Spinal cord injuries often occur in industrial and mining, traffic accidents, wartime and natural disasters can occur in batches. The injuries are serious and complex, with more multiple and compound injuries, more complications, and poor prognosis when combined with spinal cord injuries, even resulting in lifelong disability or life-threatening.
The etiology of this disease can be classified in the following ways.
I. Classification of spinal fractures.
1, according to the direction of violence at the time of injury can be divided into: flexion type, extension type, flexion-rotation type and vertical compression type.
2, according to the stability of the fracture, can be divided into: stable and unstable type.
3.Armstrong-Denis classification: it is the common classification at home and abroad. It is divided into: compression fracture, burst fracture, posterior column fracture, fracture dislocation, rotational injury, compression fracture combined with posterior column fracture, burst fracture combined with posterior column fracture.
4.Classification by site: it can be divided into cervical, thoracic and lumbar vertebrae fracture or dislocation. According to the vertebral anatomical parts can be further divided into vertebral body, vertebral arch, vertebral plate, transverse process, spinous process fracture, etc.
5, traumatic non-fracture dislocation type spinal cord injury. Most often occurs in children and middle-aged and elderly patients, characterized by the absence of fracture dislocation on imaging.
Second, spinal cord injury pathology and types.
1, spinal cord shock early spinal cord injury is mostly accompanied by spinal shock. Performance injury below the plane of sensory, motor, sphincter function completely lost. Simple spinal shock can recover on its own within a few weeks. The appearance of the ball cavernous reflex or the appearance of the deep tendon reflex is a sign of the termination of spinal shock.
2, Spinal cord contusion injury can be mild hemorrhage and edema or complete contusion or rupture of the spinal cord. Later on, cystic degeneration or atrophy may occur.
3, Spinal cord compression is due to direct compression of the spinal cord by displaced vertebrae, fragmented bone masses, intervertebral discs and other tissues that protrude into the spinal canal, resulting in changes such as hemorrhage, edema, and ischemic degeneration.
The clinical manifestations of spinal cord injury due to the above pathology can be complete paralysis or incomplete paralysis depending on the degree of injury.
I. Spinal fracture
1.History of serious trauma, such as fall from height, heavy object striking the head, neck or shoulder and back, collapse accident, traffic accident, etc.
2, the patient feels the local pain of the injury, the neck activity is impaired, the muscle spasm of the low back, and cannot turn over and stand up. Localized fracture can be found in the limited posterior protrusion deformity.
3, due to retroperitoneal hematoma on the vegetative nerve stimulation, intestinal peristalsis slowed down, often appearing abdominal distension, abdominal pain and other symptoms, sometimes need to be distinguished from abdominal organ injury.
Second, combined spinal cord and nerve root injury
After spinal cord injury, the motor, sensory, reflexes and sphincter and vegetative nerve functions below the plane of injury are impaired.
1, sensory impairment below the plane of injury, pain, temperature, touch and proprioception is reduced or disappeared.
2, motor disorders spinal shock period, spinal cord injury below the segment manifested as a soft paralysis, reflexes disappear. After the shock period, if the spinal cord is transected, there is upper motor neuron paresis, increased muscle tone, hyperactive tendon reflexes, patellar clonus and ankle clonus, and pathological reflexes.
Examination
Auxiliary examinations for this disease include the following.
1. X-ray examination routinely takes a frontal and lateral view of the spine and an oblique view if necessary. The height of the anterior and posterior vertebral body is measured and compared with the upper and lower neighboring vertebrae; the distance between the vertebral arches and the width of the vertebral body are measured; the distance between the spinous processes and the width of the intervertebral disc space are measured and compared with the upper and lower neighboring vertebral spaces. X-rays can basically determine the fracture site and type.
2.CT examination is useful to determine the degree of invasion of the displaced fracture and to detect the bone or intervertebral discs protruding into the spinal canal.
MRI (magnetic resonance imaging) is valuable for determining the status of spinal cord injury. MRI can show edema and hemorrhage in the early stages of spinal cord injury, and can show various pathological changes of spinal cord injury, such as spinal cord compression, spinal cord transection, incomplete spinal cord injury, spinal cord atrophy or cystic degeneration.
4, SEP (somatosensory evoked potential) is a test to determine the conduction function of the somatosensory system (mainly the posterior cord of the spinal cord). It is useful for determining the degree of spinal cord injury. Now there is MEP (motor induced potential).
5, jugular vein pressure test and myelography jugular vein pressure test, to determine the spinal cord injury and pressure has some reference significance. Myelography has significance for the diagnosis of old traumatic spinal stenosis.
6, sphincter dysfunction spinal shock period manifested as urinary retention, which is caused by paralysis of the bladder forced urinary muscle to form a tension-free bladder. After the shock period, if the spinal cord injury is above the sacral medullary plane, an auto-reflex bladder can be formed with less than 100 ml of residual urine, but it cannot urinate at will. If the spinal cord injury plane is in the garden cone sacral medulla or sacral nerve root injury, urinary incontinence occurs and the bladder needs to be emptied by increasing abdominal pressure (squeezing the abdomen with the hand) or by using a catheter to empty the urine. The same constipation and incontinence occurs with stool.
7, incomplete spinal cord injury is called incomplete spinal cord injury when there is still partial preservation of spinal cord movement or sensation distal to the plane of injury. Clinically, there are the following types.
(1) anterior spinal cord injury: manifested as the loss of voluntary movement and pain sensation below the plane of injury. Since there is no damage to the posterior spinal cord column, the patient’s sense of touch, position, vibration, motion, and deep pressure are intact.
(2) Central spinal cord injury: It is more common in cervical cord injury. The loss of upper extremity motor function, but the lower extremity motor function exists or the loss of upper extremity motor function is significantly more severe than that of the lower extremity. The tendon reflexes in the plane of injury are absent while those below the plane of injury are hyperactive.
(3) Spinal cord hemiplegia syndrome: the loss of contralateral pain and temperature sensation below the plane of injury, and the loss of ipsilateral motor function, position sensation, kinesthetic sensation and two-point discrimination.
(4) Posterior spinal cord injury: the loss of deep sensation, deep pressure sensation, and position sensation below the plane of injury, while pain and temperature sensation and motor function are completely normal. Most commonly seen in patients with vertebral plate fractures.
Differential diagnosis
Because of the stimulation of the vegetative nerves by the retroperitoneal hematoma and the slowing of intestinal peristalsis in this disease, symptoms such as abdominal distension and abdominal pain often occur, which sometimes need to be differentiated from abdominal organ injuries. It is also important to note that spinal fracture dislocations, burst fractures that
The probability of spinal cord edema, hemorrhage, and rupture is higher, and the probability of spinal cord injury is lower for simple compression fractures, but there are still complications of spinal cord injury, and even spinal cord injury in some spines where no fracture is found. Therefore, when the clinical symptoms are severe but not consistent with X-ray or CT examination, MRI should be performed promptly to observe and understand the spinal cord.
Prevention
This disease is caused by traumatic factors, so there is no effective preventive measures, pay attention to the safety of production and life, avoid trauma to prevent and treat the key to this disease.
For patients treated with surgery, complications should be actively prevented and early functional exercises should be carried out, starting with passive exercises and gradually replaced by active exercises, so as to maintain the best condition of the limbs and improve the quality of life after rehabilitation.
Complications
Due to the weak resistance of the body and the inability to get out of bed, patients with this disease may have some complications as follows.
1. Decubitus ulcers, which are caused by long-term local pressure, resulting in impaired blood circulation in the area;
2, urinary tract infections, spinal cord injury patients due to long-term stimulation of the retained urinary catheter in the body, resulting in the bladder defense mechanism is reduced, its infection rate is quite high;
3, joint stiffness and deformity;
4, prevention and treatment of respiratory tract infections;
5.Plant nervous system dysfunction;
6.Constipation;
7.Stress ulcers, mostly occurring in patients with large trauma, may cause changes in plant nervous function and digestive disorders due to large stimulation, and stress ulcers of the stomach and duodenum and upper gastrointestinal bleeding may occur.
8.Venous thrombosis of lower limbs, the patient’s blood is in a hypercoagulable state after trauma, the venous return is slow, and long-term bed rest is very likely to cause venous thrombosis of lower limbs.
The treatment of this disease includes the following points.
(A) First aid and handling
1, spinal cord injury sometimes combined with serious cranio-cerebral injury, chest or abdominal organ injury, limb vascular injury, endangering the life safety of the injured should be first resuscitated.
2, where the suspected spinal fracture, the patient’s spine should be kept in a normal physiological curve. Do not make the spine for over-extension, over-flexion lifting action, should make the spine in the case of non-rotating external force, three people with hands at the same time flat lift flat to the board, when fewer people available rolling method.
For patients with cervical spine injury, there should be a person to support the jaw and occipital bone, along the longitudinal axis slightly increased traction, so that the neck to maintain a neutral position, the patient placed on the board with sandbags or folded clothes on both sides of the head and neck to prevent head rotation, and to keep the airway open.
(B) Treatment of simple spinal fractures
1. Mild vertebral compression of thoracolumbar fractures is a stable type. The patient can lie flat on a hard bed with the lumbar area padded. After a few days, the back extension muscle can be exercised. After 3 to 4 weeks, the patient can get out of bed under the protection of a thoracic back brace.
2, thoracolumbar section of heavy compression more than one-third should be closed reset. Two tables can be used to reset the over-extension method. Use two tables with a height difference of about 30cm, a soft pillow on each table, the casualty lying prone, head on the high table, two hands holding the edge of the table, two thighs on the low table, to make the sternal stalk and pubic symphysis overhang, using the weight of the overhang gradually reset. After repositioning, a plaster undershirt is fixed in this position. The fixation time is 3 months.
3, thoracolumbar unstable spine fracture vertebral compression more than 1/3, deformity angle greater than 20 °, or with dislocation can be considered open reset internal fixation.
4, cervical fracture or dislocation compression displacement of light, traction reset with jaw occipital belt, traction weight 3 ~ 5kg. after reset with cephalothoracic cast fixed for 3 months. For heavy compression displacement, continuous cranial traction can be used to reset. The weight of traction can be increased to 6-10kg, and X-ray is taken for review. 3 months of fixation with cephalothoracic cast or cephalothoracic brace is required after the reset.
(C) Spinal fracture combined with spinal cord injury
The functional recovery of spinal cord injury mainly depends on the degree of spinal cord injury, but early release of the compression of the spinal cord is the primary problem to ensure the recovery of spinal cord function. Surgery is an important part of the comprehensive rehabilitation of patients with spinal cord injury. The purpose of surgery is to restore the normal axis of the spine, restore the internal diameter of the spinal canal, directly or indirectly release the compression of the spinal nerve roots by fracture mass or dislocation, and stabilize the spine (by internal fixation with bone graft fusion). The surgical methods are.
1.Anterior cervical decompression and bone graft fusion
For cervical fractures below cervical 3, traction repositioning, anterior decompression or subtotal vertebral body resection, bone graft fusion, internal fixation with plate screws or external fixation of the cervical perimeter are feasible. For obvious instability, cranial traction or cephalothoracic cast fixation can be continued.
2.Posterior cervical spine surgery
After traction and repositioning, posterior metal clip internal fixation and bone graft fusion or wire spine internal fixation and bone graft fusion are feasible for dislocation or posterior decompression plate screw internal fixation and bone graft fusion if necessary.
3.Anterior surgery for thoracolumbar fracture
For burst or comminuted fractures of thoracolumbar vertebrae, anterior decompression, bone graft fusion and plate screw internal fixation are mostly performed. For old fractures, lateral anterior decompression is feasible.
4.Posterior surgery for thoracolumbar fracture
The posterior surgery includes laminectomy decompression, internal fixation with pedicle screwed plates or steel rods, and if necessary, bone graft fusion or wire internal fixation with Harrington rods or Rukai rods.
(D) syndrome method
1, dehydration therapy application of 20% mannitol 250ml; 2 times / d, the purpose is to reduce spinal edema.
2.Hormone therapy apply dexamethasone 10-20mg intravenously once/d. It is meaningful to relieve the traumatic reaction of spinal cord.
3.The application of some free radical scavengers such as vitamin E, A, C and coenzyme Q, calcium channel blockers, lidocaine, etc. is considered to be beneficial in preventing secondary damage after spinal cord injury.
4, drugs that promote neurological recovery such as disodium cytidine triphosphate, vitamin B1, B6, B12, etc.
Supportive therapy pays attention to the maintenance of water and electrolyte balance, calories, nutrition and vitamin supplementation of the injured person.