Spinal injury

Spinal injury

Spinal cord injury is damage to the spine and spinal cord by mechanical energy. It causes changes both in the spinal cord itself and throughout the body. General provisions

    • Causes: car accidents, falls, sports injuries (diving), industrial, gunshot and stab wounds
    • The cervicothoracic (C4-Th1) and lumbar-thoracic (Th11-L1) departments are most often injured, the rest are much less common. Adults and adolescents are more commonly affected
    • Mechanisms of injury to the spinal cord and roots
    • Compression by bones, ligaments, intervertebral disc substance, foreign body or hematoma. The most severe injuries appear when compressed by bone structures.
    • Stretching as a result of strong flexion (hyperflexion) of the spine. With age, the risk of spinal cord injury when it is stretched increases.
    • Edema of the spinal cord is the main substrate of spinal shock
    • Violation of blood circulation as a result of compression by bone or other structures of the anterior or posterior arteries of the spinal cord. Classification of injuries of the spine and spinal cord
    • Uncomplicated (without dysfunction of the spinal cord and its roots) and complicated
    • Closed (without violating the integrity of the skin and underlying soft tissues) and open
    • Penetrating and non-penetrating (criterion – violation of the integrity of the dura mater)
    • According to nosology:
    • Concussion of the spinal cord
    • spinal cord injury
    • Spinal cord compression.

Clinical picture

    • Process phases
    • Spinal shock, which manifests itself immediately after an injury and is characterized by the loss of all functions – motor, sensory and reflex activity
    • Rapidly developing flaccid tetra- or paraplegia (depending on the level of damage)
    • Absence of sensation, areflexia below the level of the lesion
    • Retention of urination and defecation, lack of sweating below the level of the lesion, early appearance of bedsores, paresis and distension of the stomach, sexual dysfunction 4 Duration – several weeks and even months. After its completion, the picture of true spinal cord injury becomes clear.
    • Restoration of reflex activity (with the occurrence of spastic phenomena of spinal automatism and flexion spasm of the limbs) occurs, starting from the distal sections, spreading to the level of the lesion. With the development of severe urogenic sepsis, bronchopneumonia or intoxication (due to bedsores), the stage of spinal reflex activity can again be replaced by flaccid paraplegia and areflexia, resembling the stage of spinal shock.
    • Signs of spinal cord injury depending on the level (segmental disorders)
    • Above level C4 – respiratory paralysis
    • C4 ~ C5 – mixed tetraplegia: flaccid in the arms, spastic paralysis in the legs
    • C5 ~ C6 – abduction and flexion of the upper limbs are preserved
    • C6 ~ C7 – paralysis of the lower extremities, forearms; however, movements in the shoulder and flexion in the elbow joints are preserved
    • Cg-Thj – Horner’s syndrome
    • ThM-Th12 – muscles of the thigh and lower leg
    • Cauda equina injury – cauda equina syndrome

tail: lower flaccid paraparesis, pain and hyperesthesia in the areas of representation of the nerve roots

    • S3-S5 or spinal cone at the level of C – complete loss of control over urination and defecation.
    • Signs of impaired conduction of the spinal cord (a universal mechanism observed in any form of spinal cord injury):
    • flaccid paresis or paralysis of muscles with areflexia
    • lack of sensation below the level of damage
    • dysfunction of the pelvic organs.
    • Syndrome of complete interruption of the spinal cord – see Spinal cord contusion. Variants of partial damage to the diameter of the spinal cord.
    • Anterior spinal syndrome
    • Bilateral flaccid paresis with dissociated sensory disorders (decrease in pain and temperature sensitivity while maintaining tactile, vibrational and proprioceptive sensitivity) below the level of the lesion and dysfunction of the pelvic organs
    • Occurs with dislocation comminuted fractures and prolapse of fragments of intervertebral discs (traditionally at the cervical level), sometimes with damage to the anterior spinal artery.
    • Central cervical spinal syndrome
    • Predominant damage to the cells of the anterior horns of the cervical spinal cord and the most medially located fibers of the corticospinal tract, passing in the lateral columns (clinically manifested by tetraplegia)
    • Occurs with hyperextension fractures of the cervical vertebrae, with hyperextension injuries in patients with osteochondrosis (mainly in the elderly).
    • back pillar syndrome
    • Violations of deep types of sensitivity, sometimes accompanied by moderate paresis
    • Occurs traditionally with hyperflexion of the cervical vertebrae.
    • Brown-Séquard syndrome (damage to half the diameter of the spinal cord).

Diagnosis

    • Thorough physical examination of the spine, identification of deformities, local swelling or pain, restriction of mobility (movements are made with extreme caution)
    • Study of neurological status. The level (below which there are disorders of movement and sensitivity) and the degree of damage to the diameter of the spinal cord are revealed
    • Lumbar puncture: presence of blood in the CSF, measurement of pressure and determination of the patency of the subarachnoid space (presence or absence of compression) using cerebrospinal fluid tests
    • Radiography of the spine (all departments that could be damaged by trauma) in the anteroposterior and lateral projections, sometimes with careful use of functional tests (flexion and extension), CT
    • MRI (most informative).

Treatment:

First aid

    • If a spinal fracture and spinal cord injury is suspected, others should not try to help the patient until qualified medical personnel arrive
    • Transportation of a sick person to a medical institution is carried out with immobilization, so as not to increase spinal deformities and not cause secondary injuries of the spinal cord
    • In case of injuries of the thoracic or lumbar spine, patients are transported on a hard rigid plane in a supine or prone position; with injuries of the cervical spine with a high probability of developing difficulty in breathing – on the stomach
    • In case of trauma to the cervical spine, a solid cervical (Philadelphia) collar is also used. Conservative therapy
    • Stabilization of vital functions
    • Ensuring adequate ventilation (if mechanical ventilation is needed)
    • Compensation of blood loss, restoration of blood pressure (fluid infusion)
    • KShchr correction.
    • In the first hours after the injury, it will be necessary to administer methylprednisolone: ​​first, 30 mg / kgv / jet for 15 minutes, after 45 minutes – intravenously at a rate of 5.4 mg / kg / h during the day.
    • Preparations that improve microcirculation (reopoliglyukin, pentoxifylline), antibacterial agents, vitamins.
    • Prevention of urogenic. and lung infection, prevention of pressure sores
    • In order to avoid alkalization of urine, in the subsequent urogenous infection, ascorbic acid is immediately prescribed at a dose of 1 g 4 r / day; uroantiseptics for bladder catheterization
    • Massage of the skin to avoid the formation of bedsores, wiping with camphor alcohol, straightening the wrinkles on bed linen
    • Prevention of lung infection – breathing exercises, chest massage, shifting paralyzed patients after 2 hours.
    • Physical exercise and rehabilitation measures will need to be started as soon as possible.

Surgery. To eliminate spinal deformity and compression of the spinal cord (with ensuring the stability of the spine and preventing secondary displacement) in spinal cord injury, skeletal traction, simultaneous closed reduction and surgical interventions are used.

    • Skeletal traction
    • Indication: damage to the cervical spine with displacement of the vertebral bodies without signs of spinal cord compression
    • Use a cranial sling or a head-mounted traction apparatus (Krutchfield brace and Stryker frame) that allows force to be applied in the direction of the longitudinal axis
    • For fractures of the thoracic and lumbar sections, traction is traditionally not used.
    • One-step closed reduction
    • Indications: subluxations and dislocations of the cervical vertebrae, fractures of the thoracic and lumbar vertebrae
    • Manipulations are performed under anesthesia with the use of muscle relaxants.
    • Operational interventions
    • In the acute period, indications for surgery are:
    • Dislocation of the cervical spine with or without a fracture, requiring (if traction and closed manipulations are ineffective) open reduction
    • Cervical injury with anterior spinal syndrome due to bone fragments and prolapsed fragments of the intervertebral disc. Perform anterior decompression and internal fixation (anterior fusion)
    • Depression of the posterior structures of damaged vertebrae into the spinal canal and development of the posterior

spinal cord compression. Apply laminectomy, internal fixation of the spine through posterior fusion

    • Open penetrating wound of the spine
    • Partial spinal cord injury with a gradual increase in neurological disorders or deterioration after temporary improvement, the risk of hematoma.
    • In the later stages of the disease (weeks and months), the operation is indicated with an increase in the clinical picture of compression due to the formation of a callus or a wedge protruding into the lumen of the spinal canal from its anterior wall (Urban’s wedge), or an adhesive arachnoid process with cysts, cicatricial adhesions and bridges.
    • Requirements for surgery
    • Complete decompression of the spinal cord and its vessels
    • Restoration of normal anatomical relationships between the spinal canal and the spinal cord in order to create optimal conditions for the restoration of spinal cord functions
    • Ensuring reliable fixation of bone structures in order to prevent secondary displacements of damaged vertebrae.

Complications

    • Ascending medullary edema
    • Visceral: kidney stones, pyelonephritis, bronchopneumonia
    • Formation of bedsores
    • Muscle spasms, joint contractures
    • Deep vein thrombosis, thromboembolism of various localization.

Forecast

    • Recovery of movement and sensation during the first week after injury indicates a favorable prognosis
    • Any dysfunction that persists for more than 6 months is likely to be permanent.
    • Recovery begins only with a relatively mild dysfunction of the spinal cord
    • A significant improvement is observed in cases where severe spinal cord injury syndrome is due to spinal shock.
    • With persistent syndrome of transverse spinal cord injury, neurological disorders remain unchanged
    • The lethal outcome most often begins in the first 2 weeks after the injury. Mortality is highest in acute closed trauma of the cervical spine and spinal cord.
    • Early death depends on pulmonary complications or ascending lesions of the lower medulla oblongata. In the later period and lethal outcome – a consequence of infectious complications.

See also Hematomyelia, Compression of the spinal cord, Contusion of the spinal cord, ICD. S14 Injury of nerves and spinal cord at neck level S24 Injury of nerves and spinal cord in thoracic region S34 Injury of nerves and lumbar spinal cord at level of abdomen, lower back and pelvis

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