Spinal cord injury is an injury as a result of which the functions and anatomical integrity of the spinal column and/or spinal cord and/or its main vessels and/or spinal nerve roots were disrupted. Clinical manifestations depend on the level and severity of the injury; they can range from transient paresis and sensitivity disorders to paralysis, movement disorders, disorders of pelvic organs, swallowing, breathing, etc. In the diagnosis of spinal cord injuries, spondylography, myelography, MRI, CT, lumbar puncture are used. Treatment of spinal cord injury may include reposition, immobilization, fixation of vertebrae, decompression of the brain with subsequent rehabilitation therapy.
General information
Spinal cord injury is a violation of the anatomical and physiological relationships between the spinal column and the structures of the spinal canal (membranes, substances, vessels of the spinal cord, spinal nerves), leading to partial or complete loss of relevant functions. In different countries, the frequency of spinal cord injuries varies from 30 to 50 cases per 1 million population. Among the victims, men of young working age (20-39 years old) predominate, which determines not only the medical, but also the social significance of the problem. Neurosurgery, neurology and traumatology are engaged in the organization and provision of timely specialized assistance to victims with spinal cord injury.
The causes of damage to the spine and spinal cord in spinal cord injury can be both direct traumatic effects on the spine, and its indirect injury when falling from a height, in road accidents, forced bending during blockages, etc.
Classification
Spinal cord injuries are divided into isolated, combined (in combination with mechanical damage to other organs and tissues) and combined (in combination with damage to thermal, radiation, toxic and other factors). According to the nature of the injury, spinal cord injuries are divided as follows:
- Closed (without damage to paravertebral tissues);
- Open, not penetrating into the spinal canal;
- Open, penetrating into the spinal canal — through (damage to the spinal canal through) and blind (the injuring object remains in the spinal canal) and tangential.
- Open spinal injuries can be gunshot (fragmentation, bullet) or non-gunshot (cut, chopped, stabbed, etc.).
Spinal injuries with spinal cord injury are divided into the following nosological forms: spinal contusion, partial or complete rupture of the capsular ligamentous apparatus of the vertebral motor segment, self-corrected dislocation of the vertebra, rupture of the intervertebral disc, partial and complete dislocations of the vertebrae, vertebral fractures, fractures (a combination of displacement of the vertebrae with a fracture of their structures).
Injuries to two or more adjacent vertebrae and/or intervertebral discs are called multiple spinal column injuries; injuries to two or more non—adjacent vertebrae and/or intervertebral discs are called multilevel spinal column injuries. Multiple fractures of the vertebrae at several levels are called multiple multilevel injuries of the vertebral column.
It is important to take into account that unstable injuries can occur even without vertebral fractures: with rupture of the capsular ligamentous apparatus of the vertebral motor segment and intervertebral disc, with self-corrected dislocations of the vertebrae.
To determine the therapeutic tactics for spinal cord injury, it is not so much an assessment of the functional state of the spinal cord that is of great importance, as a nosological diagnosis. Some types of spinal cord injuries (concussion and bruising) are treated conservatively, others (compression of the brain, its main vessels and roots, hematomyelia) are treated promptly. There are the following types of lesions.
- Spinal cord concussion.
- Spinal cord injury (severity is determined retrospectively due to the presence of spinal shock in the acute period, usually leading to a syndrome of complete violation of the reflex activity of the spinal cord for an average of three weeks).
- Compression of the spinal cord (acute, earlier, later) with the development of compression myelopathy.
- Anatomical break (“complete damage” — according to American authors) of the spinal cord.
- Hematomyelia (hemorrhage in the spinal cord or intracerebral hematoma).
- Hemorrhage in the intervertebral spaces.
- Damage to the main vessel of the spinal cord (traumatic spinal cord infarction).
- Damage to the roots of spinal nerves (they are divided in the same way: concussion, bruise, compression, rupture, circulatory disorders and hemorrhages in the root).
Symptoms and diagnosis
The diagnostic algorithm for spinal cord injury includes the following stages: interviewing the victim, the doctor or the witness of the incident who delivered the patient to the hospital, with clarification of complaints and their dynamics; examination and palpation; neurological examination; instrumental research methods. The latter include: spondylography, lumbar puncture with cerebrospinal fluid tests, CT and/or MRI of the brain, myelography, CT myelography, vertebral angiography.
When collecting anamnesis, it is necessary to find out the mechanism and time of injury, the localization of pain, motor and sensory disorders; ask about what positions or movements ease or increase pain in the spine; ask if the victim moved his legs and arms immediately after the injury. The development of neurological disorders immediately after injury indicates a spinal cord injury. It can be isolated or combined with brain compression. In the case of the appearance and increase of neurological disorders (which can be detected only in the absence of spinal shock, characteristic of a brain injury), early or late compression of the spinal cord and its roots with a hematoma or damaged bone and cartilage structures that have shifted into the spinal canal for a second time should be assumed.
When talking to a patient, it is necessary to clarify all complaints in order to exclude damage to other organs and systems. If the patient does not remember the circumstances of the incident, it is necessary to exclude a traumatic brain injury. In case of sensitivity disorders, there may be no pain below the area of brain damage, therefore all parts of the spine are subject to mandatory palpation and X-ray examination. The examination allows you to identify the localization of traces of trauma, visible deformities, determine the level of mandatory X-ray examination and the algorithm of targeted treatment of other organs and tissues. So, in the presence of bruises and deformities in the chest area, it is necessary to exclude rib fracture, lung rupture, hemothorax and pneumothorax. Spinal deformity in the thoracolumbar region can be accompanied not only by injury to the vertebrae at this level, but also by damage to the kidneys, spleen, liver and other internal organs.
When examining a patient with a spinal cord injury, the absence or weakness in the extremities, the type of breathing, the participation of intercostal muscles in respiratory movements, the tension of the abdominal wall are determined. Thus, the diaphragmatic type of breathing in combination with tetraplegia indicate injury to the cervical spinal cord below the IV segment. Palpatory examination of the spine allows you to identify the localization of pain, crepitation of fragments, deformation of the line of spinous processes or an increase in the distance between them. It is forbidden to determine the pathological mobility of the vertebrae by palpation, as this can lead to additional damage not only to the nervous tissue, but also to blood vessels and other tissues and organs.
The purpose of instrumental examination methods for spinal cord injury is to distinguish compression of the spinal cord, its main vessels and roots as quickly as possible from other types of injuries subject to conservative treatment. Spinal shock (areflexia and atony of paralyzed muscles) in the acute period of injury, as well as the inability to empty the pelvic organs independently are indications for the active use of instrumental research methods for differential diagnosis. Their early use allows not only to recognize compression of the spinal cord, but also to determine the localization, nature, cause of compression and features of spinal injury. The diagnostic algorithm of instrumental studies in the acute period of spinal cord injury is as follows.
- Spondylography in anterior and lateral projections.
- Spondylography in oblique projection (for the study of arched joints and intervertebral openings) and through an open mouth (for the diagnosis of atlantoaxial segments).
- CT.
- Lumbar puncture with cerebrospinal fluid tests.
- Myelography is ascending and descending.
- CT-myelography.
- SSVP.
- Vertebral angiography.
Solving diagnostic problems with spinal cord injury does not always require all of the above diagnostic methods. Based on the results of instrumental research methods and their comparison with clinical signs, compression of the spinal cord, its main vessels and spinal nerve roots is diagnosed, in which surgical treatment is indicated.
When assessing the neurological status in spinal cord injury, the ASIA/ISCSCI scale is used – the International Standard for Neurological and Functional Classification of Spinal Cord Injuries. This unified scale allows us to quantify the functional state of the spinal cord and the degree of neurological disorders. As criteria for the condition of the spinal cord, an assessment of muscle strength, tactile and pain sensitivity, reflex activity in the anogenital zone is used.
Treatment
It is necessary to immobilize the spine, carefully and quickly transport a patient with spinal cord injury to the nearest multidisciplinary hospital, which has specialists and facilities for the treatment of spinal patients, or (preferably) to a specialized neurosurgical department. The patient in an unconscious state at the place where he was found after an accident, falling from a height, beating and other incidents that may result in spinal cord injury, it is necessary to immobilize the spine. Such a patient should be regarded as a patient with spinal injury until the opposite is proven.
Indications for emergency surgery for spinal cord injury:
- the appearance and / or increase of neurological spinal symptoms (the presence of a “light gap”), which is characteristic of those types of early compression that are not accompanied by spinal shock;
- blockade of liquor routes;
- deformation of the spinal canal by X-ray negative (hematoma, traumatic intervertebral hernia, damaged yellow ligament) or X-ray positive (bone fragments, structures of dislocated vertebrae or due to pronounced angular deformation) compression substrates in the presence of appropriate spinal symptoms;
- isolated hematomyelia, especially in combination with blockade of the cerebrospinal tract;
- clinical and angiographic signs of compression of the main vessel of the spinal cord (urgent surgical intervention is indicated);
- hyperalgic and paralytic forms of spinal nerve roots;
- unstable injuries of vertebral motor segments that pose a threat to secondary or intermittent compression of the spinal cord.
Contraindications to surgical treatment of spinal cord injury:
- traumatic or hemorrhagic shock with unstable hemodynamics;
- concomitant damage to internal organs (internal bleeding, danger of peritonitis, bruising of the heart with signs of heart failure, multiple rib injuries with hemopneumothorax and respiratory failure);
- severe traumatic brain injury with impaired level of consciousness on the Glasgow scale of less than 9 points, with suspected intracranial hematoma;
- severe concomitant diseases accompanied by anemia (less than 85 g/l), cardiovascular, hepatic and/or renal insufficiency;
- fatty embolism, pulmonary embolism, non-fixed limb fractures.
Surgical treatment of spinal cord compression should be carried out in the shortest possible time, since 70% of all irreversible ischemic changes resulting from compression of the brain and its vessels account for the first 6-8 hours. Therefore, the existing contraindications to surgical treatment should be eliminated actively and as soon as possible in the intensive care unit or intensive care unit. Basic therapy includes the regulation of respiratory functions and cardiovascular activity; correction of biochemical parameters of homeostasis, the fight against brain edema; prevention of infectious complications, hypovolemia, hypoproteinemia; regulation of pelvic organ functions by installing the Monroe tidal system or catheterization of the bladder at least four times a day; correction of microcirculation disorders; normalization of rheological parameters of blood; administration of angioprotectors, antihypoxants and cytoprotectors.
With atlantooccipital dislocation, patients are shown early reposition by craniocervical traction or simultaneous closed reduction by the Richet-Guther lever method. After the removal of atlantooccipital dislocation, immobilization with a thoracocranial plaster cast, a head holder is used. In cases of complicated dislocations of the cervical vertebrae in the first 4-6 hours (before the development of brain edema), a one-time closed dislocation reduction using the Richet-Guter method is shown, followed by external fixation for two months. If more than 6 hours have passed after a spinal cord injury and the patient has a syndrome of complete violation of the reflex activity of the brain, an open reduction of the dislocation by posterior access in combination with posterior or anterior spinal fusion is shown.
In case of comminuted fractures of the cervical vertebral bodies and their compression fractures with an angular deformation of more than 11 degrees, anterior decompression of the brain is shown by removing the bodies of broken vertebrae with their replacement with a bone graft, a cage with bone chips or a porous titanium-nickel implant in combination with or without a titanium plate. If more than two adjacent vertebrae are damaged, anterior or posterior stabilization is shown. When the spinal cord is compressed from behind by fragments of a broken vertebral arch, posterior decompression is shown. If the damage to the vertebral segment is unstable, decompression is combined with posterior fusion, preferably a transpedicular structure.
Stable compression fractures of the thoracic vertebral bodies of type A1 and A2 with kyphotic deformation of more than 25 degrees, leading to anterior compression of the spinal cord by the type of its spreading and tension on the blade, are treated with simultaneous closed (bloodless) reclination in the first 4-6 hours after injury or open reclination and decompression of the brain with intervertebral fusion with ties or other structures. Fractures of the thoracic vertebrae in the acute period are easy to repair and recline, therefore, posterior access to the spinal canal is used for decompression of the brain. After laminectomy, external and internal decompression of the brain, local hypothermia, transpedicular fusion is performed, which allows for additional repositioning and reclining of the spine.
Given the large reserve spaces of the lumbar spine, decompression of the roots of the ponytail is performed from the rear access. After removal of compressing substrates, reposition and reclination of vertebrae, transpedicular fusion and additional correction of the vertebral column are performed. After two to three weeks, anterior fusion can be performed with an autostomy, cage or porous implant.
In case of gross deformation of the spinal canal by large fragments of the lumbar vertebral bodies, an anterolateral retroperitoneal access can be used to reconstruct the anterior wall of the spinal canal and replace the removed vertebral body with a bone graft (with or without a fixing plate), a porous titanium-nickel implant or a cage with bone chips.
During the rehabilitation period after a spinal cord injury, neurologists, vertebrologists and rehabilitologists treat the patient. Exercise therapy and mechanotherapy are used to restore motor activity. The most effective combination of physical therapy with physiotherapy methods: reflexology, massage, electrical stimulation, electrophoresis and others.
Forecast
About 37% of victims with spinal cord injury die at the pre-hospital stage, about 13% — in the hospital. Postoperative mortality with isolated compression of the spinal cord is 4-5%, with a combination of compression of the brain with its contusion — from 15 to 70% (depending on the degree of complexity and nature of the injury, the quality of medical care and other factors). A favorable outcome with full recovery of the victim with stab and cut wounds of the spinal cord was recorded in 8-20% of cases, with gunshot wounds of the spinal cord — in 2-3%. Complications arising in the treatment of spinal cord injury, aggravate the course of the disease, increase the length of hospital stay, and sometimes lead to death.
Comprehensive diagnostics and early decompression-stabilizing operations contribute to reducing complications and postoperative mortality, improving the functional outcome. Modern fixation systems implanted into the spine allow for early activation of patients, which helps prevent the appearance of bedsores and other undesirable consequences of spinal cord injury.
