Spinal fractures, mostly thoracolumbar fractures, are often accompanied by spinal cord and cauda equina injuries, which seriously affect the work and survivability of the injured. According to incomplete statistics, the incidence of thoracolumbar fractures in China is about 3-10at._/102Y people, and it is conservatively estimated that 30-50,000 new patients are injured every year. Due to the vast size of China, the distribution of thoracolumbar spinal fracture injuries is not uniform, with a low incidence in modern metropolitan areas and a relatively high incidence in industrial and mining enterprises, small and medium-sized cities.
I. Pathogenesis of spinal fractures.
Most of the injuries are caused by fall from height, the patient falls from a high place, the foot or hip landing, the spine is violently flexed forward; or when bending down to work with heavy objects impacting the head, shoulder or back, the spine is suddenly flexed forward, this flexion type injury occurs in the first and second cervical vertebrae, lower cervical segment, thoracolumbar segment and the fourth and fifth lumbar vertebrae, the majority of spinal fracture dislocation is flexion type. The majority of spinal fracture dislocations are of the flexion type. Patients fall from a height on their backs, and the back or lumbar region is obstructed, causing hyperextension of the spine or external force to the forehead, forcing the neck to hyperextend causing hyperextension type spinal injury. Since the spinal cord is located in the vertebral canal made up of vertebrae, all types of spinal fractures tend to damage the spinal cord. The spinal cord is responsible for transmitting impulses from peripheral nerves to the brain, and nerves from different planes of the spinal cord innervate the sensation, movement, and reflexes of the limbs. Therefore, regardless of the type of spinal fracture, it is very likely to cause paraplegia.
Second, the clinical manifestations of spinal fractures.
The vast majority of spinal fractures are caused by trauma, with serious injuries, many complications, poor prognosis, and even life-threatening manifestations of local pain, inability to move, and in severe cases, nerve compression and paralysis. If the symmetrical sensation, movement and reflexes are completely lost below the injury plane, below the bilateral thorax and abdomen, and the function of bladder and anal sphincter is completely lost, it is called complete paraplegia; if there is still a part of function, it is called incomplete paraplegia; after the cervical spinal cord injury, there is also neurological dysfunction of both upper limbs, it is tetraplegia, or quadriplegia. In case of complete paraplegia, bilateral loss of sensory and motor functions occur below the plane innervated by the injured spinal cord, and knee reflexes disappear; loss of bladder sphincter function occurs and urinary retention occurs; loss of anal sphincter function produces constipation.
Patients have muscle spasm in the low back, cannot get up, have difficulty turning over, feel weak in the low back, and because of retroperitoneal hematoma, stimulate the vegetative nerve, slow down the intestinal peristalsis, often appear abdominal distension, abdominal pain and other symptoms. In case of incomplete paraplegia, the spinal cord innervated by the injured nerves below the face, sensation, movement, reflexes and the function of the bladder and anal sphincter are partially lost, and the prognosis of this god situation is better. If the cervical spine fracture has damaged the spinal cord, all organs of the body will show some symptoms in addition to tetraplegia. For example, there are signs of vasodilatation below the plane of injury; blood pressure decreases and heart rate slows down; respiratory difficulties due to paralysis of intercostal muscles, and abdominal breathing occurs, and secretions from the respiratory tract are not easily discharged, making it easy for lung infection to occur. The early stage of paralysis also affects the vegetative nerves, and the intestinal peristalsis is weakened, causing intestinal flatulence, which affects the movement of the diaphragm and makes breathing difficult and also affects digestion and absorption. Due to urinary and faecal dysfunction, urinary retention, and easy to cause secret urinary system infections. In early cervical fractures, the patient has head and neck pain, cannot move, and often holds the head with both hands, which should be handled properly at this time to avoid damage to the spinal cord.
Third, the first aid of spinal fracture.
1, if the injured person is still pressed by rubble, earth, etc., do not crutch the exposed limb to prevent aggravation of the vascular spinal cord, fracture injury. Immediately remove the things pressed on the injured person.
2, complete or incomplete fracture injury, should be well fixed at the scene and prevent complications, especially to take the fastest way to the hospital, in the escort on the way Zhuang close observation. Suspected spinal fracture, spinal cord injury immediately according to the set injection fracture requirements of first aid. When carrying the injured person, let the two lower extremities close together, the two upper extremities posted on the waist side, and keep the body position of the injured person in a straight line.
3, cervical spine fracture to use clothing, pillows squeezed on both sides of the head and neck, so that the fixation does not move.
4, such as thoracolumbar spine fracture, so that the injured lying on a hard bed, both sides of the body with pillows, bricks, clothing plug tight, fixed spine for the straight position. Three people need to work at the same time when transporting, the specific practice is: three people are squatting on the side of the injured, one person to support the shoulder and back, one person to support the waist and hip, one person to support the lower extremities, coordinated action, the patient supine position on the hardboard stretcher, waist with clothes and mattress pad up.
5, transport with a hard board bed, stretcher, door plate, not a soft bed. Prohibit 1 person to hold the back, should be 2-4 people to carry, to prevent aggravation of the spine, spinal cord injury.
6, the body wound part for dressing, rinse the wound, stop bleeding, bandage.
IV. Diagnosis of spinal fracture.
By questioning the patient with the examination of the first 4 have one of them, plus the 5th and 6th that the possibility of vertebral fracture is considered, should be in accordance with the set note fracture requirements for first aid.
1.Falling from a height and landing on the hip or limb first
2.Heavy objects from a height directly smashed on the head or shoulder
3.Violence directly; impact on the spine
4, is in the bent back arch back by the squeezing pressure.
5.The spine of the low back has pressure pain, swelling, or augmentation, and
6.Both lower limbs have numbness, weakness or inability to move.
V. Auxiliary examinations include.
1, x-ray examination: front and side position and oblique position of the spine, observe whether the vertebral body has compression, cracks, crushing or displacement, whether there is deformation of the vertebral canal and intervertebral foramen, whether there is fracture of the articular eminence, transverse eminence and spinous process, whether there is change in the vertebral space, whether the spine eminence spacing is equal, whether there is change in the physiological curvature and alignment of the vertebral body, and whether the distance between the odontoid process and the blocks on both sides of the atlas is equal.
2, CT and MRI examination: it is extremely important to understand the fracture, the degree of spinal cord injury, the presence of compression, and to decide whether to operate.
VI. Treatment principles of spinal fracture.
1, early treatment: according to the pathological changes of spinal cord injury, either incomplete or complete injury should be treated early, especially within 6 hours to start treatment, has a very important significance.
2, reset and fixation of spinal fractures: simple, stable vertebral fractures and accessory fractures can be reset through conservative treatment, for unstable or combined with neurological symptoms of spinal fractures, surgical treatment should be considered to create conditions for spinal cord recovery, while maintaining the stability of the spine to prevent its continued compression of the spinal cord.
3, the treatment of spinal cord injury: including dehydration, hormones, the application of drugs to promote nerve damage repair, as well as hyperbaric oxygen, cryotherapy, etc.
4.Prevention and treatment of complications: respiratory complications (pulmonary embolism) are an important cause of death in the early stages of spinal fractures, and urinary tract infections are the main cause of death in the later stages, and active preventive measures should be taken.
5.Functional reconstruction and rehabilitation: there are thanks to the function of paraplegic limbs, such as hand muscle paralysis and scissor step deformity of lower limbs, etc., some functions of the hand can be reconstructed through orthopedic surgery. For the paraplegic patients who cannot recover, through a variety of exercise rehabilitation measures, vocational exercise, etc., so that they can take the wheelchair activities, participate in family and social life, and become a useful person to society.
VII. Rehabilitation care for spinal fractures.
In order for patients to cooperate with treatment and care, restore all or part of motor and sensory functions as far as possible, reduce complications and improve quality of life, the following instructions are required
A. Dietary guidance
The timing of eating is decided according to the injury site and the degree of bloating. Generally speaking, after fasting for l week for high paraplegia, enter liquid or semi-liquid, and enter soft food after 2 weeks. Paraplegic patients without abdominal distension can enter semi-liquid 3 days after injury, and gradually transition to soft food.
B. Postural guidance.
1, cervical fracture of the neck with sandbags or neck brace brake.
2, thoracolumbar fractures after the lumbar back pillow to play a fixed role.
C. Guidance on the treatment of thermoregulation.
In cervical spinal cord injury, hyperthermia or hypothermia often occurs due to dysfunction of the vegetative nervous system and loss of the ability to regulate and adapt to changes in the temperature of the surrounding environment. When hyperthermia, generally take physical cooling, such as adjusting the room temperature with air conditioning, ice, alcohol bath, warm water bath, ice water enema and other methods to reduce body temperature; low temperature, with hot water bags to keep warm, but the temperature should be ≤ 50 ℃. And wrapped with a cloth bag to prevent burns on the skin.
D, traction guidance: line traction according to traction guidance.
E, the prevention of complications.
1, prevention of decubitus ulcers.
(1) Lie on an air mattress, turn and massage the bony prominence 1-2 times every 2-3 hours to relieve local pressure and improve blood circulation.
(1) Keep the head, shoulders and waist in a straight line when turning to prevent the spine from twisting and aggravating the injury.
② If the skin tissue is reactive congestion due to prolonged pressure, massage is not recommended to avoid more serious injury, and can be gently massaged around the reddened skin to promote local blood circulation.
(2) flat position need to raise the head of the bed, generally not higher than 30 degrees; such as the need for semi-recumbent position, should be placed in the bottom of the foot a solid wooden pad or shake up the tail, flexing the hip 30 degrees, soft pillow under the hip padding, to prevent the body from slipping and moving, in order to reduce friction and shear force, to avoid dragging, pulling, dragging and other abrasive forces formed and damage to the skin.
(3) Keep the bed tight and neat, the mat in contact with the skin is loose, clean, dry, no wrinkles, no crumbs, to prevent abrasion and abrasion of the skin.
(4) Skin care.
① Warm water rubbing bath 2 times/day to keep the skin clean and promote blood circulation throughout the body.
②Prohibit irritating cleansers for paralyzed limbs and parts, and do not wipe with force to prevent damage to the skin.
③For dry and rough skin, use skin disinfectant or talcum powder to keep the skin lubricated, but do not apply it on broken and wet skin to avoid preventing exudation and aggravating or causing infection.
2. Prevention of pulmonary complications.
(1) Pay attention to keep warm in winter to avoid catching cold and inducing respiratory tract infections.
(2) Brush your teeth and rinse your mouth after eating to remove food residues and pathogenic microorganisms in the mouth and keep your mouth clean.
(3) Take deep breathing training such as blowing balloons and bubbles. There is a simple method for the latter: use an empty infusion bottle containing half a bottle of water, and the patient uses a plastic tube or rubber tube to blow bubbles into the water in the bottle.
(4) Effective coughing and coughing up sputum.
①The method of coughing is: inhale deeply and cough when exhaling about a third; repeatedly so that sputum is coughed out.
(2) When the patient has sputum that cannot be coughed out, the right index and middle fingers can be used to press the common trachea to stimulate tracheal coughing.
3. Prevention of perineal infections and stones.
(1) Keep the perineum clean and hygienic.
① Wipe and wash twice a day.
(2) Wipe and wash immediately after urine and faeces contamination, gently, do not rub the skin. For female patients with urinary incontinence, use a good absorbent “diaper”, and for male patients, use a cunt sleeve to connect the drainage tube and urine bag to keep the perineum free from urine.
(2) Patients with urinary retention should fix the position of the catheter and drainage tube properly.
①When lying supine, the drainage tube should not be higher than the level of the pubic bone; the drainage tube should pass between the legs and not across the body.
②When lying prone, use a pillow to raise the upper body for 20-30 minutes/time.
(3) Before turning over, clamp the proximal end of the drainage tube, and then lift the urine bag and fix it to the side of the body after turning over to prevent infection caused by backflow of urine to the bladder.
(3) Continuous drainage of urine for 2 weeks after injury, followed by opening once every 2-4 hours, can prevent infection and bladder atrophy. If the stool appears cloudy and has precipitation, it indicates an infection and should be continuously drained to prevent poor drainage of urine and aggravate the infection.
(4) Drink more water, 4000ml/day, to help flush the sediment from the urine.
(5) Train the reflex urination action of the bladder to prevent urinary tract infection. When the bladder is full, the patient can have a feeling of lower abdominal distension or sweating and other discomfort, use the hand to massage and squeeze to urinate. Method go: the operator can use the right hand to massage the patient’s lower abdomen from the outside to the inside, the force is even, from light to heavy, when the bladder shrinks into a ball, one hand presses the bottom of the bladder, squeeze the bladder forward and down, when urinating with the left hand pressed on the back of the right hand to pressure, when the urine is no longer discharged, you can release the hand and press again, and strive to urinate out.
(6) Change position frequently and perform active and passive exercises within your ability to prevent urinary tract stone formation.
4.Management of stool.
(1) Prevention of constipation.
(1) Diet regulation as described above.
② rubbing the abdomen 2-3 times/day, with the umbilicus as the center of the clockwise circumferential massage, to promote intestinal peristalsis, help digestion, and prevent constipation.
(2) In case of fecal incontinence, feces soaked around the anus may cause skin erosion, so wipe gently in time.
5.Prevention of limb deformity.
(1) Support the foot with a foot protector or pillow or protective pad, avoid foot drop when turning over, and avoid deformity by active or passive movement of the ankle joint.
(2) Move the hip to the maximum extent every day, paying attention to full extension and abduction to prevent joint stiffness.
(3) Fully straighten the knee joint several times a day.
F. Functional exercise: Functional exercise includes the activities of paralyzed and non-paralyzed muscles and joints.
1.Use dumbbells or pulling springs to exercise the muscles of the upper limbs and chest and back, so as to prepare for the crutches to the ground.
2, supine or prone position should actively exercise the lumbar back muscles, the methods are.
(1) chest up.
(2) five-point support method: supine, with the head, elbows and feet to support the whole body, so that the back to try to vacate the back extension, 1 week after the injury can practice this method.
(3) four-point support method: with hands and feet propped up on the bed, the whole body vacant, in the shape of a bridge, 3-4 weeks after the injury can practice this method.
(4) three-point support method: arms in front of the chest, with the head and feet propped up on the bed, while the whole body vacant back extension, 3-4 weeks after the injury can practice this method.
(5) back extension method: prone, lift the head, chest off the bed, double upper limbs to the back, two knees straight, lift both legs from the bed, 5-6 weeks after the injury can practice this method.
3.After the condition is stabilized, start to get up and leave the bed as much as possible.
4.With the help of the upper limbs and the upper body, practice standing and walking on the ground with the help of auxiliary tools, such as braces, walkers, etc.
G. Discharge instruction.
1.Continue to prevent the aforementioned complications.
2.Continue functional exercise.
3. Engage in labor within ability.