With the aging of the population in recent years, spinal cord compression diseases such as cervical spondylosis are more common, while the continuous development of transportation, industry, and construction has made spinal cord injuries due to traffic accidents, fall injuries, and injuries from falls increasingly common, and spinal cord injuries and their secondary damage place a heavy burden on patients, families, and society. This article provides a review of the diagnosis and treatment of spinal cord injury.
I. Etiology and pathology
Pathological changes can be divided into four levels
(1) spinal cord transection, seen in severe spinal fracture dislocation, firearm spinal canal penetration injury, sharp force injury laceration, etc.
(2) Complete spinal cord injury, most of the spinal cord in the first 6 to 8 hours, although the central hemorrhage, edema, but not yet necrosis, the surrounding white matter is still good, is the golden period of treatment. In complete spinal cord injury, secondary injuries such as edema, microcirculatory disorders, free radicals, and neurotransmitter changes are progressive until spinal cord necrosis. Early treatment has the potential to inhibit the progression of secondary injury and lead to some recovery.
(3) Incomplete spinal cord injury, although the histology is also hemorrhage and edema in the center of the spinal cord, the injury itself is mild, and the secondary injury is also mild and non-progressive, with reversible self-recovery, but there may be some foci of necrosis and softening in the gray and white matter, so complete recovery is not possible. The treatment of the secondary injury, especially the more severe incomplete paralysis, is more beneficial.
(4) Minor spinal cord injury, the clinical spinal cord concussion, histologically visible in the gray matter of small focal hemorrhage and neurological tissue degeneration, but does not form foci of necrosis, can be completely recovered on its own, in histology, no abnormalities remain.
From a pathological point of view, in addition to spinal cord injury (contusion) caused by vertebral fracture subluxation, there are.
(1) Spinal cord compression injury, e.g., a fracture mass or dislocation that continuously compresses the spinal cord.
(2) Ischemic injury to the spinal cord, for example, if the anterior or posterior spinal artery or the root artery is injured as a result of a spinal injury. The arteries supplying the spinal cord can become thrombosed, or even thrombosis can spread upward or downward causing ischemic injury to multiple segments of the spinal cord, which is difficult to recover from. In addition, after spinal injury, especially those who have suffered spinal cord injury, the stability of the spine has been lost, in the process of first aid and moving, the spinal instability may aggravate the spinal cord injury, so that incomplete spinal cord injury paraplegia, aggravated into a complete spinal cord injury (complete paraplegia).
Second, clinical examination
Clinical examination of patients with spinal cord injury includes
Neurological examination: including sensory (paraplegia) plane, paralyzed muscles (by muscle group), perineal sensation and contraction of anal sphincter. Complete paraplegia and incomplete paraplegia depend on the presence or absence of sensation in the perineal area and the presence or absence of voluntary contraction of the sphincter. The plane of paraplegia is based on the plane of sensory impairment (hypoesthesia or loss), and the plane of injury is based on the muscle or muscle group with grade III muscle strength, because most of the muscles or muscle groups are innervated by two or more nerve roots, and when all the nerves are sound, the muscle strength is above grade IV. If the muscle strength is grade III or less, the plane of injury is in the inferior nerve segment innervating the muscle. In order to facilitate neurological comparison between post-injury and treatment results, it is recommended to apply a scoring system in which sensation (touch, pain) is classified as normal (2 points), diminished or impaired (1 point), or absent (0 points), and movement is calculated as the sum of muscle strength (0-5 levels) of each muscle (muscle group) below the level of injury.
Imaging examination
(1) X-ray plain film is the most basic examination method, which provides a reliable basis for determining the type of spinal injury. For burst fractures.
(2) CT can clearly show the area of the spinal canal encroached by the fracture block, as a reference to estimate the compression of the spinal cord and the basis for the choice of surgical decompression access.
(3) Magnetic resonance imaging (MRI) can provide the most direct and valuable information on spinal cord injury. In the spine, it can show herniated discs compressing the spinal cord, posterior longitudinal ligament, ligamentum flavum injury and bleeding, and fracture dislocation. In the spinal cord, acute spinal cord injury is divided into hemorrhagic (low signal in the injured segment and high signal around it), edematous (high signal in the injured segment) and mixed (mixed low and high signal), with the edematous type having a better prognosis. In the late stage of spinal cord injury, T1-weighted MRI is the main reference, and those with normal spinal cord signal but compression are incomplete paraplegia, and often recover well after decompression; those with mixed signal (uneven) and intramedullary cysts are often incomplete paraplegia, and the former can further recover after decompression, while the latter mostly do not recover; low signal thickening, very low signal, spinal cord thinning and atrophy, and spinal cord rupture are all complete paraplegia, and do not recover.
Evoked potential examination: It can provide valuable reference for the degree of spinal cord injury. The somatosensory evoked potential (SEP) of complete spinal cord injury is not elicited (97.8%), and the SEP of incomplete spinal cord injury shows prolonged latency and reduced wave amplitude. In acute spinal cord injury, those who fail to elicit SEP 12 hours after injury are more likely to have complete paraplegia, while those who can elicit SEP have a better prognosis.
(1) In cervical spinal cord injury, the SEP of median, ulnar and radial nerves cannot be elicited in the C4 plane of complete injury, while the SEP of median nerve can be elicited in the presence of C5 segment, but the latency period is prolonged and the wave amplitude is reduced. More than half of the SEPs were normal, and the SEPs of the central spinal cord injury were all elicited, but the ulnar nerve was severely involved.
(2) The spinal cord of the thoracolumbar segment (T12-L1) is mixed with the lumbosacral nerve roots, and the degree of injury to the spinal cord, conus and nerve roots is often inconsistent. If the spinal cord and nerve roots are completely injured, the femoral, tibial, and peroneal nerve SEPs cannot be elicited; if the spinal cord and nerve roots are both incompletely injured, the three nerve SEPs can be elicited but are abnormal; and if the spinal cord is completely injured and the lumbar nerve roots are incompletely injured, the tibial and peroneal nerve SEPs disappear, while the femoral nerve SEP can be elicited but is abnormal, which can provide reference for clinical diagnosis and prognosis.
In most cases of spinal cord injury, sensory and motor deficits are the same, and the SEP can represent the degree of spinal cord injury. MEP is faster than SEP.
Diagnosis and classification
. Complete spinal cord injury.
Incomplete spinal cord injury. Incomplete spinal cord injury.
. Central spinal cord injury: incomplete loss of sensation, upper extremity impairment more than lower extremity.
. Anterior spinal cord injury: loss of superficial sensation, presence of proprioception, varying degrees of motor paralysis.
. Brown-Sequard: motor impairment on the injured side, sensory impairment on the contralateral side.
. Cone injury: sensory deficit in the perineal saddle area, defecation dysfunction.
. Cauda equina injury: injury below L2, lower extremity sensory and motor deficits, defecation dysfunction.
. No radiographic fracture dislocation spinal cord injury: X-ray spine without injury, but with spinal cord injury. Cervical spine without fracture dislocation injury is mostly seen in the elderly, mostly posterior extension injury, but also in children, mostly incomplete quadriplegia, but also total paralysis. MRI shows disc herniation, anterior and posterior soft tissue injury, hemorrhage and abnormal spinal cord signal.
. Ascending spinal cord ischemic injury or spinal cord infarction: seen in the lower thoracic spine and thoracolumbar injury, the spinal cord ischemic necrosis caused by vascular embolism in the spinal cord, and spreads upward to the mid-thoracic or cervical segment, ascending to the mid-thoracic segment, mostly due to root artery injury, while ascending to the cervical medulla, the anterior, posterior and central arteries of the spinal cord are embolized. Death may occur due to paralysis of the respiratory center. Due to ischemic necrosis of the spinal cord, the lower extremities are floppy.
IV. Non-surgical treatment
According to the pathology of spinal cord injury, the earlier the treatment, the better.
. High-dose methylprednisolone (MP): The usage is 30 mg/ Kg body weight administered intravenously over 15 minutes, followed by 5.4 mg/Kg/hour over 45 minutes for 23 hours. Indications: More severe incomplete paraplegia, quadriplegia and non-spinal cord transection complete paraplegia patients, applied within 8 hours after injury, more than 8 hours of total paralysis is generally not suitable for application, because the secondary damage of spinal cord injury has been serious, central necrosis has occurred, white matter bleeding, the effect is poor.
. Hyperbaric oxygen (HBO) therapy: It is applied to severe incomplete paraplegia and non-transverse complete paraplegia, and is performed 6 to 8 hours after the injury, once every 6 hours, three times in a row within 24 hours, when the patient’s general condition allows.
. Dehydration and diuretics: The use of hypertonic dehydration and diuretics can increase urine output and can eliminate excess water from extracellular fluid of tissues after spinal cord injury. It takes 3-4 weeks for spinal cord edema to subside, but prolonged administration of dehydrating agents can easily lead to imbalance in water and electrical balance. These drugs can be used selectively, but not all of them are necessary. The use of various drugs is as follows: tachyphylaxis 20mg, intramuscular or intravenous, 1 to 2 times a day. 20% mannitol or 25% sorbitol, 250 to 500ml intravenous drip, depending on the condition, can be used once / 6h, repeatedly for several days. Human albumin 10～20g intravenous drip, can be used repeatedly for a long time. Human albumin not only can significantly reduce spinal edema, but also can supplement nutrition, and will not cause and aggravate electrolyte disorders and other common complications after spinal cord injury, and is the preferred dehydration agent for spinal cord injury.
. Nerve growth factor (NGF): its role is to promote axonal regeneration and nerve cell protection, because it promotes the regeneration of nerve fibers, it should be used 2 weeks after the completion of nerve fiber degeneration and the beginning of regeneration, and can be applied locally or systemically, such as intramuscular injection. It is suitable for severe incomplete paraplegia or complete paraplegia with good MRI spinal signal.
. Cervical spine injury, cervical spine fracture and fracture dislocation, except for joint synapse interlocking need to be surgically reset or decompression, can be treated by cranial traction or Halo frame fixation, traction or Halo frame to reset the dislocation, if there is no bone block compression of the spinal cord, surgery can be avoided, Halo frame fixation can allow the patient to leave bed early with wheelchair activities, which is conducive to rehabilitation.
V. Surgical treatment
Including spinal injury, spinal cord decompression.
(A) Spinal injury
Compression fracture, burst fracture and fracture dislocation repositioning.
Internal fixation and fusion of bone graft to stabilize the spine
(B) spinal cord decompression
Acute spinal cord injury, with spinal cord compression, should be decompressed as soon as possible, the longer the spinal cord compression time, the spinal cord recovery is limited. The best time to operate is within 3 days after the injury. If this optimal time is lost, surgery should be performed 7 d after the injury. This is because 3-7 d after cervical spine injury is the stage of the strongest stress response of the body, and the complications and mortality rate of surgery at this time are high, which is a dangerous period for cervical spine trauma surgery. However, this is not always the case. As long as the respiratory function, water electrolytes and major organ functions such as heart and kidney are well adjusted, early surgical decompression and reconstruction of cervical spine stability can create favorable conditions for the recovery of spinal cord function.
Cervical spinal cord injury
Posterior decompression: In middle-aged and elderly patients with cervical spinal cord injury, there is often a cervical degenerative base with spinal stenosis, and when they suffer a cervical spinal injury due to trauma, not only the spinal cord is injured, but also the spinal cord is compressed due to spinal edema and relative stenosis of the spinal canal. MRI shows anterior and posterior compression of multiple spinal cord segments, loss of anterior and posterior subarachnoid space, and high signal spinal cord edema, with clinical manifestations ranging from central spinal cord injury, incomplete spinal cord injury, and complete spinal cord injury. Early posterior laminar decompression is required in such cases.
Anterior decompression of the spinal cord: Suitable for those with disc herniation compressing the spinal cord, anterior decompression should reveal the dura mater and remove the disc herniation on both sides.
Thoracic spine and thoracolumbar decompression
Except for fractures of the vertebral plate that are subluxated and compress the spinal cord, the decompression of the spinal cord mostly comes from the front.
There are three options for decompression
(1) Posterior median approach through laminectomy and one side of the pedicle, the posterior edge of the vertebral body is removed, that is, anterior decompression of the spinal cord.
(2) Lateral anterior approach via thoracic or retroperitoneal anterior decompression.
(3) lateral anterior approach via thoracic or extraperitoneal anterior decompression.
Lumbar spinal canal decompression
The lumbar spinal canal is thicker and the intradural cauda equina can be slightly pulled to one side. After choosing the posterior median approach for laminectomy, anterior decompression can be performed, which also facilitates posterior internal fixation.
When is the best time to start spinal cord injury rehabilitation?
Spinal cord injury rehabilitation should begin at an early stage. There are two types of injuries: those that require surgery and those that are conservative (i.e., not surgical). As long as the condition is stable and there are no other combined injuries, rehabilitation should begin. Of course, early activity is not allowed to be too extensive, and should not affect the effect of surgery. The main activity should be to move all joints of the body and maintain normal joint mobility, 2 to 3 times a day, and each joint should be moved for less than 1 minute. In addition, with the doctor’s permission and under the nurse’s guidance, position change, that is, regular turning, to prevent pressure sores, generally once every 2 hours, protruding bone parts (such as scapula, heel, back, sacrococcygeal, double limbs) with soft pads, pay attention to the smooth discharge of urine and stool, pay attention to temperature changes, pay attention to comfort the patient, improve the patient’s psychology, notify the doctor and nurse of any abnormal changes, pay attention to the food The patient should pay attention to the nutrition of the food and drink water regularly. If early rehabilitation is done well, it will create a good foundation for comprehensive rehabilitation training in the future. The main methods of spinal cord injury rehabilitation treatment
Physical therapy: Mainly improving the movement of all joints in the body and strengthening the residual muscle strength, as well as balance and coordination movements and position exchange and transfer movements (e.g., from lying to sitting, turning over, moving from bed to wheelchair, from wheelchair to toilet, etc.), and physical therapy: using hydrotherapy, light therapy, biofeedback, etc. to promote rehabilitation in a targeted manner.
Occupational therapy: mainly daily life movements (such as basic skills for clothing, food, housing, and transportation), occupational labor movements, and craft labor movements (such as knitting, etc.) to enable patients to adapt to their personal, family, social, and labor needs after discharge from the hospital. In addition, the operation department provides patients with simple aids to facilitate the successful completion of family life movements.
Psychotherapy: A psychotherapy plan is developed for changes in different stages of the psyche (such as denial, anger, depression, opposition to various stages of independence seeking adaptation, etc.), and a variety of individual and group, family, and behavioral approaches can be carried out.
Rehabilitation engineering: The necessary supports can be custom-made to practice standing and walking, in addition to special tools such as walkers, which can be relied on to compensate for functional deficiencies.
Clinical rehabilitation: Prevention of various comorbidities by means of nursing care and medication, as well as some therapeutic clinical treatment to reduce symptoms and promote functional recovery.
Traditional Chinese medicine rehabilitation: Using traditional Chinese medicine, acupuncture, massage, electroacupuncture, and ionization of Chinese herbs are used to promote recovery, and for the treatment of comorbidities, Chinese herbs are also widely used internally and externally.
Nutritional therapy: Develop reasonable recipes and enhance nutrition to meet the needs of rehabilitation training.