I. Overview
Spinal cord injury is a common disease in orthopedics or spine surgery, mostly due to car accidents, falls, work-related injuries, sports activities and other spinal fractures or even dislocation, not only to destroy the stability of the spine, but also may compress the spinal cord, resulting in nerve damage. Spinal cord injuries are more serious and complex, often combined with thoracic, abdominal and pelvic organ injuries, handling difficulties, often serious complications, not only life-threatening, and often paraplegia, the prognosis is poor. In recent years, with aging, osteoporotic spinal compression fractures caused by minor trauma are also receiving more and more attention, and this type of injury usually has a good prognosis, but requires active treatment of osteoporosis at the same time.
Second, the clinical manifestations
1.Spine fracture
(1) A history of serious trauma, such as falls from height, heavy blows to the head, neck, shoulders and back, collapse accidents, traffic accidents, etc. In the case of osteoporotic spinal compression fractures in the elderly, the trauma is generally mild, and sometimes there is no obvious history of trauma.
(2) The patient is injured with local pain, impaired movement, inability to stand, and difficulty in turning over. The fracture is locally painful with pressure or buckling pain, and sometimes local swelling, subcutaneous bruising, and posterior protrusion deformity are seen.
(3) Attention should be paid to the presence of combined thoracic, abdominal and pelvic organ injuries, and multiple injuries are prone to shock and life-threatening. Simple thoracolumbar fracture can also cause abdominal distension, abdominal pain and other symptoms, need to be distinguished from abdominal organ injuries.
2.Combined spinal cord injury
(1) Spinal shock period: temporary inhibition of sensation, movement, reflex and autonomic function can occur when the spinal cord is traumatized, which is called spinal shock. During the period of spinal shock, flaccid paralysis occurs below the plane of injury, with loss of sensation and inability to control urination and defecation. 2-4 weeks later, spastic paralysis may evolve, manifesting as increased muscle tone, hyperactive tendon reflexes, and pathological signs.
(2) Post-spinal shock phase manifestations.
(1) complete spinal cord injury, complete paralysis below the plane of injury, complete loss of deep and superficial sensation, muscle strength level 0.
(2) Incomplete spinal cord injury, manifested as incomplete sensory and motor dysfunction.
(3) Delayed spinal cord injury: early after the injury without neurological symptoms, after several months or years, gradually appear spinal cord involvement, or even paralysis. There are many causes of delayed injury, including spinal cord compression due to disc herniation, spinal instability, angulation and displacement resulting in spinal cord wear, and spinal fracture with excessive bone scabs growing into the spinal canal to compress the spinal cord.
Diagnosis
1.Neurological examination
Neurological examination should pay attention to the distinction between spinal shock, incomplete spinal cord injury and complete spinal cord injury. For cauda equina injury, attention should be paid to check the perineal sensation and anal reflex.
2.Filming examination
In addition to the conventional frontal and lateral spine X-rays, CT examination should be performed, which is helpful to determine the degree of encroachment of the displaced fracture block into the spinal canal and to discover the bone block or intervertebral disc protruding into the spinal canal. If conditions allow, it is best to do MRI examination, which is extremely valuable to determine the status of spinal cord injury, it can show the early edema and hemorrhage of spinal cord injury, and can show various pathological changes of spinal cord injury.
3.Evoked potential examination
Spinal cord injury should be evoked potential examination when available, to determine the degree of spinal cord injury is helpful.
IV. Treatment
1.First aid and transport
Improper first aid and transport can aggravate the spinal cord injury. Can not use a soft stretcher, to use a wooden board to carry, to make the pelvis, limbs overall axial rolling to the board. Prevent the trunk from twisting or flexing, disable the floor hold or one person to lift the head, one person to lift the leg method. For cervical spine injury, to hold the head and along the longitudinal axis slightly traction and torso consistent rolling. Observe whether the respiratory tract is obstructed during moving and remove it in time, check the changes of respiration, heart rate and blood pressure, if there is any abnormality, it should be handled in time.
2.General treatment principles
(1) For stable spinal fractures without nerve injury, conservative treatment is mostly used, with external orthopedic brace fixation for 4 to 8 weeks, followed by rehabilitation.
(2) For unstable spinal fracture dislocations, especially when accompanied by nerve injury, surgery is mostly used to facilitate recovery from spinal cord injury and prevent complications.
(3) Spinal cord injury treatment principles.
① those with spinal cord compression should be surgically released from the compression.
② non-operative therapy for those with spinal cord shock and no signs of compression, and close observation.
(③) complete transection of the spinal cord injury should not be decompression, but for unstable fractures feasible internal fixation to facilitate care.
(iv) early injury can be treated with medication, such as methylprednisolone, dexamethasone, tachyphylaxis, mannitol, gangliosides, etc.
⑤ Prevention of various complications, with special attention to the prevention of respiratory and urinary tract infections, decubitus ulcers, and deep vein thrombosis.
(vi) Keep the airway open in cases of cervical medullary injury, and perform tracheotomy if necessary.
(7) Hyperbaric oxygen therapy and systemic support therapy.
3.Surgical treatment
(1) Principles of surgical treatment: try to restore the function of the injured spinal cord and increase the recovery of reversible spinal cord injury; rebuild the stability of the spine to provide an ideal environment for neurological recovery and prevent progressive aggravation of the injury; prevent complications and reduce the morbidity and mortality rate.
(2) Posterior surgery: posterior surgery in the thoracolumbar spine is less traumatic, less bleeding and easier to operate than anterior surgery, and early posterior instrumentation fixation and repositioning can indirectly decompress the spinal canal. Now the posterior short-segment fixation technique is quite mature, and for mild to moderate instability fractures, single-segment fixation via the injured spine has also achieved satisfactory results, which has little impact on the adjacent segments and is more in line with the minimally invasive concept. With the continuous improvement of the lateral anterior decompression method of the posterior arch, the decompression effect has been significantly improved, and the clinical results of posterior decompression and implant fusion are no longer significantly different from those of anterior decompression and implant fusion by performing posterior posterolateral or even transvertebral foramina. Therefore, as long as the indications are properly selected, posterior decompression internal fixation is still the preferred method for thoracolumbar spine fracture surgery.
(3) Anterior surgery: The advantage of anterior surgery is that the anterior side of the spinal canal can be fully decompressed under direct vision, and the deformity can be corrected and fixed and fused at the same time, but anterior surgery of the thoracolumbar spine is traumatic and bleeding, therefore, the indications for anterior surgery of the thoracolumbar spine must be strictly controlled. At present, the indications for anterior surgery are: those with anterior spinal cord injury syndrome after spinal cord injury; those who still have residual pressure on the anterior compression after posterior surgery; and patients with incomplete paralysis caused by anterior compression.
(4) Anterior-posterior approach selection: The controversy of thoracolumbar fracture surgery is more prominent in the selection of anterior-posterior approach. In general, incomplete neurological impairment with imaging confirmed compression from the anterior spinal canal usually requires anterior decompression; with posterior ligamentous complex disruption, posterior surgery is usually required; both injuries usually require combined anterior and posterior approaches.
(5) Vertebroplasty: With the development of minimally invasive surgery, percutaneous transluminal vertebroplasty (PVP) and percutaneous transluminal balloon-expandable kyphoplasty (PKP) are widely used in clinical practice to treat primary or secondary osteoporotic spinal compression fractures with painful symptoms. While this procedure is effective, care should be taken to prevent complications such as bone cement leakage.
V. Rehabilitation
Early and correct guidance and assistance to paraplegic patients for functional training, psychological rehabilitation to mobilize the patient’s subjective initiative and strengthen the will to overcome difficulties, so that they can adapt to post-discharge life and work as soon as possible. The contents include: lifelong health self-management, such as urinary tract management, management of comorbidity prevention; functional training, including self-care; vocational training, so that they can earn their own living and contribute to society.