACHES TO OPTIMIZATION OF EARLY DIAGNOSIS AND STATIN THERAPY - 2014
M.V. Ugryumov. NEURODEGENERATIVE DISEASES: from the genome to the whole organism. In 2 volumes. Volume 1 / Ed. M.V. Ugryumov. - M.: Scientific world, 2014. - 580 s. - year 2014
M.V. Ugryumov. NEURODEGENERATIVE DISEASES: from the genome to the whole organism. In 2 volumes. Volume 2 / Ed. M.V. Ugryumov. - M.: Scientific world, 2014. - 848 p. - year 2014
Verbitskaya Valeria Sergeevna. MECHANISMS OF DAMAGE FORMATION OF THE SMALL INTESTINE AND LIVER IN THE POST-TRAUMATIC PERIOD OF ISOLATED HEART INJURY AND PATHOGENETIC SUBSTANTIATION OF METABOLIC CYTOPROTECTION - 2014
Shust, O. G. Heart failure. Ischemic heart disease (pathophysiological aspects): studies.-method. allowance / O. G. Shust, F. I. Vismont. - Minsk: BSMU, 2013. - 36 p. - year 2013

Spinal cord injury is one of the most severe types of injuries, which in many cases cause death, long-term disability, and permanent severe disability.

Prevalence.

In the general structure of peacetime injuries, spinal cord injury is up to 4%; among patients with trauma of the nervous system - up to 10%. According to A. V. Baskov (2002), on average, 19 to 25% of patients with acute spinal cord injury die; The highest mortality rate is observed in injuries of the cervical spinal cord.

Disability due to spinal cord injury is established in 75-90% of cases; at the same time, disabled disabled people who need outside care (groups I and II) predominate.

In peacetime, among spinal cord injuries, closed injuries of the spine and spinal cord as a result of car accidents, falls from a height, and diving predominate. According to O. G. Kogan (1975), in 40-60% of cases, spinal cord injury is accompanied by damage to various structures of the spine (vertebral bodies, arches, processes, ligamentous apparatus). Up to 60% of all spinal cord injuries occur in the lower thoracic and lumbar regions; cervical spine injuries account for 27–30% of spinal injuries (IV Voronovich et al., 1998).

Classification (according to E. I. Babichenko, 1979). According to this classification, the following types of injuries are distinguished.

Concussion of the spinal cord is characterized by the occurrence of mainly reversible functional changes in it, which in the acute period of injury are manifested only by segmental disorders and should completely disappear in the coming days and hours, or no later than 5-7 days from the moment of injury.

A mild spinal cord contusion is accompanied by the appearance in it, along with functional, minor morphological changes, which can be clinically manifested both by segmental disorders and by the syndrome of partial conduction disturbance. These neurological symptoms persist for more than 7 days, gradually leveling off over the next month, and end with a significant, but not always complete recovery of spinal cord functions.

A moderate spinal cord contusion is characterized by its partial damage and neurologically manifests itself as a syndrome of partial or complete conduction disturbance. In the future, there is a slow (within 2-3 months), partial recovery of the functions of the spinal cord.

A severe spinal cord contusion occurs with a morphological violation of its anatomical integrity and manifests itself as a syndrome of complete conduction disturbance. In the future, in the absence of a break, there may be a partial recovery.

Spinal cord compression (compression) is most often accompanied by moderate or severe contusion with corresponding neurological symptoms in the form of partial or complete conduction disturbance. The outcome is favorable if decompression is performed in a timely manner, in the next few hours.

An open injury is accompanied by the same clinical manifestations as closed injuries of the spinal cord.

The spinal cord is a system of pathways (white matter) and communicative structures of segmental innervation (gray matter) that provide motor activity of muscles, sensitivity and coordination of the main part of the body. If it is damaged or completely anatomically interrupted, starting from the level of injury, motor, sensory, trophic disorders develop, and the function of the pelvic organs is impaired. The severity of these manifestations depends on the severity of damage along the length and diameter, the level of damage to the spinal cord, and is also determined by the state of the hemodynamic system, respiration, neuropsychic sphere. Each of these consequences of spinal cord injury is a severe form of pathology, defined as traumatic spinal cord disease (TSC) (GV Karepov, 1991).

TBSM periods. There are four periods during TBSM:

1) acute, due to the development of spinal shock (up to 3-4 days);

2) early (up to 4 weeks), characterized by the formation of the main clinical manifestations of spinal cord injuries;

3) intermediate (up to a year), during which the true nature of the disorders and the possibility of functional recovery are revealed;

4) late, the duration of which can be indefinitely long.

clinical picture. Depending on the localization of spinal cord injury, several clinical syndromes are distinguished, determined by the level of injury.

I. Syndrome of lesions of the spinal cord in the upper cervical region (level C \ - C 4). It occurs in 3-5% of cases of spinal injuries.

In the clinical picture, symmetrical spasticity of the flexors of the upper and lower extremities is usually observed, but the muscle tone of the legs is higher. The fingers of the hands are brought into a fist; extension of the forearms and support on the hands are sharply impaired; legs are brought to the stomach and bent at the knees. On most of the body - deep disorders of all kinds of sensitivity; disorders of pelvic functions are noted.

II. Syndrome of lesions of the spinal cord in the lower cervical region (level C 5 -C 8). Occurs in 30-40% of cases.

In the clinical picture, mixed paralysis is observed: flaccid upper paraplegia or paraparesis with a decrease in the function of the fingers and hands while maintaining active movements in the shoulder joints. In the lower extremities - central spastic paralysis or paraparesis with a predominance of flexor spasticity, which greatly complicates the maintenance of an upright posture and walking. The motor defect is accompanied by deep disorders of sensitivity and musculo-articular feeling of the segmental type, as well as a violation of the pelvic functions of the central type.

III. Syndrome of lesions of the upper thoracic spinal cord (level D!-D 9). Occurs in 10-15% of cases.

In the clinical picture, there are: lower spastic paraplegia or paraparesis with high flexor tone; flaccid paresis of the muscles of the chest and deep paravertebral muscles in the area of injury; disorder of sensitivity and musculo-articular feeling of the segmental type.

Pelvic functions are impaired by the type of delay.

IV. Syndrome of lesions of the lower thoracic spinal cord (level D 10 -D12 - lumbar thickening of the spinal cord). It is observed in 30-40% of cases.

In the clinical picture, there are: lower flaccid paraplegia and paraparesis, with progressive muscle atrophy; disorders of all types of sensitivity below the level of trauma; pelvic dysfunction.

V. Syndrome of lesions of the lumbar spinal cord (level b! - $!> - PONYTAIL.

When the lumbar region is affected, the roots of the spinal cord suffer, so pain, muscle atrophy due to flaccid paralysis can be observed in the clinical picture. Disorders of the function of the pelvic organs according to the peripheral type (true incontinence) are noted.

It is known that up to 55% of the descending motor pathways in the human body terminate in the area of the cervical thickening, which provides a finely differentiated function of the upper limbs. The size of motor units, i.e., groups of muscle fibers innervated by one motor neuron in the upper and lower extremities, is different. If in the muscles of the hands the motor unit consists of several tens, and in the muscles of the forearms and shoulder girdle - several hundred muscle fibers, then in the muscles of the legs the number of muscle fibers in one motor unit is up to 1.5 - 2 thousand. Since the muscles of the legs are innervated much worse ( only 25% of the fibers of the cortico-spinal tract end in the lumbar thickening) and the size of each motor unit is more significant, damage to the spinal cord at the level of the cervical region is manifested by deeper and more pronounced paresis in the lower extremities than in the upper ones.

Treatment. Indications for urgent neurosurgical operation are: compression of the spinal cord by a displaced vertebra or its fragments; hematoma; the presence of foreign bodies. Currently, decompression of the spinal cord is accompanied by fixation of the damaged area of the spine with metal structures or autografts, which significantly reduces the time of consolidation and creates opportunities for early activation of the patient.

In the postoperative and early recovery periods of spinal injury, medications are used to stimulate regenerative and restorative processes in the spinal cord (lidase, ribonuclease, corticosteroids, vitamins, vasoactive drugs). Means of maintaining the cardiorespiratory system, preventing infectious complications (cordiamin, glucosides, antibiotics, antihistamines) are also used. To combat bedsores, tissues are treated with camphor-alcohol solutions, body parts are shifted; rubber circles are placed under the sacral region and heels, the position of the body is changed every 2-3 hours. To prevent urinary tract infection, catheterization and washing of the bladder with antiuroseptic solutions (furatsilin, furadonin) are carried out. To sanitize the intestines and stimulate peristalsis, cleansing enemas, laxatives, prozerin are used.

The mechanism of action of physical exercises in spinal cord injury is primarily to create an afferent flow to the segmental apparatus of the spinal cord in order to turn on nerve cells that are in functional blockage due to inhibition caused by spinal shock. Violations of motor functions as a result of spinal cord injury entail the rapid development of dystrophic processes in all parts of the neuro-reflex apparatus and muscle tissues. Physical exercises performed passively, but with the participation of significant muscle groups, activate metabolic tissue processes, contribute to the prevention of dystrophies and the development of joint contractures in patients with spinal cord injury.

In experiments on animals, it was shown that the intersection of the spinal cord causes a sharp violation of the structure and function of interneurons and, to a much lesser extent, of motor motor neurons. Motor stimulation, especially started in the early stages, contributes to the normalization of the morphological picture of the neural apparatus and the restoration of reflex activity. A similar effect of the influence of physical exercises on the reflex activity of the segmental apparatus in spinal cord injury was also noted in humans. With partial damage to the substance of the brain, when some pathways are preserved, additional interneurons are switched on with the formation of new reflex connections to replace the lost ones, which ensure the maintenance of functions.

In view of the foregoing, along with the means of drug treatment and patient care activities, exercise therapy and massage procedures are important.

Subject to strict bed rest, classes are carried out in the ward. Active and passive physical exercises are performed that contribute to the normalization of breathing and the prevention of joint contractures. Physiotherapeutic means are also used: electrical stimulation of paretic muscles at rest, therapeutic massage, ultraviolet radiation.

After completion of the consolidation of the fracture, it is possible to expand the motor regime. In the intermediate period, the patient is taught the elements of self-service, the development of movement using additional supports and orthopedic devices. In the late period of TBCI, after discharge from the hospital, the patient, under the guidance of methodologists in specialized centers, masters walking, expands the possibilities of self-care or movement in a wheelchair, undergoes a course of psychocorrection, social and household adaptation.

Of great importance for patients with TSCI are the mechanisms of function compensation, which are based on the development of replacement movements and actions that are formed under the influence of prolonged training of muscle groups that have retained voluntary activity, but previously these actions did not provide. In cases of complete anatomical interruption of the spinal cord and the absence of any motor activity, the patient becomes completely dependent on extraneous care. In these cases, exercise therapy remains the main means of maintaining the activity of the respiratory, cardiovascular, digestive and excretory systems through exercises performed passively.

At present, while maintaining the motor activity of patients with spinal injury, with the observance of measures to prevent complications, their average life expectancy exceeds 15–20 years.