Today, spinal cord injuries are considered one of the most common problems in medicine. Despite the fact that diseases of this nature are much less common than injuries to the skull, disability occurs in 3 out of 4 injured patients.

Most often, injuries of this nature are indirect, and in order to eliminate the consequences of the damage, mandatory therapy is required with further rehabilitation, which takes quite a lot of time and includes the mandatory assistance of a psychotherapist.

Mechanism of development of spinal cord injuries

The spinal cord belongs to the nervous system. In its external structure, it resembles a light oblong body with corners in the lower and upper parts and a rounding in the middle.

In the center of the brain canal there are 3 membranes:

• vascular;
• arachnoid;
• hard.

The membranes are separated by cerebrospinal fluid.

The structure of the spinal cord with the characteristic arrangement of 3 membranes

Injuries are most common among men aged 18–50 years. Such lesions occur with inflammation of the spinal cord and nerve endings.

Spinal injuries are of the following types:

• isolated – with damage to the spinal membranes;
• combined - these include thermal, radiation and chemical types of damage;
• combined – accompanied by damage to internal organs.

In addition, there are open and closed injuries, which can occur with varying degrees of severity. Mechanical damage to the meninges is accompanied by compression of ligaments and bones, hematomas and foreign bodies. In addition, as a result of arterial damage, swelling occurs, which gradually increases and threatens with dangerous complications.

Symptoms

The severity of spinal cord injuries depends on the type of injury and the spread of the inflammatory process.

Stages of nerve conduction distinguish complete or partial paresis. With this form of damage, only 50% of the nerve endings function, while maintaining the possibility of restoring almost all lost functions. With complete damage, the chances of rehabilitation of motor activity are extremely small.

The main signs of brain dysfunction include:

• sharp, dull pain with a burning sensation in the damaged area;
• complete (partial) impairment of movements in the limbs;
• lack of tactile sensations;
• increased reflex activity and spasms;
• difficulty breathing;
• the presence of a painful cough;
• heart pain and arrhythmia;
• spontaneous bowel movements, urination.

In addition, in every second case there is a disorder of sexual activity and the possibility of conception.

Symptoms that suggest post-traumatic spinal cord injury include short-term fainting, pain along the spinal column, its curvature, lack of balance, as well as involuntary urination and defecation.

Forms of the disease

Spinal cord injury is accompanied by the following symptoms:

• compression and crushing (tears and ruptures);
• concussions and bruises;
• damage to nerve roots and spinal hemorrhages.

The most common causes of damage to the spinal cord that contribute to the development of negative symptoms

As a rule, a concussion is accompanied by reversible disorders that are neutralized in the first 7 days.

Damage classification

Injuries of this form can occur in the absence of damage to the spine. The most severe sign of the disease is a fracture with displacement of bone fragments, which can move along the back of the spinal canal.

Diseases are classified as follows:

Concussions

Spinal diseases of this nature are most often accompanied by swelling of the brain and membranes in the absence of serious (structural) disorders. Microscopy and macroscopy reveal the formation of pinpoint hemorrhages. Short-term paresis and dysfunction in the pelvic organs often occur. The duration of the presence of negative symptoms ranges from 5-10 minutes to 2 months. With a concussion, the symptoms gradually increase in the absence of pathological processes in the spinal fluid and the subarachnoid space is preserved.

Injury

Bruises (contusions) appear as a result of subluxation of the vertebrae, as well as a displaced fracture. Injuries of this kind are much more common than concussions, which are more dangerous. As a rule, a spinal cord contusion is accompanied by structural changes in the brain matter and its membranes. Any damage to the spinal cord is characterized by the development of spinal shock, as well as disorders of motor activity, depending on the location of the injury.

CT scan showing spinal cord injury

Impaired sensitivity is accompanied by paralysis of varying severity, insufficient functionality of the autonomic system and pelvic organs. It is important to consider that bruises and hemorrhages in the subarachnoid membrane are possible. Sometimes several foci of injury are observed at once. A diagnostic examination reveals blood in the cerebrospinal fluid. Depending on the stage of the spinal cord injury, the recovery period can range from 3 to 8 weeks. With severe damage accompanied by half breaks in the spinal cord, functional recovery is extremely rare.

Hemorrhage

The danger of hemorrhage in injuries is the growth of the hematoma, which causes significant compression of the sensitive endings. 2-3 hours after the onset of bleeding, primary complications are determined in the form of radicular pain radiating to any part of the spinal column. Then symptoms of compression of the meninges develop.

Hemorrhages can be both epidural and subarachnoid. Epidural hemorrhages (from the venous plexuses) form hematomas, which gradually put pressure on the spinal cord. With epidural hemorrhages, the symptoms of spinal cord injuries develop gradually. Subarachnoid hemorrhage can develop rapidly. In this case, the patient complains of severe pain in the entire back, limbs and neck muscles. Quite often, this type of hemorrhage leads to paresis of the limbs.

The CT image shows epidural hemorrhage with hematoma growth, which poses a serious threat to the patient

Compression

Most often, such an injury occurs as a result of vertebral fractures with their subsequent displacement, intervertebral hernias and compression of the spinal cord by foreign objects. Clinical symptoms develop quite quickly. In car accidents, falls from heights and diving, injuries to the cervical spine can occur, which are accompanied by sharp hyperextensions, leading to a significant narrowing of the spinal canal with the appearance of ischemic symptoms, and in 90% of cases there is compression of the spinal cord.

Damage to the spinal cord roots

This type of lesion can manifest itself as all kinds of sprains, compression, bruises, accompanied by intra-trunk hemorrhages, as well as separation of the spinal roots. Clinically, a decrease in sensitivity, peripheral paresis and paralysis, as well as autonomic disorders corresponding to the site of damage are detected.

During diagnosis, local pain with deformative changes in the spinal column with impaired mobility is determined. There is tension and bilateral muscle swelling (rein syndrome). Neurological status reveals loss of sensation in the limbs, impaired functionality of the pelvic organs, manifested by urinary retention.

Birth injuries

Often, under the influence of mechanical factors and the pathological course of labor, spinal injuries occur, accompanied by hemorrhage, compression, sprains and ruptures in the spinal cord.

Mechanical injury develops with diabetic fetopathy, large fetus, malpresentation, intrauterine developmental disorders, post-term pregnancies, etc. In addition, injuries of this kind can be caused by the fairly mature age of the woman in labor, tumor-like neoplasms, abnormal structure of the pelvic region and previous injuries with damage to the pelvic bones.

A common cause of spinal injury is neck twisting during childbirth.

Birth injury to the spinal cord often occurs due to hypoxia and asphyxia of the newborn. The reason for this phenomenon may be the umbilical cord entwined around the baby’s neck, as well as the accumulation of mucus in the oral cavity, retraction of the tongue with blockage of the trachea, etc.

Compression

Compression refers to all unspecified types of compression of the spine. As a rule, the source provoking compression is predominantly located extramedullary and very rarely intramedullary (within the boundaries of the spinal cord). In this case, compression can develop in 3 stages: chronic, subacute and acute.

Acute compression of the spinal cord most often occurs as a result of compression fractures of the vertebrae, accompanied by displacement of bone fragments, as well as significant damage to the ligaments and bones with an increase in hematoma, subluxation or dislocation of the vertebrae. An acute form of compression can develop within 2-3 hours.

Subacute compression in the spinal cord increases gradually. Sometimes this may take several weeks. Characteristic manifestations of this form of the disease are extramedullary metastatic tumor, epidural (subdural) abscesses (hematomas) and ruptured intervertebral discs in the cervical and thoracic regions.

CT scan of the spinal cord indicating compression

Chronic compression of the spinal cord can last for many years. The reasons for its development are cartilaginous and bone protrusions of the spinal canal in any part, especially with a pronounced congenital disorder in the structure of the spinal canal, slowly growing tumor-like formations and arteriovenous malformations.

Subluxations of the atlantoaxial joint in spinal cord injuries, as well as injuries in the craniocervical junction can lead to chronic, acute and subacute compression. When formations compress the spinal nerves, the blood supply to the spinal cord is disrupted, which is dangerous for the development of heart attacks.

Diagnostic measures

To assess the severity and level of traumatic disease, it is recommended to conduct a diagnostic examination, including myelography, a neurological examination of the patient with an assessment of the severity of symptoms, a two-plane radiograph, including CT (computed tomography) and MRI.

The MRI procedure allows you to find out the location of the spinal injury

An important diagnostic method is rightfully considered to be a neurological examination, which is performed according to a unified classification and meets the following criteria: determination of muscle strength and tactile sensitivity, assessment of motor functionality in the lower segments.

Therapeutic measures

Spinal injuries are extremely dangerous, and the success of treating symptoms of damage to the spinal cord largely depends on timely assistance to the victim:

• The first priority is to control the patient's breathing and heart rate, as well as limit spinal mobility. During a visual examination of the patient, the doctor determines the nature of the injury, its location, and, if necessary, stops the bleeding. Next, immobilization of the damaged section is carried out. For urinary retention, catheterization is used. In addition, pain relief, sedatives and neuroprotectors are prescribed.
• The doctor examines and palpates the spinal column for the presence of hematomas, swellings and wounds. After this, reflexes, muscle tone, and sensitivity of the affected area are checked. Anti-shock measures and elastic bandaging of the limbs are required to prevent the development of thromboembolism.
• The patient is transported on a rigid stretcher. For injuries of the thoracic and lumbar region, transportation is provided on the stomach with a cushion placed under the head area.
• For neck injuries, immobilization is performed using a plaster collar. The oral cavity is cleared of foreign bodies (dentures, food debris), the doctor removes the lower jaw, followed by intubation of the trachea.

A method for immobilizing a patient in emergency cases using improvised materials for spinal injuries

With injuries to the thoracic spine, problems with cardiac activity often develop, which leads to a sharp drop in blood pressure, arrhythmia and other disorders, so the administration of cardiac medications (Dapamine, Atropine) is mandatory. In the future, the question of the method of treatment is decided.

Indications for surgery

It is important to consider that contrary to the popular belief that all spinal column injuries require surgical intervention, this method of treatment is used in 50% of all reported cases.

If surgery cannot be avoided, it should be performed as soon as possible. The further prognosis for recovery and restoration of the body’s functionality depends on this. During the operation, a bone fragment that damages the membranes of the brain, foreign objects, compressive hernias, hematomas is removed and possible bleeding is stopped. Next, the spine is stabilized using implantation.

The rehabilitation period includes manual massage

The postoperative period requires long-term monitoring of the patient's condition in order to exclude possible complications (formation of contractures, the addition of infectious processes, bedsores, thromboembolism, etc.). At this time, it is recommended to carry out preventive measures and a complex of physical therapy. In addition, visits to sanatoriums and special rehabilitation centers are shown.

Forecast

As a rule, almost all patients undergoing surgery require long-term social and medical rehabilitation to restore mobility and skills of daily activities. Immunostimulants, nootropics, and vitamin therapy are prescribed as medical rehabilitation.

It must be taken into account that final recovery is possible with a mild degree of injury, when restoration of the neurological functions of the body is observed. After a patient has suffered spinal shock, rehabilitation can take quite a long period of time. In the absence of a complete break in the brain, nerve cells gradually return to anatomical functionality. If a spinal cord rupture occurs, the patient needs, first of all, psychological help from others and his own desire. The prognosis for recovery depends on the severity of the injury and the general condition of the patient, as well as on the timeliness of the therapy started.

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Spinal injuries: prevalence, causes and consequences

Prevalence of spinal injuries

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

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

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

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

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

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

Anatomical structure of the spine and spinal cord

Anatomy of the spinal column

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

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

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

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

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

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

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

A transverse ligament is stretched between the lateral surfaces of the atlas, in front of which is the medulla oblongata, and behind it is a process of the axial vertebra, called the tooth. The head, together with the atlas, rotates around the tooth, and the maximum angle of rotation in any direction reaches 90 degrees.

Anatomy of the spinal cord

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

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

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

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

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

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

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

Classification of spinal injuries

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

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

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

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

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

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

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

Symptoms of spinal injuries

Symptoms of Stable Spinal Injuries

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

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

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

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

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

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

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

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

Signs of mid- and lower-cervical spine injuries

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

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

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

Symptoms of thoracic and lumbar spine injuries

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

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

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

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

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

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

Signs of spinal cord damage

Movement disorders

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

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

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

Sensory disorders

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

The degree of severity, nature and topography of sensory impairment is of important diagnostic importance, since it indicates the location and severity of spinal cord injury.

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

Visceral-vegetative disorders

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

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

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

Treatment of spine and spinal cord injuries

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

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

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

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

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

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

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

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

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

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

Rehabilitation after spinal and spinal cord injuries

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

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

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

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

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

Before use, you should consult a specialist.

Although methods for diagnosing and providing assistance for injuries to the spine and spinal cord were given in the Egyptian papyri and the writings 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 STS 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 STS 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 the 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% are industrial injuries and those received as a result of illegal actions, and 5% are received from a fall 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. When 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)

Complete defeat		No voluntary movement or sensation below the level of the lesion
Only sensitivity is preserved		Below the level of the lesion there are no voluntary movements, sensitivity is preserved
Movements intact but non-functional		Below the level of the lesion there are voluntary movements, but without useful function. Sensitivity may or may not be preserved.
Movements are intact and functional		Useful voluntary movements below the level of the lesion are functional. Various sensitivity disorders
Normal motor function		Movements and sensitivity below the level of the lesion are preserved, pathological reflexes are possible

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 (dysphagia, aphonia, respiratory and cardiovascular disorders) appear.

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.

Injury 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 observed.

In some cases, mainly with trauma accompanied by sharp flexion of the spine, it may develop 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 quickly stops. 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 STS 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 doctor. 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, it is possible that such patients undergo catheterization of the bladder earlier 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 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%.

Impaired ventilation of the lungs can be 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 prohibit lifting heavy objects, 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.

Surgical treatment. 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 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. The damage leading in the clinical picture is determined and prompt transportation of the wounded person to the appropriate specialized or multidisciplinary medical institution (hospital or civilian hospital) is ensured. 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 match 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 spinal cord is one of the most protected human organs. It is as if suspended in the cerebrospinal fluid by thin stretch marks, which allows it to compensate for shaking and shock; it is protected from the outside by tough connective tissue. At the same time, it is protected by very strong vertebrae and a muscular frame. It is quite difficult to damage such a structure, and in a normal, measured life it is almost impossible. Even very strong blows to the spinal area usually go well, although they contribute to the development of various chronic diseases, but do not cause serious harm.

But in some situations, even this extremely durable structure cannot withstand the load and breaks. In such a situation, there is a risk that fragments of the damaged vertebra will be pressed into the spinal cord. Such a spinal cord injury leads to the most unpleasant consequences, and its subsequent manifestations depend on the specific location of the injury. In some situations, an anatomical one is possible and a person is faced with the manifestations of this problem immediately, in other cases the situation turns out to be extended over time. So, first the pinched cells die, then due to lack of oxygen a certain number of their “brothers” are added to them. And then the apoptosis mechanism is launched - this is a kind of program that is laid down by nature itself. As a result, some more cells die and the person faces the same gap, which turned out to be simply “delayed”.

About the causes and consequences of spinal cord injuries

Everyone understands that in ordinary life it is quite difficult to receive such severe damage. But in some extreme situations, the human spine receives such a large load that it simply cannot withstand it. It could be:

• car accident. Car accidents are the most common cause of injuries of this severity. In this case, both pedestrians and motorists themselves are injured. And driving a motorcycle is considered the most dangerous - it does not have a rear seat back, which could reduce the risk of injury;
• falling from a height. It doesn’t matter whether the fall is accidental or intentional, the risk of injury is equally great. For athletes, those who like to dive into water from a height and jump with a cable, this reason is the most common. There is even such a diagnosis - “diver’s injury”, in which the spine in the cervical region is injured (abroad, however, it is called “Russian injury”, hinting at the unbridled courage of our fellow citizens fueled by alcohol);
• injuries in extraordinary and everyday conditions. This category includes injuries resulting from unsuccessful falls on ice or slippery floors, from falls from stairs, knife and bullet wounds, etc. This is also a fairly common cause, but it is more typical for older people.

A bruise or injury to the spine and spinal cord received in such a situation often has very serious consequences. Of course, in cases where damage and death of only a few cells occurs, nothing particularly terrible happens. After some time, their functions will “intercept” the neighboring segments, due to which the temporarily impaired functioning of the muscles or internal organs will be restored. However, even in this situation, everything is not always so smooth, if after a while the apoptosis mechanism starts, but for some time a person is guaranteed a relatively normal life..

The situation is much more complicated if a rupture occurs in which the pathways are destroyed, the task of which was to connect the various sections and fragments of the spinal cord into a single structure. In this case, the person will live thanks to the fact that the heart and lungs are “managed” separately, as the most “critical” organs of the human body (however, serious injuries to the cervical spine sometimes interrupt this connection, which leads to death). But the work of the entire human body will be blocked for some time due to spinal shock.

What is "spinal shock"?

The spinal cord reacts in its own way to severe trauma - it simply “switches off.” For some time, you can forget about its existence, which is why a person will only have a normal functioning heart and lungs, which work “autonomously” for some time. This state is called. It must be said that previously such a condition was tantamount to a death sentence, since even the best doctors considered a cure impossible and did not know how to overcome the various spinal cord syndromes that had to be encountered if a person did experience a period of spinal shock.

Now this condition has been studied quite well, the approximate time frame for the patient to recover from this condition is known (several weeks). At the same time, since the muscles do not work and begin to gradually atrophy, they have learned to maintain their tone with the help of special therapy, which involves the use of electrical impulses. However, such therapy should not be too intense; it should not be started too early, since there is a risk of additional injury to the spinal cord.

When spinal shock passes, the human body can be divided into two parts - consciously controlled (located above the site of injury) and autonomous (below the site of injury). This is essentially where the recovery phase begins.

What is the treatment immediately after an injury?

Everything that should happen immediately after a spinal injury can be described in one word: “Immediately!” Every second of delay means the death of several more nerve cells, which means that the possible state of complete anatomical rupture of the spinal cord is getting closer and closer, in which it will no longer be possible to restore the functioning of those organs and muscles that are located below the level of damage. Therefore, almost immediately, serious doses of drugs are introduced that support the work of the injured cells, and an operation is immediately performed, the main task of which is to remove splinters and fragments of the damaged vertebra that injure the brain.

After this, it is necessary to try to restore (as far as possible) blood circulation and fix the damaged part of the spine in a motionless state. It should be understood that delaying the operation will lead to irreversible consequences, therefore doctors perform all the necessary actions in such a situation as quickly as possible.

After this, the patient will have to spend several weeks in a state of spinal shock, when he has no control over his body. Naturally, the intestines and bladder do not work normally at this time, so constant monitoring of the patient is necessary.

How does recovery happen?

Recovery of the spinal cord begins from the moment the spinal shock ends. More precisely, the restoration of nerve cells begins even earlier, but only from this moment can doctors assess the situation more or less objectively. Initially, the situation corresponds to the division of the human body into controlled and autonomous parts, but if the break was not complete, then there is a possibility of restoration of the functioning of some of the organs and muscles located below the level of injury.

The recovery process is very long, since the nerve processes are restored extremely slowly. And the patient will have to wait a long time. But over a few months, the “surviving” functions will gradually begin to return, so it may well be that a person will again be able to feel his legs, walk, and even control the functioning of his internal organs. Anything that is not restored can be considered lost. Usually the “limit” is considered to be a period of one and a half years.

Initially, the doctor can assume the likelihood of restoring some body functions by looking at the results. If the damage is great, up to a complete rupture, then there is nothing to expect improvements, since there is nothing to restore - the connections are not damaged, but simply destroyed. This means that you need to get used to the new life and adapt to it. And you shouldn’t believe those who promise to “put such a patient back on his feet” - this is basically impossible.

"I forgot how to use it"

This strange phrase is a literal translation from the English name of a recently discovered phenomenon that often occurs with serious spinal injuries. Its essence is quite simple and obvious.

A person has been in spinal shock for several weeks. Then there is a gradual restoration of damaged connections in the spinal cord. All this is the time when a person cannot move, for example, his legs. And now, after almost two years, connections have been restored, but the person still does not visit. The reason is simple - although the connections were restored during this time, they simply “fell asleep” due to the fact that they were not used all this time. This is somewhat reminiscent of the atrophy of muscles that a person does not use.

It seems that the task is not too difficult - you just need to “wake up” sleeping connections and make them work. But this is quite difficult to do, and methods that allow you to “start” such a process have also appeared recently. They are not yet so well developed, since specialists often have to develop simulators and special stimulating systems for each specific case.

This method is based on the method of electrical stimulation, which is combined with work on simulators. With it, the work of a person’s limbs is combined with special electrical impulses that cause muscles to contract and move. In this way, the work of the “sleeping” channels in the spinal cord is gradually activated, and after a while the person can get to his feet and walk.

Spinal cord injury is a dangerous condition that can threaten human health and life. It requires immediate medical attention to be able to prevent negative consequences.

The spinal cord is considered part of the nervous system and is responsible for the functioning of all organs and muscles. Through it, the brain receives signals coming from throughout the body. That is why any injuries can lead to disability and even death.

There are different types of spinal cord injuries, so if they occur, it is important to see a doctor immediately. Only a specialist, after conducting a diagnosis, will be able to tell what exactly you have to deal with. It will be useful for people to know the reasons for spinal cord injuries.

Provoking factors can be divided into three categories: traumatic, congenital and pathological. It is definitely worth considering the features of each type in order to understand what you are dealing with.

Traumatic causes include mechanical impacts leading to tissue destruction:

• Fractures. They are extremely dangerous to human health, so when they appear, it is imperative to begin treatment immediately.
• Bruises. They can appear under the influence of negative factors. Even minor bruises can negatively affect the condition of the body, so if they appear, you should be examined by a doctor.
• Hemorrhages. In this case, it is important to identify their cause, as well as eliminate the symptom itself. If you do nothing, then the consequences can be the most unexpected.
• Concussions. They can often be caused by a fall or accident. Symptoms can appear either immediately or after a while.
• Dislocations. A fairly common cause that leads to spinal cord injury. Often it can be obtained by people who engage in professional sports or heavy physical labor.

Often, a spinal injury can occur due to the fact that there are pathologies in the human body. These include tumors that appear in the spine.

Regardless of the nature of the neoplasm, a person will encounter its negative manifestations. Infectious diseases can also lead to disorders of the spine.

We are talking about those pathologies that can affect the spinal cord. Problems with blood circulation caused by various disorders in the body. Due to the deterioration of blood flow, the spine does not receive enough oxygen and nutrients. As a result, his condition worsens significantly.

Congenital spinal cord injuries occur during fetal development. They can also be inherited, therefore, if one of the parents had the disease, then it can later develop in the child. Spinal cord injury is a serious disorder and therefore requires diagnosis. It is important to notice pathological symptoms in time so that you do not have to face serious consequences later.

Symptoms

It is quite difficult to say unequivocally which signs a person will encounter. Spinal cord injuries can cause a variety of symptoms, depending on the specific pathology. You can generally consider the possible manifestations of diseases in order to roughly understand what signs should be considered alarming.

Symptoms:

• Problems with motor activity. When injured, a person may experience stiffness of movement, the inability to turn the body and bend over.
• Pain syndrome. It is often accompanied by a burning sensation, and in this case you should immediately consult a doctor to understand what exactly you are dealing with.
• Breathing problems. A spinal cord injury may make it difficult for a person to take a deep breath.

• Pain in the chest area. Unpleasant sensations can radiate to the shoulder blade and heart. Often a person cannot clearly understand why exactly such a symptom arose. Some people go to the wrong doctor, for example, they may visit a cardiologist because they think they have a heart problem.
• Severe cough. However, it does not bring relief, and the person may experience back pain. Again, people may think they have a respiratory problem. In fact, the symptom occurs due to spinal injuries.

• Uncontrolled bowel movements and urination. This is also a fairly common symptom that can occur due to problems with the spine. It significantly worsens the quality of life, because a person experiences significant discomfort due to the manifestation of diseases.
• Loss of sensitivity to touch. With spinal cord injuries, a person often suffers from poor sensation of cold, heat, and touch. The disease can affect the limbs or the whole body at once.

In addition, a spinal cord injury can cause a person to lose consciousness and cause their back to move into an unnatural position. There is constant pain, which can be both dull and sharp. In most cases, it spreads throughout the spine and can occur at any time of the day.

Types of injuries

As already mentioned, spinal injuries come in different types, which is why it is important to identify a specific variant during diagnosis. It will be useful for people to know common pathologies in order to roughly understand what they might encounter.

A disease such as hematomyelia often occurs. In such a situation, hemorrhages occur in the spinal cord, causing a hematoma. Various symptoms occur, in particular, loss of temperature and pain sensitivity.

Such manifestations remain for about 10 days, after which regression begins. If treatment is started in time, then it will be possible to restore impaired functions. It should be understood that a person often remains with neurological disorders.

It also happens that something happens damage to the spinal cord roots. In such a situation, a person begins to suffer from paralysis or paresis of the limbs. They are often accompanied by autonomic disorders, sensory disturbances, and problems with the functioning of the pelvic organs. Specific symptoms directly depend on which part of the spine is affected. For example,

If the collar area is affected, then paralysis of the upper and lower extremities begins, breathing becomes significantly more difficult, and sensitivity is also impaired.

Squeezing is a common spinal cord injury that occurs due to foreign bodies, joint appendages, and tendon problems that damage the spinal cord. As a result, a person may completely or partially lose motor activity in the upper or lower extremities.

Crush represents an injury in which the integrity of the organ in question is compromised. It ruptures, and symptoms of spinal shock are observed for two to three months. As a result, paralysis of the limbs may occur, and muscle tone may also decrease. A person’s reflexes, both somatic and vegetative, disappear. In this case, sensitivity will be completely absent, and the pelvic organs work uncontrollably.

When a concussion occurs, a reversible disruption of the spinal cord occurs, with a significant decrease in muscle tone, and a complete or partial loss of sensitivity in the parts of the body for which the damaged section is responsible. Such symptoms do not last long, after which complete restoration of the spine occurs.

As you can understand, spinal cord injuries can be different, which is why you should definitely consult a doctor for diagnosis. Just focusing on the symptoms will not be enough to find out a specific diagnosis.

Periods of injury

When making a diagnosis, doctors necessarily classify spinal cord injuries, and to do this they pay attention to various signs. Quite often it is necessary to determine the period of damage, because further therapy will depend on this.

Main types:

Spicy. It will last up to 3 days. At the same time, during this period, signs indicating spinal shock can be observed. However, it is difficult to draw specific conclusions about what form of spinal injury exists.

• Early. Its duration is on average 2 weeks. There is a complete disruption of reflex activity, as well as conductivity. The person continues to experience spinal shock, the symptoms of which will weaken only towards the end of this period.
• Intermediate. It will last up to 3 months. Over this entire period, the signs of spinal shock should disappear, which is why it will be possible to see the real picture of the damage. If the 2nd motor neuron in the cervical or lumbar enlargement is not affected, then muscle tone will significantly increase and reflexes will be restored. In this case, a person’s delay in defecation and urination during this period can be replaced by automatic emptying.
• Late. The stage begins only 3 months after the injury. At the same time, it can even last a lifetime. During this period, you can notice that the neurological picture is gradually stabilizing.

People should understand that when there is no improvement after a month, then there will be a low probability of a person's full recovery. Only in 25% of cases there is a significant improvement in a person’s well-being. At the same time, it is extremely important that a person undergoes rehabilitation procedures, which include drug therapy, stay in a sanatorium, as well as everyday and psychological adaptation.

Diagnostic methods

When diagnosing spinal cord injuries, it is imperative to take into account how the person received the injury. It is necessary to establish the existing symptoms, and also perform an external examination using palpation. It will be important for the patient to describe his complaints, talk about the intensity and location of painful sensations.

It is also worth mentioning whether there are problems with perception and memory. It is possible that a person suffers from a disorder of skin sensitivity. It is important for doctors to know all this in order to make an accurate diagnosis.

Thanks to palpation, it will be possible to determine whether there is a displacement of bone structures, as well as whether swelling, excessive muscle tension, and various deformities are observed. During a neurological examination, it will be possible to understand whether changes in reflexes are present.

In order to accurately make a diagnosis, certain examinations are used:

• CT and magnetic resonance imaging. These procedures can accurately diagnose spinal cord injuries. The examinations are safe for health and at the same time make it possible to understand whether a person has any abnormalities in the condition of the spine.

• In some cases, myelography is required. This is an x-ray that uses a contrast agent. There are several types of procedures, for example, descending, ascending, and CT myelography.
• The person may be referred for a spondylogram. It is an x-ray that analyzes bone tissue. Can be performed in different projections depending on the person’s condition.
• If you need to assess the condition of muscles and nerve endings, then the person is prescribed electroneuromyography.
• A labial puncture is required to study the composition of the cerebrospinal fluid and understand whether there are any abnormalities in it.

The doctor may refer you for other tests if he deems it necessary. In any case, spinal cord injury requires diagnosis, because it is important to assess the condition of the spinal regions, as well as to understand whether there are complications. You should not wait until your health worsens, because it is easiest to improve a person’s well-being in the early stages of pathology.

First aid

If a person has a spinal cord injury, then first aid will be required. The patient’s further well-being will depend on it. This is explained by the fact that fragments of destroyed vertebrae can negatively affect health. A shift in movement may also occur, leading to permanent damage to the spinal cord and its blood vessels.

Extremely important if a spinal cord injury occurs, immobilize the person to eliminate the possibility of the situations described above. Upon arrival, the ambulance will need to place the person on a stretcher, while he is raised above the ground only a few centimeters.

All actions are performed slowly and without any jerks. It is extremely important to take into account that if the spine is not immobilized, then a person cannot be carried even short distances.

Can be used for immobilization Elansky tires or Kendrick, Shants collar, as well as circles made of cotton wool and soft fabric. Moreover, the specific method of immobilization directly depends on where the spinal cord injury is located.

If a person needs to be resuscitated on the spot, then artificial ventilation of the lungs is performed, indirect massage of the heart muscle is performed, and the mouth is cleaned of foreign bodies.

If spinal shock develops, then cardiac improvement using dopamine and atropine may be necessary. If intense pain is observed with a spinal cord injury, it can be relieved with the help of analgesics. For example, doctors prescribe Ketanov, Fentanyl and Promedol.

In cases of spinal injuries, it is extremely important to prevent further infection. For this purpose, antibiotics with a broad spectrum of action are used. For example, a person is prescribed Ampicillin, Ceftriaxone and Streptomycin.

Further treatment for spinal cord injuries will definitely be required. It depends on what exactly you have to deal with. A specific treatment regimen will be prescribed after testing. Spinal injuries are treated in a hospital, because the person must be under constant supervision from medical specialists. The person will be prescribed a number of medications and may also be referred for physical therapy.

In any case, it is worth understanding that spinal cord injuries require long-term rehabilitation. However, there will be no guarantee that all functions will be restored. In any case, timely medical care will significantly increase the likelihood of spinal recovery.