Trauma with spinal cord injury rehabilitation. Injuries to the spine and spinal cord

The spinal cord is located in the spinal canal and is responsible for the functioning of the digestive, respiratory, reproductive, urinary and other important systems of the body. Any violations and injuries of the spine and nervous tissue are fraught with disturbances in the functioning of organs and other pathological phenomena.

Doctors consider spinal cord injuries to be stretching, squeezing, bruising with intracerebral hemorrhage, ruptures or detachments of one or more nerve roots, as well as infectious lesions and developmental anomalies. In the article, we will look at the symptoms, diagnosis and treatment of injuries of the spine and spinal cord. You will learn how pre-hospital care and transportation of a victim with spinal cord injuries is performed.

Disorders in the spinal cord cause both independent diseases and injuries of the spine. The causes of spinal cord injuries are divided into 2 large groups: traumatic and non-traumatic.

Traumatic causes include:

Non-traumatic causes of spinal cord injury:

• inflammatory processes: myelitis (viral or autoimmune);
• tumors: sarcoma, lipoma, lymphoma, glioma;
• radiation myelopathy;
• vascular spinal syndromes, vascular compression;
• myelopathy associated with metabolic disorders;
• purulent or bacterial infection: tuberculous, mycotic spondylitis;
• chronic rheumatic pathologies of the spine: rheumatoid, reactive arthritis, disease;
• degenerative changes in the spine: osteoporosis, spinal canal stenosis,.

Types of injury

Spinal cord injuries are classified on various grounds. There are open injuries with damage to soft tissues and skin and closed injuries without external damage.

Types of spinal injuries:

• sprains or ruptures of the ligaments of the spine;
• vertebral fractures: compression, comminuted, marginal, explosive, vertical and horizontal;
• intervertebral disc injuries;
• dislocations, subluxations, fracture-dislocations;
• spondylolisthesis or displacement of the vertebrae.

Types of spinal cord injuries:

• injury;
• squeezing;
• partial or complete break.

Bruises and compression are usually associated with spinal injury: dislocation or fracture. With a bruise, the integrity of the spinal tissue is violated, hemorrhage and swelling of the brain tissue are observed, the scale of which will depend on the degree of damage.

Compression occurs with fractures of the vertebral bodies. It can be partial or complete. Squeezing is not uncommon in divers; most often damaged lower cervical vertebrae.

The victim develops atrophic paralysis of the arms, paralysis of the legs, decreased sensitivity in the area below the level of the lesion, problems with the pelvic organs and bedsores appear in the area of ​​the sacrum.

Compression in the area of ​​the lumbosacral spine leads to paralysis of the legs, loss of sensation and dysfunction of the pelvic organs.

Symptoms

Signs of spinal cord injury depend on the type of injury and where it occurred.

Common signs of spinal cord problems:

Spinal cord injury in newborns most often occurs in the cervical or lumbar regions. The fact is that the spinal cord in a baby, in comparison with the spine and ligaments, is less extensible and is easily damaged during injuries without visible changes in the spine itself.

In some situations, even a complete rupture of the spinal cord occurs, although no changes will be visible on the x-ray.

Due to neck injury during childbirth, the baby will be in a state of anxiety. The neck can be bent, lengthened or shortened. An infant has the same symptoms as an adult: spinal shock, edema, breathing problems, disturbances in the functioning of internal organs, muscle atrophy, reflex and movement disorders.

First aid

The consequences of injuries will be less dangerous if first aid is provided correctly. The victim is laid flat on a hard surface and transported on a rigid shield. If immobilization is not carried out, bone fragments and fragments will continue to compress the spinal cord, which is fraught with death.

The injured person is carried exclusively on a hard surface. If damage to the cervical region is suspected, the head is additionally fixed with a tire from improvised means (cloth rollers are suitable).

Attention! Do not sit down or try to lift the victim to his feet. It is required to monitor breathing and pulse and, if necessary, to carry out resuscitation.

Main rules:

1. Restrict the victim's movements, place him on a hard surface and fix the injured area with improvised means.
2. Give pain medication if needed.
3. Make sure the victim is conscious.

In a situation of severe injury, the spinal cord is switched off for some time, a state of shock occurs. Spinal shock is accompanied by impaired sensory, motor and reflex functions of the spinal cord.

The disturbance extends below the damage level. During this period, it is impossible to determine a single reflex, only the heart and lungs work. They function offline, other organs and muscles also do not work.

While waiting for the shock to pass and the spinal cord to start working, the muscles are supported with electrical impulses to prevent atrophy.

Diagnostics

How to check the spinal cord in a person after an injury? To determine the level of damage, an x-ray is taken (at least in 2 planes).

Computed and magnetic resonance imaging provide the most detailed picture of the state of the spine and spinal cord. Here you can see the spinal cord in both longitudinal and transverse sections, identify hernias, splinters, hemorrhages, damage to the nerve roots and tumors.

Myelography carried out for the purpose of diagnosing nerve endings.

Vertebral angiography shows the state of the blood vessels of the spine.

Lumbar puncture is done to analyze the cerebrospinal fluid, to detect infection, blood, or foreign bodies in the spinal canal.

Treatment Methods

Treatment for the spinal cord depends on the severity of the injury. In case of mild injury, the victim is prescribed bed rest, taking painkillers, anti-inflammatory and restorative drugs.

In case of violation of the integrity of the spine, compression of the spinal canal and the presence of severe injuries, surgery is necessary. It is produced to restore damaged tissues of the spine and spinal cord.

Serious injuries require emergency surgery. If you do not help the victim in time, 6-8 hours after the injury, irreversible consequences may occur.

In the postoperative period, a course of intensive therapy is carried out to prevent side effects. In this process, the work of the cardiac system, respiration is restored, cerebral edema is eliminated and infectious lesions are prevented.

Orthopedic

Orthopedic treatment includes reduction of dislocations, fractures, traction and prolonged immobilization of the spine. The patient is recommended to wear a cervical collar for injuries of the cervical spine or an orthopedic corset for the treatment of the thoracic or lumbar regions.

Conservative treatment involves the use of the spinal traction method. If the thoracic and lumbar spine is damaged, traction is carried out using loops, hanging the patient by the armpits.

Also used are beds with a raised headboard. In the treatment of cervical traction, a Glisson loop is used. This device is in the form of a loop, where the head with a cable and a counterweight is attached. Due to the counterweight, a gradual stretching occurs.

Medical therapy includes taking anti-inflammatory and analgesic drugs. Preparations are prescribed to restore blood circulation, strengthen the body and activate the processes of tissue regeneration.

If the victim develops spinal shock, dopamine, atropine, and large doses of methylprednisolone are used. With pathological muscle stiffness, centrally acting muscle relaxants are prescribed (). To prevent the development of inflammatory phenomena, broad-spectrum antibiotics are taken.

Rehabilitation

The rehabilitation period takes up to several months. After the restoration of the integrity of the spinal cord, training begins to restore physical activity.

Therapeutic training of the first week begins with breathing exercises. In the second week, they include movements with arms and legs. Gradually, depending on the condition of the patient, the exercises complicate, transfer the body to a vertical position from a horizontal one, increase the range of motion and load.

As you recover, massage is included in the rehabilitation process.

Physiotherapy is carried out to restore motor activity, prevent bedsores and disorders of the pelvic organs. It promotes tissue regeneration in the area of ​​injury and lymphatic drainage, improves blood circulation, cell and tissue metabolism, reduces swelling and inflammation.

For treatment, ultrasound, magnetotherapy, general ultraviolet irradiation, electrophoresis with lidase and novocaine, phonophoresis are used.

Reference. Physiotherapy in combination with drugs improves nutrition and absorption of active substances in tissues and cells.

For paralysis and paresis of the lower extremities, hydro-galvanic baths, massage with a shower under water, mud applications are used. Mud therapy can be replaced with ozocerite or paraffin.

For pain syndrome, balneotherapy, radon and coniferous baths, as well as vibration and whirlpool baths are used.

Along with physical therapy, hydrokinesiotherapy and swimming in the pool are used.

Complications of spinal cord injury

Complications come:

• in case of untimely medical assistance;
• in case of violations by patients of the discipline of treatment and rehabilitation;
• in case of neglect of the doctor's recommendations;
• as a result of the development of infectious and inflammatory side processes.

There are no serious consequences from a slight bruise, local hemorrhage in the tissues of the spinal cord, compression or concussion, the victim recovers completely.

In severe cases - with extensive bleeding, fractures of the spine, severe bruises and pressure - bedsores, cystitis, pyelonephritis appear.

If the pathology takes a chronic form, paresis, paralysis develop. In the event of an unfavorable outcome, a person completely loses motor functions. These patients require constant care.

Conclusion

Any damage to the spinal cord is fraught with serious problems. Untimely treatment, disregard for the condition of your spine and medical recommendations can lead to disastrous results.

Spinal cord - it 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 in the form of a bone structure that protects the spinal cord from various injuries.

Thirty-one spinal nerves branch from the spinal cord to the chest, abdomen, legs, and arms. These nerves instruct 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 - the sensation of pain, temperature, body position, and so on.

Causes of spinal cord injury

• road traffic injuries
• falling from height
• sports injuries
• brain tumor
• infectious and inflammatory processes
• vascular aneurysm
• prolonged lowering of 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 can be the result of more than one process: spinal injuries, circulatory disorders, infections, tumors, etc.

Spinal cord injury

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

The location of the 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, then such damage causes more paralysis. For example, fractures of the upper spine, especially the first and second cervical vertebrae, lead 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 body can be paralyzed.

Degree of damage.

Distinguish the 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 in this case was damaged.

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 remain sensitive, but only to some extent. Separate motor functions are also preserved below the affected area.

Complete damage to the spinal cord. With complete, there is a complete or almost complete loss of motor function, as well as sensitivity below the affected area. But I must say that the spinal cord, even with complete damage, will not be cut. But only the spinal cord, which has undergone partial damage, can be restored, while a completely damaged brain is not 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 functioning of the bladder and bowels
• mild cough, shortness of breath
• changes in sexual and reproductive functions

Critical symptoms

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

Causes of emergencies in spinal lesions may be traumatic or non-traumatic.

To non-traumatic reasons include:

• Medullary processes:
  • spinal cord inflammation: myelitis, viral and autoimmune
  • medullary tumors (gliomas, ependymomas, sarcomas, lipomas, lymphomas, drip metastases); paraneoplastic myelopathy (eg, in bronchial carcinoma and Hodgkin's disease)
  • radiation myelopathy in the form of acute, from incomplete to complete, symptoms of lesions at a certain level of the spinal cord at radiation doses of 20 Gy with a latency of 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 stasis and congestive ischemia or hemorrhage)
  • metabolic myelopathy (with acute and subacute course); funicular myelosis with vitamin B 12 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 (eg, bronchial cancer, multiple myeloma [plasmocytoma]);
  • spinal subdural and epidural hemorrhages in blood clotting disorders (anticoagulation!), condition after trauma, lumbar puncture, epidural catheter and vascular malformations;
  • degenerative diseases such as osteoporotic fractures of the spine, spinal canal stenosis, herniated discs.

To traumatic reasons include:

• Contusion, infringement of the spinal cord
• Traumatic hemorrhages
• Fracture/dislocation of the vertebral body

Non-traumatic spinal cord injuries

Inflammation/infection of the spinal cord

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

Risk factors for spinal infection are:

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

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

spinal ischemia

Spinal ischemia, compared with cerebral ischemia, is rare. In this regard, a favorable effect is exerted, first of all, by good collateralization of the blood flow of the spinal cord.

The following are considered as causes of spinal ischemia:

• Arteriosclerosis
• aortic aneurysm
• Operations on the aorta
• Arterial hypotension
• Obstruction/dissection of the vertebral artery
• Vasculitis
• Collagenosis
• Embolic vascular occlusion (eg, decompression sickness in divers)
• Spinal volumetric processes (intervertebral discs, tumor, abscess) with vascular compression.

In addition, there are also idiopathic spinal ischemias.

Tumors of the spinal cord

According to anatomical localization, spinal tumors/volume processes are subdivided into:

• Vertebral or extradural tumors (eg, metastases, lymphomas, multiple myeloma, schwannomas)
• Tumors of the spinal cord (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
• Blood clotting disorders
• Malformations of the spinal vessels
• Injuries
• Tumors
• Vasculitis
• Manual therapy
• Rarely, aneurysms in the cervical region (vertebral artery)

Vascular malformations include:

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

Symptoms and signs of non-traumatic spinal cord injury

The clinical picture in spinal emergencies depends mainly on the underlying etiopathogenesis and localization of the lesion. These conditions typically present with acute or subacute neurological deficits, which include:

• Sensitization disorders (hypesthesia, par- and dysesthesia, hyperpathia) usually caudal to spinal cord injury
• Motor deficits
• Vegetative disorders.

The phenomena of prolapse may be lateralized, but they also manifest themselves in the form of acute symptoms of a transverse spinal cord lesion.

ascending myelitis can lead to damage to the brainstem with cranial nerve prolapse and dative insufficiency, which may clinically correspond to the pattern of Landry's palsy (= ascending flaccid paralysis).

Back pain, often drawing, stabbing or blunt, felt primarily in extramedullary inflammatory processes.

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

spinal tumors initially often accompanied by back pain, which is aggravated by percussion of the spine or during exercise, neurological deficits do not have to be present. Radicular pain can occur with damage to the nerve roots.

Symptoms spinal ischemia develops over a period of minutes to hours and, as a rule, covers the pool of the vessel:

• Syndrome of the anterior spinal artery: often radicular or girdle pain, flaccid tetra- or paraparesis, lack of pain and temperature sensitivity while maintaining vibration sensitivity and joint-muscular feeling
• Sulco-commissural artery syndrome
• Posterior spinal artery syndrome: loss of proprioception with ataxia when standing and walking, sometimes paresis, bladder dysfunction.

Spinal hemorrhages are characterized by acute - often unilateral or radicular - back pain, usually with incomplete symptomatology of the transverse spinal cord lesion.

Due to malformations of the spinal vessels often slowly progressing symptoms of transverse lesions of the spinal cord develop, sometimes fluctuating or paroxysmal.

At metabolic disorders it is necessary, first of all, to remember the deficiency of vitamin B12 with a picture of funicular myelosis. It often presents in patients with pernicious anemia (eg, Crohn's disease, celiac disease, malnutrition, a strict vegetarian diet) and slowly progressive motor deficits, such as spastic paraparesis and gait disturbance, and sensory deficits (paresthesias, decreased vibration sensitivity). ). Additionally, cognitive functions usually worsen (confused consciousness, psychomotor retardation, depression, psychotic behavior). Rarely, with impaired liver function (mainly in patients with a portosystemic shunt), hepatic myelopathy develops with damage to the pyramidal tract.

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

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

Myelitis with tick-borne encephalitis often associated with "severe transverse symptomatology" involving the upper extremities, cranial nerves, and diaphragm, and has a poor prognosis.

Optic neuromyelitis(Devic'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, as a rule, with a latency of several weeks to months and can be manifested by acute spinal symptoms (paresis, sensory disturbances). The diagnosis is indicated by the history, including the size of the radiation field.

Diagnosis of non-traumatic spinal cord injuries

Clinical examination

Localization of damage is established by the study of sensitive 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 identified, 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 on tapping and squeezing.

Symptoms of spinal inflammation at first can be completely non-specific, which significantly complicates and slows down the diagnosis.

Difficulties arise in the differentiation caused by the pathogen and parainfectious myelitis. In the latter case, an asymptomatic interval between a 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 lesions, metabolic changes and tumors especially well visualized on T2-weighted images. Inflammatory or edematous changes, as well as tumors, are well displayed in STIR sequences. After the injection of a contrast agent in T1 sequences, blooming inflammatory foci and tumors are usually well differentiated (sometimes subtractions of the original T1 from T1 after the injection of a contrast agent for more accurate delimitation of the contrast). If bone involvement is suspected, T2 or STIR sequences with fat saturation, or T1 after contrast agent injection, are appropriate for better differentiation.

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

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

In rare cases (functional imaging, intradural volume 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 plain x-ray.

Liquor research

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

Bacterial inflammation usually accompanied by marked increases in cell count (> 1000 cells) and total protein. If a bacterial infection is suspected, it is necessary to strive to isolate the pathogen by sowing cerebrospinal fluid on the flora or by PCR. With signs of systemic inflammation, the bacterial pathogen is detected by blood culture.

At viral inflammations, apart from a slight or moderate increase in the number (usually from 500 to a maximum of 1000 cells), there is usually only a slight increase in the level of proteins. 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 CSF can be reliably confirmed by determining the avidity index of specific antibodies (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, there is a slight pleocytosis (< 100 клеток), а также нарушения гематоэнцефалического барьера и повышение уровня белков

In multiple sclerosis, more than 80% of patients have oligoclonal bands in the CSF. Optical neuromyelitis in more than 70% of patients is associated with the presence in the serum of specific antibodies to aquaporin 4.

Other diagnostic measures

Routine laboratory diagnostics, complete blood count and C-reactive protein in the case of isolated inflammatory spinal processes do not always help, and often in the initial phase no anomalies are found in the analyzes, or there are only minor changes. However, an increase in C-reactive protein in bacterial spinal inflammation is a non-specific 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: such a phenomenon in the cerebrospinal fluid can occur with "cerebrospinal fluid blockade" (in the absence of cerebrospinal fluid flow as a result of mechanical displacement of the spinal canal).

The differential diagnosis for 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 a 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 - a typical EMG picture;
• Parasagittal cortical syndrome (eg, sickle brain tumor);
• Psychogenic symptoms of transverse lesions of the spinal cord.

Complications of emergencies in spinal lesions

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

Treatment of non-traumatic spinal cord injuries

Inflammation of the spinal cord

In addition to specific therapy directed against the pathogen, general measures should first be carried out, such as the installation of a urinary catheter for violations of bladder emptying, prevention of thrombosis, changing the position of the patient, timely mobilization, physiotherapy and pain therapy.

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

In the beginning, a broad combination antibiotic therapy should be carried out using an antibiotic that acts on the central nervous system.

In principle, antibiotics or virostatic agents should be used in a targeted manner.

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 it is possible from an anatomical and functional point of view), the possibility should be discussed and an individual decision should be made on neurosurgical debridement of the focus.

Specific therapy:

• idiopathic acute transverse myelitis. There are no placebo-controlled randomized trials that unequivocally 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 performed. Patients with a severe clinical condition may also benefit from more aggressive cyclophosphamide therapy and plasmapheresis.
• myelitis associated with herpes simplex and herpes zoster: acyclovir.
• CMV infections: ganciclovir. In rare cases of intolerance to acyclovir in HSV, varicella-zoster or CMV infections, foscarnet can also be used.
• neuroborreliosis: 2-3 weeks antibiosis with ceftriaxone (1x2 g/day IV) or cefotaxime (3x2 g/day IV).
• neurosyphilis: penicillin G or ceftriaxone 2-4 g/day intravenously (the 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 prolapse (eg, myelopathic signal on MRI) or pronounced signs of a volumetric process require urgent surgical intervention.
• spondylitis and spondylodiscitis are often treated conservatively with immobilization and (if possible targeted) antibiotic therapy for at least 2-4 weeks. Antibiotics that act well on the CNS 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. In the absence of effect or severe symptoms, before
  In general, bone destruction with signs of instability and/or depression of the spinal cord may require surgical debridement with removal of the intervertebral disc and subsequent stabilization. Surgical measures should be discussed primarily in the case of compression of neural structures.
• - neurosarcoidosis, neuro-Behcet, lupus erythematosus: immunosuppressive therapy; depending on the severity of the disease, cortisone is used and, mainly in long-term therapy, also methotrexate, azathioprine, cyclosporine and cyclophosphamide.

spinal ischemia

Therapeutic options for spinal ischemia are limited. There are no evidence-based medicine recommendations. The restoration or improvement of the spinal circulation comes to the fore in order to prevent further damage. Accordingly, it is necessary, as far as possible, to therapeutically address the underlying causes of spinal ischemia.

In case of vascular occlusion, blood coagulation (anticoagulation, heparinization) should be taken into account. Administration 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 shown.

Tumors

In the case of isolated volumetric processes with compression of the spinal cord, urgent surgical decompression is necessary. The longer there is or continues spinal cord injury (>24 hours), the worse the chances of recovery. In the 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, irradiation (including gamma knife), chemotherapy, thermocoagulation, embolization, vertebroplasty, and with signs of instability, various stabilization measures. Therapeutic approaches should be discussed interdisciplinary, with neurologists, neurosurgeons/trauma surgeons/orthopedics oncologists (radiotherapy specialists).

For spinal volume processes with edema, cortisone is used (eg 100 mg hydrocortisone 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 data.

Spinal hemorrhages

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

With small hemorrhages without signs of a mass effect and with minor symptoms, conservative expectant management with control of 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 occluded. Other arteriovenous malformations may not always be occluded, but can often be reduced in size.

Prognosis for non-traumatic spinal cord injuries

Prognostically unfavorable factors in inflammatory lesions of the spinal cord include:

• Initially rapidly progressive course
• Duration of neurological loss for more than three months
• Detection of protein 14-3-3 in CSF as a sign of neuronal damage
• Pathological motor and sensory evoked potentials, as well as signs of denervation on 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 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 a persistent neurological deficit, depending mainly on the type of primary lesion.

The prognosis for spinal volumetric processes depends on the type of tumor, its prevalence, the scale 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 small 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 impact. Common reasons include:

• high speed crash
• Fall from a great height and
• Direct force.

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

Approximately 15-20% of patients with severe traumatic brain injury have concomitant injuries of the cervical spine. Approximately 15-30% of patients with polytrauma have spinal injuries. Fundamentally recognized is the allocation in the spine of the anterior, middle and posterior columns or column ( three-column model Denis), and the anterior and middle columns of the spine include the vertebral bodies, and the posterior - 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 of the categories includes three further subtypes and three subgroups. Instability increases in the direction from type A to type C and within the respective subgroups (from 1st to 3rd).

For injuries of the upper cervical spine, 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
• Bruises and swelling of the spinal cord
• Spinal cord ischemia (due to compression or rupture of arteries)
• Ruptures, as well as displacement of the intervertebral discs.

Symptoms and signs of traumatic spinal cord injury

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

• Pain in the area of ​​the fracture during tapping, compression, movement
• Stable fractures are usually painless; unstable fractures often cause more severe pain with limited movement
• Hematoma at the fracture site
• Spinal deformity (such as hyperkyphosis)
• Neurological prolapse: radicular pain and / or sensory disturbances, symptoms of incomplete or complete transverse spinal cord injury, dysfunction of the bladder and rectum in men, sometimes priapism.
• Respiratory failure with high cervical paralysis (C 3-5 innervate the diaphragm).
• Prolapse of the brainstem/cranial nerves in atlanto-occipital dislocations.
• Rarely traumatic injuries of 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 of the cervical and thoracic spine in the form of a triad: hypotension, bradycardia and hypothermia.
• Autonomic dysreflexia in case of lesions within T6; as a result of the action of various nociceptive stimuli (for example, tactile stimulation), an excessive sympathetic reaction with vasoconstriction and a rise in systolic pressure up to 300 mm Hg, as well as a decrease in peripheral circulation (pallor of the skin) may develop below the level of the focus. Above the level of the focus in the spinal cord, compensatory vasodilation develops (skin redness and sweating). In view of blood pressure crises 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 semi-spinal cord lesion with ipsilateral paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensations.
• Medullary cone syndrome: damage to the sacral spinal cord and nerve roots of the lumbar region with areflexia of the bladder, intestines and lower extremities with occasional reflexes at the sacral level (for example, bulbocavernosus reflex).
• Cauda equina syndrome: damage to the lumbosacral nerve roots with areflexia of the bladder, intestines and lower extremities.

Diagnosis of traumatic spinal cord injuries

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

Every patient with neurological deficits due to trauma needs adequate and timely primary diagnostic imaging. In patients with moderate to severe traumatic brain injury, it is necessary to examine the cervical spine, including the upper part of the thoracic region.

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

• Changing state of consciousness
• Intoxication
• Pain in the spine
• Distraction damage.

An important role in the decision to perform imaging is played by the patient's advanced age and significant past or concomitant diseases, as well as the mechanism of the accident.

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

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 a limited assessment of the extent of bone damage. However, in case of neurological deficits and ambiguous CT results, MRI should be additionally performed in case of emergency diagnosis.

MRI is shown mainly in the sub-acute phase and to monitor the dynamics of neural damage. In addition, the ligamentous and muscular components of the injury can be better assessed, as well as, if necessary, lesions in these components.

Visualization should answer the following questions:

• Is there any trauma at all?
• If yes, what type (fracture, dislocation, hemorrhage, brain compression, ligament lesions)?
• Is there an unstable situation?
• Is surgery required?
• Daffner recommends assessing spinal injury as follows:
• Alignment and anatomical abnormalities: anterior and posterior margin of the vertebral bodies in the sagittal plane, spinolaminar line, lateral masses, inter-articular and interspinous distance;
• Bone - violation of the integrity of the bone: rupture of the bone / fracture line, compression of the vertebral bodies, "bone nodules", displaced bone fragments;
• Cartilage-anomalies of the cartilage / joint cavity: an increase in the distances between the small vertebral joints (> 2 mm), inter-articular and interspinous distances, expansion of the intervertebral space;
• Soft tissue - soft tissue abnormalities: hemorrhages with extension to the retrotracheal (< 22 мм) и ретрофарингеальное пространство (>7 mm), paravertebral hematomas.

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

Laboratory diagnostics includes a hemogram, coagulogram, determination of the level of electrolytes and functional indicators of the kidneys.

For neurological disorders in subacute phase needs to be additional electrophysiological diagnostics to assess the extent of functional damage.

Complications of injuries of the spine and spinal cord

• Spinal instability with secondary spinal cord injuries
• Spinal cord injury (myelopathy) due to compression, contusion with various types of prolapse:
• - complete transverse paralysis (depending on the level of tetra- or paraplegia and corresponding sensory deficits)
• incomplete transverse paralysis (paraparesis, tetraparesis, sensory deficits)
• With a high cervical transverse lesion - respiratory failure
• Cardiovascular Complications:
• orthostatic hypotension (most pronounced in the initial phase, improvement over time)
• loss/weakening of diurnal fluctuations in blood pressure
• cardiac arrhythmias (in the case of lesions above T6, mainly 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 months or years later with neurological pain above the level of the focus, as well as increased neurological deficits and spasticity, deterioration of the functions of the bladder and rectum (diagnosis is established using MRI)
• heterotopic ossification = neurogenic paraarticular ossification below the level of the lesion
• spasticity
• painful contractures
• bedsores
• chronic pain
• urinary disorders with an increased percentage of urinary tract/kidney infections
• increased risk of infections (pneumonia, sepsis)
• 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 the immobility associated with them, 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;
• With arterial hypotension, an attempt at 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 mobilization and physiotherapy measures.

Attention: autonomic disorders (orthostatic hypotension, autonomic dysreflexia) significantly complicate mobilization.

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

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

In 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 prolapse or in case of inoperability, depending on the type of injury, the possibility of conservative (non-invasive) treatment tactics is considered individually, for example, using a head HALO fixator for injuries of the cervical spine.

The use of methylprednisolone in spinal cord injury remains controversial. Despite scientific indications of an effect in case of early onset, critics note primarily side effects (eg, increased incidence of pneumonia and sepsis) and possible comorbid injuries (eg, traumatic brain injury, CRASH study). In case of spinal cord edema (or expected edema), methylprednisolone (eg Urbason) may be given. As a bolus, 30 mg/kg of body weight is administered intravenously followed by a long-term infusion. If the introduction is carried out within the first three hours after injury, a long-term infusion is carried out within 24 hours, if started between 3 and 8 hours after injury - within 48 hours.

The therapy of autonomic dysreflexia consists, first of all, in the elimination of the provoking stimulus. For example, a clogged urinary catheter that caused a distension of the bladder, inflammation of the skin, distension of the rectum. With persistent, despite the elimination of provoking stimuli, arterial hypertension, medications are used to reduce pressure, such as 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, an MRI is necessary to elucidate morphological lesions, and additional electrophysiological diagnostics (evoked sensory and motor potentials, EMG) are required to identify functional foci. Depending on the primary damage, complete loss of function, partial loss of motor and sensory functions, but also their full recovery are possible. The prognosis for severe intramedullary hemorrhage, edema, and spinal cord compression is poor.

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

Represents the greatest threat of all possible misfortunes that can happen to the spine, since its narrowness in this area can lead to impaired conduction of the spinal cord. Trauma treatment should be immediate and mobile.

Cervical spine injury

The most frequent injuries of the cervical spine occur during diving, the second "honorable" place is occupied by road accidents, and the third - by falls from a height.

According to the direction of the effort, traumatic injuries are divided into the following:

• Flexion
• extensor
• Flexion-rotational
• Vertically squeezing
• Lateral flexion
• Indefinite direction

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

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

1. Edema of the spinal cord
2. Hemorrhage and hematomas
3. ischemia
4. Falling blood pressure
5. Violation of blood flow and movement of cerebrospinal fluid

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

Symptoms of injuries of the cervical spine

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

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

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

Symptoms of complete failure:

• The disappearance of absolutely all motor reflexes and loss of sensitivity in all areas of the body located below the point of damage
• Delayed or involuntary urination and defecation

Symptoms with partial violation:

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

Complete loss of conductivity occurs when:

• Rupture of the spinal cord - in this case, its full recovery is hardly possible
• Spinal shock (complete inhibition of all reflexes) - after a while, conductivity is restored

Neurological syndromes in myelopathy in the cervical segments

If the spinal cord is damaged at the level of the upper vertebrae of the cervical spine C1-C4 the following symptoms are observed:

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

In case of damage to the brain of the lower part of the cervical region C5 - C7 and in the first thoracic vertebra Th1 the symptoms are:

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

Spinal Cord Conductivity Scale

In modern medicine, there are two options for classifying spinal cord injuries on a scale Frenkel.

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

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

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

Symptoms corresponding to each degree of conduction disturbance:

• A. Absence of any movement and sensation in the vertebrae S4 - S5 of the sacral spine
• b. Preservation of only sensitivity, but not motor ability, below the level of damage and also in the segment S4 - S5
• C. Muscle motor strength below the affected level is less than 3 points
• D. Muscle strength is equal to or greater than 3 points
• E. Functions of the movement and sensitivity are not broken. Muscle strength 5 points or more

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

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

Treatment of injuries of the cervical spine

After a bruised spine has occurred, relatives, friends, or simply witnesses of the incident are required to call an ambulance, even if no special damage is noticed on the surface of the neck, and the victim declares that he is in perfect order. What first aid should be provided by emergency and emergency room doctors?

First aid emergency

The first care of a patient with a trauma of the cervical spine and further treatment should be extraordinary. The account can go for minutes. The doctor must be prepared for a sudden drop in blood pressure, respiratory arrest, post-traumatic complications

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

Conservative treatment of cervical spine injury

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

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

1. Taking painkillers
2. Traffic restriction mode
3. Therapeutic exercise with gentle loads
4. Physiotherapy procedures

To eliminate dislocations and displacements resulting from trauma, produce orthopedic treatment ( hood) or an operation.

Cervical traction

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

Over the head with Glisson loops:
.
This method has hardly been used recently due to trophic disorders of the facial muscles as a result of facial compression.

For the tubercles of the parietal part of the head:

• Advantages of the method: the possibility of using large loads and achieving a good result of stretching
• Disadvantage: unreliable fastening of the bracket and pins, the possibility of excessive stretching of the spinal cord

With the help of a special Halo-device:
.
The ring is attached to the skull with clamps and attached to a corset worn on the cervical region.

• With the help of the Halo-device, the extraction is more accurate, it is possible to produce dosed necessary loads
• There is a danger of an inflammatory process in the cranium, in the places where the clamps are attached

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

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

Surgical treatment of cervical injury

Surgical treatment is resorted to:

• when squeezing the spinal cord and nerve roots, threatening serious neurological disorders now and in the future
• with a decrease in the height of the vertebra by more than half
• cervical kyphosis more than 11 ̊
• anterior-posterior displacement of the vertebra more than 3.5 mm
• severe deformity and pain

Operations are of three types:

• With posterior surgical access
• Anterior surgical approach
• Mixed type (use both accesses)

Anterior surgical approach is preferred for spinal cord decompression

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

After restoration, the damaged vertebra or segment is fixedly connected to the neighboring one.

The operation can have two or three technical steps:

1. Reduction of the vertebrae and discs with the help of a hood
2. Removal of fragments in damaged segments in comminuted injuries
3. Reconstruction of a damaged vertebra or disc (for example, an iliac crest graft is inserted in place of a collapsed disc)

Postoperative complications and its treatment

Surgery on the cervical spine is often complicated by such phenomena:

• instability of the injury, that is, a large area of ​​damage that requires additional fixation
• the ability to move the cervical graft
• risk of neurological complications

Therefore, to avoid such complications in neck surgery, external fixation is often used with a Halo device or a thoracocranial dressing applied for up to four months.

After the operation, such complications are also very frequent, due to which the treatment is delayed:

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

Treatment of postoperative complications includes:

• taking antibiotics
• vasodilators
• neuroprotectors

Active rehabilitation after injury

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

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

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

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

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

Brief conclusions:

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

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

Spinal cord injury is a pathological condition dangerous for a person, in which the integrity of the spinal canal is partially or completely violated. The symptomatology of the violation can be different, it directly depends on the type of injury. Patients with injuries are hospitalized urgently.

When the spinal canal is damaged in humans, neurological disorders occur, 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 (especially often the spine is injured by the elderly);
• Gunshot and stab wounds;
• Some sports activities (motorcycling, diving and others).

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

Damage can be localized in different parts of the spine, but most often the thoracic or lumbar region suffers.

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

1. Closed - the skin over the damage is intact;
2. Open - soft tissues over the site of damage 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 dura mater is damaged).

With injuries of the spinal column, the ligamentous apparatus (rupture or tear of the ligament), vertebral bodies (various types of fractures, cracks, separation of the end plates, dislocation, fracture dislocation), spinous and transverse arches / articular vertebral processes can be damaged.

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

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

• Flexion. A sharp bend causes a rupture of the posterior ligamentous apparatus and a dislocation occurs in the region of the 5-7th cervical vertebra;
• Hyperextension. It is characterized by rough extension, accompanied by a rupture of the already 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 protrusion forms;
• Vertical compression fracture. Due to movements along the vertical axis, the vertebrae are subject to dislocation or fracture;
• Fracture due to lateral bending.

Separately, injuries of a stable and unstable nature are distinguished. Explosive fractures, rotations, dislocations and fractures of various degrees are considered unstable. All these injuries are necessarily accompanied by a rupture of the 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 vertebral process fractures and wedge-shaped/compression fractures of their bodies.

Clinical forms of damage to the CM

The severity of spinal cord injury and its course in the 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 below the injury.

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

Bone fragments, foreign particles, and subcutaneous hemorrhages can maintain spinal shock. They are also able to stimulate the violation of hemo-and liquorodynamics. Accumulations of nerve cells located near the traumatic focus are in a strong inhibited state.

The clinical picture of damage depends on the type of spinal cord injury. Each injury is different in its characteristics, their symptoms are more similar to each other.

With a concussion, an irreversible process occurs in which the function of the spinal cord is impaired. Typical 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 trauma;

Motor disturbances are usually absent, but there may be a feeling of tingling and numbness in the legs. With a concussion of the spinal cord, the 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 the spinal tissue and infection through cracks, which can cause sepsis;
• Severe - nerve conduction is disturbed, due to which the medulla oblongata swells and thromboembolism and thrombosis 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 a rupture of the reflex arc.

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

1. Dorsal;
2. Ventral;
3. internal.

There are cases when compression is both dorsal and ventral at the same time. Usually this often happens with complex injuries. Compression of the spinal canal and roots is manifested by a 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 have symptoms of spinal shock, which manifests itself in the following way:

• Disappearance of somatic and autonomic reflexes;
• Paralysis of the 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, body parts below the point of injury are inactive, there is uncontrolled urination and defecation, thermoregulation and the process of sweating are disturbed.

Such an injury can be characterized as a single or multiple detachment of the roots, their compression or bruising, followed by hemorrhage. The clinical picture depends in part on which nerve roots have been damaged.

Common symptomatic manifestations of the lesion include:

1. Point pains;
2. Symptom of the reins (bilateral roller-shaped muscle spasm on the sides of the spinous process of the corresponding vertebra);
3. Swelling over the affected root;
4. Violation of sensitive perception (with the defeat of the roots of the cervical region, the arms and legs suffer, the thoracic or lumbar region - only the legs;
5. Dysfunctions of the pelvic organs;
6. Vegeto-trophic disorders.

If the roots in the cervical region (level 1-5 vertebrae) are damaged, the patient develops pain in the back of the head and neck, tetraparesis. Respiratory processes, swallowing and local blood circulation may also be disturbed. In addition, in patients with trauma to the cervical roots, stiffness in the movements of the neck is observed.

If the roots at the level of 5-8 cervical vertebrae are affected, various paralysis of the arms and legs occurs. With partial involvement of the roots of the thoracic region, Bernard-Horner syndrome is observed.

If the chest roots were damaged, abdominal reflexes disappear, the activity of the cardiovascular system and sensitivity are disturbed, and paralysis occurs. According to the hyposensitivity zone, it is possible to determine at what level the roots are affected.

Damage to the nerve roots at the level of the lower back and cauda equina is manifested by a violation of the innervation of the pelvic organs and lower extremities, 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 there is a rupture of blood vessels located near the central spinal canal or the posterior horns in the lumbar or cervical thickening.

Symptoms of hematomyelia are caused by compression of the gray matter and segments of the spine with 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 for a full recovery, but dysfunctions may occasionally return during life.

In very many clinical cases, trauma 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 completely lose their motor function and doctors cannot help in such a situation.

In addition, they have other background pathologies:

• Sexual impotence;
• Spasticity of muscles;
• bedsores;
• Tendinitis of the shoulder (it appears due to the constant manual control of a manual stroller);
• Dysreflexia of the autonomic nervous system;
• problems with the respiratory system;
• Violations 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 the motor function was nevertheless preserved, patients have to actively restore it and literally learn to walk again. However, spinal cord injuries almost never go unnoticed.

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

Patients who have suffered injuries of the spinal column and spinal cord in the past become more susceptible to other various injuries. Against the background of injuries in patients, sensitivity is disturbed and they can injure themselves without even noticing it.

Such patients should always perform potentially hazardous work with extreme caution and check themselves for injuries upon completion.

A patient who has received 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 deep diagnosis, doctors use instrumental studies. Patients may be given:

Treatment tactics

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

• Operational intervention. It is used in different periods of trauma treatment. After the operation, the patient goes through a long rehabilitation period. In some clinical cases, one patient may undergo several multi-purpose operations;
• Medical therapy. It is mainly used to combat neurological disorders, restore metabolism, increase reactivity, stimulate conductivity and increase capillary blood flow;
• Physiotherapeutic methods. 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, and prevent contractures and bedsores. For this, sessions of UHF, magnetotherapy, UVI, thermal procedures, electrophoresis and others are carried out;
• exercise therapy. It is carried out for the same purpose as physiotherapy. In some clinical cases, physiotherapy exercises are prohibited, therefore, 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 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 localization, the patient will experience a certain clinical picture.

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