Posttraumatic myelopathy is a chronic neurodegenerative disease of the spinal cord that occurs after a spinal injury. The clinical picture of the disease depends on the level and nature of the damage, includes segmental and conductive motor and sensory disorders, musculotonic, reflex and pelvic disorders. Diagnostic search is carried out with the help of X-ray, electrophysiological and tomographic studies, if necessary, spinal puncture and cerebrospinal fluid analysis are performed. Conservative therapy consists of vascular and neurometabolic pharmaceuticals, physiotherapy methods, massage and physical therapy. According to the indications, surgical treatment is possible — spinal decompression, discectomy, spinal stabilization, etc.
General information
Posttraumatic myelopathy develops in the intermediate and late periods of spinal cord injury. According to some data, it is formed in 28% of patients with traumatic injuries of the spinal cord and spine. Considering that more than 50% of spinal injuries occur in people of the most able-bodied and active age (up to 45 years) and 70-80% lead to disability of the victim, it is necessary to emphasize the social significance of this problem. Therefore, the solution of issues of treatment and rehabilitation of such patients is an important task, which specialists in various fields of medical knowledge — traumatology, neurology, neurosurgery, vertebrology, orthopedics, rehabilitation work together on. In American medicine, posttraumatic myelopathy is included in the concept of traumatic spinal cord disease.
Causes
Posttraumatic myelopathy has as its root cause either direct damage to the spinal cord during spinal injury (spinal contusion with spinal contusion; injury to the spinal substance or the membranes of the brain with fragments of a vertebral fracture; penetrating gunshot, stab or cut wound; hematomyelia), or secondary damage to spinal structures due to compression of the spinal cord or vessels feeding it with post-traumatic hematoma, displaced vertebrae in case of rupture of the intervertebral disc or subluxation of the vertebra.
As a rule, posttraumatic myelopathy is formed against the background of spinal compression of the spinal cord that persists after spinal injury, causing compression of its structures or block of subarachnoid space. Compression can be aggravated by the progression of the adhesive process in the membranes of the spinal cord, obliteration of the subarachnoid space, the formation of a post-traumatic cyst or non-absorbable hematoma. If compression of the vessels feeding the spinal cord comes to the fore, then posttraumatic myelopathy is of a discirculatory (ischemic) nature, since it is formed against the background of chronic insufficiency of spinal circulation.
Posttraumatic myelopathy can be permanent and residual. In other cases, its progressive course is noted with an increase in neurological deficit. Factors contributing to the progression of myelopathy include: adhesive process in the spinal membranes, congenital spinal canal stenosis, the presence of an intervertebral hernia prolapsing into the spinal canal, hyperplasia of the posterior longitudinal ligament, deformation of the spinal canal and spinal cord. Progressive posttraumatic myelopathy is observed in several morphological variants. It may be based on diffuse or local atrophy of the cerebrospinal substance, myelomalacia (focal necrosis or gliosis), micro- or macrocystic degeneration. A combination of the described morphological changes is possible.
Symptoms
Posttraumatic myelopathy is characterized by a spinal syndrome of varying severity and variable in the clinic, the severity of which depends on the type of injury and the course of its acute period. As a rule, spinal syndrome includes segmental disorders corresponding to the level of lesion and conduction disorders below this level. The first include segmental sensory disorders and peripheral paresis with muscular hypotension and hyporeflexia. The second category includes conductor sensitivity disorders and central paresis with muscle spastic hypertonus and hyperreflexia.
High cervical myelopathy can be accompanied by bulbar paralysis, dizziness and vestibular ataxia, superficial sensory disturbances on the face. Damage to the spinal cord to the level of the sacral segments is accompanied by pelvic disorders of the central type — urinary retention in combination with its periodic incontinence, constipation and stool retention. With myelopathy at the SI-SIV level and below, pelvic disorders of the peripheral type are observed — true urinary incontinence and encopresis. Pelvic disorders often provoke the development of infectious diseases of the urinary system — urethritis, cystitis, pyelonephritis.
Often, posttraumatic myelopathy occurs with a dissociated variant of sensory disorders – the preservation of deep types of sensitivity and the loss of its surface types. Such a clinical picture resembles the course of syringomyelia, in connection with which it is distinguished as a syringomyelitic variant. If posttraumatic myelopathy is caused mainly by vascular disorders, then it proceeds with a predominance of dysfunction of motor neurons, the least resistant to hypoxia, in comparison with sensory neurons. In such cases, the disease may have a clinic similar to amyotrophic lateral sclerosis.
Diagnostics
At the diagnostic stage, a patient with myelopathy with a history of spinal injury should be examined not only by a neurologist, but also by a traumatologist. Neurological examination and electrophysiological examinations (EMG, ENG) help to determine the level of spinal lesion. To determine the state of bone structures at this level, it is possible to conduct radiography of the spine, or better — CT of the spine. The most comprehensive information about the state of the spinal cord to date is provided by MRI of the spine. It allows you to determine the nature of the spinal lesion, the degree of compression of the spinal cord, to identify the presence of a herniated disc, epi- or subdural hematoma, hematomyelia. MRI data are used to decide whether surgical treatment is appropriate. If it is impossible to use CT or MRI, contrast myelography is resorted to. However, this diagnostic method is less informative and is dangerous for the development of complications.
Posttraumatic myelopathy is differentiated with syringomyelia, ALS, spinal cord tumor, discogenic myelopathy, infectious myelopathy, etc. In some cases, it is advisable to conduct a lumbar puncture and a study of cerebrospinal fluid to clarify the diagnosis. Spinal MR angiography is recommended if vascular disorders are suspected. The presence of pelvic disorders is an indication for consultation with a urologist with cystoscopy, cystometry, EMG of the bladder.
Treatment
In cases where posttraumatic myelopathy has a stable course, conservative treatment aimed at improving blood circulation and neurometabolism at the level of the affected spinal segments is sufficient. From vasoactive drugs, coplamine, cavinton, papaverine, no-shpu are used, pentoxifylline, ginkgo biloba extract, nicotinic acid are used to improve microcirculation. Neurometabolites used in complex therapy include vitamin B1, vitamin B6, hydralizate from calf serum. Along with pharmacotherapy, physiotherapy procedures are carried out — UHF, electrical stimulation, thermal procedures (paraffin therapy, ozokerite), SMT, electrophoresis, reflexotherapy, etc. Physical therapy and massage are used to restore lost motor activity and prevent joint contractures, and mechanotherapy is used for deep paresis.
Progressive posttraumatic myelopathy requires the intervention of a neurosurgeon to resolve the issue of whether there are indications for surgical treatment. In order to eliminate compression of the spinal cord, decompressive operations are performed — laminectomy and facetectomy, in the presence of post-traumatic hernia, discectomy is performed. According to the indications, drainage of a post-traumatic cyst, elimination of post-traumatic deformation of the vertebral column, fixation of the spine with its post-traumatic instability is carried out.
Posttraumatic myelopathy, accompanied by pelvic disorders, may require urological manipulations — catheterization of the bladder, its flushing, installation of a Foley catheter. In case of infection of the urinary tract, appropriate antibacterial treatment is prescribed.
Prognosis and prevention
During the first two years after the spinal injury, 70% of patients have partial or complete regression of neurological symptoms, 9% of patients have its progression, 21% of the condition remains unchanged. Subsequently, about half of the victims of posttraumatic myelopathy have a stable course, 30% of patients have some gradual improvement and functional adaptation to the defect that has arisen. In 20% of cases, posttraumatic myelopathy is characterized by a slow progressive course with a gradual aggravation of the existing symptoms.
Prevention of myelopathy is closely related to the prevention of injuries in general and spinal injuries in particular, as well as to the adequacy and timeliness of treatment of spinal cord injuries. Patients with spinal injury should be under the supervision of a traumatologist and neurologist, undergo a long course of rehabilitation with careful dosing of loads.