Spinal cord injury
Spinal cord injury (PSMT) is mechanical damage to the spine and the contents of the spinal canal (spinal nerves, spinal cord, its vessels and membranes). The symptoms of the injury depend on the severity of the spinal injury and range from sensitivity disorders to paralysis, respiratory and swallowing disorders. PSMT patients are considered to be the most severe contingent of patients in rehabilitation institutions, since their treatment is long and complex.
The content of the article:
Classification of spinal cord injuries
Classification of closed spinal injuries
Classification of open spinal injuries
Classification of spinal cord injuries and other neurovascular formations of the spinal canal
Etiology of spinal cord injuries
Diagnosis and clinical picture of spinal cord injuries
Treatment of spinal cord injury
Prognosis for spinal cord injury
Spinal cord injury
The prevalence of spinal cord injuries is 29-50 episodes of the disease per million people. At the same time, most of the victims are people younger than 40 years old, mostly men (they are injured 2-4 times more often than women). The treatment of spinal cord injuries is in the competence of traumatologists, neurologists and neurosurgeons.
Classification of spinal cord injuries
All spinal cord injuries are classified into closed and open. The division is made on the basis of skin damage in the injury area and the risk of infection of the spine.
Classification of closed spinal injuries
All closed damages are stable and unstable. The latter are characterized by a violation of the integrity of the intervertebral discs and ligaments, which causes the displacement of the vertebrae. Closed PSMTS, by analogy with brain injuries, are divided into bruising, compression and concussion of the spinal cord.
Depending on the level of injury, there are PSMTS of the roots of the ponytail, cervical, thoracic, lumbosacral spinal cord. Injuries are also divided into injuries to the vertebral body, ligamentous apparatus, posterior semicircle of vertebrae.
Classification of open spinal injuries
Open PSMTS are divided into penetrating and non-penetrating, based on the integrity of the dura mater. This shell is a biological and anatomical barrier that prevents infection from entering the wound.
Also, open spinal cord injuries are classified, depending on the type of weapon that the wound was inflicted, into firearms and non-firearms. Gunshot wounds are divided into five subspecies depending on the type of injury:
through: there is an intersection of the spinal canal with the wound canal;
blind: the wound canal in this case ends blindly in the spinal canal, where the foreign body is localized;
non-penetrating: the wound canal passes directly through the vertebra, but damages the walls of the spinal canal;
tangential: with this type of injury, the wound canal tangentially passes near the walls of the spinal canal, destroys them, but does not penetrate;
paravertebral: this type of injury is characterized by the passage of the wound canal next to the spine, but there is no damage to the bone tissue of the vertebra.
Classification of spinal cord injuries and other neurovascular formations
of the spinal canal of the spinal canal
This classification is important in the context of the fact that the treatment tactics of the disease depends on the type of spinal cord injury. Some types of trauma can be treated conservatively, while others can only be treated surgically. An error in the choice of treatment can cause serious complications. Therefore, in neurology, a detailed classification of spinal cord injuries is used:
Spinal cord concussion: accompanied by functional changes that disappear a week after the injury. It is manifested by a disorder of sensitivity, decreased reflexes, muscle weakness.
Spinal cord injury: characterized by the appearance of irreversible changes along with reversible ones.
Compression of the spinal cord: it can be triggered by fragments of discs and ligaments, fragments of vertebrae, intravertebral hematoma.
Hematomyelia (intracerebral hematoma or cerebral hemorrhage).
Etiology of spinal cord injuries
The causes of spinal cord injuries are very diverse. However, according to statistics, spinal injuries most often occur during car accidents. Motorcyclists are particularly at risk of injury. Another cause of injury is falling from a height due to carelessness. Spinal injuries often occur due to falling down stairs, on a slippery floor, in icy conditions, due to bullet or knife wounds.
Diagnosis and clinical picture of spinal cord injuries
Diagnosis of spinal cord injury involves the collection of complaints of the victim or witness of the incident, examination of the patient, neurological examinations, laboratory tests and instrumental methods (lumbar puncture, CT or MRI of the brain, spondylography, vertebral angiography, myelography, CT myelography).
It is extremely important to collect the anamnesis correctly, since the timeliness and correctness of further treatment depends on it. Namely, the doctor must find out the time and mechanism of injury, determine the localization of pain, sensory and motor disorders, find out whether the victim made any movements after injury. If the patient has neurological symptoms in the acute period, this indicates a brain injury. The doctor pays attention to the type of breathing, the presence of weakness in the limbs, the tension of the abdominal wall.
Instrumental methods are used for differential diagnosis of the disease. They help to distinguish compression of the spinal cord from other types of spinal injury, which are treated conservatively. Instrumental diagnostics is also indicated for spinal shock and the inability of the patient to empty the bladder independently. To make a diagnosis, the doctor does not need to use the whole range of instrumental methods. The choice of the technique depends on the doctor’s suspicions and the results of the neurological examination.
The symptoms of spinal cord injury depend on the period of the disease. In total, there are four main periods of the course of the disease, which reflect the dynamics of restorative and destructive processes:
The acute period lasts for the first two to three days after injury. It is characterized by necrotic and necrobiotic lesions of the spinal cord, circulatory and lymphatic disorders. During this period of injury, symptoms such as spinal shock and conduction disorder are manifested.
The early period takes 2-3 weeks. This period is characterized by the cleansing of the foci of traumatic necrosis, signs of pathological changes in nerve bundles and nerve fibers.
The intermediate period lasts about 3-4 months. Patients have symptoms of fiber regeneration and scar formation. In this period of the disease, all reversible changes and signs of spinal shock disappear.
The late period starts from the third or fourth month and lasts for a long time. Clinically manifested by the final stage of scarring and formation of cysts, pathological processes in the nervous tissue.
Treatment of spinal cord injury
In the acute stage of the disease, immediately after the injury, all the efforts of doctors should be aimed at saving human life and preventing severe damage to the spinal canal. To prevent dislocations in the spine, the patient is transported from the scene on shields or a rigid stretcher in a supine position. To immobilize the limbs, special tires are applied to them. Shifting the patient, carrying out diagnostic and therapeutic measures should be carried out as carefully as possible.
Intensive care
Intensive therapy is carried out, which is aimed at maintaining the normal functioning of important body systems. First of all, it is necessary to maintain a normal blood pressure level, since hypotension can aggravate circulatory disorders in the injury area. After normalization of blood pressure, doctors begin drug therapy for spinal cord edema, for which diuretics and methylprednisolone are prescribed.
In the first 4 hours after spinal injury, hypothermia of the spinal cord is indicated. To maintain the normal volume of circulating blood in traumatic shock, the patient is shown blood up to 1200 ml, low- and high-molecular dextrans. To prevent hypovolemia, which can worsen circulatory disorders, helps the patient to get plenty of fluid (at least 2.5 liters). In acute respiratory failure, ventilation of the lungs is indicated.
Intensive therapy also provides for the maintenance of cardiac activity and electrolyte balance, correction of metabolic disorders. From the first days, patients are necessarily prescribed antibacterial therapy. Also, in the acute period, periodic catheterization of the bladder and washing it with a solution of furacilin is indicated. If an open wound is found in the victim, its primary treatment is necessary.
Surgical intervention
Surgical intervention may be required to treat the injury. The operation (decompression of the spinal cord) should be performed as soon as possible (in the first four hours after spinal injury), because then it will be possible to hope for a favorable outcome of the disease.
Indications for surgery may be as follows:
noticeable deformation of the spinal canal by X-ray positive or X-ray negative, or compressing structures;
block of liquor paths;
rapid development of spinal cord dysfunction;
aggravation of acute respiratory failure, which was provoked by edema of the cervical spinal cord;
signs (clinical and angiographic) of compression of the main vessel of the spinal cord.
There are a number of contraindications, in the presence of which the operation cannot be performed:
traumatic brain injury with a severe course, which is accompanied by disturbances in the level of consciousness and suspicion of intracranial hematoma;
damage to internal organs (risk of peritonitis, internal bleeding, bruising of the heart with concomitant symptoms of heart failure, rib damage);
traumatic or hemorrhagic shock;
severe diseases accompanied by anemia, renal, cardiovascular and hepatic insufficiency;
fatty embolism, non-fixed limb fractures, pulmonary embolism.
In the early period after the stabilization of the patient’s condition, it is necessary to create favorable conditions for his effective rehabilitation. Also, the attention of doctors focuses on the prevention or treatment of complications of injury. Spinal injury is accompanied by a number of serious complications, which can be divided into four large groups:
Infectious and inflammatory complications arise due to the development of infection in the body, there are late and early. Early complications of trauma include purulent epiduritis (inflammation affects the epidural tissue), spinal cord abscess, purulent meningomyelitis. In the later stages of pathology, serious complications such as epiduritis and arachnoiditis may occur.
Trophic disorders are ulcers and bedsores that occur due to a violation of the trophic tissues provoked by damage to the spinal cord. Bedsores go through several stages of formation: necrosis (this stage is characterized by tissue decay), epithelialization (active growth of the epithelium), the appearance of granulations, trophic ulcers (occur if the pathological process does not lead to scarring of the bedsore).
Damage to the pelvic organs is accompanied by urinary retention. Disorders of the bladder are often complicated by the development of an infectious process in the urinary tract, which can provoke urosepsis. Patients can be diagnosed with different forms of neurogenic bladder: hyporeflective, normoreflective, hyperreflexive, areflexive.
Deformations of the musculoskeletal system are manifested by scoliosis and kyphosis. These pathologies occur due to paralysis and paresis of the muscles of the trunk, which provoke a violation of static. Patients may also be diagnosed with limb deformities due to neurogenic arthropathies and muscle tone disorders.
Successful rehabilitation of patients depends on the speed of recovery processes in the spinal cord. It is quite possible to stimulate them with the help of drug therapy, therapeutic gymnastics, physiotherapy. The patient is prescribed drugs that normalize metabolism, improve the supply of oxygen to the spinal cord, soften the formation of glious tissue. Such medications include nootropics, anabolic hormones, immunoactive drugs, muscle relaxants, sedatives and tranquilizers.
Physiotherapy treatment involves the use of one or several techniques at once:
UHF-inductothermy, which affects the lesion in an oligothermic dose;
UHF electric field: has an effect on the lesion in a low-heat or non-heat dose;
longitudinal galvanization (carried out with the application of electrodes near the lesion);
mud applications (in the case of drug treatment, it is prescribed from the second week after injury, with surgery — immediately after the removal of stitches).
Therapeutic gymnastics is prescribed according to indications, depending on the degree of damage to the spine. The stable nature of the fracture and the absence of severe spinal cord disorders are considered indications for performing special physical exercises almost immediately after the patient’s hospitalization. The primary tasks of therapeutic gymnastics are: improving the functioning of the respiratory and cardiovascular systems, preventing muscle atrophy, general toning effect.
In the early period, patients are recommended to perform breathing exercises, as well as exercises for working out the distal parts of the limbs. Then, gradually, movements are added to the set of exercises, in which the muscles of the spine should participate. If the patient’s cervical spine has been damaged, all exercises are performed initially in a lying position, and eventually sitting and standing.
If the cervical spinal cord is damaged, patients are shown breathing exercises. Its main tasks are to increase the gas exchange of the lungs and strengthen the muscles that participate in breathing. First, patients master static breathing exercises, especially training of diaphragmatic breathing. A week after injury or surgery, you can start performing dynamic exercises. In the acute period of the disease, the duration of classes should be no more than 3-5 minutes. As the patient’s condition stabilizes, this time may increase.
Prognosis for spinal cord injury
The outcome of treatment and prognosis for the patient depend on the severity and localization of the injury, the patient’s age, timely first aid and adequate treatment. Often, the prognosis for the health and life of the patient becomes known after intraoperative spinal cord control. Nevertheless, a macroscopically normal spinal cord does not always indicate the possibility of reverse development of the pathological process and recovery of the patient. If, after spinal injury, the syndrome of complete violation of spinal cord conduction persists for two days, and there is no minimal regression of sensory and motor disorders, the chances of recovery of the patient are minimal.
The statistics of spinal cord injuries are disappointing. At least 37% of all victims die before medical care has been provided. Another 13% of the victims die already in the hospital. After the operation, the mortality rate is 4-5%. If compression of the spinal cord is combined with its contusion, the mortality rate increases to 15-70%, depending on the severity of the injury. Complete recovery of patients after cut and stab injuries is observed in 8-20% of all cases. For gunshot wounds, this figure is 2-3%. All complications arising during the treatment of spinal injury reduce the chances of complete recovery of the patient and increase the risk of death.
A favorable course of the disease can be achieved if the spinal deformity and compression of the spinal cord are eliminated as completely and rationally as possible, and effective prevention of urological complications and bedsores is prescribed. Timely and comprehensive rehabilitation after injury treatment will allow patients to fully restore impaired functions.
A full-fledged surgical decompression of the spinal cord in the early stages will be able to increase the patient’s chances of recovery. Improvement is also observed after surgery in the treatment of injuries of the cervical, lumbar and lower thoracic spinal cord. Thanks to the implantation of innovative fixation systems into the spine, patients get the opportunity to start rehabilitation as early as possible, which helps prevent bedsores and other dangerous complications.
