Spinal cord edema is a nonspecific pathological process in which there is an excessive accumulation of fluid in the intercellular spaces. The disease occurs as a complication of spinal cord injury, tumor process, demyelinating or vascular pathologies. The condition is manifested by ascending paralysis, loss of all types of sensitivity, lack of reflexes, and other symptoms, taking into account the root cause. Diagnosis of edema requires CT or MR scans of the spinal cord, radiography of the spine. Treatment includes massive dehydration, neurometabolic support, neurosurgical operations (according to indications).
ICD 10
G95.1 Vascular myelopathies
General information
The true prevalence of the condition has not been established, since spinal cord edema serves as a universal response to traumatic injury. It occurs in all patients with complicated spinal injury. After surgical removal of neoplasms, the probability of edema is about 0.6%, The pathology is widespread in practical neurology, is dangerous to the life and health of the patient, therefore, the development of new methods of diagnosis and effective treatment of spinal cord edema does not lose relevance.
Causes
The main cause of edema is spinal cord injury (SCI) – damage that is accompanied by contusion, violation of the anatomical integrity of the spinal cord. Pathology occurs in the initial acute period (the first 2-3 days), significantly aggravates the patient’s condition after injury. In addition to SCI, the following diseases can be the causes of edema:
- Spinal cord tumors. Edema increases during the first 2-5 days after surgical removal of neoplasms, especially when they are localized in the upper neck. The condition causes 50% of cases of death of patients in the early postoperative period.
- Degenerative diseases. With organic demyelinating lesions of the spinal cord (amyotrophic lateral sclerosis, multiple sclerosis), foci of neurodegeneration are formed, which trigger the process of impaired cerebrospinal fluid dynamics, accumulation of interstitial fluid. Edema is also possible with transverse myelitis, other inflammatory spinal diseases.
- Vascular disorders. Disorders of the cerebrospinal circulation, which can cause swelling of the nervous tissue, are possible with congenital vascular malformations or acquired lesions of the vascular system of the spinal cord. Less often, the condition is formed as an iatrogenic complication — after therapeutic blockades, spinal anesthesia, and aortography.
Pathogenesis
Several factors are involved in the mechanism of edema development: traumatic, circulatory, vascular, and tissue. There is damage to tissue elements, accumulation of pro-inflammatory mediators, violation of vascular permeability, which is accompanied by excessive filtration of fluid into the interstitial space. At the same time, the spinal cord increases in volume, and since it is limited by the space of the spinal canal, compression phenomena occur.
Post-traumatic edema causes spinal cord ischemia, which causes damage to the myelin sheaths of the nerves. Subsequently, a specific gliosis is formed — the replacement of dead neurons with neuroglia cells, which is accompanied by a violation of spinal functions. These changes are visible on MRI in the form of myomalacia: in the first six months, the condition may be partially reversible, then a persistent neurological deficit is fixed.
Symptoms
The clinical picture is due to the underlying disease. With the transferred SCI, the leading symptom is back pain, which is concentrated at the place of application of mechanical force, spreads to other parts of the spine. According to the level of damage, sluggish paralysis of the distal parts of the legs or all the lower extremities develops, supplemented by paresis of the abdominal muscles, back, chest.
When the lesion is localized at the level of the upper neck of the spinal cord, tetraplegia of the central type is observed with loss of sensitivity, which is complemented by sluggish paralysis of the cervical muscles. If the injury occurred in the lower neck, signs of damage to the brachial plexus, one- or two-sided Gorner syndrome, different position of the arms (lowered, folded on the chest, thrown back) are determined.
Edema of the spinal cord is steadily increasing, after a few hours the pathological process captures a significant number of segments. Neurological symptoms gradually worsen: ascending paralysis appears, which spreads from the lower to the upper extremities, trunk, neck and head muscles. Convulsive syndrome may occur.
Complications
Spinal cord edema is a formidable condition that, without treatment, can quickly spread to the overlying segments, reaching the cerebral level. When the medulla oblongata is involved in the process, the patient’s vital functions are disrupted: respiratory (Biota breathing), cardiovascular activity (slowing of the pulse, hypotension). There is a lack of tendon and periosteal reflexes, dilation of the pupils, immobility of the eyeballs.
With SCI, spinal edema is often complicated by spinal shock, which is characterized by overexpression of the organ or deprivation of supraspinal influences from the cerebral structures. Patients are diagnosed with atonic paralysis, the absence of all types of reflexes and sensitivity below the level of trauma. There are also disorders of the functions of the pelvic organs, rapidly increasing trophic disorders.
The probability of death is up to 25%. With successful relief of urgent complications, they may appear at the stage of restoration of neurological functions. Due to irreversible damage to neurons in the residual period, there is a deficit of motor functions below the damaged level, complete or dissociative sensitivity disorder. Some patients receive disability after the disease.
Diagnostics
The examination begins with a standard examination by a neurologist. The patient has paresis and paralysis, various sensitivity disorders, areflexia and other symptoms of cerebrospinal lesion. The injury is indicated by local soreness, signs of vertebral fracture, a characteristic anamnesis. Instrumental and laboratory methods are used to confirm the diagnosis:
- MRI of the spinal cord. The study is considered the most informative for studying the structure of the organ, detecting local lesions of the nervous tissue, symptoms of the underlying disease that caused edema. In the absence of the possibility of MRI, a CT scan of the spinal cord is performed.
- Radiography of the spine. In case of back injury and physical signs of vertebral damage, the study is necessary to visualize the fracture site and its nature. A CT scan of the spinal column provides more accurate information about the injury.
- ENMG. Electroneuromyography is prescribed after relief of an acute condition to assess the function of neuromuscular transmission, control the dynamics of recovery.
- Blood test. General clinical and biochemical studies are necessary to determine the water-electrolyte balance, to clarify the general condition of the patient, to detect concomitant problems or complications.
Treatment
Conservative therapy
Medical treatment is carried out according to the general principles of emergency care in neurology. Therapy is aimed at reducing the amount of fluid in the interstitial, thereby reducing the compression of the organ, preventing irreversible organic changes. Several groups of drugs are used in the treatment of edema:
- Dehydrators. For this purpose, drugs from the category of osmotic diuretics are prescribed, which are supplemented with saluretics. To potentiate the action of diuretics, patients are injected with a hypertonic glucose solution, a solution of magnesium sulfate.
- Amino acids. The role of L-lysine escinate in the pathogenetic therapy of edematous phenomena has been proved. This drug normalizes vascular-tissue permeability, has a decongestant effect, increases vascular tone. The medicine is effective during the first days of the disease.
- Neurometabolites. To improve energy and other biochemical reactions in the spinal cord tissue, drugs from the group of antihypoxants, nootropics are used. They are recommended from the acute period of edema to the recovery period.
- Glucocorticosteroids. The effectiveness of hormonal drugs is due to their ability to stabilize cell membranes, strengthen the vascular wall. The drugs enhance the effect of diuretics and lysine.
In a serious condition, damage to the muscles of the diaphragm and neck, the threat of respiratory failure, an emergency transfer of the patient to a ventilator is necessary. Anticonvulsants, painkillers, anti-inflammatory drugs are prescribed as symptomatic treatment for certain conditions accompanied by spinal cord edema. In case of penetrating injuries, antibiotic therapy is indicated to prevent infectious complications.
Surgical treatment
In case of traumatic or tumor genesis of edema, the patient needs qualified help from neurosurgeons. The type and scope of the operation is selected individually: fixation of vertebral fractures with plates or screws, installation of lumbar drainage, excision of neoplasms, etc. In case of compression of the spinal cord, surgical intervention is carried out as early as possible in order to prevent irreversible changes.
Prognosis and prevention
Spinal cord edema has an unfavorable course, the risk of death in the first hours of the disease, as well as a high probability of disability in the recovery period. Timely initiation of treatment significantly increases the chances of recovery of neurological deficits. Prevention of the condition consists in the prevention of injuries, early detection and treatment of tumor, neurodegenerative, vascular diseases.