The spinal cord is damaged. Spinal cord injury. Complications of spine and spinal cord injuries

Spinal cord injury is a dangerous pathological condition for humans in which the integrity of the spinal canal is partially or completely disrupted. Symptoms of the disorder can be different; it directly depends on the type of injury. Patients with injuries are hospitalized urgently.

When the spinal canal is damaged, a person experiences neurological disorders, localized mainly to the bottom of the affected area of ​​the spinal column.

Statistics say that most injuries occur due to:

• Road accidents (almost half of the cases);
• Falls (the elderly especially often injure the spine);
• Gunshot and knife wounds;
• Participation in some sports (motorsports, diving, etc.).

In more than half of clinical cases, injuries to back structures are diagnosed in young and middle-aged men.

Damage can be localized in different parts of the spine, but most often the thoracic or lumbar regions are affected.

All damage is divided into two categories. The injury may be:

1. Closed—the skin over the injury is intact;
2. Open - the soft tissues above the site of injury to the spinal column are injured.

With open injuries, the risk of infection of the spinal membranes and the canal itself increases. Open injuries, in turn, are divided into non-penetrating and penetrating (the inner wall of the spinal canal or the hard spinal membrane is damaged).

Injuries to the spinal column may damage the ligamentous apparatus (rupture or tear of the ligament), vertebral bodies (various types of fractures, cracks, separation of endplates, dislocation, fracture dislocation), spinous and transverse arches/articular vertebral processes.

Fractures of different parts of the vertebra with single or multiple displacements can also occur.

According to their mechanism, injuries to the nervous and bone structures of the spine are divided into:

• Flexion. A sharp bend causes a rupture of the posterior ligamentous apparatus and dislocation occurs in the area of ​​the 5-7 cervical vertebrae;
• Hyperextension. It is characterized by rough extension, accompanied by rupture of the anterior group of ligaments. With such an injury, compression of all structures of the column occurs, as a result of which the vertebra pops out and a protrusion is formed;
• Vertical compression fracture. Due to movements along the vertical axis, the vertebrae are subject to dislocation or fracture;
• Fracture due to lateral flexion.

Injuries of a stable and unstable nature are distinguished separately. Fractures of the explosive type, rotation, dislocations and fractures of various degrees are considered unstable. All these injuries are necessarily accompanied by rupture of ligaments, due to which the structures of the spinal column are displaced and the spinal roots or the canal itself are injured.

Stable fractures include fractures of the vertebral processes and wedge-shaped/compression fractures of their bodies.

Clinical forms of SM injuries

The severity of spinal cord injury and its course in early or late stages largely depend on the intensity of spinal shock. This is the name of a pathological condition in which motor, reflex and sensory sensitivity is impaired in the area located below the injury.

Injuries cause loss of motor function, decreased muscle tone, dysfunction of the subphrenic organs and structures located in the pelvis.

Spinal shock can be maintained by bone fragments, foreign particles, and subcutaneous hemorrhages. They are also capable of stimulating disruption of hemo- and liquor dynamics. Clusters of nerve cells located next to the traumatic focus are in a severely inhibited state.

The clinical picture of the injury depends on the type of spinal cord injury. Each injury differs in its characteristics; their symptoms are largely similar to each other.

When a concussion occurs, an irreversible process occurs in which the function of the spinal cord is disrupted. Characteristic symptoms of injury:

1. Violation of reflex reactions in the tendons;
2. Pain spreading down the back;
3. Loss of muscle tone;
4. Generalized or partial loss of sensitivity at the point of injury;

There are usually no motor disturbances, but there may be a feeling of tingling and numbness in the legs. With a spinal cord concussion, symptoms last a maximum of a week, after which they regress.

Injury

This is a more complex and dangerous injury; the prognosis in this case is not so favorable. The injury may be:

• Lungs - bone and muscle structures are not damaged;
• Medium - a hematoma is formed and nerve structures are damaged. There is also a risk of injury to spinal tissue and infection through cracks, which can cause sepsis;
• Severe - nerve conduction is disrupted, causing the medulla oblongata to swell and thromboembolism and thrombosis to develop.

With a spinal cord injury, patients experience complete or partial paralysis of the legs/arms (depending on the location of the injury), impaired muscle tone, dysfunction of the pelvic organs, hyposensitivity and the absence of some reflexes, which occurs due to rupture of the reflex arc.

Most often, compression occurs due to swelling, hemorrhages, damage to the ligamentous apparatus and intervertebral discs, fragments of parts of the vertebrae or foreign bodies. Spinal cord compression can be:

1. Dorsal;
2. Ventral;
3. Internal.

There are cases when compression is both dorsal and ventral. This usually happens with complex injuries. Compression of the spinal canal and roots is manifested by complete or partial loss of motor function in the arms and legs.

When crushed, a partial rupture of the spinal canal occurs. For several months in a row, the patient may continue to experience symptoms of spinal shock, which manifests itself as follows:

• Disappearance of somatic and autonomic reflexes;
• Paralysis of legs/arms;
• Decreased muscle tone in the limbs.

With a complete anatomical rupture of the spinal canal, patients lack all skin and tendon reflex reactions, parts of the body below the point of injury are not active, there is uncontrolled urination and defecation, thermoregulation and the process of sweating are disrupted.

Such an injury can be characterized as a single or multiple avulsion of the roots, their compression or bruise with subsequent hemorrhage. The clinical picture depends in part on which nerve roots are damaged.

Common symptomatic manifestations of the lesion include:

1. Point pain;
2. Rein sign (bilateral roller-shaped muscle spasm on the sides of the spinous process of the corresponding vertebra);
3. Swelling over the affected root;
4. Impaired sensory perception (if the roots of the cervical spine are affected, the arms and legs are affected, the thoracic or lumbar spine - only the legs;
5. Dysfunction of the pelvic organs;
6. Vegetative-trophic disorders.

If the roots in the cervical spine (level 1-5 vertebrae) are damaged, the patient experiences pain in the back of the head and neck, and tetraparesis. Respiratory processes, swallowing and local circulation may also be impaired. In addition, patients with cervical root injuries experience stiffness in neck movements.

If the roots at the level of 5-8 cervical vertebrae are damaged, various forms of paralysis of the arms and legs occur. When the thoracic roots are partially affected, Bernard-Horner syndrome is observed.

If the thoracic roots are damaged, abdominal reflexes disappear, the activity of the cardiovascular system and sensitivity are disrupted, and paralysis occurs. By the zone of hyposensitivity, you can determine at what level the roots are affected.

Damage to the nerve roots at the level of the lumbar spine and cauda equina is manifested by a violation of the innervation of the pelvic organs and lower extremities, and the presence of burning pain in the injured area.

With hematomyelia, blood flows into the spinal cavity and a hematoma appears. Most often this occurs when vessels located near the central spinal canal or posterior horns in the lumbar or cervical enlargement rupture.

The symptoms of hematomyelia are caused by compression of the gray matter and segments of the spine by blood fluid.

A characteristic symptom of such an injury is inhibition of sensitivity to pain and temperature, multiple bruises on the back.

Symptomatic manifestations of hematomyelia last about 10 days and then begin to subside. In the event of such an injury, there is a chance of full recovery, but dysfunction may occasionally return during life.

In many clinical cases, injury to the spinal cord and spine entails many complications. The most global of them is disability and being confined to a wheelchair. Unfortunately, some patients are completely deprived of motor function and doctors cannot help in this situation.

In addition, they develop other background pathologies:

• Sexual impotence;
• Muscle spasticity;
• Bedsores;
• Shoulder tendinitis (this occurs due to constant manual operation of a manual wheelchair);
• Dysreflexia of the autonomic nervous system;
• Problems with the respiratory system;
• Disturbances in the urinary tract and intestines (especially uncontrolled urination and defecation, impaired intestinal motility);
• Formation of blood clots in deep veins;
• Embolism of arteries in the lungs;
• Uncontrolled weight gain.

If motor function is still preserved, patients have to actively restore it and literally learn to walk again. However, spinal cord injuries almost never go away without leaving a trace.

Due to impaired conduction of nerve impulses and lack of muscle tone, patients may experience rare disorders of various organ systems.

Patients who have previously suffered injuries to the spinal column and spinal cord become more susceptible to various other injuries. Against the background of injuries, patients experience impaired sensitivity and can injure themselves without even noticing it.

These patients should always exercise extreme caution when performing potentially hazardous work and check themselves for injury upon completion.

A patient who has suffered a spinal cord injury is always referred to a neurosurgeon for examination. He assesses the severity of the injury and assigns it a certain category:

1. A-category - paralysis of the body below the point of injury;
2. B-category - the body below the point of injury is sensitive, but the patient cannot move;
3. C-category - sensitivity is present and the patient can move, but cannot walk;
4. D-category - sensitivity is present and the patient can move and walk, but only with the help of another person or a supporting device;
5. E-category - sensitivity and motor function below the point of injury are preserved.

For in-depth diagnosis, doctors use instrumental studies. Patients may be prescribed:

Treatment tactics

Patients with spinal cord and spinal injuries should be hospitalized immediately. Treatment of injuries is usually multi-stage. This may include:

• Surgical intervention. Used in different periods of trauma treatment. After the operation, the patient undergoes a long rehabilitation period. In some clinical cases, one patient may undergo several multi-purpose operations;
• Drug therapy. Used mainly to combat neurological disorders, restore metabolism, increase reactivity, stimulate conductivity and enhance capillary blood flow;
• Physiotherapeutic techniques. They are used to accelerate regenerative and reparative processes, restore the activity of the musculoskeletal system and pelvic organs, increase the compensatory capabilities of the body, prevent contractures and bedsores. For this purpose, sessions of UHF, magnetic therapy, ultraviolet radiation, thermal procedures, electrophoresis and others are carried out;
• Exercise therapy. It is carried out for the same purpose as physiotherapy. In some clinical cases, physical therapy is prohibited, so only a doctor should prescribe it and select a set of exercises;
• Treatment in a sanatorium-resort institution. In them, patients with spinal cord injuries will be able to receive proper care and provide all the conditions for recovery. In addition, in such institutions there are almost always doctors present who can be consulted.

Conclusion

Injury to the spinal cord and spinal column is a serious injury that, in the worst case, can result in disability. Depending on the severity of the injury and its location, the patient will experience a certain clinical picture.

Diagnosis of injuries consists of several instrumental procedures. Treatment is mainly surgical in combination with supportive therapy.

Spinal cord injury is damage due to injury or disease to any part of the spinal cord or nerves of the spinal canal. These injuries often cause impairment or loss of motor or sensory function.

Many scientists do not give up the idea that spinal cord damage will one day be completely reversible. Therefore, research in this area is being conducted all over the world. At the same time, treatment and rehabilitation programs that exist today allow many patients to once again become active members of society.

The ability to control the limbs of the body after a spinal cord injury depends on two factors: the location of the injury (part of the spinal cord) and the severity of the injury. If the spinal cord is seriously damaged, the pathways that connect several parts of the spinal cord together are destroyed, then the consequences of a spinal injury are catastrophic.

The severity of injury is divided into:

Complete damage

Such an injury leads to loss of sensitivity and motor functions of all organs and parts of the body located below the level of injury.

Incomplete damage

With an incomplete spinal cord injury, the organs and limbs located below the injury site retain partial motor activity.

Also, spinal cord injuries can lead to tetraplegia (aka quadriplegia) - impairment or loss of the functions of the arms, torso, legs and functions of the pelvic organs.

Paraplegia is complete paralysis or paralysis affecting part of the torso, legs and pelvis.

• Your doctor will perform a series of tests to determine the neurological level of damage and the severity of the injury.
• Signs and symptoms of spinal cord injury (may manifest as several or one of the following):
• loss of motor functions,
• loss of sensation, including the ability to sense heat, cold, or touch.
• loss of bowel and bladder control
• increased muscle tone or uncontrollable spasms
• sexual dysfunction and infertility
• pain or tingling caused by damage to the nerve fibers of the spinal cord
• difficulty breathing, cough.

The first signs of a spinal cord injury:

• Severe back pain or pressure in the neck and head
• Weakness, incoordination, or paralysis in any part of the body
• Numbness, tingling, or loss of sensation in the hands, fingers, feet, or toes
• Loss of bowel or bladder control
• Difficulty walking and maintaining balance
• Respiratory problems

When to see a doctor

Anyone who suffers a serious head or neck injury should seek immediate medical attention. Doctors will also evaluate possible spinal cord damage. Whenever a spinal cord injury is suspected, doctors must perform all appropriate medical procedures until proven otherwise, this is important because:

• A serious spinal injury is not always immediately obvious. If it is not recognized in time, it can lead to more serious consequences.
• Numbness or paralysis may also not appear immediately, and without prompt diagnosis, the situation can be worsened by prolonged internal bleeding and swelling in or around the spinal cord.
• The time elapsed after the injury and medical care directly affects possible complications and subsequent rehabilitation of the patient.

How to behave with a person who has just been injured:

1. Call 1719 or the nearest hospital ambulance service.
2. Place towels on both sides of your head and neck to keep them stationary and wait for emergency help.
3. Provide first aid to the victim: take measures to stop the bleeding and provide comfort to the victim as much as possible, but without moving the neck or head.

Spinal cord injury may result from damage to the vertebrae, ligaments, or discs of the spine. Traumatic spinal cord injury may involve a sudden blow to the spine that fractures, dislocates, or compresses the vertebrae. Spinal cord injury can also be caused by a gunshot or knife wound. Complications usually occur within days or weeks after the injury due to bleeding, swelling, inflammation, and fluid accumulation in and around the spinal cord.

Non-traumatic spinal cord injury is also possible due to a number of diseases: arthritis, cancer, inflammation, infection or spinal disc degeneration.

Your Brain and Central Nervous System

The central nervous system consists of the brain and spinal cord. The spinal cord, made up of soft tissue surrounded by bones (vertebrae), runs down from the base of the brain, made up of nerve cells and their processes, and ends slightly above the waist. Below this area there is a bundle of nerve endings called the cauda equina.

The nerve branches of the spinal cord are responsible for communication between the brain and the body. Motor neurons transmit signals from the brain to control muscle movement. Sensory areas carry signals from body parts to the brain to convey information about heat, cold, pressure, pain, and limb position.

Damage to nerve fibers

Regardless of the cause of spinal cord injury, the nerve fibers passing through the injured area may also be affected. This leads to deterioration in the functioning of the muscles and nerves located below the site of injury. Damage to the thoracic or lumbar region can affect the functioning of the muscles of the trunk, legs and internal organs (bladder and bowel control, sexual function). And neck injuries can affect arm movement and even the ability to breathe.

Common Causes of Spinal Cord Injury

The most common causes of spinal cord injury in the United States are:

Road traffic accidents. Automobile and motorcycle accidents are the leading cause of spinal cord injury, accounting for more than 40% annually.

Falls. Spinal cord injuries in older adults (over 65 years of age) are usually associated with falls. In general, statistics assign ¼ of all cases to this reason.

Acts of violence. 15% of spinal cord injuries are caused by violence (including gunshots and knife wounds). Data from the National Institute of Neurological Disorders and Stroke.

Sports injuries. Professional sports carry many dangers, as do active recreation, for example, shallow water diving. 8% of back injuries fall under this heading.

Alcohol. Every fourth injury is, in one way or another, related to alcohol use.

Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord can also cause damage to this organ.

Despite the fact that such injuries usually occur as a result of an accident, a number of factors have been identified that predispose to risk, such as:

Gender. Statistically, there are many times more men affected. In the United States, there are only 20% of women with similar injuries.

Age. As a rule, injuries occur at the most active age - from 16 to 30 years. The main cause of injury at this age remains road accidents.

Love of risk and extreme sports. Which is logical, but the main thing is that athletes and amateurs are the first to get injured when safety precautions are violated.

Diseases of bones and joints. In the case of chronic arthritis or osteoporosis, even a minor injury to the back can be fatal for the patient.

After spinal cord injuries, patients face a large number of unpleasant consequences that can radically change their lives. When such a serious injury occurs, a team of specialists comes to the patient’s aid, including neurosurgeons, neurologists and doctors from a rehabilitation center.

Specialists of the Rehabilitation Center will offer a number of methods for monitoring vital processes (bladder and intestinal function). A special diet will be developed to improve organ function, which will help avoid future formation of kidney stones, urinary tract and kidney infections, obesity, diabetes, etc. Under the supervision of experienced physiotherapists, an exercise program will be developed to improve the patient's muscle tone. You will receive detailed recommendations on skin care to avoid bedsores and maintain the functioning of the cardiovascular and respiratory systems. Specialists in urology and infertility treatment may also be involved if necessary. Doctors will teach you how to deal with pain and depression. We are able to offer an integrated approach to completely stabilize the patient's condition.

Medical Research:

Radiography. This is where it makes sense to start the research. The images give a general picture of the situation, allow you to assess the deformation of the spine, detect fractures, dislocations of vertebral bodies and processes, and clarify the level of damage.

Computed tomography (CT). A CT scan provides more detailed information about the damaged area. During the scan, the doctor takes a series of cross-sectional images and provides a detailed examination of the walls of the spinal canal, its membranes and nerve roots.

Magnetic resonance imaging (MRI). MRI makes it possible to obtain images of the entire length of the spinal cord in different projections. And it will be very useful in identifying herniated discs, blood clots and other masses that can compress the spinal cord.

A few days after the injury, when the swelling has subsided, the doctor may perform a neurological examination to determine the severity of the injury. It includes testing muscle strength and sensory sensitivity.

Unfortunately, spinal cord damage cannot be completely cured. But ongoing research is providing doctors with more and more new tools and techniques to treat patients that can promote the regeneration of nerve cells and improve nerve function. At the same time, we should not forget about the work that is being done in the field of maintaining an active life for patients after injury, expanding opportunities and improving the quality of life of people with disabilities.

Providing emergency medical care

Providing prompt first aid is critical to minimizing the consequences after any head or neck injury. Likewise, treatment of a spinal cord injury often begins at the scene of the accident.

Upon arrival, the emergency medical team should immobilize the spine as gently and quickly as possible using a rigid cervical collar and a special stretcher to transport the victim to the hospital.

When a spinal cord injury occurs, the patient is taken to the intensive care unit. The patient may also be taken to a regional spinal cord injury center where a team of neurosurgeons, orthopedic surgeons, psychologists, nurses, therapists and social workers is always on duty.

Medicines. Methylprednisolone (Medrol) is used in cases of acute spinal cord injury. When treated with Methylprednisolone within the first eight hours after injury, there is a chance of obtaining a moderate improvement in the patient's condition. This drug reduces damage to nerve cells and relieves inflammation of tissues around the site of injury. However, it is not a cure for the spinal cord injury itself.

Immobilization. Stabilization of the injured spine during transport is extremely important. To do this, the team has special devices in its arsenal to hold the spine and neck motionless.

Surgical intervention. Often, doctors are forced to resort to surgery to remove bone fragments, foreign objects, herniated discs, or fix vertebral fractures. Surgery may also be needed to stabilize the spine to prevent pain or bone deformity in the future.

Hospitalization period

Once the patient has been stabilized and initial treatment has been provided, staff begin working to prevent complications and related problems. This may include deterioration in the patient's physical condition, muscle contracture, bedsores, bowel and bladder dysfunction, respiratory infections and blood clots.

The length of hospital stay depends on the severity of the injury and the pace of recovery. After discharge, the patient is sent to the rehabilitation department.

Rehabilitation. Work with the patient can begin in the early stages of recovery. The team may include physiotherapists, occupational therapists, specially trained nurses, a psychologist, a social worker, a dietician and a supervising physician.

In the initial stages of rehabilitation, therapists typically work to preserve and strengthen muscle function by using fine motor skills and teaching adaptive behaviors in everyday activities. Patients receive advice on the consequences of injuries and the prevention of complications. You will be given recommendations on how you can improve your quality of life under current conditions. Patients are taught new skills, including the use of special equipment and technologies, which make it possible not to depend on outside help. Having mastered them, you can find a new hobby, participate in social and sporting events, return to school or the workplace.

Drug treatment. The patient may be prescribed medications to control the effects of a spinal cord injury. These include medications to control pain and muscle spasms, as well as medications to improve bladder control, bowel control, and sexual function.

New technologies. Today, modern means of transportation have been invented for people with disabilities, providing complete mobility for patients. For example, modern lightweight electric wheelchairs. Some of the latest models allow the patient to independently climb the stairs and lift the seated person to any required height.

Forecasts and recovery

Your doctor will not be able to predict the recovery of just an admitted patient. In case of recovery, if it can be achieved, it will take from 1 week to six months after the injury. For another group of patients, small improvements will come after a year of working on oneself or more time.

In the event of paralysis and subsequent disability, you need to find the strength to accept the situation and start a different life, adaptation to which will be difficult and frightening. A spinal cord injury will affect every aspect of life, whether it be daily activities, work or relationships.

Recovery from such an event takes time, but it is up to you to choose whether you will be happy in the current situation, and not the injury. Many people have gone through this and were able to find the strength to start a new full life. One of the main components of success is quality medical care and support from loved ones.

The causes of emergency conditions with spinal lesions can be traumatic or non-traumatic.

TO non-traumatic reasons include:

• Medullary processes:
  • inflammation of the spinal cord: myelitis, viral and autoimmune
  • medullary tumors (gliomas, ependymomas, sarcomas, lipomas, lymphomas, “drip” metastases); paraneoplastic myelopathies (eg, bronchial carcinoma and Hodgkin's disease)
  • radiation myelopathy in the form of acute, from incomplete to complete, symptoms of damage at a certain level of the spinal cord at radiation doses of 20 Gy with a latency from several weeks to months and years
  • vascular spinal syndromes: spinal ischemia (eg, after aortic surgery or aortic dissection), vasculitis, embolism (eg, decompression sickness), vascular compression (eg, due to mass effect) and spinal arteriovenous malformations, angiomas, cavernomas or dural fistulas ( with venous stagnation and congestive ischemia or hemorrhage)
  • metabolic myelopathy (with acute and subacute course); funicular myelosis with vitamin B12 deficiency; hepatic myelopathy in liver failure
• Extramedullary processes:
  • purulent (bacterial) spondylodiscitis, tuberculous spondylitis (Pott's disease), mycotic spondylitis, epi- or subdural abscess;
  • chronic inflammatory rheumatic diseases of the spine, such as rheumatoid arthritis, seronegative spondyloarthropathy (ankylosing spondylitis), psoriatic arthropathy, enteropathic arthropathy, reactive spondyloarthropathy, Reiter's disease;
  • extramedullary tumors (neurinomas, meningiomas, angiomas, sarcomas) and metastases (for example, bronchial cancer, multiple myeloma [plasmocytoma]);
  • spinal subdural and epidural hemorrhages due to bleeding disorders (anticoagulation!), condition after injury, lumbar puncture, epidural catheter and vascular malformations;
  • degenerative diseases such as osteoporotic fractures of the spine, spinal canal stenosis, herniated intervertebral discs.

TO traumatic reasons include:

• Contusions, spinal cord injuries
• Traumatic hemorrhages
• Vertebral body fracture/dislocation

Non-traumatic spinal cord injuries

Spinal cord inflammation/infection

Frequent causes of acute myelitis are, first of all, multiple sclerosis and viral inflammation; however, in more than 50% of cases, pathogens are not detected.

Risk factors for spinal infection are:

• Immunosuppression (HIV, immunosuppressive drug therapy)
• Diabetes
• Alcohol and drug abuse
• Injuries
• Chronic liver and kidney diseases.

Against the background of systemic infection (sepsis, endocarditis), especially in the above risk groups, additional spinal manifestations of infection may also be observed.

Spinal ischemia

Spinal ischemia, compared to cerebral ischemia, is rare. In this regard, a beneficial effect is primarily due to good collateralization of the blood flow of the spinal cord.

The causes of spinal ischemia are considered:

• Arteriosclerosis
• Aortic aneurysm
• Surgeries on the aorta
• Arterial hypotension
• Vertebral artery occlusion/dissection
• Vasculitis
• Collagenosis
• Embolic vascular occlusion (eg, decompression sickness in divers)
• Spinal space-occupying processes (intervertebral discs, tumor, abscess) with vascular compression.

In addition, there are also idiopathic spinal ischemia.

Spinal cord tumors

According to anatomical location, spinal tumors/mass processes are divided into:

• Vertebral or extradural tumors (eg, metastases, lymphomas, multiple myeloma, schwannomas)
• Spinal cord tumors (spinal astrocytoma, ependymoma, intradural metastases, hydromyelia/syringomyelia, spinal arachnoid cysts).

Hemorrhage and vascular malformations

Depending on the compartments there are:

• Epidural hematoma
• Subdural hematoma
• Spinal subarachnoid hemorrhage
• Hematomyelia.

Spinal hemorrhages are rare.

The reasons are:

• Diagnostic/therapeutic measures such as lumbar puncture or epidural catheter
• Oral anticoagulation
• Bleeding disorders
• Malformations of spinal vessels
• Injuries
• Tumors
• Vasculitis
• Manual therapy
• Rarely, aneurysms in the cervical spine (vertebral artery)

Vascular malformations include:

• Dural arteriovenous fistulas
• Arteriovenous malformations
• Cavernous malformations and
• Spinal angiomas.

Symptoms and signs of non-traumatic spinal cord injuries

The clinical picture in spinal emergencies depends mainly on the underlying etiopathogenesis and location of the lesion. Such conditions usually manifest as acute or subacute neurological deficits, which include:

• Sensitization disorders (hypoesthesia, par- and dysesthesia, hyperpathia) are usually caudal to the spinal cord injury
• Motor deficits
• Autonomic disorders.

The symptoms of prolapse can be lateralized, but also manifest themselves in the form of acute symptoms of transverse spinal cord lesions.

Ascending myelitis may result in brainstem involvement with cranial nerve loss and dative failure, which clinically may correspond to the pattern of Landry's palsy (=ascending flaccid paralysis).

Back pain, often pulling, stabbing or dull, are felt primarily during extramedullary inflammatory processes.

For local inflammation fever may initially be absent and develops only after hematogenous dissemination.

Spinal tumors at first they are often accompanied by back pain, which intensifies with percussion of the spine or with exercise; neurological deficits do not necessarily have to be present. Radicular pain can occur when nerve roots are damaged.

Symptoms spinal ischemia develops over a period of minutes to hours and usually covers the basin of the vessel:

• Anterior spinal artery syndrome: often radicular or encircling pain, flaccid tetra- or paraparesis, lack of pain and temperature sensitivity while maintaining vibration sensitivity and joint-muscular sensation
• Sulcocommissural artery syndrome
• Posterior spinal artery syndrome: loss of proprioception with ataxia when standing and walking, sometimes paresis, bladder dysfunction.

Spinal hemorrhages characterized by acute - often unilateral or radicular - back pain, usually with incomplete symptoms of transverse spinal cord lesions.

Due to malformations of spinal vessels Slowly progressive symptoms of transverse spinal cord lesions often develop, sometimes fluctuating or paroxysmal.

At metabolic disorders It is necessary, first of all, to remember about vitamin B12 deficiency with the picture of funicular myelosis. It often occurs in patients with pernicious anemia (eg, Crohn's disease, celiac disease, malnutrition, strict vegetarian diet) and slowly progressive motor deficits, such as spastic paraparesis and gait disturbances, and sensory loss (paresthesia, decreased vibration sensitivity). ). Additionally, cognitive functions usually deteriorate (confusion, psychomotor retardation, depression, psychotic behavior). Rarely, in case of liver dysfunction (mainly in patients with portosystemic shunt), hepatic myelopathy develops with damage to the pyramidal tracts.

Polio classically occurs in several stages and begins with fever, followed by a meningitis stage until the development of the paralytic stage.

Spinal syphilis with tabes spinal cord (myelitis of the posterior/lateral cord of the spinal cord) as a late stage of neurosyphilis is accompanied by progressive paralysis, sensory disturbances, stabbing or cutting pain, loss of reflexes and impaired bladder function.

Myelitis due to tick-borne encephalitis often associated with “severe transverse symptoms” involving the upper extremities, cranial nerves and diaphragm and has a poor prognosis.

Neuromyelitis optica(Devick's syndrome) is an autoimmune disease that predominantly affects young women. It is characterized by signs of acute (transverse) myelitis and optic neuritis.

Radiation myelopathy develops after irradiation, usually with a latency of several weeks to months and can manifest itself as acute spinal symptoms (paresis, sensory disturbances). The diagnosis is indicated by medical history, including the size of the radiation field.

Diagnosis of non-traumatic spinal cord injuries

Clinical examination

The localization of damage is determined by examining sensory dermatomes, myotomes and stretch reflexes of skeletal muscles. The study of vibration sensitivity, including the spinous processes, helps in determining the level of localization.

Autonomic disorders can be determined, for example, through the tone of the anal sphincter and impaired bladder emptying with the formation of residual urine or incontinence. Limited inflammation of the spine and adjacent structures is often accompanied by pain when tapping and squeezing.

Symptoms of spinal inflammation can initially be completely nonspecific, which significantly complicates and slows down diagnosis.

Difficulties arise in differentiating pathogen-caused and parainfectious myelitis. In the latter case, an asymptomatic interval between the previous infection and myelitis is often described.

Visualization

If a spinal process is suspected, the method of choice is MRI in at least two projections (sagittal + 33 axial).

Spinal ischemia, inflammatory foci, metabolic changes and tumors are especially well visualized on T2-weighted images. Inflammatory or edematous changes, as well as tumors, are well imaged in STIR sequences. After the administration of a contrast agent, blooming inflammatory foci and tumors are usually well differentiated in T1 sequences (sometimes subtraction of the original T1 from T1 after the administration of a contrast agent for more accurate delineation of contrast). If osseous involvement is suspected, T2 or STIR sequences with fat saturation, or T1 after administration of a contrast agent, are appropriate for better differentiation.

Spinal hemorrhages can be recognized on CT for emergency diagnosis. The method of choice for better anatomical and etiological classification, however, is MRI. Hemorrhages appear differently on MRI depending on their stage (< 24 часов, 1-3 дня и >3 days). If there are contraindications to MRI, then a CT scan of the spine with contrast is performed to assess bone damage and clarify the issue of significant mass effects in extramedullary inflammatory processes.

To minimize the radiation dose received by the patient, it is advisable to determine the level of damage based on the clinical picture.

In rare cases (functional imaging, intradural space-occupying processes with bone involvement), it is advisable to perform myelography with postmyelographic computed tomography.

Degenerative changes, fractures and osteolysis of the vertebral bodies can often be recognized on a regular x-ray.

CSF examination

An important role is played by cytological, chemical, bacteriological and immunological analysis of cerebrospinal fluid.

Bacterial inflammation usually accompanied by a marked increase in cell number (> 1000 cells) and total protein. If a bacterial infection is suspected, it is necessary to strive to isolate the pathogen by inoculating the cerebrospinal fluid for flora or using the PCR method. If there are signs of systemic inflammation, the bacterial pathogen is detected by blood culture.

At viral inflammations Apart from a slight to moderate increase in number (usually 500 to a maximum of 1000 cells), there is usually only a slight increase in protein levels. A viral infection may be indicated by the detection of specific antibodies (IgG and IgM) in the cerebrospinal fluid. The formation of antibodies in the cerebrospinal fluid can be reliably confirmed by determining the specific antibody avidity index (AI). An index >1.5 is suspicious, and values ​​>2 indicate the formation of antibodies in the central nervous system.
Antigen detection by PCR is a fast and reliable method. This method can, in particular, provide important information in the early phase of infection, when the humoral immune response is still insufficient. In autoimmune inflammation, slight pleocytosis is observed (< 100 клеток), а также нарушения гематоэнцефалического барьера и повышение уровня белков

In multiple sclerosis, oligoclonal bands are found in the cerebrospinal fluid in more than 80% of patients. Neuromyelitis optica is associated with the presence of specific antibodies to aquaporin 4 in the serum in more than 70% of patients.

Other diagnostic measures

Routine laboratory diagnostics, complete blood count and C-reactive protein do not always help in the case of isolated inflammatory spinal processes, and often in the initial phase no anomalies are detected in the tests, or only minor changes are present. However, an increase in the level of C-reactive protein in bacterial spinal inflammation is a nonspecific sign that should lead to a detailed diagnosis.

Pathogens are identified by bacterial blood culture, sometimes by biopsy (CT-guided puncture for abscess or discitis) or intraoperative sampling.

Electrophysiological studies serve to diagnose functional damage to the nervous system and, above all, to assess the prognosis.

Differential diagnosis

Attention: this phenomenon in the cerebrospinal fluid can occur during “cerebrospinal fluid blockade” (in the absence of cerebrospinal fluid flow as a result of mechanical displacement of the spinal canal).

Differential diagnosis of non-traumatic spinal injuries includes:

• Acute polyradiculitis (Guillain-Barré syndrome): acute “ascending” sensorimotor deficits; It is usually possible to differentiate myelitis on the basis of typical cell-protein dissociation in the cerebrospinal fluid with an increase in total protein while maintaining a normal number of cells.
• Hyper- or hypokalemic paralysis;
• Syndromes with polyneuropathy: chronic inflammatory demyelinating polyneuropathy with acute deterioration, borreliosis, HIV infection, CMV infection;
• Myopathic syndromes (myasthenia gravis, dyskalemic paralysis, rhabdomyolysis, myositis, hypothyroidism): usually an increase in creatine kinase, and in dynamics there is a typical picture on the EMG;
• Parasagittal cortical syndrome (eg, falx cerebri tumor);
• Psychogenic symptoms of transverse spinal cord lesions.

Complications of emergency conditions with spinal lesions

• Long-term sensorimotor deficits (paraparesis/paraplegia) with increased risk
  • deep vein thrombosis (prevention of thrombosis)
  • contractures
  • spasticity
  • bedsores
• With high cervical injuries, there is a risk of respiratory disorders - increased risk of pneumonia, atelectasis
• Autonomic dysreflexia
• Impaired bladder function, increased risk of urinary tract infections up to urosepsis
• Bowel dysfunction - risk of excessive bloating, paralytic ileus
• Temperature regulation disorders in the case of lesions located at the level of 9-10 thoracic vertebrae with a risk of hyperthermia
• Increased risk of orthostatic hypotension

Treatment of non-traumatic spinal cord injuries

Spinal cord inflammation

In addition to specific therapy directed against the pathogen, general measures should first be carried out, such as installing a urinary catheter for bladder emptying disorders, preventing thrombosis, changing the patient's position, timely mobilization, physical therapy and pain therapy.

General therapy: drug therapy depends mainly on the etiopathogenesis of the spinal lesion or on the causative agent. Often in the initial phase it is not possible to unambiguously establish the etiological identity or isolate pathogens, so the choice of drugs is made empirically, depending on the clinical course, the results of laboratory diagnostics and cerebrospinal fluid examination, as well as on the expected spectrum of pathogens.

Initially, broad combination antibiotic therapy should be carried out using an antibiotic acting on the central nervous system.

In principle, antibiotics or virostatic agents should be used purposefully.

The choice of drugs depends on the results of a study of bacteriological cultures of blood and cerebrospinal fluid or cerebrospinal fluid punctures (an angiogram is required!), as well as on the results of serological or immunological studies. In the case of a subacute or chronic course of the disease, if the clinical situation allows it, a targeted diagnosis should first be carried out, if possible, with isolation of the pathogen, and, if necessary, a differential diagnosis.

In case of bacterial abscesses, in addition to antibiotic therapy (if this is possible from an anatomical and functional point of view), the possibility should be discussed and an individual decision made on neurosurgical sanitation of the lesion.

Specific therapy:

• idiopathic acute transverse myelitis. There are no randomized, placebo-controlled studies that clearly support the use of cortisone therapy. By analogy with the treatment of other inflammatory diseases and based on clinical experience, 3-5 days of intravenous cortisone therapy with methylprednisolone at a dose of 500-1000 mg is often carried out. Patients with severe clinical conditions may also benefit from more aggressive cyclophosphamide therapy and plasmapheresis.
• myelitis associated with herpes simplex and herpetic herpes zoster: acyclovir.
• CMV infections: ganciclovir. In rare cases of intolerance to acyclovir due to infections with HSV, varicella-zoster virus or CMV, foscarnet can also be used.
• neuroborreliosis: 2-3 weeks of antibiosis with ceftriaxone (1x2 g/day intravenously) or cefotaxime (3x2 g/day intravenously).
• neurosyphilis: penicillin G or ceftriaxone 2-4 g/day intravenously (duration of therapy depends on the stage of the disease).
• tuberculosis: multi-month four-component combination therapy with rifampicin, isoniazid, ethambutol and pyrazinamide.
• spinal abscesses with progressive neurological loss (for example, a myelopathic signal on MRI) or pronounced signs of a space-occupying process require urgent surgical intervention.
• Spondylitis and spondylodiscitis are often treated conservatively with immobilization and (if possible, targeted) antibiotic therapy for a minimum of 2-4 weeks. Antibiotics that are effective against the central nervous system for Gram-positive pathogens include, for example, fosfomycin, ceftriaxone, cefotaxime, meropenem and linezolid. In the case of tuberculous osteomyelitis, multi-month anti-tuberculosis combination therapy is indicated. If there is no effect or severe symptoms, first
  In total, bone destruction with signs of instability and/or depression of the spinal cord may require surgical sanitation with removal of the intervertebral disc and subsequent stabilization. Surgical measures should be discussed primarily for compression of neural structures.
• - neurosarcoidosis, neuro-Behçet, lupus erythematosus: immunosuppressive therapy; Depending on the severity of the disease, cortisone and, mainly with long-term therapy, also methotrexate, azathioprine, cyclosporine and cyclophosphamide are used.

Spinal ischemia

Therapeutic options for spinal ischemia are limited. There are no evidence-based medicine recommendations. The priority is to restore or improve spinal circulation to prevent further damage. Accordingly, it is necessary, as far as possible, to therapeutically influence the underlying causes of spinal ischemia.

In case of vascular occlusion, blood clotting (anticoagulation, heparinization) should be taken into account. The use of cortisone is not recommended due to potential side effects.

In the initial phase, the basis of therapy is the control and stabilization of vital functions, as well as the prevention of complications (infections, bedsores, contractures, etc.). In the future, neurorehabilitation measures are indicated.

Tumors

In the case of isolated space-occupying processes with spinal cord compression, urgent surgical decompression is necessary. The longer the spinal cord injury is present or continues (>24 hours), the worse the chances of recovery. In case of radiosensitive tumors or metastases, the possibility of irradiation is considered.

Other therapeutic options, depending on the type of tumor, its prevalence and clinical symptoms, include conservative therapy, radiation (including gamma knife), chemotherapy, thermocoagulation, embolization, vertebroplasty, and, if there are signs of instability, various stabilization measures. Therapeutic approaches should be discussed interdisciplinaryly, together with neurologists, neurosurgeons/trauma surgeons/orthopedic oncologists (radiation therapy specialists).

For spinal mass lesions with edema, cortisone is used (eg hydrocortisone 100 mg per day, according to the standards of the German Society of Neurology 2008, alternatively dexamethasone, eg 3 x 4-8 mg/day). The duration of treatment depends on the clinical course and/or changes in imaging findings.

Spinal hemorrhages

Depending on the clinical course and extensive nature of the process, sub- or epidural spinal hemorrhage may require surgical intervention (often decompressive laminectomy with blood aspiration).

For small hemorrhages without signs of mass effect and with minor symptoms, a conservative wait-and-see approach with monitoring the dynamics of the process is initially justified.

Spinal vascular malformations respond well to endovascular therapy (embolization). First of all, type I arteriovenous malformations (= fistulas) can often be “clogged.” Other arteriovenous malformations cannot always be occluded, but their size can often be reduced.

Prognosis for non-traumatic spinal cord injuries

Prognostically unfavorable factors for inflammatory spinal cord injuries include:

• Initially rapidly progressive course
• Duration of neurological loss more than three months
• Detection of protein 14-3-3 in the cerebrospinal fluid as a sign of neuronal damage
• Abnormal motor and sensory evoked potentials, as well as signs of denervation on the EMG.

Approximately 30-50% of patients with acute transverse myelitis have a poor outcome with residual severe disability, and the prognosis for multiple sclerosis is better than for patients with other causes of transverse cord lesion syndrome.

The prognosis of spondylitis/spondylodiscitis and spinal abscesses depends on the size and duration of damage to neural structures. The decisive factor is therefore timely diagnosis and therapy.

The prognosis of spinal ischemia, due to limited therapeutic options, is poor. Most patients have persistent neurological deficits, depending primarily on the type of primary lesion.

The prognosis for spinal space-occupying processes depends on the type of tumor, its prevalence, the extent and duration of damage to neural structures and the possibilities or effect of therapy.

The prognosis of spinal hemorrhages is determined mainly by the severity and duration of neurological deficits. With minor hemorrhages and conservative tactics, the prognosis in most cases can be favorable.

Traumatic spinal cord injury

Spinal injuries occur as a result of high-energy force. Common reasons include:

• High speed accident
• Falling from a great height and
• Direct force.

Depending on the mechanism of the accident, axial forces can lead to compression fractures of one or more vertebrae, as well as flexion-extension injuries of the spine with distraction and rotation components.

Up to 15-20% of patients with severe traumatic brain injury have associated cervical spine injuries. Approximately 15-30% of patients with polytrauma have spinal injuries. It is fundamentally recognized to distinguish the anterior, middle and posterior column or column in the spine ( three-column model Denis), and the anterior and middle columns of the spine include the vertebral bodies, and the posterior columns include their dorsal segments.

A detailed description of the type of injury, reflecting functional and prognostic criteria, is classification of injuries of the thoracic and lumbar spine, according to which spinal injuries are divided into three main types A, B and C, where each category includes three further subtypes and three subgroups. Instability increases in the direction from type A to type C and within the corresponding subgroups (from 1st to 3rd).

For upper cervical spine injuries, due to anatomical and biomechanical features, there is separate classification.

In addition to fractures, the following injuries occur with spinal injuries:

• Hemorrhages in the spinal cord
• Contusions and swelling of the spinal cord
• Spinal cord ischemia (due to compression or rupture of arteries)
• Ruptures and displacements of intervertebral discs.

Symptoms and signs of traumatic spinal cord injuries

In addition to the medical history (primarily the mechanism of the accident), the clinical picture plays a decisive role in further diagnostic and therapeutic measures. The following are the main clinical aspects of traumatic spinal injuries:

• Pain in the area of ​​the fracture when tapping, squeezing, or moving
• Stable fractures are usually less painful; unstable fractures often cause more severe pain with limited movement
• Hematoma at the fracture site
• Spinal deformity (eg, hyperkyphosis)
• Neurological loss: radicular pain and/or sensory disturbances, symptoms of incomplete or complete transverse lesion of the spinal cord, dysfunction of the bladder and rectum in men, sometimes priapism.
• Respiratory failure in high cervical paralysis (C Z-5 innervates the diaphragm).
• Prolapse of the brain stem/cranial nerves with atlanto-occipital dislocations.
• Rarely, traumatic injuries to the vertebral or basilar arteries.
• Spinal shock: transient loss of function at the level of spinal cord injury with loss of reflexes, loss of sensorimotor functions.
• Neurogenic shock: develops mainly with injuries to the cervical and thoracic spine in the form of a triad: hypotension, bradycardia and hypothermia.
• Autonomic dysreflexia in the case of lesions within T6; as a result of the action of various nociceptive stimuli (for example, tactile irritation) below the level of the lesion, an excessive sympathetic reaction with vasoconstriction and an increase in systolic pressure up to 300 mm Hg, as well as a decrease in peripheral circulation (pallor of the skin), can develop. Above the level of the lesion in the spinal cord, compensatory vasodilation develops (redness of the skin and sweating). Due to crises of blood pressure and vasoconstriction - with the risk of cerebral hemorrhage, cerebral and myocardial infarction, arrhythmias up to cardiac arrest - autonomic dysreflexia is a serious complication.
• Brown-Séquard syndrome: usually a hemilateral spinal cord lesion with ipsilateral paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensations.
• Conus medullary syndrome: damage to the sacral spinal cord and lumbar nerve roots with areflexia of the bladder, bowel and lower extremities with sometimes persisting reflexes at the sacral level (for example, bulbocavernosus reflex).
• Cauda equina syndrome: damage to the lumbosacral nerve roots with areflexia of the bladder, bowel and lower extremities.

Diagnosis of traumatic spinal cord injuries

To determine the level and severity of spinal cord injury, the classification developed by the American Spinal Injury Association can be used.

Every patient with neurological deficits due to trauma requires adequate and timely initial diagnostic imaging. In patients with moderate to severe traumatic brain injury, the cervical spine including the upper thoracic spine should be examined.

For mild to moderate injuries (without neurological deficit), the following signs indicate the need for timely imaging:

• Variable state of consciousness
• Intoxication
• Pain in the spine
• Distraction injury.

The patient's advanced age and significant past or concomitant diseases, as well as the mechanism of the accident, play an important role in the decision to perform imaging.

Patients with a minor mechanism of injury and a low risk of injury often do not need hardware diagnostics, or only conventional radiography is sufficient (if indicated, additional functional radiography). As soon as the likelihood of spinal injury is identified based on risk factors and the course of the injury, a CT scan of the spine should be performed first, due to its higher sensitivity.

In case of possible vascular damage, CT angiography is additionally required.

MRI is inferior to CT in the emergency diagnosis of spinal injury, since it allows only limited assessment of the extent of bone damage. However, in case of neurological deficits and ambiguous CT results, MRI should also be additionally performed in case of emergency diagnosis.

MRI is indicated primarily in the acute phase and to monitor the dynamics of neural damage. In addition, the ligamentous and muscular components of the injury and, if necessary, the lesions within these components can be better assessed.

During visualization, it is necessary to obtain answers to the following questions:

• Is there any trauma at all?
• If yes, what type (fracture, dislocation, hemorrhage, compression of the brain, lesions in the ligaments)?
• Is there an unstable situation?
• Is surgery required?
• Daffner recommends that spinal injury be assessed using the following procedure:
• Alignment and anatomical abnormalities: anterior and posterior margins of vertebral bodies in the sagittal plane, spinolaminar line, lateral masses, interspinal and interspinous distances;
• Bone - violation of bone integrity: bone rupture/fracture line, compression of vertebral bodies, “bone spurs”, displaced bone fragments;
• Cartilage-anomalies of the cartilage/articular cavity: increased distances between small vertebral joints (> 2 mm), interspinal and interspinous distances, expansion of the intervertebral space;
• Soft tissue - soft tissue abnormalities: hemorrhages extending into the retrotracheal (< 22 мм) и ретрофарингеальное пространство (>7 mm), paravertebral hematomas.

In case of severe spinal injuries, a search for other injuries (skull, chest, abdomen, blood vessels, extremities) should always be carried out.

Laboratory diagnostics includes a hemogram, coagulogram, determination of electrolyte levels and kidney function indicators.

For neurological loss in the subacute phase must be carried out additional electrophysiological diagnostics to assess the extent of functional damage.

Complications of spine and spinal cord injuries

• Spinal instability with secondary spinal cord injuries
• Spinal cord injuries (myelopathy) due to compression, contusion with various types of prolapses:
• - complete transverse paralysis (depending on the level of tetra- or paraplegia and corresponding sensory deficits)
• incomplete transverse paralysis (paraparesis, tetraparesis, sensory deficits)
• With high cervical transverse lesions - respiratory failure
• Cardiovascular complications:
• orthostatic hypotension (most pronounced in the initial phase, improvement over time)
• loss/weakening of daily blood pressure fluctuations
• heart rhythm disturbances (in the case of lesions above T6, predominantly bradycardia as a result of loss of sympathetic innervation and dominance of vagus nerve stimulation)
• Deep vein thrombosis and pulmonary embolism
• Long-term complications of transverse paralysis:
• areflexia (diagnosis=combination of arterial hypertension and vasoconstriction below the level of injury)
• post-traumatic syringomyelia: symptoms often last months or several years with neurological pain above the level of the lesion, as well as increasing neurological deficits and spasticity, deterioration of bladder and rectal function (diagnosis is established using MRI)
• heterotopic ossification = neurogenically caused perarticular ossification below the level of the lesion
• spasticity
• painful contractures
• bedsores
• chronic pain
• urinary disorders with increased rates of urinary tract/kidney infections
• increased risk of infections (pneumonia, sepsis)
• impaired intestinal motility and bowel movements
• psychological and psychiatric problems: stress disorder, depression

Treatment of traumatic spinal cord injuries

Depending on the scale of neurological damage and associated immobility, great importance is attached to conservative, preventive and rehabilitation measures:

• Intensive medical monitoring, especially in the initial phase, to maintain normal cardiovascular and pulmonary functions;
• For arterial hypotension, attempt therapy by adequate fluid replacement; in the initial phase, according to indications, the appointment of vasopressors;
• Prevention of bedsores, thrombosis and pneumonia;
• Depending on the stability and course of the disease, early implementation of mobilization and physiotherapeutic measures.

Caution: Autonomic impairments (orthostatic hypotension, autonomic dysreflexia) make mobilization significantly more difficult.

The indication for surgical intervention (decompression, stabilization) depends, first of all, on the type of injury. In addition to eliminating possible myelocompression, surgical intervention is necessary in unstable situations (types B and C injuries).

Surgical intervention requires the appropriate competence of neurosurgeons, trauma surgeons and orthopedists.

In case of severe traumatic compression of the spinal cord with neurological symptoms, urgent surgical decompression is indicated (within the first 8-12 hours). In the absence of neurological loss or in case of inoperability, depending on the type of injury, the possibility of conservative (non-invasive) treatment tactics is individually considered, for example, using a HALO head fixator for injuries of the cervical spine.

The use of methylprednisolone for spinal injury remains controversial. Despite scientific indications of benefit when started early, critics primarily note side effects (eg, increased incidence of pneumonia and sepsis) and possible associated injuries (eg, traumatic brain injury, CRASH study). If spinal cord swelling (or expected swelling) occurs, methylprednisolone (eg, Urbason) may be prescribed. As a bolus, 30 mg/kg body weight is prescribed intravenously, followed by a long-term infusion. If administration is carried out within the first three hours after injury, long-term infusion is carried out within 24 hours, if started between 3 and 8 hours after injury, within 48 hours.

Therapy for autonomic dysreflexia consists primarily of eliminating the provoking stimulus. For example, a blocked urinary catheter causing bladder distension, skin inflammation, rectal distension. In case of persistent arterial hypertension, despite the elimination of provoking irritants, medications are used to lower blood pressure, for example nifedipine, nitrates or captopril.

Prognosis for traumatic spinal cord injuries

The prognosis depends mainly on the location of the injury, its severity and type (polysegmental or monosegmental), as well as on the primary neurological status. In addition to the clinical picture, MRI is required to clarify morphological damage, and additionally electrophysiological diagnostics (sensory and motor evoked potentials, EMG) are required to identify functional lesions. Depending on the primary damage, complete loss of function, partial loss of motor and sensory functions, but also their complete recovery are possible. The prognosis for severe intramedullary hemorrhage, swelling and compression of the spinal cord is poor.

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Closed injuries of the spine and spinal cord are divided into three groups:

1) spinal injuries without dysfunction of the spinal cord;

2) spinal injuries accompanied by impaired conduction function of the spinal cord;

3) closed spinal cord injuries without damage to the spine.

Damage to the spine occurs in the form of fractures of the bodies, arches, and processes; dislocations, fracture-dislocations; ligamentous ruptures, damage to intervertebral discs. Lesions of the spinal cord can be in the form of compression of the brain and its roots by an epidural hematoma or bone fragments, concussion or contusion of the medulla, rupture of the spinal cord and its roots, subarachnoid hemorrhage and hemorrhage into the medulla (hematomyelia).

Spinal cord contusion is characterized by dysfunction of the pathways and is manifested by paralysis and loss of sensitivity below the level of damage, retention of urination and defecation. All phenomena develop immediately after injury and last for 3-4 weeks. During this period, pneumonia, bedsores, ascending cystopyelonephritis and urosepsis may develop.

Spinal cord compression may be sharp (occurs at the time of injury), early (hours or days after injury) and late (months or years after injury).

Compressions are classified according to location: rear (broken vertebral arch, epidural hematoma, torn ligamentum flavum), front (body of a broken or displaced vertebra, prolapsed intervertebral disc), internal (cerebral edema, intracerebral hematoma, detritus in the softening area).

Compression may be with complete obstruction cerebrospinal fluid tracts and conduction functions of the spinal cord, with partial obstruction liquor-conducting pathways, and by the nature of development - acutely progressive and chronic.

Diagnosis of spinal cord compression syndrome is based on data from a neurological examination, survey spondylograms and special research methods, including assessment of the patency of the subarachnoid space during lumbar puncture with CSF tests, positive myelography with water-soluble contrast agents, or pneumomyelography. Spinal cord compression syndrome is characterized by a block of the subarachnoid space and an increase in neurological disorders. Ascending edema is especially dangerous in cases of cervical spinal cord injury.

When the spinal cord is compressed by the posterior structures of the vertebrae, decompressive laminectomy of 2–3 arches is used. Timing for its implementation in case of closed spinal injuries:

• emergency laminectomy - within the first 48 hours after injury;
• early laminectomy - the first week after injury;
• late laminectomy - 2-4 weeks.

When the anterior structures of the spinal cord are compressed by bone fragments displaced into the lumen of the spinal canal or damaged intervertebral discs, an operation is used - anterior decompression of the spinal cord (removal of bone fragments and damaged intervertebral discs using an anterior approach) followed by anterior corporedesis with a bone autograft.

Vertebral fractures without damage to the spinal cord are treated either conservatively: lumbar and thoracic regions - by traction with straps on the axillary areas on a bed with a shield, using rollers to reposition the vertebrae in bed; cervical spine - by skeletal traction over the parietal tuberosities and zygomatic bones, or surgically, in order to restore the configuration of the spinal canal and stabilize the spine: vertebrae are repositioned, bone fragments are removed and the spine is fixed with metal structures.

For spinal cord injuries without damage to the spine, conservative treatment is performed.

Gunshot wounds of the spine and spinal cord are divided into:

• according to the type of wounding projectile - bullet and fragmentation;
• according to the nature of the wound channel - through, blind, tangential;
• in relation to the spinal canal - into penetrating, non-penetrating, paravertebral;
• by level - to the cervical, thoracic, lumbar, sacral regions; isolated, combined (with damage to other organs), multiple and combined injuries are also distinguished.

Penetrating spinal injuries are injuries in which mainly the bony ring of the spinal canal and the dura mater are destroyed.

In the acute period of spinal cord injury, spinal shock develops, manifested by inhibition of all functions of the spinal cord below the site of injury. In this case, tendon reflexes are lost, muscle tone decreases, sensitivity and function of the pelvic organs are disrupted (according to the type of acute retention). The state of spinal shock lasts 2–4 weeks and is supported by foci of irritation of the spinal cord: foreign bodies (metal fragments, bone fragments, fragments of ligaments), areas of traumatic and circular necrosis.

The more severe the spinal cord injury, the later its reflex activity is restored. When assessing the degree of spinal cord damage, the following clinical syndromes are distinguished:

Syndrome of complete transverse destruction of the spinal cord; characterized by tetra- and paraplegia, tetra- and paraanesthesia, dysfunction of the pelvic organs, progressive development of bedsores, hemorrhagic cystitis, rapidly occurring cachexia, edema of the lower extremities;

Partial spinal cord injury syndrome - in the acute period is characterized by varying severity of symptoms - from preservation of movement in the limbs with a slight difference in reflexes, to paralysis with dysfunction of the pelvic organs. The upper limit of sensitivity disorders is usually unstable and can change depending on circulatory disorders, cerebral edema, etc.;

Spinal cord compression syndrome due to gunshot wounds - in the early period most often occurs due to pressure on the brain substance from a wounding projectile, bone fragments, displaced vertebrae, as well as due to the formation of subdural and epidural hematomas;

Perineural radicular position syndrome is observed with a blind wound of the spine in the cauda equina region with a subdural location of the foreign body. The syndrome is expressed by a combination of pain and bladder disorders: in an upright position, pain in the perineum intensifies, and emptying the bladder is more difficult than in a lying position.

Injuries to the upper cervical spine and spinal cord are characterized by a severe condition with severe respiratory impairment (due to paralysis of the muscles of the neck and chest wall). Often such injuries are accompanied by stem symptoms: loss of consciousness, swallowing disorder and disturbances in the functioning of the cardiovascular system due to ascending edema.

Injuries to the lower cervical spine are accompanied by respiratory distress, high paralysis (tetraplegia), impaired sensitivity below the level of the collarbone, and often Horner's symptom (narrowing of the pupil, palpebral fissure, and some retraction of the eyeball).

When the thoracic spinal cord is damaged, paraplegia of the lower extremities, dysfunction of the pelvic organs and sensitivity disorder depending on the level of the lesion develop (the fifth thoracic segment corresponds to the level of the nipples, the seventh to the costal arch, the tenth to the line of the navel, the twelfth to the inguinal folds). Damage to the lumbar spinal cord, segments of which are located at the level of the I-X-XI thoracic vertebrae, is accompanied by paraplegia, dysfunction of the pelvic organs (like incontinence) and a disorder of sensitivity downward from the inguinal folds.

When the epiconus and roots of the initial section of the cauda equina are affected, flaccid paralysis of the muscles of the legs, feet, and buttocks occurs, and sensitivity disorders are detected on the skin of the lower extremities and in the perineal area.

Injuries of the lower lumbar and sacral spine are accompanied by damage to the roots of the cauda equina and are clinically characterized by flaccid paralysis of the lower extremities, radicular pain and urinary incontinence.

Instructions for military field surgery

Spinal cord - This is the nerve tissue that runs down from the brain in the spinal canal of the back. The spinal canal is surrounded by the spine as a bony structure that protects the spinal cord from various injuries.

Thirty-one spinal nerves extend from the spinal cord to the chest, abdomen, legs, and arms. These nerves tell the brain to move certain parts of the body. In the upper part of the spinal cord there are nerves that control the arms, heart, lungs, in the lower part - the legs, intestines, bladder, etc. Other nerves return information from the body to the brain - sensations of pain, temperature, body position, etc.

Causes of spinal cord injury

• road traffic injuries
• falling from height
• sports injuries
• brain tumor
• infectious and inflammatory processes
• vascular aneurysm
• long-term decrease in blood pressure

The spinal cord, unlike other parts of the body, is incapable of recovery, so damage to it leads to irreversible processes. Spinal cord injury may be the result of more than one process: spinal injuries, circulatory disorders, infections, tumors, etc.

Spinal cord injuries

Severe symptoms Spinal cord injury manifests itself depending on two factors: the location of the injury and the extent of the injury.

Location of damage.

The spinal cord can be damaged either at the top or at the bottom. Depending on this, the symptoms of damage are also distinguished. If the upper part of the spinal cord is damaged, such damage causes greater paralysis. For example, fractures of the upper spine, especially the first and second cervical vertebrae, lead to damage to both arms and both legs. In this case, the patient is able to breathe only with the help of an artificial respiration apparatus. If the lesions are located lower, in the lower parts of the spine, then only the legs and lower part of the torso can paralyze.

Degree of damage.

There are different degrees of severity of spinal cord injuries. Damage can be either partial or complete. This again depends on the location of the injury - that is, which part of the spinal cord was damaged in this case.

Partial spinal cord injury. With this type of injury, the spinal cord transmits only some signals to and from the brain. In this regard, patients retain sensitivity, but only to some extent. And also certain motor functions below the affected area are preserved.

Complete spinal cord damage. With complete, there is a complete or almost complete loss of motor function, as well as sensitivity below the affected area. But it must be said that the spinal cord, even with complete damage, will not be cut. But only the spinal cord that has been partially damaged can be restored, while a completely damaged brain cannot be restored.

Symptoms of Spinal Cord Injury

• intense burning and pain
• inability to move
• partial or complete loss of sensation (heat, cold, tactile sensations)
• inability to control the bladder and bowels
• mild cough, difficulty breathing
• changes in sexual and reproductive functions

Critical symptoms

• occasional loss of consciousness
• loss of coordination
• numbness in fingers, toes, hands and feet
• paralysis of body parts
• curvature of the neck and back