Spinal cord injury: treatment and rehabilitation. Cervical injuries are the most dangerous Complete rupture of the spinal cord in the cervical region

Statistically, spinal cord injuries are most often associated with damage to the spinal regions.

According to numerous studies, about 95% of road accidents, various types of accidents and acts of violence in one way or another are the main cause of spinal cord injuries.

At the same time, both men and women aged 20 to 60 years are at greatest risk. And the mortality rate is quite high and disappointing.

Treatment of all types of spinal cord injuries should be carried out immediately, since the preservation and restoration of most functions of the human body directly depends on this factor.

Injuries to the back can have serious consequences that can affect the major motor and nerve regions. It is not uncommon for spinal injuries to result in complete or partial loss of sensory function, as well as disturbances in heart rate and breathing.

However, there are cases when injuries received by a person can only be overcome through long-term combined rehabilitation.

Specially developed programs for such people help not only to find psychological and emotional balance, but to fully adapt to the surrounding everyday and social conditions.

Most common causes of spinal cord injury

The human spinal cord is the main coordination center of the body, which controls all processes in muscles and organs.

It is through it that all systems of the body are informed. Additionally, the structure of the spinal cord is quite unusual.

It is a cylinder with a diameter of 1 to 1.5 centimeters, which is covered with three types of shells: soft, hard and arachnoid.

To protect the brain, dense muscle tissue is intended, which covers the main brain canal.

Currently, medicine classifies three types of spinal cord injuries:

• congenital defects and postpartum deviations;
• spinal circulation disorder;
• fractures, bruises, dislocations due to exposure to external factors.

Despite the fact that the main causes of spinal cord injuries have become quite commonplace in human understanding, they can be divided into the following groups:

• Car accidents- this reason is inherent not only to drivers, but also to pedestrians;
• Altitude falls- intentional or accidental fall from a certain height level, mainly occurs among athletes;
• Domestic and extraordinary injuries- differ in a fairly wide variety, these include falls on ice or from stairs, knife or bullet wounds.

From a medical point of view, spinal injuries are open And closed.

In addition, they can lead to impaired functionality of the spinal cord or its complete rupture.

By nature, spinal injuries are divided into:

• shake;
• injury;
• crushing;
• hematomyelia;
• Traumatic radiculitis.

Doctors call the most common cases of damage to the back area, in particular the spinal cord, the 1st and 2nd lumbar, 5th and 6th cervical, 12th thoracic vertebrae.

Even minor violations in them can lead to serious and sometimes unpredictable consequences. Irreversible processes in damaged spinal areas are often observed.

The main tools for examining the spinal region susceptible to injury are:

Radiography - images of the spinal cord are taken in two projections;

Nuclear magnetic tomography - consists of a detailed examination of all canals and layers of the brain, vertebrae and discs, pressure and swelling.

Spinal shock

This phenomenon is a rupture of transverse sections of the spinal cord due to injury.

Main symptomatic manifestations:

• inhibition of the motor and autonomic systems of the body in certain segments of the spine;
• sudden cessation of control by the central nervous system.

The concept of “spinal shock” has not been fully studied. However, specialists in the treatment and diagnosis of spinal injuries There are several stages of this phenomenon:

• first- complete areflexia lasting from 4 to 6 weeks;
• second- small reflex movements in the legs and arms, usually lasting from 2 weeks to several months;
• third- presence of flexion and extension reflexes.

In order to provide quality and timely first aid to the victim, it is necessary to thoroughly know the main symptoms and signs of this process.

Injuries to the cervical vertebrae are considered the most dangerous for any person.

A characteristic feature of this process is the appearance of acute pain in the neck and limited mobility of the head.

When the spine is fractured, the victim instantly develops paralysis of the limbs or pelvic organs.

Among the basic rules of first aid in such cases are:

• The first thing you need to do is call an ambulance.
• Make sure the victim is conscious and breathing normally.
• If you need to move the injured person, you should lay him down on a flat surface.
• Avoid moving the person using a blanket or cloth.
• Do not allow the injured spine to bend under any circumstances.
• Secure the vertebra with a thick layer of cotton wool or tightly rolled newspaper.
• Place pillows or bundles of clothing under your shoulders and neck.
• Stay with the victim until medical help arrives.

It is worth remembering that properly provided assistance to someone who has suffered from a spinal cord injury will make it possible to preserve the motor functions of the limbs and the sensitivity of all parts of the body.

Treatment and surgery

The treatment process for various spinal cord injuries must be performed in a neurosurgical hospital.

In this case, this type of treatment should begin with immobilization of the spinal region, especially at the site of injury.

It consists in creating the most comfortable conditions for moving the victim. In addition, it is necessary to take measures to maintain normal blood pressure levels and the functioning of the cardiovascular system.

Most spinal cord injuries require mandatory surgical intervention. It is this method that allows you to eliminate the presence of possible bone fragments, compression of the spinal cord, and swelling of the spinal cord.

In cases of damage to the genitourinary system, it is necessary to unload the urinary tract using all possible methods. For example, insert a catheter into the urethra. And to prevent infection, the bladder is washed with furatsilin in tandem with antibiotics.

At an early stage of diagnosing the extent of damage to the spinal cord injury, the attending physician may offer several treatment options:

1. Drug treatment- in acute forms of spinal injury, solymedrol is used, which significantly reduces the number of damaged nerve cells and existing inflammatory foci near the site of the injury.
2. Immobilization- to stabilize the position of the spine, a splint is applied that fixes the body.
3. Surgical intervention- used when foreign objects or bone fragments or a hernia are found. This method allows not only to eliminate these nuances, but also eliminates the appearance of pain and deformation.

Of course, it is impossible to accurately predict the course of treatment, despite significant scientific strides in the field of neurosurgery. In addition, as practice shows, not in all cases of spinal cord injury, surgery can help in the complete recovery and recovery of the victim.

However, significant hope for a full recovery after spinal injuries is given by use of specific imported metal structures. Carrying out such operations requires special equipment and tools. But this method of neurosurgery has already helped patients with minor fractures and dislocations in the spinal cord area.

Recovery and rehabilitation

As for activities related to rehabilitation, the following adaptation and restoration methods should be noted:

• The use of physical therapy programs based on physical exercise to restore normal strength in the arms and legs.
• Treatment with medications to relieve symptoms and complications after injuries, as well as to treat possible urinary tract infections.
• The use of specialized wheelchairs to improve the comfort of patients with spinal injuries.
• Readaptation of the immediate place of residence consists of constructive changes to the property for high-quality and simple self-service for the victim.

In the struggle to restore the performance and normal functioning of a patient with spinal cord injury, doctors take measures that help prevent further damage to the spinal cord, and also make it possible to freely refer the victim to rehabilitation centers, where there is a real opportunity to achieve independence in independent movement.

In such centers it is often used occupational therapy. This type of rehabilitation is developed individually for each case, since both the damage and the rate of recovery are considered unique to each person.

One of the recognized methods of returning functions of the human body lost as a result of injury is considered electrical stimulation. This procedure is not complicated, but it does a good job of getting the main systems up and running.

After the rehabilitation process is completed, the patient must continue to independently work on his own recovery. To do this, you need to maintain muscle mass and joint flexibility. Constant physical activity and exercise will undoubtedly have a positive effect on the general physiological condition of a person. And he will be able to stand on his feet at the moment when his body is ready for this.

You cannot lose faith in achieving this goal, since the orthopedic consequences of spinal cord injury can be very unpredictable. A person may develop spinal instability, or scoliosis, secondary dislocations, pathological changes in the intervertebral discs and joints, and deformation of the spinal canals.

Video

The video shows an example of recovery from a spinal cord injury.

Life after a spinal cord injury has its own characteristics. This is due to the fact that the immediate process of returning a person to normal life is quite lengthy. The time period for such recovery can range from several months to several years. Therefore, you should be prepared morally and emotionally, and strive to regain all lost body functions.

Spinal injuries have always been considered the most dangerous, since they not only cause ruptures of muscles, tendons, dislocations and fractures of the vertebrae, but also possible damage to the spinal cord. This can occur due to the instantaneous and sudden application of dynamic force in one direction or another, as happens, for example, in accidents and falls. In an accident, secondary damage to the spinal cord is more often observed, manifesting itself as a complication after a spinal injury.

It represents the greatest threat of all possible misfortunes that can happen to the spine, since its narrowness in this area can lead to disruption of the conductivity of the spinal cord. Treatment of injury must be immediate and mobile.

Cervical spine injury

The most common injuries to the cervical spine occur during diving, the second “honorable” place is occupied by road accidents, and the third is falls from a height.

Based on the direction of force, traumatic injuries are divided into the following:

• Flexion
• Extensor
• Flexion-rotation
• Vertical compression
• Lateral flexion
• Uncertain direction

• dislocations and subluxations of the atlas
• fractures, dislocations
• vertebral displacement
• spinous process fractures
• fracture of the second cervical vertebra
• intervertebral disc ruptures
• compression fractures and other injuries

Any damage to the spine is dangerous because it can lead to complications:

1. Spinal cord edema
2. Hemorrhage and hematomas
3. Ischemia
4. Falling blood pressure
5. Impaired blood flow and cerebrospinal fluid movement

In this case, they speak of a complicated injury. For the cervical spine, such consequences can be disastrous and lead to death, so it is important to start treatment from the very first minutes. Within a few hours, irreversible changes in the white matter of the brain and necrosis of certain areas may occur.

Symptoms of cervical spine injuries

With a cervical bruise, symptoms of damage to nerve fibers and myelopathic syndromes caused by spinal cord compression:

• pain in the neck with the slightest change in the position of the neck, radiating to the back of the head, shoulders, shoulder blades, arms
• loss of sensation and motor activity
• pelvic organ dysfunction

Damage to the spinal cord can lead to complete or partial disruption of brain conduction:

Symptoms in case of complete violation:

• Disappearance of absolutely all motor reflexes and loss of sensitivity in all areas of the body located below the point of injury
• Delayed or involuntary urination and bowel movements

Symptoms of partial violation:

• Some reflexes and the ability to move below the site of injury are partially preserved, as is local sensitivity. The patient can make individual movements, responds to the capture of skin-muscular folds

Complete loss of conductivity occurs when:

• Spinal cord rupture - in this case, its complete recovery is hardly possible
• Spinal shock (complete inhibition of all reflexes) - after some time, conduction is restored

Neurological syndromes with myelopathy in the cervical segments

In case of spinal cord injury at the level of the upper vertebrae of the cervical spine C1 - C4 the following symptoms are observed:

• flaccid and spastic paralysis of all four limbs (tetraparesis and tetraplegia)
• breathing problems (possible paralysis)
• vertigo (dizziness)
• dysphagia (inability to swallow)
• aphonia (difficulty speaking)
• slow heart rate
• syndrome of pain and temperature insensitivity (with unilateral brain damage)

For brain damage to the lower cervical region C5 - C7 and in the first thoracic vertebra Th1 the symptoms are:

• Peripheral paraparesis of the upper extremities and paraplegia of the lower extremities
• Constriction of the pupils, colorless iris and sunken eyeball ( Claude Bernard-Horner syndrome)

Spinal cord conductivity scale

In modern medicine, there are two options for classifying spinal cord injuries according to the scale Frenkel.

The modern version of the Frenkel scale includes five degrees of conduction impairment:

• A-full
• B, C And D- incomplete
• E- norm

The system for assessing muscle strength on this scale is 5-point.

Symptoms corresponding to each degree of conduction disturbance:

• A. Absence of any movement and sensitivity in the vertebrae S4 - S5 of the sacral spine
• B. Preservation of only sensitivity, but not motor ability, below the level of damage and also in the S4 - S5 segment
• C. Motor strength of muscles below the affected level is less than 3 points
• D. Muscle strength equals or exceeds 3 points
• E. Movement functions and sensitivity are not impaired. Muscle strength 5 points and above

This scale allows you to assess the prognosis for restoration of conductivity after a month from the moment of injury:

• If the sum of muscle scores of a certain group, for example, the lower extremities, is such that each pair of muscles accounts for more than 3 points, then the prognosis that the patient will learn to walk by the end of the year, at least with the help of crutches, is very high
• If at the end of the month muscle activity is near zero, then unfortunately, the possibility of recovery in the future is also small

Treatment of cervical spine injuries

After a spinal bruise has occurred, relatives, friends or simply witnesses to the incident are obliged to call an ambulance, even if no special damage is noticed on the surface of the neck, and the victim declares that he is completely fine. What first aid should emergency and emergency room doctors provide?

First emergency medical aid

The first assistance to a patient with a cervical spine injury and further treatment should be extraordinary. The count can go on for minutes. The doctor must be prepared for a sudden drop in blood pressure, respiratory arrest, post-traumatic complications

1. First, all external injuries (bruises and abrasions) should be examined to determine the location, strength and direction of the traumatic load. The absence of external signs of damage does not mean anything
2. Carefully transfer the patient onto the backboard
3. Produce immobilization(immobilization) of the injured neck with or Shants collar, which can be made independently according to the height of the victim’s neck from flexible cardboard and gauze (the front height of the collar is always greater than the back). The immobility of the cervical spine is needed not only to save from pain. Injuries to the vertebrae can be splintered, and then careless movement of the neck can lead to rupture of the vertebral artery and death
4. Test pupils and eyeballs
5. Measure blood pressure and check pulse
6. Ask the patient about his pain, palpate the body below the level of injury
7. Carry out an initial x-ray examination of the cervical spine in a lateral projection

Conservative treatment of cervical spine injury

1. At least three x-rays are taken: frontal, lateral and through the mouth
2. If necessary, a detailed computer study is performed to determine the nature of the vertebral damage
3. If there are signs of spinal cord damage, magnetic resonance imaging is done to identify damaged segments
4. In case of severe painful shock, make a blockade using novocaine And hydrocortisone, preferably inside the damaged spinal disc.
   This is not an easy procedure: the needle is inserted under control spondylography
5. Blood pressure and blood circulation are controlled. In case of respiratory failure, the patient is connected to a ventilator
6. Increased pressure promotes more favorable and rapid treatment of the spinal cord and accelerates recovery from spinal shock
7. In case of urination problems, a catheter is inserted into the urinary canal
8. If swelling of the spinal cord occurs, excess fluid from the body - intercellular and cerebrospinal fluid - is removed.
   Intracranial hypertension, which accompanies edema, leads to increased intracranial pressure, which is manifested by severe bursting headaches. Treatment of edema and hypertension is carried out: by draining excess liquor, with help diuretics
9. Treatment of cervical spine injury also includes taking the following medications: Antirheumatic,Vitamins B1, B2 and C,A nicotinic acid, In a non-acute period, in the absence of infectious inflammatory processes, it can be used to reduce pain at the site of injury. electrophoresis with novocaine

For minor injuries, without damage to the spine and spinal cord, such as, for example, a sprain or rupture of neck ligaments, the following conservative treatment is prescribed:

1. Taking painkillers
2. Motion restriction mode
3. Therapeutic exercise with gentle loads
4. Physiotherapeutic procedures

To eliminate dislocations and displacements resulting from injury, orthopedic treatment ( hood) or surgery.

Cervical traction

Cervical traction is performed in an inclined position or sitting. This can be done in several ways:

Behind the head with Glisson loops:
.
This method has recently been almost never used due to trophic disorders of the facial muscles as a result of squeezing the face.

For the tubercles of the parietal part of the head:

• Advantages of the method: the ability to use large loads and achieve good stretching results
• Disadvantage: unreliable fastening of the bracket and pins, possibility of excessive stretching of the spinal cord

Using a special Halo device:
.
The ring is attached to the skull with clamps and attached to a corset worn around the cervical region

• With the help of the Halo device, the hood is more accurate, and it is possible to produce the dosed required loads
• There is a danger of inflammation in the skull, in the places where the clamps are attached

After traction, a plaster cast is applied to the neck. thoracocranial bandage for three whole months. After removing the bandage, put it on for two weeks Shants collar.

Cervical traction is also performed at the initial stage of operations to remove the consequences of injury.

Surgical treatment of cervical spine injury

Surgical treatment is used:

• with compression of the spinal cord and nerve roots, threatening serious neurological disorders now and in the future
• when the vertebral height decreases by more than half
• cervical kyphosis more than 11 ̊
• anterior-posterior displacement of the vertebra is more than 3.5 mm
• severe deformation and pain

There are three types of operations:

• With posterior surgical approach
• Anterior surgical approach
• Mixed type (both accesses are used)

Anterior surgical approach is preferable for spinal cord decompression

The main method used by surgeons in the treatment of spinal injuries is spinal fusion:

The damaged vertebra or segment, after restoration, is immovably connected to the neighboring one.

The operation may have two or three technical stages:

1. Repositioning of vertebrae and discs using traction
2. Removal of fragments in damaged segments in case of splinter injuries
3. Reconstruction of a damaged vertebra or disc (for example, replacing a damaged disc with an iliac crest graft)

Postoperative complications and its treatment

Surgical intervention on the cervical spine is often complicated by the following phenomena:

• instability of the injury, that is, a large area of ​​damage that requires additional fixation
• possibility of moving the cervical graft
• danger of neurological complications

Therefore, to avoid such complications during neck operations, external fixation is often used using a Halo device or a thoracocranial bandage applied for up to four months.

After surgery, the following complications are also very common, due to which treatment is delayed:

1. Danger of blood clots
2. Diseases of the stomach and intestines
3. Trophic ulcers
4. Pulmonary complications
5. Urological diseases

Treatment of postoperative complications includes:

• taking antibiotics
• vasodilators
• neuroprotectors

Active rehabilitation after injury

Prolonged wearing of plaster casts and collars leads to muscle-tendon contractures. This is the main obstacle preventing the patient from learning to move as before

To develop long-term immobilized muscles and tendons, active rehabilitation is carried out:

1. Biomechanical stimulation
2. Special therapeutic exercises prescribed by a doctor: performed at home and on exercise machines
3. Hardware physiotherapy: high-frequency impulses on the device Darsonval,electrical stimulation,laser and magnetic therapy
4. Ozocerite and paraffin applications
5. Massage
6. Swimming

The duration of active rehabilitation is approximately equal in time to the duration of immobilization

This means: if you wore a plaster cast or corset for three months, then the restoration of motor activity should take no less.

Brief conclusions:

Thus, treatment of cervical spine injury depends on its severity:

1. It may be limited to immobilization and rest for several days - in the absence of damage
2. In case of ligament rupture - can take place in the form of conservative treatment from 2 to more weeks
3. For more serious spinal injuries, with damage to the vertebrae or discs, traction and possibly surgery are performed, followed by a rehabilitation period of 3 to 4 months.
4. Finally, complicated cervical spine injury with spinal cord damage and conduction disturbances requires long-term multi-stage treatment, including: Elimination of complications in the spinal cord (edema, hemorrhages). Sometimes a neurosurgical operation is performed to restore the conductivity of the spinal cord, if there is no complete rupture, or the possibility of partial return of sensitivity through the connection of the spinal nerves remains. Conservative or surgical treatment of cervical spine injuries. Active rehabilitation

Although methods for diagnosing and providing assistance for injuries of the spine and spinal cord were given in the Egyptian papyri and the works of Hippocrates, for a long time a spinal injury with neurological disorders was considered practically a death sentence. Back in the First World War, 80% of those wounded in the spine died within the first 2 weeks. Progress in the treatment of spinal cord injury (SCI), based on an improved understanding of its pathogenesis and the development of radically new treatment methods, began only during the Second World War and in the post-war years. Today, SCI remains a severe, but usually not fatal, type of injury, and a significant contribution to minimizing its consequences is made by the timely and adequate provision of first, qualified and specialized medical care to victims.

Traumatic injuries of the spine and spinal cord are much less common than TBI. In adults, the incidence of SMT is 5 per 100 thousand population per year, in children it is even lower (less than 1 per 100 thousand population per year), but in children SMT is more often associated with polytrauma and is more severe, with a worse prognosis. In Russia, approximately 80% of victims are men under 30 years of age. Since today the majority of victims even with severe STS survive, the number of people with consequences of STS in the population of developed countries is approximately 90 per 100 thousand population (for Russia today this is approximately 130 thousand people, of which 13 thousand are with paraplegia or tetraplegia) . The social significance of the problem is difficult to overestimate.

The main cause of SMT is road traffic accidents (50% of cases). This is followed by sports injuries and those associated with active recreation (25%, of which 2/3 are injuries to the cervical spine and spinal cord received while diving in a shallow place). Approximately 10% each are industrial injuries and those received as a result of illegal actions, and 5% are received when falling from a height, in natural disasters, etc.

Most often the cervical spine is damaged (55%), less often - the thoracic (30%), even less often - the lumbosacral

Damage to the spinal cord and its roots occurs in approximately 20% of cases of SCI. Such injuries are called complicated.

Damage Level(defeats) spinal cord assessed by the lower segment, in the dermatome of which sensitivity and at least minimal voluntary movements have been preserved. Often, but not always, this level corresponds to the established level of spinal injury. In assessing the level of spinal cord damage, one should not rely on pathological reflexes (Babinsky, Rossolimo, Oppenheim, defensive and synkinesis); their reflex arc may pass below the level of complete spinal cord damage.

Highlight complete And incomplete spinal cord injury. With complete damage (group A on the Frankel scale, Table 12.1), there is no sensitivity and voluntary movements below the level of the lesion. Usually in such a situation the spinal cord is anatomically destroyed. With incomplete damage (groups B, C, D on the Frankel scale), disturbances in sensitivity and movement are expressed to a greater or lesser extent; group E corresponds to the norm.

Injuries to the spine and spinal cord are divided into open, in which the integrity of the skin and underlying soft tissues is compromised, and closed, in which these damages are absent. In peacetime, closed

Table 12.1. Spinal Cord Disability Rating Scale (Frankel)

Closed injuries of the spine and spinal cord

Spinal injuries. Closed spinal injuries occur under the influence of excessive flexion, extension, rotation and axial compression. In many cases, a combination of these mechanisms is observed (for example, with the so-called whiplash injury of the cervical spine, when flexion of the spine is followed by its extension).

As a result of the influence of these mechanical forces, various changes in the spine are possible:

Sprain and rupture of ligaments;

Damage to intervertebral discs;

Subluxations and dislocations of the vertebrae;

Vertebral fractures;

Fracture-dislocations.

The following types of vertebral fractures are distinguished:

Fractures of vertebral bodies (compression, comminuted, explosive);

Fractures of the posterior half ring;

Combined with simultaneous fracture of the bodies, arches, articular and transverse processes;

Isolated fractures of the transverse and spinous processes.

It is of fundamental importance to classify spinal injury as stable or unstable. The stability of the spine is understood as the ability of its structures to limit their mutual displacement so that, under physiological loads, it does not lead to damage or irritation of the spinal cord and its roots. Unstable spinal injuries are usually associated with rupture of ligaments, fibrous ring, multiple destruction of bone structures and are fraught with additional trauma to the spinal cord even with minor movements in the affected segment.

It is easier to understand the causes of spinal instability if we turn to the concept of Denis (Fig. 12.1), who identifies 3 support systems (pillars) of the spine: front the supporting complex (column) includes the anterior longitudinal ligament and the anterior segment of the vertebral body; average the column unites the posterior longitudinal ligament and the posterior segment of the vertebral body; rear column - articular processes, arches with yellow ligaments and spinous processes with their ligamentous apparatus. Violation of the integrity of two of the mentioned supporting complexes (pillars), as a rule, leads to instability of the spine.

Rice. 12.1. Denis’s diagram: the anterior, middle and posterior supporting complexes (pillars) of the spine are highlighted; instability of the spinal segment develops when two of them are affected in any combination

Spinal cord injuries. Based on the type of spinal cord injury, it is classified as concussion, bruise, compression And violation of anatomical integrity(partial or complete rupture of the spinal cord); often these mechanisms are combined (for example, a bruise with vascular rupture and hemorrhage - hematomyelia, causing direct damage to the axons and cells of the spinal cord). The most severe form of local damage to the spinal cord is its complete anatomical break with diastasis of the ends at the site of damage.

The degree of damage to the spinal cord and its roots is of primary importance for the fate of the patient. This damage can occur both at the time of injury (which is incurable) and in the subsequent period, when prevention of secondary spinal cord injuries is potentially possible.

Currently, there are no methods to restore the function of anatomically damaged neurons and cells of the spinal cord. The goal of treating STS is to minimize secondary damage to the spinal cord and provide optimal conditions for the restoration of neurons and axons caught in the zone of impaired blood supply - the “ischemic penumbra.”

A frequent and dangerous consequence of spinal cord injury is edema, caused both by an increase in tissue osmotic pressure during the destruction of cell membranes, and by disturbances in venous outflow due to compression of the spinal veins (hematomas, bone fragments, etc.) and their thrombosis. An increase in the volume of the spinal cord as a result of edema leads to an increase in local hypertension and a decrease in perfusion pressure, which, according to the principle of a vicious circle, leads to a further increase in edema, ischemia and can lead to irreversible damage to the entire diameter of the spinal cord.

In addition to the listed morphological changes, functional disorders caused by disturbances at the cellular level are also possible. Such spinal cord dysfunctions regress, as a rule, within the first 24 hours after injury.

Clinical picture of spinal injury. The main manifestation of a spinal fracture is local pain, which increases significantly with load (standing up, bending and even turning in bed). Spinal damage may also be indicated by:

Abrasions and hematomas;

Swelling and local tenderness of soft tissues in the paravertebral region;

Pain on palpation of the spinous processes;

Different distances between the apices of the spinous processes, displacement of one or more of them anteriorly, posteriorly or to the side from the midline;

Angular change in the spinal axis (traumatic scoliosis, kyphosis or lordosis).

With a fracture of the lower thoracic and lumbar spine, even without damage to the spinal cord, intestinal paresis may develop due to a retroperitoneal hematoma (compressing the vessels and nerves of the mesentery).

Clinical picture of spinal cord damage in spinal injury

The clinical symptoms of a complicated spinal fracture are determined by a number of reasons, primarily the level and degree of damage to the spinal cord.

There are syndromes of complete and partial transverse spinal cord lesions.

At complete transverse spinal cord syndrome down from the level of the lesion, all voluntary movements are absent, flaccid paralysis is observed, deep and cutaneous reflexes are not evoked, all types of sensitivity are absent, control over the functions of the pelvic organs is lost (involuntary urination, defecation disorders, priapism); autonomic innervation suffers (sweating and temperature regulation are impaired). Over time, flaccid muscle paralysis can be replaced by spasticity, hyperreflexia, and automatisms in the functions of the pelvic organs are often formed.

Features of the clinical manifestations of spinal cord injury depend on the level of damage. If the upper cervical part of the spinal cord is damaged (C I-IV at the level of the I-IV cervical vertebrae), tetraparesis or spastic tetraplegia develops with the loss of all types of sensitivity from the corresponding level. If there is concomitant damage to the brain stem, bulbar disorders appear (dysphagia, aphonia, respiratory and cardiovascular disorders).

Damage to the cervical enlargement of the spinal cord (C V -Th I at the level of the V-VII cervical vertebrae) leads to peripheral paraparesis of the upper extremities and spastic paraplegia of the lower extremities. Conduction disorders of all types of sensitivity occur below the level of the lesion. There may be radicular pain in the arms. Damage to the ciliospinal center causes the appearance of Horner's symptom, decreased blood pressure, and slowed pulse.

Trauma to the thoracic part of the spinal cord (Th II-XII at the level of I-IX thoracic vertebrae) leads to lower spastic paraplegia with the absence of all types of sensitivity, loss of abdominal reflexes: upper (Th VII-VIII), middle (Th IX-X) and lower (Th XI-XII).

If the lumbar thickening (L I S II at the level of the X-XII thoracic and I lumbar vertebrae) is damaged, peripheral paralysis of the lower extremities occurs, anesthesia of the perineum and legs downward from the inguinal (pupart) ligament occurs, and the cremasteric reflex falls out.

In case of injury to the conus of the spinal cord (S III-V at the level of the I-II lumbar vertebrae), there is a “saddle-shaped” anesthesia in the perineal area.

Damage to the cauda equina is characterized by peripheral paralysis of the lower extremities, anesthesia of all types in the perineum and legs, and sharp radicular pain in them.

Spinal cord injuries at all levels are accompanied by disorders of urination, defecation and sexual function. With transverse damage to the spinal cord in the cervical and thoracic parts, dysfunction of the pelvic organs appears, such as the “hyper-reflex neurogenic bladder” syndrome. At first after the injury, urinary retention occurs, which can last for a very long time (months). The sensitivity of the bladder is lost. Then, as the segmental apparatus of the spinal cord disinhibits, urinary retention is replaced by spinal automaticity of urination. In this case, involuntary urination occurs when there is a slight accumulation of urine in the bladder.

When the conus of the spinal cord and the roots of the cauda equina are damaged, the segmental apparatus of the spinal cord suffers and the syndrome of “hyporeflex neurogenic bladder” develops: urinary retention with paradoxical phenomena is characteristic.

noi ischuria - the bladder is full, but when the pressure in it begins to exceed the resistance of the sphincters, part of the urine flows out passively, which creates the illusion of intact urinary function.

Defecation disorders in the form of stool retention or fecal incontinence usually develop in parallel with urination disorders.

Damage to the spinal cord in any part is accompanied by pressure sores that occur in areas with impaired innervation, where bony protrusions are located under the soft tissues (sacrum, iliac crests, heels). Bedsores develop especially early and quickly with severe (transverse) damage to the spinal cord at the level of the cervical and thoracic regions. Bedsores quickly become infected and cause the development of sepsis.

When determining the level of spinal cord damage, the relative position of the vertebrae and spinal segments must be taken into account. It is easier to compare the location of the spinal cord segments with the spinous processes of the vertebrae (with the exception of the lower thoracic region). To determine the segment, add 2 to the vertebral number (so, at the level of the spinous process of the third thoracic vertebra the fifth thoracic segment will be located).

This pattern disappears in the lower thoracic and upper lumbar regions, where at the level of Th XI-XII and L I there are 11 segments of the spinal cord (5 lumbar, 5 sacral and 1 coccygeal).

There are several syndromes of partial spinal cord damage.

Half spinal cord syndrome(BrownSequard syndrome) - paralysis of the limbs and impairment of deep types of sensitivity on the affected side with loss of pain and temperature sensitivity on the opposite side. It should be emphasized that this syndrome in its “pure” form is rare; its individual elements are usually identified.

Anterior spinal syndrome- bilateral paraplegia (or paraparesis) combined with decreased pain and temperature sensitivity. The reason for the development of this syndrome is a violation of blood flow in the anterior spinal artery, which is injured by a bone fragment or a prolapsed disc.

Central spinal cord syndrome(more often occurs with a sharp hyperextension of the spine) is characterized mainly by

paresis of the arms, weakness in the legs is less pronounced; Sensory disturbances of varying severity below the level of the lesion and urinary retention are noted.

In some cases, mainly with trauma accompanied by sharp flexion of the spine, dorsal cord syndrome- loss of deep types of sensitivity.

Damage to the spinal cord (especially when its diameter is completely damaged) is characterized by disturbances in the regulation of the functions of various internal organs: respiratory disorders with cervical damage, intestinal paresis, dysfunction of the pelvic organs, trophic disorders with the rapid development of bedsores.

In the acute stage of injury, the development of “spinal shock” is possible - a decrease in blood pressure (usually not lower than 80 mm Hg) in the absence of signs of polytrauma and internal or external bleeding. The pathogenesis of spinal shock is explained by the loss of sympathetic innervation below the site of injury while maintaining parasympathetic innervation (causes bradycardia) and atony of skeletal muscles below the level of injury (causes deposition of blood in the venous bed with a decrease in circulating blood volume).

Clinical forms of spinal cord injury

Spinal concussion is very rare. It is characterized by damage to the spinal cord of a functional type in the absence of obvious structural damage. More often, paresthesia and sensory disturbances below the injury zone are observed, less often - paresis and paralysis, and dysfunction of the pelvic organs. Occasionally, clinical manifestations are severe, up to the picture of complete damage to the spinal cord; The differential diagnostic criterion is complete regression of symptoms within 24 hours.

The cerebrospinal fluid is not changed during a concussion of the spinal cord, the patency of the subarachnoid space is not impaired. Changes in the spinal cord are not detected by MRI.

Spinal cord contusion - the most common type of lesion in closed and non-penetrating spinal cord injuries. A bruise occurs when a vertebra is fractured with its displacement, prolapse of the inter-

vertebral disc, vertebral subluxation. When the spinal cord is contused, structural changes always occur in the substance of the brain, roots, membranes, and vessels (focal necrosis, softening, hemorrhages).

The nature of motor and sensory disorders is determined by the location and extent of the injury. As a result of a spinal cord contusion, paralysis, changes in sensitivity, dysfunction of the pelvic organs, and autonomic disorders develop. Trauma often leads to the appearance of not one, but several areas of injury. Secondary disorders of the spinal circulation can cause the development of foci of softening of the spinal cord several hours or even days after the injury.

Spinal cord contusions are often accompanied by subarachnoid hemorrhage. In this case, an admixture of blood is detected in the cerebrospinal fluid. The patency of the subarachnoid space is usually not impaired.

Depending on the severity of the injury, restoration of impaired functions occurs within 3-8 weeks. However, with severe bruises that cover the entire diameter of the spinal cord, the lost functions may not be restored.

Spinal cord compression occurs when a vertebrae is fractured with displacement of fragments or when there is a dislocation or herniation of an intervertebral disc. The clinical picture of spinal cord compression can develop immediately after injury or be dynamic (increasing with spinal movements) if it is unstable. As in other cases of SMT, symptoms are determined by the level of damage, as well as the severity of compression.

There are acute and chronic compression of the spinal cord. The latter mechanism occurs when the compressing agent (bone fragment, prolapsed disc, calcified epidural hematoma, etc.) persists in the post-traumatic period. In some cases, with moderate compression, after the acute period of SMT has passed, a significant or complete regression of symptoms is possible, but their reappearance in the long term due to chronic trauma to the spinal cord and the development of a focus of myelopathy.

There is a so-called hyperextension injury of the cervical spine(whiplash injury) that occurs when

car accidents (rear impact with incorrectly installed or missing head restraints), diving, falling from a height. The mechanism of this spinal cord injury is a sharp hyperextension of the neck, exceeding the anatomical and functional capabilities of this section and leading to a sharp narrowing of the spinal canal with the development of short-term compression of the spinal cord. The morphological focus that forms in this case is similar to that of a bruise. Clinically, hyperextension injury is manifested by spinal cord lesion syndromes of varying severity - radicular, partial dysfunction of the spinal cord, complete transverse lesion, anterior spinal artery syndrome.

Hemorrhage in the spinal cord. Most often, hemorrhage occurs when blood vessels rupture in the area of ​​the central canal and posterior horns at the level of the lumbar and cervical thickenings. Clinical manifestations of hematomyelia are caused by compression of the posterior horns of the spinal cord by gushing blood, spreading to 3-4 segments. In accordance with this, segmental dissociated disturbances of sensitivity (temperature and pain) acutely occur, located on the body in the form of a jacket or half-jacket. When blood spreads to the area of ​​the anterior horns, peripheral flaccid paresis with atrophy is detected, and when the lateral horns are affected, vegetative-trophic disorders occur. Very often in the acute period, not only segmental disorders are observed, but also conduction sensitivity disorders, pyramidal symptoms due to pressure on the lateral cords of the spinal cord. With extensive hemorrhages, a picture of complete transverse lesion of the spinal cord develops. The cerebrospinal fluid may contain blood.

Hematomyelia, if not combined with other forms of structural damage to the spinal cord, is characterized by a favorable prognosis. Neurological symptoms begin to regress after 7-10 days. Restoration of impaired functions may be complete, but more often certain neurological disorders remain.

Hemorrhage into the spaces surrounding the spinal cord can be either epidural or subarachnoid.

An epidural spinal hematoma, unlike an intracranial hematoma, usually occurs as a result of venous bleeding (from

venous plexuses surrounding the dura mater). Even if the source of bleeding is an artery passing through the periosteum or bone, its diameter is small and the bleeding stops quickly. Accordingly, spinal epidural hematomas rarely reach large sizes and do not cause severe compression of the spinal cord. The exception is hematomas caused by damage to the vertebral artery during a fracture of the cervical spine; such victims usually die from circulatory disorders in the brain stem. In general, epidural spinal hematomas are rare.

The source of a subdural spinal hematoma can be both the vessels of the dura mater and spinal cord, and the epidural vessels located at the site of traumatic damage to the dura mater. Subdural spinal hematomas are also rare; usually bleeding inside the dural sac is not limited and is called spinal subarachnoid hemorrhage.

Clinical manifestations. Epidural hematomas are characterized by an asymptomatic interval. Then, a few hours after the injury, radicular pain appears with varying irradiation depending on the location of the hematoma. Later, symptoms of transverse compression of the spinal cord develop and begin to increase.

The clinical picture of intrathecal (subarachnoid) hemorrhage in spinal cord injury is characterized by acute or gradual development of symptoms of irritation of the membranes and spinal roots, including those located above the site of injury. Intense pain in the back and limbs, stiffness of the neck muscles, and Kernig's and Brudzinski's symptoms appear. Very often they are accompanied by paresis of the limbs, sensory conduction disturbances and pelvic disorders due to damage or compression of the spinal cord by gushing blood. The diagnosis of hemorrhachis is verified by lumbar puncture: the cerebrospinal fluid is intensely stained with blood or xanthochromic. The course of hemorrhachis is regressive, and complete recovery often occurs. However, hemorrhage in the cauda equina area can be complicated by the development of an adhesive process with severe neurological disorders.

Anatomical spinal cord injury occurs at the time of injury or secondary spinal cord injury

a wounding object, bone fragments, or when it is overstretched and ruptured. This is the most severe type of SMT, since restoration of anatomically damaged spinal cord structures never occurs. Occasionally, anatomical damage is partial, and Brown-Séquard syndrome or another of those described above develops, but more often such damage is complete. Symptoms are determined by the nature and level of the lesion.

Objective diagnosis

Radiography. Direct radiological signs of a spinal fracture include disturbances in the structure of the bodies, arches and processes of the vertebrae (discontinuity of the external bone plate, the presence of bone fragments, a decrease in the height of the vertebral body, its wedge-shaped deformation, etc.).

Indirect radiological signs of SMT - narrowing or absence, less often - widening of the intervertebral space, smoothing or deepening of natural lordoses and kyphosis, the appearance of scoliosis, changes in the axis of the spine (pathological displacement of one vertebra relative to another), changes in the course of the ribs due to trauma to the thoracic region, as well as poor visualization spinal structures in the area of ​​interest even with targeted images (caused by paravertebral hematoma and soft tissue edema).

X-ray examination makes it possible to detect bone-destructive changes and metal foreign bodies with sufficient reliability, but provides only indirect, unreliable information about the state of the ligamentous apparatus of the spine and intervertebral discs, hematomas and other factors of spinal cord compression.

To identify the condition of the spinal cord and its roots, as well as to assess the patency of the spinal subarachnoid space, previously myelography- X-ray examination of the spine after introducing a radiopaque substance into the subarachnoid space of the lumbar or occipital cistern, contouring the spinal cord and its roots. Various preparations were proposed (air, oil and aqueous solutions of iodine salts), the best in terms of tolerability and quality of contrast were non-ionic water solutions.

suitable radiopaque agents. With the advent of CT and MRI, myelography is practically not used.

CT- the main method for diagnosing the condition of the bone structures of the spine. Unlike spondylography, CT is good at detecting fractures of the arches, articular and spinous processes, as well as linear fractures of the vertebral bodies, which do not lead to a decrease in their height. However, before a CT scan, X-ray or MRI of the spine is mandatory, since it allows you to establish “areas of interest” in advance and thereby significantly reduce the radiation dose. Three-dimensional reconstruction of spinal structures obtained from spiral CT helps plan surgical intervention. CT angiography provides visualization of the internal carotid and vertebral arteries, which can be damaged by trauma to the cervical spine. A CT scan may be performed if there are metallic foreign bodies in the wound. The disadvantage of CT is unsatisfactory visualization of the spinal cord and its roots; some assistance in this may be provided by the introduction of a radiopaque substance into the subarachnoid space of the spinal cord (computed myelography).

MRI- the most informative method for diagnosing SMT. It allows you to assess the condition of the spinal cord and its roots, the patency of the spinal subarachnoid space and the degree of compression of the spinal cord. MRI clearly visualizes intervertebral discs and other soft tissues, including pathological ones, and obvious bone changes. If necessary, MRI can be supplemented with CT.

The functional state of the spinal cord can be assessed using electrophysiological methods- studies of somatosensory evoked potentials, etc.

Algorithm for providing medical care for spinal cord injury

1. At the scene of injury, as with TBI, the DrABC algorithm works (Danger remove, Air, Breathing, Circulation). That is, the victim must be transferred from the place of maximum danger, ensure airway patency, mechanical ventilation in case of breathing problems or in patients in stupor and coma, and maintain adequate hemodynamics.

Rice. 12.2. Philadelphia collar; Various modifications are possible (a, b)

If the victim is unconscious and complains of pain in the neck or weakness and/or numbness in the limbs, external immobilization of the cervical spine with a Philadelphia collar (included in the set of external ambulance orthoses) is necessary - Fig. 12.2. The trachea can be intubated in such a patient after applying the specified external cervical orthosis. If damage to the thoracic or lumbosacral spine is suspected, no special immobilization is carried out; the patient is carefully placed on a stretcher and, if necessary, fixed to it.

The main thing at this stage is to ensure arterial normotension and normal arterial blood oxygen saturation, which, as with TBI, prevents the development of secondary consequences of TBI. In the presence of external and/or internal injuries, among other things, compensation for blood loss is necessary.

There is no specific drug treatment for STS. Glucocorticoids may inhibit lipid peroxidation at the site of injury and may reduce secondary spinal cord injury to some extent. There are recommendations for the administration of high doses of methylprednisolone (30 mg per 1 kg of body weight as a bolus in the first 3 hours after SMT, then 5.4 mg per 1 kg of body weight per hour for 23 hours); The effectiveness of this regimen has not yet been confirmed in independent studies. Other previously proposed drugs (“nootropic”, “vascular”, “metabolic”) are ineffective.

2. Inpatient (hospital) stage of medical care. Assessment of the condition of the spine is necessary in all victims with TBI of any severity, in victims with neurological symptoms that appeared after the injury (impaired sensitivity, movements, sphincter function, priapism), in persons with multiple injuries to the skeletal bones, as well as in cases of complaints of back pain in the absence of noticeable damage and neurological deficits.

Victims with clinical manifestations or a high risk of STS (see below) must undergo one or more objective neuroimaging studies.

Algorithm of actions in the emergency room. First of all, the severity of the patient’s condition is assessed using the GCS, hemodynamic parameters and pulmonary ventilation are determined and, if necessary, emergency measures are taken to correct them. At the same time, the presence and nature of combined injuries to internal organs and extremities are assessed, signs of combined damage (thermal, radiation, etc.) are identified and the order of therapeutic and diagnostic measures is determined.

All patients with clinical signs of SMT or in an unconscious state must have a permanent urinary catheter and nasogastric tube installed.

The general rule is to eliminate the most life-threatening factor first. However, even if SMT is not leading in the severity of the patient’s condition or is only suspected, all diagnostic and therapeutic measures should be carried out with maximum immobilization of the spine.

In victims with mild TBI (15 GCS points) in the absence of complaints and neurological symptoms, assessing the condition of the spine using physical methods is sufficient. Obviously, in such victims the likelihood of SMT is extremely low, and the patient can be released under the supervision of a family physician. Neuroimaging studies are usually not performed in these cases.

In the absence of signs of TBI or SCI, but with multiple bone injuries, a thorough neurological and physical assessment of the condition of the spinal cord and spine is necessary. In such a situation, even in the absence of clinical signs of STS, radiography of the cervical spine is advisable, and in patients in serious condition, of the entire spine.

Radiography is performed by most victims (only with closed SMT and, accordingly, confidence in the absence of metallic foreign bodies in the patient’s body, is it possible to refuse radiography in favor of MRI).

In patients with impaired consciousness, radiography of the cervical spine is required in at least a lateral projection

Rice. 12.3. Compression fracture of the VII cervical vertebra with retrolisthesis (“diver’s fracture”); spondylogram, lateral projection: a - before stabilization; b - after it

(Fig. 12.3); For the remaining victims with complaints of back pain or neurological symptoms, radiography of the presumably damaged part of the spine is performed in 2 projections. In addition to radiography in standard projections, if necessary, radiography is performed in special settings (for example, if there is a suspicion of injury to the 1st and 2nd cervical vertebrae, pictures through the mouth).

If radiological signs of spinal damage (direct or indirect) are detected, the diagnosis is verified using MRI or CT (Fig. 12.4). As already mentioned, with closed SMT, it is possible to abandon radiography in favor of MRI.

Rice. 12.4. Fracture of the odontoid process of the II cervical vertebra: a - MRI; b - CT; due to the loss of the supporting function of the odontoid process as a result of a fracture, the first cervical vertebra is displaced anteriorly, the spinal canal is sharply narrowed

Assessment of the functional state of the spinal cord using electrophysiological methods is usually performed in a hospital on a routine basis.

Algorithm of actions in the hospital. After the diagnosis of STS and associated injuries is established, the patient is hospitalized in the department according to the profile of the main (most life-threatening) pathology. From the first hours of SMT with spinal cord injury, complications are prevented, the main of which are bedsores, urinary tract infections, deep vein thrombosis of the legs and pelvis, intestinal paresis and constipation, gastric bleeding, pneumonia and contractures.

Measures to prevent bedsores include the use of an anti-bedsore mattress, hygienic skin care, frequent changes in the patient’s position in bed and, in the absence of spinal instability, early (after 1-2 days) activation of the victim.

Urinary infection develops in almost all patients with spinal cord injury, and the “trigger” is the resulting acute urinary retention, leading to overstretching of the bladder, ureters and renal pelvis, circulatory disorders in their walls and retrograde spread of infection due to vesicoureteral reflux . Therefore, perhaps earlier, such patients undergo catheterization of the bladder with preliminary introduction into the urethra of a solution or gel of an antiseptic and anesthetic (usually chlorhexidine with lidocaine); If possible, the permanent catheter is removed after a few days and periodic catheterization of the bladder is performed (once every 4-6 hours; to prevent overdistension of the bladder, the volume of urine should not exceed 500 ml).

Deep vein thrombosis of the legs and pelvis develops in 40% of patients with spinal cord injury and often occurs without clinical manifestations, but in 5% of cases it leads to pulmonary embolism. The greatest risk of deep vein thrombosis is in the first 2 weeks after injury with a maximum on the 7-10th day. Prevention consists of the use of periodic pneumatic compression of the legs and/or stockings with graduated compression, passive exercises and early activation (for stable or surgically stabilized spinal injuries);

in the absence of contraindications, low molecular weight heparin preparations are prescribed.

Intestinal paresis develops in the majority of victims with STS and can be caused by both central and peripheral mechanisms (compression of the mesentery with the vessels and nerves passing through it by a retroperitoneal hematoma that occurs during a fracture of the lumbar and sometimes thoracic spine). Therefore, on the first day, such victims are fed parenterally and then gradually increase the amount of food with sufficient fiber content; If necessary, laxatives are prescribed.

In many patients, on the 1st day after SMT, erosions of the mucous membrane of the stomach and duodenum occur, leading to gastric bleeding in 2-3% of cases. Therefore, victims are given a nasogastric tube and prescribed H 2 blockers (ranitidine, famotidine), taking them during the first 7-10 days reduces the risk of gastric bleeding to 1%.

Violations of pulmonary ventilation are caused by impaired innervation of the intercostal muscles, pain with concomitant rib fractures and immobilization with the development of congestion in the posterior parts of the lungs. Prevention consists of breathing exercises, anesthesia for rib fractures, and early activation of the patient. In case of injury to the cervical spine, there is a need for periodic sanitation of the upper respiratory tract, sometimes using a bronchoscope. Mechanical ventilation is carried out with a periodic increase in end-expiratory pressure; if long-term mechanical ventilation is necessary, a tracheostomy is performed.

Prevention of contractures begins on the 1st day after SMT and consists of active and passive gymnastics at least 2 times a day; To prevent contractures in the ankle joints, the feet are fixed in a flexed position using pillows or external orthoses.

It should be borne in mind that even if immediately after the injury the clinical picture of complete spinal cord damage is determined, in 2-3% of victims, a greater or lesser recovery of impaired functions is observed after a few hours. If the clinical picture of complete spinal cord injury persists after 24 hours from the moment of SMT, the chances of further neurological improvement are extremely low.

Until the nature of the lesion is clarified and an adequate treatment method is selected, external immobilization is maintained. Algorithm for the treatment of spinal cord injury

The treatment algorithm for STS is determined by the nature of the damage to the spine (stable or unstable) and spinal cord (complete or incomplete).

For stable damage indications for urgent surgery rarely arise, only when there is compression of the spinal cord or spinal root. Limiting the load on the affected segment is usually sufficient. To do this, in case of damage to the cervical spine, external orthoses (“head holders”) are used; in case of stable fractures of the thoracic and lumbar spine, various corsets are used or simply prohibiting heavy lifting, bending, and sudden movements for 2-3 months. With concomitant osteoporosis, calcium supplements with ergocalceferol and, if necessary, synthetic calcitonin are prescribed to accelerate fracture healing.

For unstable damage immobilization is necessary - external (using external devices) or internal, carried out during surgery. It should be noted that even with complete damage to the spinal cord and instability of the spine, its stabilization is necessary - this improves the possibilities of rehabilitation.

Treatment of complicated spinal fractures

The main goals that are pursued when providing care to patients with a complicated spinal fracture are the elimination of compression of the spinal cord and its roots and the stabilization of the spine.

Depending on the nature of the injury, this goal can be achieved in different ways:

Surgical method;

Using external immobilization and reposition of the spine (traction, cervical collars, corsets, special fixing devices).

Spinal immobilization prevents possible dislocation of the vertebrae and additional damage to the spinal cord, creates conditions for eliminating existing spinal deformation and fusion of damaged tissues in a position close to normal.

One of the main methods of immobilizing the spine and eliminating its deformation is traction, which is most effective for cervical trauma.

Traction is carried out using a special device consisting of a bracket fixed to the skull and a system of blocks that perform traction (Fig. 12.5).

The Crutchfield clamp is fixed to the parietal tuberosities with two screws with sharp ends. Traction using weights is carried out along the axis of the spine. At the beginning of traction, a small load is usually installed (3-4 kg), gradually increasing it to 8-12 kg (in some cases - more). Changes in spinal deformation under the influence of traction are monitored by repeated radiography.

The disadvantage of traction is the need for the victim to stay in bed for a long time, which significantly increases the risk of developing bedsores and thromboembolic complications. Therefore, recently, implantable or external immobilizing devices that do not interfere with the early activation of the patient have become increasingly widespread.

In case of damage to the cervical spine, immobilization of the spine can be carried out using a device consisting of a special corset such as a vest, a metal hoop rigidly fixed to the patient’s head, and rods connecting

Rice. 12.5. Skeletal traction for a fracture of the cervical spine using a Crutchfield clamp

wearing a hoop with a vest (halo fixation, halo vest- rice. 12.6). In cases where complete immobilization is not required for injuries to the cervical spine, semi-soft and hard collars are used. Corsets of a special design are also used for fractures of the thoracic and lumbar spine.

When using external immobilization methods (traction, corsets), it takes a long time (months) to eliminate spinal deformity and heal damaged structures in the required position.

In many cases, this method of treatment is unacceptable: first of all, if it is necessary to immediately eliminate compression of the spinal cord. Then there is a need for surgical intervention.

The purpose of the operation is to eliminate compression of the spinal cord, correct spinal deformity and reliably stabilize it.

Surgery. Various types of operations are used: approaching the spinal cord from behind through laminectomy, from the side or from the front with resection of the vertebral bodies. To stabilize the spine, a variety of metal plates, bone screws, and occasionally wire are used. Resected vertebral fragments are replaced with bone fragments taken from the patient's ilium or tibia, special metal and polymethyl methacrylate prostheses. You should know that stabilizing systems provide only temporary immobilization of the damaged part of the spine for up to 4-6 months, after which, due to osteoporosis around the screws embedded in the bone, their supporting function is lost. Therefore, implantation of a stabilizing system is necessarily combined with the creation of conditions for the formation of bone fusions between the above and underlying vertebrae - spinal fusion.

Indications for surgery for spinal and spinal cord injuries

When determining surgical indications, it is necessary to take into account that the most dangerous spinal cord injuries

Rice. 12.6. Halofixation system

occur immediately at the time of injury and many of these injuries are irreversible. So, if a victim immediately after an injury has a clinical picture of a complete transverse lesion of the spinal cord, then there is practically no hope that an urgent operation can change the situation. In this regard, many surgeons consider surgical intervention in these cases to be unjustified.

However, if there are symptoms of a complete break in the spinal cord roots, despite the severity of the damage, surgery is justified primarily due to the fact that it is possible to restore conductivity along the damaged roots, and if they are ruptured, which is rare, a positive result can be obtained with microsurgical suturing ends of damaged roots.

If there are even the slightest signs of preservation of some of the functions of the spinal cord (slight movement of the fingers, the ability to determine a change in the position of a limb, perception of strong pain stimuli) and at the same time there are signs of compression of the spinal cord (presence of a block, displacement of the vertebrae, bone fragments in the spinal canal, etc.) , the operation is indicated.

In the late period of injury, surgery is justified if compression of the spinal cord persists and the symptoms of its damage progress.

The operation is also indicated for severe deformation and instability of the spine, even with complete transverse damage to the spinal cord. The purpose of the operation in this case is to normalize the supporting function of the spine, which is an important condition for more successful rehabilitation of the patient.

The choice of the most adequate treatment method - traction, external fixation, surgery, a combination of these methods is largely determined by the location and nature of the injury.

In this regard, it is advisable to separately consider the most typical types of injury to the spine and spinal cord.

Cervical spine injury

The cervical region of the spine is the most susceptible to damage and the most vulnerable. Cervical injuries are especially common in children, which can be explained by weakness of the neck muscles, significant extensibility of the ligaments, and large head size.

It should be noted that injury to the cervical vertebrae is more often than other parts of the spine accompanied by damage to the spinal cord (up to 40% of cases).

Damage to the cervical vertebrae leads to the most severe complications and, more often than with injuries to other parts of the spine, to the death of the patient: 25-40% of victims with injury localized at the level of the 3 upper cervical vertebrae die at the scene of the accident.

Due to the unique structure and functional significance of the 1st and 2nd cervical vertebrae, their damage should be considered separately.

The first cervical vertebra (atlas) can be damaged alone or together with the second vertebra (40% of cases). Most often, as a result of injury, the atlas ring ruptures in its different parts. The most severe type of SMT is atlanto-occipital dislocation - displacement of the skull relative to the first cervical vertebra. In this case, the area of ​​transition of the medulla oblongata into the spinal cord is injured. The frequency of this type of SMT is less than 1%, mortality is 99%.

When the second cervical vertebra is damaged (epistrophy), a fracture and displacement of the odontoid process usually occur. A peculiar fracture of the second vertebra at the level of the articular processes is observed in hanged people (“hangman’s fracture”).

The C V -Th I vertebrae account for over 70% of injuries - fractures and fracture dislocations with accompanying severe, often irreversible damage to the spinal cord.

For fractures of the first cervical vertebra, traction by rigid external stabilization using halo fixation is usually successfully used. For combined fractures of the 1st and 2nd cervical vertebrae, in addition to these methods, surgical stabilization of the vertebrae is used, which can be achieved by tightening the arches and spinous processes of the first 3 vertebrae with wire or fixing them with screws in the area of ​​the articular processes. Fixing systems have been developed that allow maintaining a certain range of movements in the cervical spine.

In some cases, to eliminate compression of the spinal cord and medulla oblongata by the broken off odontoid process of the second cervical vertebra, anterior access through the oral cavity can be used.

Surgical fixation is indicated for fracture-dislocations of the vertebrae C In -Th r Depending on the characteristics of the damage, it can be performed using various implanted systems. In case of anterior compression of the spinal cord by fragments of a crushed vertebra, a prolapsed disc, or a hematoma, it is advisable to use an anterior approach with resection of the body of the affected vertebra and stabilization of the spine with a metal plate fixed to the vertebral bodies, with the installation of a bone graft in place of the removed vertebra.

Trauma to the thoracic and lumbar spine

Injuries to the thoracic and lumbar spine often result in compression fractures. More often, these fractures are not accompanied by spinal instability and do not require surgical intervention.

With comminuted fractures, compression of the spinal cord and its roots is possible. In this case, indications for surgery may arise. To eliminate compression and stabilize the spine, complex lateral and anterolateral approaches, including transpleural ones, are sometimes required.

Conservative treatment of patients with consequences of spinal cord injury

The main thing in the treatment of patients with complete or incomplete spinal cord injury is rehabilitation. The goal of rehabilitation treatment carried out by professional rehabilitation specialists is the maximum adaptation of the victim to life with an existing neurological defect. For these purposes, special programs are used to train intact muscle groups and teach the patient techniques that ensure the maximum level of independent activity. Rehabilitation provides for the victim to achieve the ability to take care of himself, move from a bed to a wheelchair, go to the toilet, take a shower, etc.

Special devices have been developed that allow victims, even with severe neurological impairments, to perform

take on socially useful functions and serve yourself. Even with tetraplegia, it is possible to use tongue-activated manipulators, voice-controlled computers, etc. The most important role is played by the help of a psychologist and social rehabilitation - training in a new, accessible profession.

Methods of conservative and surgical treatment of the consequences of SMT are auxiliary, but sometimes essential.

One of the common consequences of spinal cord injury is a sharp increase in tone in the muscles of the legs and torso, which often complicates rehabilitation treatment.

To eliminate muscle spasticity, drugs that reduce muscle tone (baclofen, etc.) are prescribed. For severe forms of spasticity, baclofen is injected into the spinal subarachnoid space using implantable, programmable pumps (see Chapter 14, Functional Neurosurgery). Surgical interventions described in the same section are also used.

In case of persistent pain syndromes, which more often occur with damage to the roots and the development of adhesions, there may be indications for pain interventions, also described in Chapter 14 “Functional Neurosurgery”.

The effectiveness of many drugs previously used to treat SMT (and TBI) - “nootropic”, “vasodilator”, “rheological”, “metabolic”, “neurotransmitter” - has been called into question by the results of independent studies.

Open injuries to the spine and spinal cord

In peacetime, open wounds with penetration of a wounding object into the cavity of the spinal canal are rare, mainly in criminal SMT. The frequency of such injuries increases significantly during military operations and anti-terrorist operations.

The incidence of military injuries to the spine approximately corresponds to the length of each section and is 25% for the cervical spine, 55% for the thoracic spine and 20% for the lumbar, sacral and coccygeal spine.

Features of mine-explosive and gunshot injuries of the spine and spinal cord are:

Open and often penetrating nature of the wounds;

High frequency and severity of damage to the spinal cord and its roots, caused by the high energy of the traumatic agent (causing a shock wave and cavitation);

Long pre-hospital stage of medical care;

High frequency of combined injuries (multiple wounds, fractures, dislocations, bruises, etc.);

High frequency of combined (with burns, compression, potentially radiation and chemical damage) injuries.

The principles of first aid are the same as for any type of injury (DrABC). A special feature is attention to preventing secondary infection of the wound by antiseptic treatment of its edges and applying an aseptic dressing; if there is moderate bleeding, the wound should be packed with a hemostatic sponge containing gentamicin (and then applied with an aseptic dressing).

Transportation of the wounded is carried out according to the same principles. Cervical immobilization is necessary but performed whenever possible. In the absence of a stretcher, it is better to carry a wounded person with suspected STS on a board made of boards, etc.

At the stage of qualified care, anti-shock measures are carried out (if they are not started earlier), stopping bleeding, external immobilization of the damaged part of the spine, primary surgical treatment of the wound, administration of tetanus toxoid, catheterization of the bladder, installation of a nasogastric tube. They determine the leading damage in the clinical picture and ensure prompt transportation of the wounded person to the appropriate specialized or multidisciplinary medical institution (hospital or civilian hospital). Immobilization of the spine during transportation is mandatory.

At the stage of specialized medical care, carried out at a certain distance from the war zone, the algorithm for diagnostic and therapeutic measures for STS is similar to that in peacetime. Peculiarities:

Even if MRI is available, preliminary radiography is required to identify metallic foreign bodies;

The use of glucocorticoids (methylprednisolone or others) is contraindicated;

High incidence of wound liquorrhea and infectious complications;

The rarity of spinal instability.

It should be borne in mind that unnecessarily extensive surgical interventions with resection of bone structures, especially those performed before the stage of specialized medical care, significantly increase the incidence of spinal instability.

Indications for surgery for wartime STS

Tissue damage (primary surgical treatment of the wound is required, in the absence of liquorrhea it is carried out according to the usual principles).

Massive tissue damage with crush areas and hematomas. Excision and closed external drainage are performed to reduce the risk of infectious complications.

Wound liquorrhea. It sharply, approximately 10 times, increases the risk of meningitis with the development of a cicatricial adhesive process, often leading to disability and sometimes death of the victim. To relieve liquorrhea, a wound revision is performed with detection and suturing of the dura mater defect (if it is impossible to compare the edges, a graft from local tissues is sutured into the dura mater defect) and careful layer-by-layer suturing of the wound (preferably with absorbable polyvinyl alcohol sutures). Sutures on the dura mater can be strengthened with fibrin-thrombin compositions.

Epidural hematoma. In the absence of the possibility of objective diagnosis, the likelihood of developing an epidural hematoma is indicated by the increase in local neurological symptoms that began several hours after the injury. The operation significantly improves the prognosis.

Compression of the nerve root(s) by a wounding agent or hematoma, bone, cartilage fragments, etc. It manifests itself as pain in the area of ​​innervation of the root and motor disturbances. The operation is indicated even with the assumption of complete anatomical damage, because the ends of the roots can sometimes be compared and sutured; in any case, decompression usually leads to the disappearance of pain.

Damage to the roots of the cauda equina. To decide on surgery in this case, it is desirable to verify the nature of the damage using CT or MRI, but even in the case of an anatomical break, microsurgical suturing of the roots can be beneficial; The greatest difficulty is in identifying the ends of the torn roots, which is problematic even in peaceful conditions.

Damage to blood vessels (vertebral or carotid arteries) is an absolute indication for surgery, during which it is possible to remove the accompanying epidural hematoma.

The presence of a copper-jacketed bullet in the spinal canal. Copper causes an intense local reaction with the development of a scar-adhesive process. It should be understood that the type of bullet can be established in case of criminal wounds in peacetime during operational search activities; during hostilities this is very problematic.

Spinal instability. As mentioned, it is rare with gunshot and mine-explosive wounds; If there is instability of the spine, its stabilization is required. In cases of open wounds, external stabilization (halo-fixation or other) is preferable, since implantation of a stabilizing system and bone grafts significantly increases the risk of infectious complications.

Compression of the spinal cord with the clinical picture of incomplete damage. As already mentioned, due to the high energy of the traumatic agent, even anatomically incomplete spinal cord damage in these situations is usually severe, and the prognosis for recovery is unfavorable. However, if there is at least minimal preservation of neurological function below the level of compression, decompressive surgery is sometimes beneficial.

To prevent infectious complications in case of penetrating wounds, reserve antibiotics are immediately prescribed - imopenem or meropenem with metrogyl, tetanus toxoid is necessarily administered (if not previously administered), and if an anaerobic infection is suspected, hyperbaric oxygenation is performed.

Indications for surgical treatment in the long-term period of gunshot and mine blast wounds are:

Pain syndromes - in order to eliminate them, devices are implanted for delivering painkillers to the central nervous system or systems for analgesic neurostimulation (see section “Functional neurosurgery”).

Spasticity - the same treatment methods are used as for closed SMT.

Migration of a traumatic agent with the development of neurological symptoms (rare).

Spinal instability. More often it is caused by inadequate primary surgical intervention (laminectomy with resection of the articular processes). Requires surgical stabilization.

Lead intoxication (plumbism). A very rare condition caused by the absorption of lead from a bullet located in the intervertebral disc. Lead bullets encapsulated anywhere outside the joints do not cause lead toxicity. Manifested by anemia, neuropathy (motor and/or sensory), intestinal colic. The operation involves removing the bullet; usually performed under X-ray television control. To accelerate the removal of lead residues from the body, calcium trisodium pentetate is used in a high dose (1.0-2.0 g intravenously slowly every other day, a total of 10 to 20 injections).

Rehabilitation of victims does not differ from that for other types of SMT. Psychological rehabilitation for wartime STS is less complex (due to obvious motivation), but physical rehabilitation tends to be a more significant challenge due to the greater severity of the neurological deficit.

Public opinion and government policy of assistance to persons with disabilities are of great importance for the psychological and social adaptation of persons with consequences of SMT of any origin. Similar programs have now achieved great success in developed countries.

The causes of emergency conditions with spinal lesions 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 a late stage of neurosyphilis is accompanied by progressive paralysis, sensory disturbances, stabbing or cutting pain, loss of reflexes and impaired bladder function.

Myelitis due to tick-borne encephalitis often associated with “severe transverse symptoms” involving the upper extremities, 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 the 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 a bacterial infection is suspected, it is necessary to strive to isolate the pathogen by inoculating the cerebrospinal fluid for flora or using the 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. A viral infection may be indicated by 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, a 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 to the 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 installing a urinary catheter for bladder emptying disorders, preventing thrombosis, changing the patient's position, timely mobilization, physical therapy 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 etiological identity or isolate the pathogens, so the choice of drugs is made empirically, depending on the clinical course, the results of laboratory diagnostics and cerebrospinal fluid examination, 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 with 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 the control and stabilization of vital 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 prevalence and clinical symptoms, include conservative therapy, radiation (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 the 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, and the prognosis for multiple sclerosis is better than for patients with other causes of transverse cord lesion syndrome.

The prognosis of spondylitis/spondylodiscitis and spinal abscesses depends on the size and duration of damage to neural structures. The 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. Common reasons include:

• High speed accident
• Falling from a great height 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 of 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). As soon as the likelihood of spinal injury is identified based on risk factors and the course of the injury, a CT scan of the spine should be performed first, due to its higher sensitivity.

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, in case of neurological deficits and ambiguous CT results, MRI should also be additionally performed in case of emergency diagnosis.

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
• heart rhythm disturbances (in the case of lesions above T6, predominantly bradycardia 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 benefit when started early, critics primarily note 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 function, partial loss of motor and sensory functions, but also their complete recovery are possible. The prognosis for severe intramedullary hemorrhage, swelling and compression of the spinal cord is poor.

Spinal injuries are one of the most severe types of injuries. Recently, the prevalence and severity of spinal column injuries has been increasing, which is associated with an increase in the amount of transport, traffic speed, the spread of high-rise construction and other factors in the modern way and rhythm of life.

Patients with spinal injuries make up 18% of all patients in trauma hospitals. These are mostly young people (average age is 17-35 years). Therefore, the treatment of spinal injuries is not only a responsible medical and social problem, but also an economic one, because the risk of developing permanent disability after spinal injury is very high.

The risk of disability after a spinal injury is very high

Causes of spinal injuries

Among the causes of damage to the spinal column and the spinal cord, which is located inside, include:

• Road traffic accidents. In such cases, a person can be injured both as a pedestrian and while inside a vehicle. Particular importance is given to whiplash injury, which occurs when the neck is sharply bent and then straightened with the same force, throwing the head back. Such circumstances arise when 2 vehicles collide, during sudden braking at high speed. It is to prevent this type of injury to the cervical spine that there are head restraints in cars.
• Falling from height. Such incidents are almost always accompanied by spinal fractures and spinal cord damage. Particularly dangerous is the case when the victim lands on his feet - most of the spinal column is injured.
• Diver's injury. It develops when a person dives from a height into the water head down. In this case, the victim hits his head against obstacles in the pond and strong flexion or extension occurs in the cervical spine with subsequent traumatization.
• Also, the cause of damage to the spine and spinal cord can be knife, gunshot, or explosive injuries when the traumatic factor hits the spinal area.

The most common mechanisms of spinal injury

Classification of spinal injuries

Injury to the spine and spinal cord has a clear classification, on which treatment tactics and prognosis directly depend. All injuries can be divided into open (with violation of the integrity of the skin) and closed (without them).
Depending on the nature of damage to the anatomical structures of the spine, there are:

1. Injuries to the ligamentous apparatus of the spinal column (ruptures and sprains of ligamentous structures). Refers to mild degree.
2. Vertebral body fractures. This includes compression injury, when the vertebral body is compressed and a compression fracture occurs (people with osteoporosis are especially susceptible to this mechanism). Also, fractures of the vertebral bodies can be comminuted, marginal, vertical, horizontal and explosive.
3. Damage to the intervertebral discs (rupture of the fibrous ring with prolapse of the inner part of the disc, acute Schmorl's hernia).
4. Fractures of the processes (spinous, transverse, articular) and vertebral arches.
5. Dislocations and subluxations of the vertebrae, fracture-dislocations.
6. Traumatic spondylolisthesis.

All fractures are divided into 2 groups:

• with displacement, when the normal axis of the spine is disrupted and there is a high risk of spinal cord compression;
• without displacement.

It is also important to divide spinal injuries into stable and unstable. Stable fractures occur when only the anterior part of the spine (vertebral bodies) is damaged. Moreover, if at the time of the blow the spinal cord was not damaged due to displacement of the vertebra, then in the future this risk is minimal.

An unstable fracture occurs when both the anterior and posterior parts of the spine (arches and processes) are damaged simultaneously. Moreover, if compression of the spinal cord did not occur at the time of injury, then the high risk of this complication remains in the future, since any movement can lead to such consequences.

Types of spinal cord injuries:

• concussion (this is a reversible functional impairment);
• bruise or contusion (organic damage to nerve tissue);
• compression, which can be caused by vertebral fragments, damaged disc, hematoma, edema, etc.;
• partial and complete rupture is the most severe damage, the consequences of which depend on the level of violation.

Symptoms of spinal injuries

The clinical symptoms of spinal injury primarily depend on whether the spinal cord is damaged, as well as on the location of the injury, its type and mechanism.

Signs of stable injuries

Stable spinal column injuries include:

• soft tissue bruises;
• ligament damage;
• stable fractures of the vertebrae (body, spinous, transverse processes without displacement).

Characteristic clinical symptoms:

• diffuse pain at the site of injury;
• swelling, bruising, hematomas in the area of ​​injury;
• movements may be limited slightly or severely, depending on the degree of pain;
• when the spinous processes are fractured, local pain occurs, sometimes you can feel their pathological mobility;
• in some cases, signs of radiculitis are added;
• with fractures of the transverse processes there is pain in the paravertebral areas;
• There are no neurological symptoms, except in cases of secondary radiculitis.

Cervical spine injury

Damage to the upper segments of the cervical spinal cord is life-threatening. The function of the cardiovascular and respiratory centers suffers, and this can lead to immediate death. If there is an injury at the level of the 3-4 segment of the spinal cord, the patient experiences tetraplegia (paralysis of the arms and legs), all types of sensitivity below the site of injury are lost. The respiratory muscles and diaphragm also suffer, which can lead to respiratory arrest.

MRI shows a fracture in the cervical spine and compression of the spinal cord

When the 4-5 segment of the spinal cord is compressed, tetraplegia occurs, but without respiratory disorders. If 5-8 segments of the spinal cord are damaged, paralysis of various arm muscles develops and lower paraparesis is observed; dysfunction of the pelvic organs may be present.

Damage to the thoracic and lumbar spine

Damage to the thoracic spinal cord due to spinal injuries is accompanied by weakness in the legs and dysfunction of the genital and pelvic organs. Paralysis of the muscles of the anterior abdominal wall may occur. Respiratory disturbances may occur due to paralysis of the intercostal muscles.

Damage at the lumbar level leads to paralysis of various muscle groups of the lower extremities (foot, leg or thigh). Sensitivity below the location of the injury also suffers, and the function of the pelvic organs and reproductive system is impaired.

Diagnosis of injuries to the spine and spinal cord consists of interviewing the patient, clarifying complaints, the mechanism of injury, examination data of the person, determining the presence of neurological symptoms of spinal cord injury, as well as data from additional examination methods (radiography, MRI, CT, myelography, etc.).

Natal injuries

Birth injuries are a whole group of mechanical damage to fetal tissue that occurs during childbirth. One of the most serious types of birth trauma is spinal injury. Recently, the number of such injuries has decreased significantly as the number of deliveries by caesarean section has increased.

Factors that can lead to birth injury to the spine:

• obstetric care during childbirth;
• application of obstetric forceps;
• breech and other types of pathological presentation of the fetus;
• postmaturity;
• large fruit;
• rapid or prolonged labor;
• deep prematurity;
• abnormalities of fetal development.

Most often, the cervical spine and the adjacent brachial plexus are affected. Symptoms depend on the level of damage. As a rule, such an injury is accompanied by pain (the child is restless, constantly changes his position, testing physiological reflexes is painful). Torticollis, shortened or elongated neck may be observed. If the upper cervical segments of the spinal cord are damaged, a picture of spinal shock, various respiratory disorders, the “frog” position, urinary retention or incontinence can be observed.

Obstetric care during childbirth can cause spinal injury

If the brachial plexus is damaged, the child may develop Cofferat syndrome (paresis of the phrenic nerve), Duchenne-Erb, Dejerine-Klumpke, and Kehrer palsy. All these syndromes have their own distinctive features and consequences.

Damage to the thoracic region is manifested by respiratory disorders resulting from paresis of the intercostal muscles, as well as lower paraparesis of the legs of a spastic nature, “flat belly” syndrome.

Trauma to the lumbar and sacral regions in infants is accompanied by flaccid paraparesis of the legs and dysfunction of the pelvic organs.

Recovery from a spinal injury in a newborn is long. In some cases, due to the high plasticity and degree of regeneration in infants, it is possible to completely get rid of the symptoms and consequences of injury, but in some cases persistent disability develops throughout subsequent life.

First aid for spinal injury

It is necessary to note 2 main points of care for spinal injury:

• reliable and correct fixation of the injured area;
• If possible, administer anesthesia.

Transportation of a victim with a spinal injury

It is necessary to lay the victim on a hard surface with his back, and he is not allowed to sit down or stand up. Regardless of the damaged area, the cervical spine must be securely fixed. There are special collars for this. If you don’t have such a device at hand, you can roll up a thick roll of clothing and secure it around your neck.

Several people should carry the victim to keep the body at the same level and minimize movements in the spine. Such transportation will help avoid secondary spinal cord injury.

In this case, it is necessary to monitor the person’s pulse and breathing. In case of violations, resuscitation assistance must be provided according to the general rules. Under no circumstances leave the victim alone and do not move him from place to place unless absolutely necessary. It is imperative to call an ambulance.

Principles of treatment and rehabilitation after spinal injury

The consequences of spinal injuries directly depend on the timeliness and correctness of first aid, on the type and mechanism of injury, and on concomitant damage to the spinal cord.

Treatment can be conservative or surgical. For mild injuries, treatment is only conservative. Prescribe symptomatic medications (analgesics, hemostatic, restorative, anti-inflammatory), strict bed rest, massage, exercise therapy, and physiotherapy.

In more severe cases, conservative treatment can be supplemented by closed reposition (simultaneous reduction of dislocations, fractures, traction) followed by immobilization of damaged segments of the spine (collars for the cervical spine, corsets for the thoracic or lumbar spine).

Exercise therapy is the main method of rehabilitation after spinal injuries

Surgical treatment is used in cases of spinal cord injury or high risk of injury due to spinal instability. Surgery may also be prescribed if conservative therapy is ineffective. After surgery, strict immobilization or traction is used.

Recovery from a spinal injury is a rather long and labor-intensive process. For injuries without compression of the spinal cord, exercise therapy is indicated from the first days of rehabilitation. They start with breathing exercises and gradually perform exercises for the limbs and spine. The classes must be supervised by a rehabilitation specialist. Massage and physiotherapy are also prescribed.

In case of spinal cord injuries, recovery is complemented by drug treatment, which is aimed at the regeneration of nervous tissue, electrical pulse therapy, and acupuncture.

Unfortunately, it is not always possible to restore functions lost due to spinal injury. But the desire to get better, as well as competent treatment and a rehabilitation program, sometimes work wonders.