Clinical manifestations
I. Sensory impairment
In complete spinal cord injury, all kinds of sensation are lost below the plane of damage, and in partial injury, some sensation is preserved depending on the degree of damage.
Second, spinal cord shock
After damage to the spinal cord, complete delayed paralysis below the plane of injury, various reflexes, sensory and sphincter function loss, recovery begins within a few hours, 2-4 weeks to fully recover. More severe injuries have a course of spinal shock, and it is usually 3-6 weeks before functional spinal cord activity below the level of damage gradually occurs. During the period of spinal shock it is difficult to determine whether the spinal cord damage is functional or organic. However, complete sensory loss at the time of injury or within a few hours, especially limb paralysis with loss of vibration sensation, suggests an organic injury. The longer the duration of spinal cord shock, the more serious the degree of spinal cord injury.
Third, abnormal motor function
Transverse injury, after the spinal cord shock period, the motor function below the damaged plane is still completely lost, but hypertonia hyperreflexia; partial injury, after the shock period, gradually appear part of the muscle autonomic activity. After spinal cord injury, there are signs of lower motor neuron injury such as relaxation and atrophy of the muscles innervated by the damaged segment and disappearance of tendon reflexes, which have localized diagnostic significance.
Autonomic nerve dysfunction
Abnormal penile erection, Horner’s syndrome, paralytic intestinal obstruction, non-sweating of the skin below the damaged plane and hyperthermia can often occur.
V. Abnormal reflex activity
After the shock period, the reflexes of the limbs below the damaged plane gradually change from absent to hyperactive, and the tone changes from sluggish to spastic. Complete spinal cord injury is flexion paraplegia, while partial injury presents extension paraplegia. Sometimes stimulation of the lower extremity can cause irrepressible flexion and urination, called the total reflex.
VI. Abnormal bladder function
The spinal cord shock period for the dystonic neurogenic bladder; spinal cord shock gradually recovered to show reflex neurogenic bladder and interstitial incontinence; spinal cord recovery to the reflexes appear, stimulation of the skin will appear involuntary reflex urination, late manifestation of contractile neurogenic bladder.
Seven, the early manifestations of different planes of spinal cord injury
1, the 1st to 2nd cervical spinal cord segmental injury.
(1) motor changes: metacarpophalangeal muscle, scapular hyoid muscle, sternocostal hyoid muscle and sternocostal turbinate muscle function is limited.
(2) Sensory changes: hyperalgesia or hyperalgesia in the ear or occipital area.
2, the 3rd cervical spinal cord segment injury: C3 innervates the diaphragm and intercostal muscles, and death can not breathe on its own after the injury.
3, the 4th cervical spinal cord segment injury.
(1) motor changes: all voluntary activities of the extremities and trunk are lost after the injury. Traumatic reaction to the third cervical nerve, can cause loss of voluntary respiration, serious death will soon.
(2) Sensory changes: loss of sensation below the clavicular plane. In addition, there are symptoms such as difficulty in swallowing, difficulty in breathing, inability to cough, etc., and severe death due to hypoxia.
4, the 5th cervical spinal cord segment injury.
(1) Motor changes: Patients have no voluntary movement of both upper limbs at all due to damage to the ganglion innervating deltoid, biceps, brachialis, and flexor brachii muscles. The shoulder can be shrugged due to the pull of the scapular raphe and trapezius muscle.
(2) Sensory changes: All sensations were lost except for the neck and a deltoid region in front of the upper arm.
(3) Reflex changes: All reflexes disappeared except for the diminished biceps reflex.
5.6th cervical spinal cord segment injury.
The patient’s respiratory function may be significantly disturbed due to the traumatic reaction of the spinal cord and the effect of intestinal distension.
(1) Motor changes: pectoralis major, latissimus dorsi, subscapularis, triceps brachii are paralyzed, the shoulder loses its droop function, the elbow loses its extension function, the scapularis, trapezius, deltoid and biceps can be contracted, thus the patient’s shoulder can be elevated, the upper arm can be abducted by 90 degrees, the forearm is flexed, and the hand is placed near the head. The radial extensor carpi radialis longus showed lower motor neuron damage, while the fingers, trunk and lower limb muscles innervated by the nerves below the 6th cervical spinal cord segment were paralyzed.
(2) Sensory changes: Except for the lateral part of the upper limb and the dorsal part of the forearm, the rest of the upper limb has sensory deficits.
(3) Reflex changes: The biceps and flexor brachii reflexes were normal, and the triceps reflexes were absent.
6, the 7th cervical spinal cord segment injury.
(1) motor changes: biceps muscle strength is normal, extensor digitorum generalis muscle strength is reduced, rotary anterior garden muscle, radial flexor carpi radialis, flexor digitorum profundus, flexor digitorum superficialis, flexor digitorum longus are weak, so the hand is semi-recumbent.
(2) Sensory changes: sensory deficits in the trunk, lower extremities, upper arm, medial forearm, and three fingers on the ulnar side of the hand.
(3) Reflex changes: loss of triceps reflex.
7, the 8th cervical spinal cord segment injury: unilateral or bilateral Horner’s sign can be seen, and positional hypotension can occur when changing from the prone position to the sitting position.
(1) Motor changes: flexor hallucis longus, extensor hallucis shortus, interosseous muscle, earthworm muscle, para-palmar machine, para-finger muscle strength is weakened or lost, and the abductor hallucis shortus is completely paralyzed and claw-shaped hand.
(2) Sensory changes: the 4-5 fingers of the hand, interosseous muscles and medial forearm, trunk and lower extremities are hypoesthesia.
(3) Reflex changes: triceps reflex and abdominal wall reflex, raphe reflex, knee tendon reflex, and Achilles tendon reflex are impaired.
8, 1st thoracic spinal cord segment injury: Horner’s sign is seen, no sweating on the face, neck and upper arm.
(1) Motor changes: partial paralysis of the thumb retractors, interosseous muscles, and earthworm muscles, and complete non-function of the short thumb extensors. Intercostal muscles and lower limbs are paralyzed .
(2) Sensory changes: sensory impairment of the medial distal upper arm, medial forearm, trunk and lower extremities.
(3) Reflex changes: abdominal wall reflex, raphe reflex, knee tendon reflex and Achilles tendon reflex are impaired.
9, upper thoracic spinal cord segment (2nd-5th thoracic spinal cord) injury: abdominal breathing, postural hypotension.
(1) motor changes: paralysis of intercostal muscles, abdominal muscles, trunk and lower limbs below the plane of injury, paraplegia.
(2) Sensory changes: loss of sensation below the plane of injury.
(3) Reflex changes: abdominal wall reflex, tic reflex, knee tendon reflex and Achilles tendon reflex are impaired.
10, lower thoracic spinal cord segment (6th-12th thoracic spinal cord) injury.
(1) motor changes: the upper segment has contractile function of the rectus abdominis muscle, while the middle and lower segments lose function of the rectus abdominis muscle, so the belly button moves upward when the abdomen is closed. Lower limbs are paralyzed.
(2) Sensory changes: sensory change planes:T6 for the level of the saber process, T7 and 8 for the subcostal area, T9 for the upper abdomen. T10 for the flat umbilicus, T11 for the lower abdomen, and T12 for the groin.
(3) Reflex changes: abdominal wall reflex: all disappeared in the 6th thoracic segment injury. In the 10th thoracic segment, the upper and middle abdominal wall reflexes were present while the lower abdominal wall reflexes were absent. In the 12th thoracic segment, the upper, middle and lower abdominal wall reflexes were all present. The testicular reflex, knee tendon reflex and Achilles tendon reflex were all absent.
11, the first lumbar spinal cord segmental plane injury.
(1) motor changes: the lumbar muscles are weakened and the lower limbs are paralyzed. These include the levator muscle, iliopsoas muscle, suture muscle and hip abductor muscle. The sphincter muscles of the bladder and anus cannot be controlled autonomously.
(2) Sensory changes: sensory disturbances throughout the lower extremities, groin, buttocks and perineum.
(3) Reflex changes: the testicular reflex, knee tendon reflex, Achilles tendon reflex, and plantar reflex are absent.
12 Second lumbar spinal cord segmental plane injury.
(1) Motor changes: iliopsoas and sutures muscles are weakened, and the rest of the muscles of the lower limbs are paralyzed. Loss of control of the bladder and anal sphincter.
(2) Sensory changes: loss of sensation in the upper third of the thigh and perineum.
(3) Reflex changes: testicular reflex and abdominal wall reflex exist, knee tendon reflex and Achilles tendon reflex are impaired.
13, the third lumbar spinal cord segmental plane injury.
(1) motor changes: lower limbs are externally rotated deformity, weak knee extension, paralysis of muscles below the knee joint.
(2) Sensory changes: sensory deficit in the lower and middle thighs and the saddle area.
(3) Reflex changes: knee tendon reflex disappears, Achilles tendon reflex and plantarflexion reflex disappears, and testicular reflex can be elicited.
14, the fourth lumbar spinal cord segmental plane injury.
(1) motor changes: the patient can barely stand and walk, but due to the weakness of the gluteus medius muscle, the patient has an unstable gait. Similar to duck gait.
(2) Sensory changes: loss of sensation in the saddle area and below the calf.
(3) Reflex changes: knee tendon reflex disappears or is weakened, Achilles tendon reflex and plantarflexion reflex disappear.
15, fifth lumbar spinal cord segmental plane injury.
(1) motor changes: hip joint is flexion inversion deformity, biceps femoris, semitendinosus, semimembranosus and muscle strength is weakened or paralyzed, knee hyperextension deformity may appear. Swaying gait, may appear horseshoe inversion foot, loss of control of bladder and anal sphincter.
(2) Sensory changes: decreased sensation in the lateral and deviated posterior calf, dorsalis pedis and saddle area.
(3) Reflex changes: normal knee tendon reflex and loss of Achilles tendon reflex.
16, 1st sacral spinal cord segmental plane injury.
(1) motor changes: due to paralysis of the triceps and flexor muscles of the calf and strong extensor muscles, the foot was heel-foot deformity, the biceps femoris, semitendinosus and semimembranosus muscles were weakened, and the bladder and anal sphincter were non-functional.
(2) Sensory changes: decreased sensation in the metatarsal surface, lateral foot, lateral calf, posterior thigh and saddle area.
(3) Reflex changes: knee tendon reflex exists and Achilles tendon reflex disappears.
17, 2nd sacral spinal cord segmental plane injury.
(1) Motor changes: paralysis of flexor digitorum longus and small muscles of the foot, and the patient cannot stand on the toes. Loss of control of the bladder and anal sphincter.
(2) Sensory changes: loss of sensation in the posterior upper calf and posterior lateral thigh, metatarsal surface of the foot and saddle area.
(3) Reflex changes: weakened Achilles tendon reflex.
18, 3rd sacral spinal cord segmental plane injury.
(1) Motor changes: good motor function of the limbs, partial function of the bladder sphincter, and uncontrolled anal sphincter.
(2) Sensory changes: scrotal 2/3, glans, perineum, perianal, and posterior upper 1/3 of thigh skin sensory disturbance.
(3) Reflex changes: anal reflex and bulbocavernosal reflex are diminished, and sexual function may be impaired.
VIII. Complications.
1. Pressure sores: The key prevention is to take measures to change position regularly, reduce pressure on bone protrusions, choose good cushions and mattresses, improve the nutritional status of the whole body, and educate patients and their families on skin care to prevent pressure sores.
2. Urinary tract infection: urinary system management measures, early discontinuation of indwelling urinary catheters, and implementation of intermittent catheterization. According to the results of urodynamics, appropriate voiding methods and medications should be applied to keep the bladder at low pressure for urine storage and voiding. Regularly check urinary ultrasound, urinary routine, midstream urine culture, and urodynamics. Cultivate good personal hygiene habits and pay attention to keep the perineum clean. Oral medication for stone prevention is available. No antibiotics are needed for long-term asymptomatic bacteriuria to avoid causing multi-drug resistant bacteria to multiply and risk of infection.
3. Spasms: Treatment measures: identify and remove factors that contribute to worsening spasms, such as avoiding positions that cause muscle tension, controlling infection, stabilizing mood, and maintaining environmental temperature. Physical therapy: ROM, standing, cold therapy, hydrotherapy, alternating electrical stimulation. Medications: Baclofen. Local nerve block: botulinum toxin injection. Posterior spinal rhizotomy.
4.Heterotopic ossification.
5.Deep vein thrombosis of lower limbs: prophylaxis starting 48 hours after injury. 1) mechanical prophylaxis: intravenous pump, elastic stockings, etc. 2) pharmacological prophylaxis: heparin vitamin K antagonist, etc.
6.Upright hypotension
7, osteoporosis: the gold standard for diagnosis: bone density. Treatment with early interventions: passive standing training, functional electrical stimulation, pulsed electromagnetic field.
8, paraplegic neuralgia: comprehensive measures: medication + physical therapy (myoelectric biofeedback or high-frequency electricity) + behavioral psychotherapy.
9.Physeal reflex: the most serious complication, more common in segmental injury above T6. Common causes: irritation of the lower urinary tract (urinary retention, infection, urethral dilatation, stones, etc.), stool retention. Manifestations: facial flushing, sweating of the skin above the plane of injury, elevated blood pressure (40 higher than usual), bradycardia or tachycardia.
10, respiratory complications: the main cause of early death, with ventilation disorders, pulmonary atelectasis, pneumonia is common.
[Diagnosis and differential diagnosis
The history of acute spinal cord injury caused by trauma is clear, and the diagnosis is easy when combined with imaging data. However, for chronic spinal cord injury, attention must be paid to the consistency of history, clinical manifestations, signs and imaging data to avoid misdiagnosis and mistreatment in clinical work. These points are described in detail in the literature, so we will not repeat them here, but only discuss the localization in the neurological examination in the context of our clinical practice. The neurological examination includes both sensory and motor components, which should be described separately. What needs to be examined should be able to determine the level of sensory and/or motor neurology, to score, to show sensory and/or motor function, and to determine the completeness of the injury. The examination of random items is not scored, but the description of the idiosyncratic patient can be used as a reference.
(1) Sensory examination: pin prick (pin prick) and light touch (1ight touch) should be performed on the left and right side of each key point, respectively. The key sensory points are as follows.
C2: occipital ridge C3: supraclavicular fossa
C4: top of the rostral clavicular joint C5: lateral elbow fossa
C6: thumb C7: middle finger
C8: little finger T1: medial elbow fossa
T2: Axillary tip T3: 3rd intercostal space
T4: 4th intercostal space (nipple line) T5: 5th intercostal space (between T4 and T6)
T6: 6th intercostal space (at the level of the sternocleidomastoid) T7: 7th intercostal space (between T6 and T8)
T8: 8th intercostal space (between T6 and T10) T9: 9th intercostal space (between T8 and T10)
T10: 10th intercostal space (umbilicus) T11: between T10 and T12
T12: midpoint of inguinal ligament L1: between T12 and L2
L2: mid-anterior thigh L3: medial femoral condyle
L4: medial ankle L5: dorsal aspect of the 3rd metatarsophalangeal joint
S1: lateral aspect of the heel S2: midline of the N fossa
S3: sciatic tuberosity S4-5: anal area
In addition to the above points, the external anal sphincter should be examined with the finger and its sensation recorded with or without the finger to determine whether the paralysis is complete or incomplete. To evaluate the SCI, the following selective examinations can be performed, such as positional and deep pressure/deep pain sensation. It is also recommended to examine one joint on each side of the upper and lower extremities, the index finger and [toe.
(2) Motor examination: 10 key muscles of each of the 10 muscle segments on the left and right sides are examined in cephalad order. Muscle strength was recorded at 6 levels. The following 10 muscles were examined according to the above grading, so these muscles were chosen because the innervated nerve segments were consistent and easy to examine in the supine position.
C5: elbow flexors (biceps, brachialis)
C6: wrist extensors (radial wrist long and short extensors)
C7: elbow extensors (triceps brachii)
C8: finger flexors (deep finger flexors, to middle finger)
T1: little finger extensors (little finger extensors)
L2: hip flexors (iliopsoas muscle)
L3: knee extensors (quadriceps)
L4: Ankle dorsiflexors (tibialis anterior)
L5: [long extensors (M long extensors)
S1: ankle plantarflexors (gastrocnemius, hallux valgus)
In addition to the above-mentioned muscles, the contraction of the external anal sphincter should also be checked by finger-anal examination, with or without recording, to determine whether the injury is complete or incomplete. Some other muscles may also be selected: diaphragm, deltoid, and lateral N cord (biceps femoris) for muscle strength examination and recorded as absent, weak, or normal.
It should be understood that each segmental nerve (root) innervates more than one muscle, and most muscles do not receive only one segmental nerve. Therefore, the use of a muscle or muscle group to represent a particular segment is a simplification. If a muscle receives two segmental nerves at the same time, the presence of one and the absence of the other can cause muscle weakness. By convention, if a key muscle has a strength of at least level 3, it still has full innervation on its most cephalic side. The key muscle closest to the cephalad has a strength of at least level 4 or 5 when determining the level of movement.
As an example, if the C7 key muscle is not contracting, at least a level 4 muscle strength of the C5 muscle is required to determine the level of movement to be C6. When deciding on a level 4 muscle strength, different factors such as pain, patient posture at different times after the injury. Excessive tension and disuse often cannot be elicited, and the above factors must be excluded and the patient is incompetent to contract in order to arrive at the correct result. In conclusion, the motor level, i.e. the lowest normal motor segment (left and right side can be different), has a muscle strength of at least level 3 in its lowest key muscles, while the muscle strength of its upper key muscles needs to be normal, level 4 or level 5.