I. Classification of injury
Nerve injury occurs in approximately 20% of patients with spinal fractures. Usually the more severe the spinal injury, the more severe the spinal cord injury, but this is not always the case. On the other hand, mild spinal injuries often do not cause spinal cord injury, but can sometimes cause complete neurological dysfunction, possibly in the absence of a fracture, because of impaired vascular supply, which can lead to spinal cord injury.
1, cervical spinal cord
A, prefabricated spinal cord is most commonly injured by flexion-rotation dislocation or fracture dislocation, with the best occurring sites being C5 through 6.
B, compression fractures. C5-6 is the most common site. Only half of the patients with such injuries cause complete neurological deficits below the plane of injury.
C. Hyperextension injuries are most common in the elderly spine with degenerative changes and account for about 30% of cervical spine injuries. It is most commonly seen in C4 through 5, the most stable injuries. Most injuries are a result of extrusion between the front vertebrae and discs and the thickened ligaments and ligamentum flavum in the back, compressing the spinal cord and causing incomplete spinal cord injury. The combination of these forces causes central spinal cord injury.
2.Thoracolumbar spinal cord
A. At this level most spinal injuries are flexion-type rotational dislocation or fracture dislocation. This is most commonly seen from T12 to L1, causing the upper vertebrae to move forward compared to the lower vertebrae. This injury is usually unstable and often results in complete impairment of spinal cord, conus, or cauda equina function.
B. Compression fractures are common and usually manifest as a reduction in vertebral body height. The injury is stable and nerve damage is rare.
3, Hyperextension injury. Rare, usually resulting in complete spinal cord injury.
4, open injury. Can be seen in gunshot wounds or knife wounds. Spinal cord injury can be due to a burst injury, but also due to a bullet through or fracture fragments piercing the spinal cord.
Second, the determination of the plane of nerve injury
1, the basic definition
Skin area: refers to multiple nerve segments (nerve roots) within the sensory nerve axons innervated by the skin area.
Muscle segment: refers to a group of muscle fibers innervated by the motor axons of each segment nerve root.
Nerve plane refers to the most compressed segment of the spinal cord with bilateral sensory and motor functions of the body. The four segments, right sensory segment, left sensory segment, left motor segment, and right motor segment, are used to determine the neural plane. Sensory and motor planes refer to the lowest spinal cord segment with normal sensory and motor functions on both sides of the body.
Vertebral plane: refers to the plane of the vertebral body where the most severe damage is found on X-ray.
Incomplete damage: If the damage is found to be below the neural plane including the lowest sacral segment retaining some sensory and motor functions, this damage is incomplete and the sacral sensation includes the anal mucosal skin junction and the deep anal sensation. Motor function is examined by finger anal examination to determine the voluntary contraction of the external anal sphincter.
Complete damage: refers to the complete loss of sensory-motor function in the sacral segment.
Zone of partial preservation (ZPP): refers to the lowest nerve planes, cortical areas and muscle segments that still retain some innervation. When impaired sensorimotor function is found below the lowest normal plane, the plane of involvement of the partially preserved area on both sides of the body should be recorded. This term is used only for complete through injuries.
Sacral preservation (SacrslSparing). The lowest preserved area in spinal cord injury is the tissue margin of the perineum, as blood is supplied here by the radicular arteries (Radiculararteries). Sensation here is innervated by the lowest sacral segment. Therefore, the absence of sensation in the saddle area is considered a complete performance spinal cord injury, with complete loss of sensation below the plane of injury.
Nerve root escape. If the spinal cord is injured to that segment and involves a nerve root, and that nerve root has not yet separated, there can be nerve recovery in the closest 1-2 segments. This level of recovery is for low motor neurons.
Spinal cord concussion. Temporary and reversible loss of spinal cord or cauda equina physiologic function is seen in patients with only simple compression fractures, even if radiographically negative. It is generally assumed that there is no mechanical compression of the spinal cord or anatomical damage in this condition. Another hypothesis is that the loss of spinal cord function is due to a short pressure wave. The slow recovery process suggests the regression of reactive spinal cord edema. Hyperreflexia but no muscle spasm is common in this type of patient.
The deep tendon reflex was used to identify the reflex arc corresponding to the spinal cord segment.
C5: biceps reflex C6: posterior rotator reflex C7: triceps reflex L3 quadriceps reflex S1: gastrocnemius reflex S2, 3, 4: bulbourethral reflex
Quadriplegia: refers to the impairment and loss of motor sensory function of the cervical segment due to injury to the spinal cord nerve tissue in the spinal cord cavity. Quadriplegia causes functional impairment of the upper limbs, trunk, thighs and pelvic organs, excluding brachial plexus lesions or injury to peripheral nerves outside the spinal canal.
Paraplegia: injury to the nerve tissue within the spinal canal causing impairment or loss of motor-sensory function in the thoracic, lumbar or sacral segments of the spinal cord (excluding the neck). Paraplegia does not involve upper extremity function, but may involve the trunk, legs, and pelvic organs depending on the plane of injury. This term includes injury to the cauda equina must cone, but does not include lumbosacral plexus lesions or injury to peripheral nerves outside the spinal canal.
2, the determination of the plane of sensory injury
The mandatory part of the sensory examination is to examine the 28 key points of the cortex on each side of the body. Each key point should be checked for two sensations, namely pinprick and light touch, and scored according to three levels. 0=absent; 1=impaired (partial impairment or altered sensation, including sensory hypersensitivity); 2=normal; NT=unable to check
The examination sites of the two lateral sensory keypoints were as follows.
C2-occipital ramus C3-supraclavicular fossa C4-top of the acromioclavicular joint C5-lateral aspect of the anterior elbow fossa C6-thumb C7-middle finger C8 -little finger
T1 – ulnar side of the anterior elbow fossa T2 – axillary fossa T3 – third intercostal space T4 – fourth intercostal space (breast line) T5 – fifth intercostal space (between T4 and T6) T6 – sixth intercostal space ( level of the raphe) T7 – seventh intercostal space (between T6 and T8) T8 – eighth intercostal space (between T7 and T9) T9 – ninth intercostal space (between T8 and T10) T10 – tenth intercostal space (at the level of the navel) T11 -eleventh intercostal space (between T10 and T12) T12 – middle inguinal ligament
L1- upper 1/3 between T12 and L2 L2- anterior mid-thigh L3- medial epicondyle of femur
L4-medial ankle L5-dorsal third Tsuga joint of the foot
S1-lateral heel S2-midpoint of the slapping fossa S3-sciatic tuberosity S4-5-peri-anus (as a plane)
Sensory examination: select items – positional sensation and deep . Nociception, check only the left and right side of the index finger and thumb.
3. Determination of the plane of motor injury
Anatomical basis- skeletal muscles associated with spinal cord segments.
C1-C3: cervical muscles C4: diaphragm and trapezius C5: deltoid, biceps C6: radial wrist extensors C7 triceps and common finger extensors C8: common finger flexors T1: internal hand muscles (refers to the small muscle groups of the hand) T2 to T12: intercostal muscles T7-L1: abdominal muscles L2: iliopsoas muscle, internal femoral retractors L3: quadriceps L4 L5: medial femoralis, anterior tibialis L5: lateral femoralis, posterior tibialis, peroneus brevis S1: common toe extensors, bunions, gastrocnemius and hallux valgus S2: common toe flexors, bunions S2, 3, 4: bladder and lower rectum
The following muscles were examined to determine the plane of motion.
C5- flexor elbow muscles (biceps brachii, rotator anterioris roundus) C6- extensor carpi radialis (radial extensor carpi radialis longus and shortus) C7- extensor elbow muscles (triceps brachii) C8- middle finger flexor muscles (deep finger flexors) T1- little finger adductor muscles ( L2 – hip flexors (iliopsoas) L3 – knee extensors (quadriceps) L4 – ankle dorsiflexors (anterior tibialis) L5 – long toe extensors (long toe extensors) S1 – ankle flexors (gastrocnemius, hallux valgus) )
Motor examination: select items – (1) diaphragm (2) deltoid (3) lateral slapping cord muscle.
Muscle strength was classified as absent, diminished or normal.
The nerve roots of each segment innervate more than one muscle, and again most muscles are innervated by more than one nerve segment. The motor plane refers to the lowest normal motor plane, in the body of the botomus speaks of the rounded Huang?R about ×χ辽傥? Grade of that key muscle determines the plane of movement, but requires that the muscle strength of the key muscle innervated by that segment above that plane must be normal (grade 4-5).
4.ASIA damage grading
A-complete impairment. There is no preserved sensorimotor function in the sacral segment.
B- Incomplete damage. There is sensory function below the nerve plane including the sacral segment (S4-S5), but no motor function.
C-Incomplete impairment. Motor function is present below the plane of the nerve and most of the key muscles have less than grade 3 muscle strength.
D-Incomplete impairment. Motor function is present below the nerve plane and the muscle strength of most of the key muscles is greater than or equal to grade 3.
E-Normal. Sensory and motor function is normal.
5, the level of spinal cord injury and functional prognosis
The lowest level of injury has functional muscle mobility life activity ability
C4-5 diaphragm, oblique, triangular, biceps electric, special wheelchair drive fully dependent
C6 thoracic, radial wrist extension wheelchair drive moderate dependence
C7-T1 triceps, radial wrist flexion wheelchair practical, bed wheelchair, mostly self-care
Finger flexion and extension, internal hand muscle toilet, transfer between bathrooms.
Can drive special modified car since
T6 upper intercostal muscles, upper back muscles with brace with lumbar belt, walking with crutches mostly self-care
Walking with a long leg brace with crutches
T12 abdominal, thoracic and dorsal muscles with short leg brace, walking with cane basically self-care
L4 quadriceps walking, basic self-care without wheelchair