Spinal cord injuries often result in severe disability and last a lifetime, and are one of the main targets of rehabilitation medicine. Traumatic spinal cord injuries predominate in young adults and are more common in men than women. Patients with spinal cord injuries have a long survival period, and their average life expectancy is only 4-5 years less than that of an able-bodied person. Therefore, there are many spinal cord injury patients surviving in the community, and the need for rehabilitation medicine is very urgent.
I. Overview
1. Causes of injury
(1) Traumatic: The most common cause of spinal cord injury is caused by closed blunt trauma, usually related to fracture or misalignment of the spine. About 20% of patients with spinal fractures occur in varying degrees of spinal cord injury.
Cervical spinal cord injuries: flexion-type rotational dislocations or fracture dislocations are the most common, with the best site being C5-6. Compression fractures C5-6 are the most common. Hyperextension-type injuries are most common in the elderly, accounting for about 30% of cervical spinal injuries, most commonly in C4-5, which are stable injuries.
② thoracolumbar spinal cord injury: flexion-type rotational dislocation or fracture dislocation is the most common, mostly located in T12-L1, resulting in anterior displacement of the vertebral body, which is usually unstable and leads to complete impairment of spinal cord, conus or cauda equina function.
(iii) Hyperextension injury: rare, usually resulting in complete spinal cord injury.
④Open injury: less common.
⑤ whipping injury: X-rays are often negative, and spinal cord injury is mostly incomplete.
(2) non-traumatic
①vascular: arteritis, spinal thrombophlebitis, arteriovenous malformation, etc.
(2) Infectious: Grimballi syndrome, transverse myelitis, spinal cord anterior horn poliomyelitis, etc.
③degenerative: spinal muscular atrophy, amyotrophic lateral sclerosis, spinal cavernous disease, etc.
(iv) Tumor: primary – cerebral (spinal) meningioma, glioma, neurofibroma, multiple myeloma, etc. Secondary – secondary to lung cancer, prostate cancer, etc.
⑤ Others.
2, pathological changes: minutes after spinal cord injury vascular endothelial cell damage, edema, ischemia and secondary damage, 12h after the emergence of macrophage infiltration and other inflammatory reactions, 72h to reach a peak, resulting in motor neuron necrosis, axonal degeneration and decomposition.
3, clinical syndrome: typical transverse injury is divided into paraplegia and tetraplegia according to the level of injury. However, some incomplete injuries have special manifestations, including.
(1) Central bundle syndrome: common in the cervical spinal cord vascular injury. The damage begins in the central part of the spinal cord and then spreads to the periphery in the case of vascular injury. The motor nerves of the upper extremities are biased towards the central part of the spinal cord, while those of the lower extremities are biased towards the periphery of the spinal cord, resulting in more nerve involvement in the upper extremities than in the lower extremities, so that the upper extremities are more impaired than the lower extremities. Patients may be able to walk but have partial or complete paralysis of the upper extremities.
(2) Hemisection syndrome: It is commonly seen in knife or gunshot wounds. The spinal cord is injured only halfway, and the warm-nociceptive nerves cross in the spinal cord, thus causing loss of proprioception and movement in the injured ipsilateral limb and loss of warm-nociceptive sensation in the contralateral side.
(3) Anterior bundle syndrome: injury to the anterior part of the spinal cord, resulting in the loss of motor and thermo-nociceptive sensation below the plane of injury, while proprioception exists.
(4) Posterior tract syndrome: injury to the posterior part of the spinal cord, resulting in loss of proprioception below the level of injury, while motor and warm-nociceptive sensations are present.
(5) Spinal cord cone syndrome: mainly for the spinal cord sacral segment cone injury, can cause loss of bladder, bowel and lower extremity reflexes. Occasionally, sacral reflexes may be preserved.
(6) Cauda equina syndrome: refers to injury to the lumbosacral nerve roots in the spinal canal, which can cause loss of bladder, bowel and lower extremity reflexes. The nature of the cauda equina is actually a peripheral nerve, and therefore there is the possibility of nerve regeneration, which leads to gradual recovery of nerve function. The growth rate of peripheral nerves is 1 mm/d, so the recovery of nerve function after cauda equina injury is likely to take about 2 years.
(7) Spinal cord concussion: refers to temporary and reversible loss of spinal cord or cauda equina nerve physiological function, seen in patients with only simple compression fractures or even negative radiographs. There is no mechanical compression of the spinal cord and no anatomical damage. Another hypothesis suggests that the loss of spinal cord function is due to a short pressure wave. The slow recovery process suggests the regression of reactive spinal cord edema. Hyperreflexia but no muscle spasm is seen in this type of patient.
II. Rehabilitation problems
1. Muscle paresis: It can originate from muscle dysfunction due to loss of innervation or disuse atrophy due to prolonged inactivity. Muscle paralysis is the main cause of motor dysfunction. Patients can get different degrees of rehabilitation through functional training, orthotic application, walking aids, functional electrical stimulation, etc.
2, joint contracture deformity: long-term lack of activity due to longitudinal muscle atrophy and shortening of tendon elastic fibers often leads to joint contracture, or even bone and joint deformity, thus affecting the patient’s walking and activities. Correction of contracture deformity is a necessary prerequisite for the application of orthoses. Retraction training, physical therapy, and manipulative therapy are all effective methods to correct contractures.
3, muscle spasm: upper motor neuron lesions are often combined with uncontrolled excitability of the spinal cord center, resulting in excessive muscle tone, overactive activity or spasm.
Disadvantages of spasticity.
(1) Leads to stronger skin shear, which causes skin damage or pressure sores.
(2) Restriction of joint movement that interferes with activities of daily living.
(3) Spasm of the internal femoral retractor muscle interferes with bowel and perineal hygiene.
(4) Induces pain or discomfort.
Advantages of spasm.
(1) Quadriceps spasm helps the patient to stand and walk.
(2) Bladder and abdominal muscle spasms help with urination.
(3) Limb muscle spasm helps prevent upright hypotension.
(4) Prevention of deep vein thrombosis. Because of the dual nature of the spasticity effect, spasticity management is a reflection of the artistry of rehabilitation treatment.
(4) Pressure sores: Pressure sores are the most common comorbidity and are closely related to sensory impairment, physical activity impairment, circulation impairment, and nutritional impairment in patients with spinal cord injury. Skin damage from pressure sores is often a source of infection, and also makes it more difficult for patients to maintain the necessary training positions, even affecting the recumbent position. Rehabilitation therapy can allow most pressure sore problems to be resolved.
5. Bladder and rectal disorders: Loss of innervated bladder dysfunction seriously affects patients’ daily life care, and incontinence gives patients heavy psychological stress and affects social and daily activities. Bladder training, clean catheterization, and functional electrical stimulation are effective methods for bladder disorders. And rectal dysfunction can also be addressed through dietary restructuring, the use of various types of laxative drugs.
6, pain: pain after spinal cord injury is very common, the causes are complex, mainly central and somatic pain, which affects the quality of life of patients. In addition to drugs, physical therapy, exercise, occupational therapy, and psychotherapy are also very commonly used.
7. Autonomic dysregulation: Autonomic dysregulation includes loss of autonomic function and hyperreflexia, leading to sudden and severe hypertension. Control of autonomic disorders is often a necessary prerequisite for rehabilitation.
8, sexual life/fertility: Most patients with spinal cord injury have varying degrees of sexual and reproductive dysfunction, which affects patients’ psychological and quality of life and is one of the important elements of rehabilitation treatment.
Third, the rehabilitation treatment mechanism and assessment
1. Rehabilitation treatment mechanism
(1) Substitution and substitution: For completely paralyzed limbs, the use of orthopedic devices to fix joints, combined with the application of crutches or walking aids, can enable paraplegic patients to restore walking ability. The use of electric wheelchairs can restore some mobility to tetraplegic patients.
(2) Improvement and training: Promote the function of residual muscles and compensate for insufficient muscle strength through physiotherapy methods such as muscle strength training, while working to promote the awakening and restoration of function of depressed and hibernating nerve cells.
(3) Training and learning: help patients adapt to new patterns to complete daily life movements through neural reflex re-establishment or neuromuscular re-learning. For example, bladder training, occupational therapy.
2, the degree of injury classification, the international spinal cord injury degree grading method.
(1) Incomplete injury: the sacral segment retains some sensory and motor functions, that is, there is sensation in the anal mucosal skin junction and deep anus, or there is voluntary contraction of the external anal sphincter.
(2) Complete injury: the sensory-motor function of the sacral segment is completely lost.
(3) Spinal cord shock: refers to the complete loss of spinal cord nerve function below the plane of injury within a short period of time after the spinal cord is subjected to external force. The duration is usually a few hours to a few weeks, and occasionally a few months. The extent of damage cannot be properly assessed during spinal shock.
(4) Quadriplegia: impairment or loss of motor sensory function in the cervical segment of the spinal cord. Quadriplegia causes dysfunction of the extremities, trunk, and pelvic organs, but does not include brachial plexus lesions or extravertebral nerve injuries.
(5) Paraplegia: impairment or loss of motor-sensory function in the thoracic, lumbar or sacral segments of the spinal cord. Paraplegia does not involve upper extremity function, but may involve the trunk, legs, and pelvic organs. This term includes cauda equina and conus injuries but does not include lumbosacral plexus lesions or extradural nerve injuries.
(6) nerve root escape: refers to complete cervical or lumbar medullary injury patients, the injury plane above the spinal nerve root injury gradually recovered, so that the illusion of nerve injury plane “downward shift”.
3.Main examination indexes
(1) Ball (cavernous body)-anal reflex and anal reflex. Reflex contraction of the anal sphincter caused by stimulation of the male glans or female clitoris. Direct stimulation of the anus causes contraction of the rectal muscles called the anal reflex. The presence of these two reflexes suggests that spinal shock has ended.
(2) Anal finger examination. Anal finger examination is to insert a finger into the anus to check the sensation and movement of the anus to determine whether the patient’s injury is complete; anal reflex or bulbocavernose-anal reflex can also be performed to determine spinal shock. This is a mandatory test for patients with spinal cord injury.
(3) Partially preserved area. Refers to the neurological plane of complete injury below still retains part of the innervation of the cortical area and muscle ganglion.
4, the plane of injury and functional prognosis: spinal cord injury plane and functional prognosis directly related.
5, neurological injury plane assessment standards: neural plane refers to the lowest segment of the spinal cord with normal sensory and motor functions of the body bilaterally. The right sensory segment, left sensory segment, left motor segment and right motor segment are used to indicate the neural plane. The sensory and motor planes may not coincide and may be different on the left and right sides. The comprehensive judgment of the nerve plane is based mainly on the motor plane, but the T2-L1 injury cannot assess the motor plane, so it relies mainly on the sensory plane to determine the nerve plane. the C4 injury can use the diaphragm as the main reference for the motor plane. The neural plane was determined using the key muscle and key point approach.
The integral approach was used so that the severity of patients with different planes and injury classifications could be compared horizontally.
(1) Sensory injury plane key points: refers to the cutaneous landmarks of the sensory nerve plane. The sensory examination includes 28 pairs of cutaneous key points on both sides of the body (Table 3). Each key point was examined for pinprick sensation and light touch sensation and scored on three separate scales. 0=absent; 1=impaired (partial impairment or altered sensation, including sensory hypersensitivity); 2=normal; NT=unable to examine. The total score for pinprick sensation and light touch sensation on each side was 112 points for normal individuals. Selected items for sensory examination-positional sensation and deep pressure pain sensation, only the left and right side of the index finger and thumb were examined.
(2) Motor injury plane: key muscles refer to the landmark muscles that define the nerve plane. Due to the nature of one nerve innervating multiple muscles and one muscle innervated by multiple nerves, the key muscle with muscle strength level 3 is the motor nerve plane based on the relationship between the nerve segment and the muscle, but the muscle strength of the key muscle above this plane must be level 4. The motor score was calculated by adding up the scores of each key muscle by using the muscle strength (grade 0-5) as the score. The total score of motor planes on both sides of a normal person is 100.
IV. Rehabilitation treatment
(I) Early treatment
Rehabilitation intervention should be started as early as possible after the rescue period of spinal cord injury.
1, rehabilitation care
(1) Bed and mattress: For spinal stability, decompression bed, leather bed or general bed with air mattress can be used.
(2) Turning: Emphasize turning once every 2h to prevent skin pressure sores.
(3) Position: Patients can lie flat or on their sides, but all parts of the body in contact with the bed are required to be in uniform contact with the bed to avoid excessive local pressure to avoid pressure sores. If the patient’s condition permits, gradually let the patient transition from a flat position to a semi-recumbent and sitting position.
(4) Personal hygiene activities: Assist patients to groom and wash, paying attention to the use of neutral soap. Take care of the bowels and perineum, paying attention to avoiding local moisture to reduce the possibility of pressure sores. Wipe with soft paper after urination and defecation to avoid skin abrasions.
2.Ensure breathing
Acute high spinal cord injury can cause comorbidities such as pneumonia due to respiratory dysfunction and decreased ability to expel sputum. The method of light percussion of chest and postural drainage can be used to promote sputum excretion, and abdominal breathing is advocated.
3.Rehabilitation training
(1) Joint protection and training: Passive activities of all joints should be started immediately after the vital signs are stabilized, 1-2 times/d, and each joint should be moved several times in each axis to avoid joint contracture. When performing passive activities, pay attention to gentle, slow and rhythmic movements, and the range of activities should reach the maximum physiological range, but should not exceed it so as not to strain the muscles or ligaments. Hip abduction should be limited to 45° to avoid injury to the adductor muscles. The medial aspect of the knee joint should be protected to avoid injury to the medial collateral ligament.
In the case of fractures of the lower thoracic segment or lumbar spine, the hip flexion and knee flexion exercises should be controlled within the pain-free range and should not cause lumbar spine activities. Simultaneous flexion of the wrist and finger joints is prohibited to avoid straining the extensor tendons. Patients above the lumbar plane need special emphasis on hip flexion and cord muscle distraction exercises because it is only possible to sit independently in bed when the straight leg flexion of the hip joint reaches or exceeds 90°, which is the basis for various transfer training and bed activities. Patients with high spinal cord injuries can use shoulder orthoses in order to prevent shoulder subluxation. Ankle-foot orthoses can also be used to prevent foot drop and Achilles tendon contracture. Passive activity and training of the scapula and shoulder girdle muscles are of great significance for restoring the function of the upper limbs and should not be neglected.
(2) Upright adaptation training: gradually shift from prone position to semi-prone position, or sitting position, with the height of tilt gradually increasing daily, to the extent that there is no dizziness and other hypotensive discomfort symptoms, and gradually. An elastic bandage can be used for the lower limbs, and a lap band can be used to reduce venous blood stagnation. A week of adaptation time is required from the prone position to the upright position. The length of adaptation time is related to the plane of injury. Patients with cervicothoracic medullary injuries should be trained to rise in bed.
(3) bladder and rectal training: early after spinal cord injury there is often urinary retention, usually by way of indwelling catheterization. When indwelling catheters are placed, attention should be paid to the direction of the male catheter in the prone position must face the abdomen to avoid pressure on the urethral wall from the catheter, causing pressure sores in the urethra. When placing a catheter, attention should also be paid to the timing of clamping and placing the catheter. Bladder urine storage at 300-400ml is beneficial to the recovery of the bladder’s voluntary contraction function. Water intake and output should be recorded to determine the timing of urinary release. Daily water intake must be 2,500-3,000ml when catheterization is left in place to avoid the growth of bacterial colonization of the bladder urine.
Urinary tract infections in indwelling catheters can be asymptomatic and antibacterial medications are often ineffective; the best course of action is to remove the catheter. Once systemic bacteremia occurs it can be treated with sensitive antimicrobials. Intermittent clean catheterization can be used after removal of the catheter, i.e., a thinner catheter is used, the vulva is cleaned locally at the time of catheter insertion, and the catheter is rinsed with water after use and then placed in saline or disinfectant solution for storage. The main rectal problem after spinal cord injury is constipation. Enemas, anal-rectal lubricants, and laxatives may be used. Diarrhea is rare and is most often a combination of intestinal infections. It can be treated with antibacterial drugs and intestinal astringents.
(4) Pressure sore treatment: The main points are to keep the skin clean and dry; maintain good nutritional status; and avoid prolonged skin pressure.
(5) Physiotherapy: Physiotherapy is helpful in reducing inflammatory reactions and improving nerve function.
(6) Psychotherapy: Almost all spinal cord injury patients have serious psychological disorders after the injury, including extreme depression or depression, irritability, and even schizophrenia. Therefore, the rehabilitation treatment must be patient and meticulous psychological work to patients, giving encouraging answers to patients’ questions, helping them to build confidence and actively participate in rehabilitation training.