Symptom complexes of injuries of various parts of the spinal cord. Spinal cord injury Spinal cord injury complete recovery

Injuries to the spine and spinal cord are divided into closed- without violating the integrity of the skin and underlying soft tissues, open- with violation of the integrity of the latter (gunshot and stab wounds).
Closed injuries of the spine in turn are divided into two groups:

1. Uncomplicated spinal injuries without dysfunction of the spinal cord or its roots.
2. Complicated injuries of the spine with impaired function of the spinal cord and its roots:
   1. with X-ray revealed fractures, fracture-dislocations, dislocations of the vertebral bodies;
   2. without radiographically detectable spinal injuries.

In peacetime, the frequency of damage to the spinal cord and its roots with closed spinal injuries is about 30% of cases. Spinal fractures with spinal cord injury most often occur in the mining industry, in transport, less often in production, at home, during sports exercises (especially when diving).

Most often, spinal fractures occur in the area of ​​Thxn-Ln, which is explained by the predominant transfer of kinetic forces to the area of ​​articulation of the movable sections of the spine with relatively inactive ones. In second place in frequency are fractures localized in the Cv-Cvii region, i.e., in the region of the mobile parts of the neck on the border with the inactive thoracic region.

Of particular note is the fairly common discrepancy between the x-ray picture of bone displacement and the severity of neurological pathology. With a significantly pronounced picture of fracture and displacement of the vertebrae, there may be no clinic of spinal cord injury, or it is expressed to a small extent and, conversely, in the absence of radiological evidence of brain compression, there may be various symptoms lesions of the spinal cord up to the syndrome of complete transverse break.

Types of injuries of the spine and spinal cord

All violations of the integrity and functionality of the spine and spinal cord are divided into open and closed. That is, accompanied by damage to soft tissues and skin and not marked as such, respectively. The former create an additional danger in the form of the likelihood of spinal cord infection. In addition, there are open penetrating injuries, which are characterized by damage not only to soft tissues, but also to the hard shell of the brain. Closed injuries can lead to dysfunction of the spinal cord and roots (complicated) or not be accompanied by such complications.

Classification of injuries is possible according to the causes (bending, impact, etc.), nature (bruise, fracture, dislocation, etc.). An important role is also given to the differences in injuries in terms of their stability, that is, the likelihood of displacement and its further repetition. In addition, the types of injuries differ in their localization in different parts of the spine.

Cervical spine and spinal cord injury

Injury cervical spine poses the greatest threat to the life and health of the patient. In the case of spinal cord injury, the likelihood of death is extremely high due to respiratory arrest following diaphragmatic paralysis. More often than others, such injuries (even without violating the integrity of the spinal cord) lead to limited musculoskeletal function and severe pain, in case of an effect on the spinal cord, there is a high probability of loss of sensitivity. Operative intervention in this department is also dangerous, therefore the decision on the need for such is made in a situation where the risk is justified by saving a life or is reduced by general factors.

Injury of the lumbar spine and spinal cord

The most common injury in clinical practice is the lumbar injury, since this localization experiences the maximum load during flexion and extension, lifting weights, etc. As a rule, the injury occurs on the upper, inactive part, in the region of I-III vertebrae. This localization of the lesion is characterized by periodic or constant sharp pains, limited movements when turning and bending the body. Often accompanied by disruption of the gastrointestinal tract, intestinal paresis and delays in work Bladder, bloating and vomiting. Possible violation of reflex activity. The likelihood of loss of sensitivity is quite high. Rehabilitation, taking into account thermal procedures, exercise therapy and massage, is highly effective in case of damage to the lumbar spine. Often, patients are recommended pastel mode for up to two months. With compression of the structure of the nerve or spinal cord, surgery is indicated.

Injuries of the thoracic spine and spinal cord

It should be noted that the thoracic spine is inactive and more stable. However, at the same time, it is limited by the mobile cervical and lumbar region, in addition, due to the structure of the human body, this part of the spine has a narrow spinal canal. Often these facts become decisive in the event of an injury, as they cause complications. Most often, injuries of the thoracic region are bruises or horizontal fractures, wedge-shaped deformities. Comminuted and compression fractures are less common. As a rule, the methods of treatment are conservative. Surgical intervention is used in case of complicated injury. In all cases, a sufficiently long bed rest with minimization of vertical loads is recommended. After treatment, rehabilitation measures are required, including exercise therapy.

Symptoms of injuries of the spine and spinal cord

Symptoms vary depending on the severity of the injury. In particular, spinal contusion is expressed in soreness, swelling of the affected area. The pain, as a rule, "spills", but can increase to acute, movements are partially limited, bring painful, unpleasant sensations. Subcutaneous hemorrhages accompanying trauma are less common. There is pain on palpation. History usually includes heavy lifting, muscle contraction, stroke, etc.

In case of fractures and dislocations, local pain sensations arise, the pain can “radiate” to the opposite or diseased side, “spill”. In case of violation of the integrity of the transverse processes, the symptom of Payr and / or the stuck heel manifests itself. Whiplash injuries lead to pain in the cervical region and head, numbness of the limbs, impaired neuralgia, and memory functions are often observed. Transdental dislocation of the atlas is often the cause of death due to a sharp impact on the medulla oblongata. In other cases, the position of the head may be fixed or unstable, pain is manifested, often complete or partial loss of sensitivity in the neck, neurological symptoms.

Spinal cord injury is also expressed depending on the level of criticality. The most critical area is the level of the IV vertebra of the cervical region. An injury that occurs above it leads to paralysis of the diaphragm, which in turn leads to a complete cessation of breathing and death. In all other cases, manifestations may consist in a violation or complete absence of sensitivity, limited functionality of the pelvic organs. In various cases, severe burning pain, partial or complete loss of motor function, impaired reflex activity, and spasm may occur. Complicated breathing, coughing with pulmonary secretions are also symptoms of spinal cord injury. It also has a negative effect on sexual function. Blood and lymph flow can also slow down, leading to the rapid formation of pressure sores. Rupture of the spinal cord is characterized by ulceration of the gastrointestinal tract with profuse bleeding.

Morphological changes in the spinal cord in closed spinal injuries

At closed injury spine various degrees of spinal cord injury are observed - from microscopic to bruises, crush injuries and anatomical breaks, respectively, according to the level of fracture and dislocation of the spine. Cerebral edema can reach such a degree that the brain fills the entire lumen of the dural canal. In pathoanatomical examination in cases of death after closed injuries of the spine with clinical manifestations lesions of the spinal cord, lesions of neuronal structures in the form of chromatolysis (regarded as a morphological manifestation of spinal shock), foci of necrosis and softening, swelling and irregularity of the structure of axons, degeneration of myelin sheaths, small punctate, central hematomyelia, sometimes intra- and extradural hemorrhages, swelling of the spinal cord, root damage.

Due to direct damage to molecular structures, disorders of blood supply and oxygen starvation, damage to blood vessels and tissue of the spinal cord, perifocal edema, impaired liquor circulation in the spinal cord, necrosis, softening, degenerative changes in cellular and conductive structures and vascular system, processes of organization and scarring, accompanied by pathological changes in the membranes, which is clinically manifested by various syndromes.

Neurological symptoms in spinal injuries

Spinal fractures without spinal cord dysfunction are more common fractures with a disorder of these functions. These fractures are not life threatening and proper treatment full recovery is often observed. Spinal fractures in combination with spinal cord injury are among the most unfavorable prognostic injuries. The frequency of complicated fractures of the spine is about 25% of all fractures and depends on the nature and location of the injury, as well as the conditions of its occurrence.

With all types of spinal injury, all degrees of spinal cord injury can occur - from the mildest to the irreversible syndrome of transverse injury. With complicated spinal injuries, the syndrome of complete transverse spinal cord injury occurs in approximately 50% of the victims.

There are the following syndromes of traumatic injury of the spinal cord:

• shake
• contusion (contusion of the spinal cord)
• crush

under the term " concussion of the spinal cord”(commotio spinalis) understand a reversible violation of its functions in the absence of visible damage to the brain structure. It is assumed that the symptoms of concussion of the spinal cord are the result of dysfunction of nerve cells with a sudden shutdown of supraspinal influences, as well as microstructural changes and parabiotic state of nerve cells and nerve fibers below the level of damage. With mild forms of concussion, the reverse development of symptoms occurs in the next few hours after the injury, with more severe forms - in the coming days or weeks (up to a month).

In clinical practice, the initial period of injury, characterized by a sudden loss of motor, sensory and reflex activity, is denoted by the term " spinal shock". The duration of this period in cases of reversibility of neurological symptoms is very variable and can reach several weeks and even months.

under the term " spinal cord contusion”(contusio spinalis) understand bruising it with damage to the tissue itself. At the same time, in the final stage of the disease, residual effects of impaired brain function can be observed. Spinal cord injury in most cases is accompanied by a picture of spinal shock, i.e., temporary paresis, paralysis, hypotension, areflexia, sensory disorders, dysfunction of the pelvic organs and some autonomic functions (sweating, pilomotor reflexes, false temperature, etc.). Symptoms of spinal shock obscure the true picture of damage to the spinal cord, and only after the signs of shock have passed, persistent symptoms remain, which are the result of brain contusion or crushing.

In most cases, the picture of spinal cord injury reaches its maximum severity immediately after spinal injury, which indicates the importance of a sudden change in the configuration of the spinal canal at the level of injury. Only in relatively rare cases in the subsequent period is there a progression of neurological symptoms as a result of edema and hemorrhage. During a neurological examination in the next few hours after the injury, it is necessary first of all to find out whether there is a picture of a complete transverse lesion of the spinal cord or only a partial loss of its functions. The preservation of any elements of motility or sensitivity below the level of damage indicates partial lesion spinal cord. Long-term priapism and early trophic disorders, as a rule, indicate irreversible brain damage. If no signs of functional recovery are seen in the clinical picture of a complete transverse lesion in the next 24-48 hours, then this usually indicates the irreversibility of the damage and is a poor prognostic sign.

Symptoms of spinal cord injury in spinal injury reflect different phases of the disease. Initially, there are signs of spinal shock in the form of suddenly developed flaccid paraplegia, lack of sensitivity, areflexia below the level of the lesion, urinary retention and defecation, often with priapism and lack of sweating below the level of the lesion.

Histologically, this phase is manifested by chromatolysis of affected neurons. Then the spinal reflex activity increases with the appearance of spastic phenomena, spinal automatism and, in some cases, flexion spasm. Recovery of reflex activity begins much distal to the level of the lesion, rising higher up to this level.
However, with the development of severe urogenic sepsis, bronchopneumonia, or intoxication due to bedsores, the stage of spinal reflex activity may again be replaced by flaccid paraplegia and areflexia, resembling the stage of spinal shock.

Hematomyelia. In cases of localization of hematomyelia in the cervical region, lethal outcomes are often observed. In the pathogenesis of respiratory disorders in case of damage at the level of Civ-Cv of the cervical segment, the developing paralysis of the diaphragm is important. In the presence of spinal shock, its symptoms obscure the picture of hematomyelia, and it can manifest itself clinically much later.
Syndrome of damage to the anterior parts of the spinal cord. The syndrome of damage to the anterior spinal artery, described mainly in vascular lesions of the spinal cord, can also be observed in traumatic lesions, since the anterior spinal artery supplies 2/3 of the substance of the spinal cord. This syndrome is characterized by paralysis with dissociated disorders of sensitivity and dysfunction of the pelvic organs, but in the absence of signs of damage to the posterior columns.

The syndrome of damage to the anterior spinal cord manifests itself immediately after injury with complete paralysis of the limbs and hypesthesia to the level of the affected segment, and the sensations of movement and position of the limbs and partially vibrational sensitivity are preserved. This syndrome may also result from a flexion injury. In its pathogenesis, compression of the anterior sections of the spinal cord by the posteriorly displaced vertebral body is of particular importance, which is aggravated by tension of the odontoid ligaments and deformation of the lateral parts of the brain. If at the same time careful -X-ray examination excludes bone damage, then acute hernial prolapse of the posterior intervertebral disc should be suspected. The absence of a block during liquorodynamic tests does not exclude the permanent anterior compression of the spinal cord, and under these conditions there are indications for laminectomy with transection of the odontoid ligaments. In such cases, sometimes it is necessary to do pneumoencephalography, which specifies the degree and localization of the displacement of the anterior structures of the damaged vertebra and the protrusion of the destroyed discs into the lumen of the spinal canal. Damage to the anterior spinal cord in complicated spinal injuries is common, and is observed, according to Ya. L. Tsivyan et al. (1976), in 4/s patients with injuries of the spine and spinal cord. In such cases, if after skeletal traction and forced reduction during the day there is at least a slight regression of neurological pathology, indicating the possibility of restoring the function of the spinal cord, the most appropriate is the operation of anterior decompression of the spinal cord, with stabilization of the anterior structures of the damaged spine.

Circulatory disorders in the spinal cord

In the past decades, the pathology of the spinal cord in spinal injury was considered mainly as a mechanical injury. However, in last years concepts are put forward that emphasize the importance of circulatory disorders in certain segments of the brain with the development of ischemia, tissue hypoxia and anoxia with spinal prolapse. functions.

Experimental, pathological and clinical data show that circulatory disorders in. the spinal cord can occur with concussion of the spinal cord and is considered as a reflex. At the same time, vasomotor disorders, stasis, diapedetic nature of plasmorrhea with the development of cerebral edema and petechial hemorrhages disrupt the blood supply to the nervous tissue and can lead to tissue hypoxia, secondary parenchymal necrosis and softening. Mechanical effects on the spinal cord during displacement of a vertebra or disc prolapse, along with damage to the brain tissue, are accompanied by compression or rupture of blood vessels in this area and reflex circulatory disorders in adjacent or distant segments of the brain due to pathological impulses emanating from the damage zone. In this case, one should also take into account the possibility of compression of the well-developed radicular artery located in the area of ​​damage to the spine, which is of great importance in the blood supply to the brain.

These concepts are supported by clinical observations, according to which the level of damage to the spinal cord sometimes does not correspond to the level of damage to the spine.

In some cases, the level of segmental pathology of the spinal cord corresponds to the indicated level, but in this case, a second level of transverse spinal cord lesion is detected, located significantly below or above the level of spinal injury.
So, for example, in case of damage to the cervical spine and spinal cord, two levels of injury:

1. predominantly segmental in the region upper limbs;
2. transverse lesion of the spinal cord in the region of the ThiV segment due to a violation of the blood circulation of the brain at the junction of the supply of two arterial systems.

Most often, spinal pathology that does not correspond to the level of spinal injury occurs at the level of Cv, Thiv, Thxii and Li segments, which is explained by the existence of so-called critical circulation zones at the junction of two arterial systems of the spinal cord, which are most prone to decompensation in circulatory disorders.

Hemodynamic disorders lead to ischemic softening of the spinal cord, most often in cases of "minimal blood supply" in the so-called dangerous or critical zones.

Anatomical studies have established that the blood supply to the spinal cord is carried out not by a segmental system of radicular arteries, but only by single, well-developed arterial trunks. Easily pronounced violations blood supply cause only functional phenomena of prolapse. Violations medium degree cause, first of all, damage to the central sections with the subsequent development of necrosis, softening and cysts, and severe ischemia leads to a breakdown in the functions of the entire diameter of the spinal cord.

Damage to the cauda equina and cone in fractures of the lumbar and sacral vertebrae

This lesion leads to the appearance of radicular symptoms, to the development of the syndrome of damage to the cauda equina or conus of the spinal cord. It should be noted that in the absence of neurological symptoms in the near future after the injury, distant terms radicular syndrome may occur and clinical picture intervertebral osteochondrosis. Naturally, in case of spinal fractures, not only damage to the spinal cord or its roots can be observed, but also combined damage to the plexuses, sympathetic formations and nerves of the extremities (especially with concomitant fractures of the extremities).

The method of examination of the patient and the principles of treatment

The most appropriate in the treatment of complicated spinal fractures is the joint work of a neuropathologist, orthopedist and neurosurgeon. Examination of the patient is aimed at determining the degree and nature of the lesion nervous system, deformities of the spine, general somatic condition, exclusion of concomitant injuries of the limbs and internal organs.

Clinical picture of fractures characterized by pain in the area of ​​damage on palpation, deformity (for example, the formation of acute angular kyphosis - a hump with a compression fracture in the thoracic region), tension in the muscles of the neck or back. In the case of forward displacement of the three upper cervical vertebrae, the deformity is easily established by palpation through the mouth. At severe symptoms damage to a certain level of the spinal cord or its roots, a topical diagnosis of spinal injury can be made with a greater degree of probability, taking into account neurological symptoms. Radiography of the spine is performed under conditions that prevent increased dislocation of the spine.

Therapeutic measures for fractures of the spine are as follows.

1. Transportation of the patient to a medical institution is carried out in such a way as not to increase the deformation of the spine and not cause secondary damage to the spinal cord. The most appropriate in case of damage to the cervical spine is immediate fixation of the patient in the Stricker frame, to which a device for skeletal traction is attached.
2. IN medical institution the victim with the same precautions is placed on a hard bed or on a shield, on top of which a dense or airy mattress and a tightly stretched (without any folds) sheet are placed. It is most expedient to use a bed with a specially rotatable Stricker double-leaf frame. She provides good immobilization, traction, facilitates turning the patient, changing clothes and caring for the skin, emptying the intestines, and also transporting to another room.
3. In a medical institution, orthopedic measures should be carried out to eliminate the deformation of the spine (especially the lumen of the spinal canal), ensure its stability and prevent secondary displacement. The spinal cord in most cases is damaged at the time of injury, and subsequent compression of the brain by displaced vertebrae only exacerbates this damage.

Naturally, compression of the spinal cord damaged at the time of injury by displaced parts of the vertebrae, intervertebral cartilage located within the spinal canal, edematous tissues, and sometimes hematoma is a complicating factor that worsens the condition of the spinal cord and should be eliminated as soon as possible with the help of orthopedic interventions or surgically.

This is achieved by the following therapeutic measures:

1. simultaneous closed reduction of fractures and dislocations of the spine;
2. traction;
3. open (operatively) reduction of these fractures and dislocations (open reposition);
4. posterior or anterior decompression operation;
5. long-term immobilization of the spine, achieved either by surgery (posterior or anterior fusion surgery), or by applying fixing bandages (gypsum, etc.).
   Surgical intervention must meet the following requirements:
   1. complete decompression of the spinal cord and its vessels;
   2. restoration of normal anatomical relationships between the spinal canal and the spinal cord in order to create optimal conditions for maximum possible recovery spinal cord functions;
   3. ensuring reliable stabilization of the damaged spinal segment in order to prevent secondary displacements of damaged vertebrae;
6. subsequent functional treatment to prevent atrophy of the muscles that provide spinal statics during standing and walking;
7. in the late stage of the disease, when the limit of reversibility and eurological symptoms is already clear, the main task of the doctor is to create conditions for the maximum use of residual functions, therefore orthopedic measures are the main ones here.

A special place among spinal injuries is occupied by fractures and dislocations of the two upper cervical vertebrae, which is due both to the peculiarities of their topographic relationships and the risk of damage to the medulla oblongata and spinal cord with a fatal outcome.

In the atlanto-axial region are found:

1. traumatic anterior dislocation or subluxation of the atlas without fracture of the odontoid process;
2. fracture of the odontoid process without displacement;
3. fracture-dislocation of the atlas and odontoid process;
4. atlas fracture.

Dislocation (displacement) in the atlanto-axial joint may also be the result of acute or chronic infectious processes (mainly rheumatoid arthritis or inflammatory processes in the nasopharyngeal region), causing relaxation of the periarticular tissues of this joint, or congenital anomalies atlas and epistrophy (epiphyseal division of the odontoid process), absence of epistrophy, deformity of the atlas.

Therapeutic measures for fracture and dislocation of the two upper cervical vertebrae include prolonged skeletal traction behind the cranial vault, and in some cases, surgery to eliminate spinal cord compression and ensure stability in the atlanto-occipital joint. In the last decade, attention has been drawn to the so-called hyperextension injury of the cervical spine (a subspecies of which is the so-called whiplash injury). These injuries occur during transport (especially automobile), football injuries, diving, falling from a height, facing forward from a ladder, with complicated tracheal intubation. In this case, the so-called acute cervical syndrome develops, which is expressed to varying degrees and occurs after forcing hyperextension of the neck, exceeding the anatomical and functional limits of mobility of this section of the spine. On spondylograms, it is often not possible to detect bone pathology of the spine; in more severe cases, especially in road accidents with an extensor mechanism of violence, fractures of the cervical vertebrae and damage to the ligamentous disc apparatus occur.

Clinically, this injury is manifested in varying degrees of severity by syndromes of damage to the nervous system, among which there are:

1. Radicular syndrome (which occurs in about 25% of cases), manifested by pain in the cervical-occipital region for weeks, and sometimes months.
2. Syndrome of partial dysfunction of the spinal cord with the presence of pyramidal syndrome (also observed in about 25% of cases). At the same time, burning transient pains in the arms are typical due to damage to the posterior columns and compression of the roots of Sup and Sush with a rapidly transient feeling of weakness in the lower extremities.
3. Syndrome of transverse spinal cord injury, detected in approximately 30% of cases. In cases where this syndrome is unstable and quickly regresses, there is reason to consider it a manifestation of spinal shock. With partial regression of this syndrome, persistent dysfunction of the spinal cord of varying severity remains.
4. Anterior spinal artery syndrome is detected in approximately 20% of cases and is manifested by distal paresis of the upper limbs with hypotension and muscle hypotrophy, lower paraparesis, distant and. dissociated disorders of sensitivity, disorders of the function of the pelvic organs.

In hyperextension injury, there is a faster and full recovery movements in the lower extremities (compared to the upper ones) due to the predominant lesion of the anterior horns of the cervical thickening and the internal parts of the pyramidal bundle, where the fibers for the upper extremities are located. Sometimes against the background of rapid and almost complete regression of severe tetraparesis long time nevertheless, there is paresis of the upper limbs with muscle atrophy, especially the small muscles of the hand, fibrillation in the muscles of the shoulder girdle and mild hyperesthesia in the forearms.

Treatment of injuries of the spine and spinal cord

Treatment of a patient who has received (even presumably) a spinal injury, as well as a suspected spinal cord injury, begins at the time of his discovery and even before he is delivered to the hospital. The first necessary measure is the immobilization of the spine along its entire length. It is preferable to transport the injured to the neurosurgery department or a multidisciplinary department with the possibility of treating spinal patients.

In many cases, injuries to the spine and spinal cord require surgery. The decision on such a specialist takes on the basis of the severity of neurological symptoms. The operation, if necessary, is carried out in the shortest possible time, since 6-8 hours after the fact of compression of the spinal cord and the vessels that ensure its operation, the results of ischemic changes may be irreversible. For this reason, all contraindications to surgical intervention present at the time of hospitalization of the patient are eliminated as part of intensive care. This, as a rule, includes the optimization of the work of the respiratory and of cardio-vascular system, indicators of homeostasis in terms of biochemistry, elimination (partially or, if possible, complete) of cerebral edema, prevention of infections, etc. The operation may consist in the removal, prosthetics or correction of the position (reduction, decompression, reclination) of the vertebrae, restoration of the integrity of damaged organs and other actions that provide the best possible connection between the spine and the spinal cord.

If the injury does not require surgical intervention, the treatment consists in fixing the spine in its natural position (with previous reduction, if necessary) and stimulating the processes of tissue regeneration, nerve endings and the functioning of organs whose work was disrupted due to the injury itself or its complications. The complex of therapeutic measures often includes the development of muscles around the damaged section, thermal procedures and massage, in more complex cases we are talking about immobilization of the spine in the affected areas, traction. The result of treatment determines the complex of rehabilitation measures.

Over the past decade and a half, there has been a trend towards conservative methods treatment of hyperextension injury of the cervical spine (immobilization of the cervico-occipital region with a bandage followed by physiotherapy, application of a thoracocranial bandage, traction if indicated) to surgical intervention in cases where there is reason to believe the impact of factors causing spinal cord compression [Irger I. M., Yumashev G. S., Rumyantsev Yu. V., 1979; Schneider et al., 1954, 1971; Schlosbree 1977].

Care of patients with injuries of the spine and spinal cord is very difficult for attendants, especially in the absence of regression of severe neurological disorders.

Bladder dysfunction is one of the most frequent and threatening complications of spinal cord injury.
Three methods are used to empty the bladder urgently:

1. intermittent or permanent catheterization;
2. manual emptying of the bladder;
3. bubble puncture.

Two methods are used to remove urine from the bladder for a long time:

1. Monroe drainage using tidal drainage;
2. suprapubic cystostomy.

Drainage according to Monroe consists in the periodic entry into the bladder of a weak antiseptic solution or a liquid that dissolves urinary salts, removing it from the bladder using the system and “breaking” the siphon after emptying the bladder. Clinical observations show that the Monroe system does not completely prevent urinary tract infection, but, compared with other methods, delays its development, reduces its manifestations and ensures the restoration of urination according to the so-called automatic type. In those cases where there is reason to assume a prolonged violation of the function of urination, the method of imposing a suprapubic fistula is used.

The main reason for the occurrence and development of bedsores in areas where innervation is impaired due to spinal cord injury is the high sensitivity of dystrophic tissues to mechanical and infectious influences. However, in areas not subjected to pressure, bedsores never occur with any severity of spinal cord injury. In the treatment of bedsores, it is important to create conditions that prevent difficulties in the lymph and blood circulation in the affected tissues and stimulate these processes. For this purpose, various ointment dressings are used (which sometimes include antibiotics), UVI (erythemal doses), removal of scabs, and excision of necrotic tissues. With the development of deep bedsores, wound refreshment is recommended, staged excision necrotic tissues with early or late skin grafting, and in osteomyelitis - removal of the underlying bone.

Rehabilitation of injuries of the spine and spinal cord

From the point of view of the rehabilitation process, the greatest attention should be paid to spinal injuries associated with violations of the integrity and functionality of the vertebrae. The rehabilitation plan and packages of measures vary depending on the stability of the damage. So, if a tendency to displacement of the vertebra (unstable damage) is demonstrated, rehabilitation is based on fixing it. The injury, which is expressed in wedge-shaped compression, avulsion of the anterior corners of the body of the bone, does not require fixation and may include a wider range of exercises. Each of the methods used today is applied strictly according to the indications and based on the results of the examination of the patient. At the same time, all approaches are aimed at strengthening the muscles of the body to create a "muscle corset", including exercise therapy, physiotherapy and mechanotherapy. In the event of complications, electropulse therapy is indicated, stimulation of metabolic processes, as well as blood circulation and regeneration.

Rehabilitation after injuries that led to dysfunction of the spine and spinal cord varies depending on the degree of damage received. In most cases, the purpose of rehabilitation is the most complete restoration of partially or completely lost or oppressed, as well as the development of preserved functions of the spinal cord. The least reversible consequences of injury occur in the event of a functional or anatomical interruption. In this case, therapeutic and restorative measures are aimed at developing functions that ensure the adaptation of the body to new conditions for it. In addition, the task of specialists is to ensure the maximum full connection between sections of the spinal cord.

All measures for the rehabilitation of patients involve a gradual increase in loads to an optimal level. In each case, the end of the recovery process is individual, but rarely less than 2-3 months. In particular, the first half of the first month of rehabilitation is aimed at restoring the work of the cardiovascular and respiratory system, raising the tone of the patient, preventing the deterioration of the muscles of the body. In the future, until the end of the first month (depending on the damage, this period may increase), the actions of the staff and the patient are aimed at restoring the work of other internal organs, stimulating natural regeneration, preparing the muscles and the whole body for expanding the complex of movements.

According to statistics, spinal cord injuries are most often associated with damage to the vertebral sections.

According to the results of numerous studies, about 95% of traffic accidents, various types of accidents and acts of violence in one way or another become the main cause of spinal cord injuries.

Wherein greatest danger exposed to both men and women aged 20 to 60 years. And the mortality rate is quite high and disappointing.

Treatment of all types of spinal cord injuries should be carried out immediately, since the preservation and restoration of most functions of the human body directly depends on this factor.

Injuries in the back area are fraught with serious consequences that can affect the main motor and nervous departments. There are frequent cases when the result spinal injuries there may be a complete or partial loss of sensory function, as well as disruptions in heart rate and breathing.

However, there are cases when injuries received by a person can only be overcome through long-term combined rehabilitation.

Specially designed programs for such people help not only to find psychological and emotional balance, but to fully adapt to the surrounding domestic and social conditions.

Most common causes of spinal cord injury

The human spinal cord is the main coordination center of the body, which controls all processes in the muscles and organs.

It is through him that all body systems are informed. In addition, the structure of the spinal cord is rather unusual.

It is a cylinder with a diameter of 1 to 1.5 centimeters, which is covered with three types of shells: soft, hard and cobweb.

To protect the brain is designed dense muscle, which covers the main brain canal.

Currently, medicine classifies three types of spinal cord injuries:

• congenital malformations and postpartum abnormalities;
• violation of spinal circulation;
• fractures, bruises, dislocations due to external factors.

Despite the fact that the main causes of spinal cord injuries have become quite common for human understanding, they can be divided into the following groups:

• car accidents - given reason inherent not only to drivers, but also to pedestrians;
• high-altitude falls- intentional or accidental fall from a certain level of height, mainly occurs among athletes;
• Domestic and extraordinary injuries- differ in a fairly wide variety, they include falls on ice or from stairs, stab or bullet wounds.

WITH medical point spinal injuries are open And closed.

In addition, they can lead to dysfunction of the spinal cord or its complete rupture.

The nature spinal injuries subdivided into:

• shake;
• injury;
• crush;
• hematomyelia;
• traumatic radiculitis.

The most common cases of damage to the back, in particular the spinal cord, doctors call the 1st and 2nd lumbar, 5th and 6th cervical, 12th thoracic vertebrae.

Even minor violations in them can lead to serious and sometimes unpredictable consequences. Often there are irreversible processes in the damaged spinal areas.

The main instruments for examining the spinal region subject to injury are:

Radiography - in two projections, pictures of the spinal cord are taken;

Nuclear magnetic tomography - consists in a detailed examination of all channels and layers of the brain, vertebrae and discs, pressure and swelling.

spinal shock

This phenomenon is a rupture of transverse sections of the spinal cord during injury.

Main symptomatic manifestations:

• inhibition of motor and vegetative systems organism in certain segments of the spine;
• abrupt cessation of control from the central nervous system.

Until the end, the concept of "spinal shock" has not been studied. However, specialists in the field of treatment and diagnosis of spinal injuries there are several stages of this phenomenon:

• first- complete areflexia lasting from 4 to 6 weeks;
• second- small reflex movements in the legs and arms, usually lasts from 2 weeks to several months;
• third- the presence of flexion and extensor reflexes.

In order to provide the victim with first aid in a quality and timely manner, it is necessary to thoroughly know the main symptoms and signs of this process.

The most dangerous for any person are injuries of the cervical vertebrae.

A characteristic feature of this process is the appearance of acute pain in the neck and limitation of mobility of the head.

With fractures of the spine, the victim instantly develops paralysis of the limbs or pelvic organs.

Among the basic rules of first aid in such cases are:

• First of all, you need to call ambulance.
• Make sure the victim is conscious and breathing normally.
• If necessary, move the injured person should lay him on a flat surface.
• Eliminate the movement of a person with a blanket or tissue flap.
• In no case do not allow the bending of the damaged spine.
• Fix the vertebra with a thick cotton pad or tightly folded newspaper.
• Place pillows or bundles of clothing under the shoulders and neck.
• Stay with the victim until medical help arrives.

It is worth remembering that properly rendered assistance to someone who has suffered from a spinal cord injury will make it possible to save him motor functions limbs and sensitivity of all parts of the body.

Treatment and operation

The process of treatment of various spinal cord injuries must be performed in a neurosurgical type hospital.

At the same time, this type of treatment should begin with immobilization of the spinal region, especially at the site of injury.

It consists in creating the most comfortable conditions for moving the victim. In addition, it is necessary to take measures to maintain a normal level blood pressure and activity of the cardiovascular system.

Most spinal cord injuries require mandatory surgery. It is this method that eliminates the presence of possible bone fragments, compression of the spinal region, and swelling of the spinal cord.

In cases of damage genitourinary system, it is necessary to unload the urinary tract by all possible methods. For example, insert a catheter into the urethra. And to prevent infection, the bladder is washed with furatsilin in tandem with antibiotics.

At an early stage of diagnosing the degree of damage to the received spinal cord injuries, the attending physician can offer several treatment options:

1. Medical treatment - at acute form spinal injuries are treated with solumedrol, which significantly reduces the number of damaged nerve cells and existing inflammatory foci near the site of injury.
2. Immobilization- to stabilize the position of the spine, a splint is used that fixes the body.
3. Surgical intervention- used when foreign objects or bone fragments, hernia are found. This method allows not only to eliminate these nuances, but also eliminates the appearance of pain and deformation.

Of course, it is impossible to accurately predict the course of treatment, despite significant scientific advances in the field of neurosurgery. In addition, as practice shows, not in all cases of spinal cord injury, surgery can help in the complete recovery and recovery of the victim.

However, significant hopes for a full recovery after spinal injuries are given by the use of specific metal structures of imported production. Such operations require special equipment and tools. But this method of neurosurgery has already helped patients with minor fractures and dislocations of the spinal cord.

Recovery and rehabilitation

With regard to activities related to rehabilitation, the following adaptation and recovery methods should be noted:

• Application of performance-based physiotherapy programs exercise to restore normal working strength in the arms and legs.
• Treatment with drugs to relieve symptoms and complications after injuries, as well as to treat possible urinary tract infections.
• The use of specialized wheelchairs to improve the comfort of patients with spinal injuries.
• Readaptation of the immediate place of residence - consists in constructive changes in the property for high-quality and simple self-service of the victim.

In the struggle to restore the working capacity and normal life of a patient with spinal cord injury, doctors take measures that help prevent further damage to the spinal cord, and also make it possible to freely refer the victim to rehabilitation centers, where there is a real opportunity to achieve independence in independent movement.

These centers often use occupational therapy. This type of rehabilitation is developed individually for each case, since both injuries and the rate of recovery are considered unique for each person.

One of the recognized methods of returning the functions of the human body lost as a result of trauma is considered to be electrical stimulation. This procedure is not complicated, but it does a good job of getting the main systems up and running.

After the end of the rehabilitation process, the patient must continue to work independently on his own recovery. To do this, you need to maintain muscle mass and joint flexibility in tone. Permanent physical exercise and classes will undoubtedly positively affect the overall physiological state person. And he will be able to get on his feet at the moment when the body is ready for this.

It is impossible to lose faith in achieving this goal, since the orthopedic consequences of spinal cord injury can be the most unpredictable. A person may develop spinal instability, or scoliosis, secondary dislocations, pathological changes in the intervertebral discs and joints, and deformation of the spinal canals.

Video

The video shows an example of recovery from a spinal cord injury.

Life after a spinal injury has its own characteristics. This is due to the fact that the immediate process of returning a person to normal life is quite lengthy. The time period for such a recovery can vary from several months to several years. Therefore, it is worth being prepared mentally and emotionally, and strives to restore all the lost functions of the body.

Spinal cord injury is one of the most severe injuries encountered in clinical practice. Previously, the prognosis for such injuries was almost always unfavorable, patients often died. But modern medicine allows in most cases to save lives and restore at least a small part of the lost functions of the spinal cord.

Assistance to the victim must be started immediately, but always correctly. Any erroneous action can be deadly or significantly worsen the recovery process. Therefore, each person needs to know the signs of spinal cord injury, to have an idea about the types of injuries and prognosis regarding recovery.

Symptoms

The spine and spinal cord are arranged very reliably. IN normal conditions they are almost impossible to damage, therefore, another version of the injury, due to which the spinal cord is damaged, is a rather rare occurrence.

This usually happens in emergency situations: a car accident, a natural disaster, a fall from a height, a bullet or knife wound to the spinal cord. The nature of the damage and the chances of a complete recovery of the spinal cord depend on the mechanism of injury.

Any doctor will say that he has never seen two identical injuries of the spine and spinal cord. This is due to the fact that the symptoms and prognosis for spinal cord recovery differ significantly in different patients depending on the severity of the injury, its location, body characteristics, and even mood.

The main differences in the symptoms of a spinal cord injury depend on whether the injury is partial or complete. According to the localization of the consequences, it is possible to determine the level of the spinal cord that was injured. It also matters whether there are open or closed damage. Below are the symptoms that are typical for most patients with a diagnosis of "injury of the spine and spinal cord".

Partial damage

With partial damage, only part of the brain tissue is injured. Accordingly, some of the functions will be preserved. Therefore, signs of spinal cord injury will gradually decrease if appropriate treatment is provided immediately.

Usually in the first hours it is impossible to assess how severe the injury is and whether there are surviving fibers. This is due to the phenomenon of spinal shock. Then, when it passes, it gradually becomes clear what part of the brain substance has survived. final result can be seen only after a few months, and sometimes after 1-2 years. In the clinical course, doctors distinguish four periods, their features are listed in the table, which can be seen below:

With different degrees of spinal cord injury, the symptoms and timing of their manifestations may vary slightly. But in any case, during the first three periods, the victim must be in the appropriate medical center. In the later period, it is also important to listen to the guidance of doctors.

Full break

Symptoms of spinal cord injury with its complete rupture in the acute period are also manifested by spinal shock. But in the future, there is no restoration of even a part of the lost functions. The part of the body below the spinal cord injury remains paralyzed. This option is possible for both open and closed injuries.

Unfortunately, at present, a technique has not yet been developed that has made it possible, surgically or otherwise, to restore the connection of the body and limbs with the main part of the central nervous system, if a complete rupture of the brain is observed. Therefore, when confirming such a diagnosis, psychological and emotional problems often arise associated with anxiety about one's future, about one's family, a feeling of helplessness, and social adaptation becomes more difficult.

Classification of injuries

There are several classifications that are used to characterize an injury. The most important thing is to know how and to what extent the spine is damaged and in which place there is a violation of the integrity of the nerve fibers. This can be determined by instrumental examination and inspection.

Different classifications take into account different parameters. Below are the most common characteristics and those that are important to know to understand the severity of the victim's condition.

By location

Depending on the location of the injury, which ones will not be able to fully function. The localization of the injury must be recorded on the medical card in the form of a capital Latin letter and a number. The letter means the spine (C - cervical, T - thoracic, L - lumbar, S - sacral), and the number is the number of the vertebra and the nerve emerging from the corresponding intervertebral foramen.

There is a direct relationship between the nature of disorders and the location of damage to the spine and spinal cord:

• Up to 4 cervical vertebrae - the most dangerous injuries. There is no work of all four limbs (central tetraplegia), the functions of the organs located in the pelvic region are completely impaired, usually it is not possible to detect signs of preservation of at least some type of sensitivity below the injury site. With a complete rupture, the work of the heart and lungs stops, a person can live only if he is connected to life support devices.
• Lower cervical region (5–7 vertebrae) - there is no sensitivity, paralysis of the legs develops according to the central type, arms according to the peripheral type, pronounced pain syndrome at the site of damage.
• At the level of up to 4 chest - a violation of cardiac and respiratory activity, the function of the pelvic organs, radicular pain.
• 5–9 chest - paresis of the lower extremities with the possibility of maintaining deep sensitivity, disruption of the pelvic organs.
• The thoracic region below the 9th vertebra - violations of the sensitivity of half of the body (lower), flaccid paralysis of the legs.
• The lower parts of the spine - sometimes flaccid paralysis of the legs, sensitivity is preserved, although not fully, the functions of the bladder are partially preserved, radicular pain bothers quite often.

But it is worth remembering that the possible degree of recovery depends not only on the location of the damage, but also on its nature. With minor damage and the right approach to rehabilitation, it is possible to achieve better results than the usual indicators for an injury of a similar location.

According to the nature of the damage

Often, when making a diagnosis, the level of damage to the bone structures of the spinal column is also indicated. But the injuries of the vertebrae themselves do not always correspond in severity exactly with the depth of damage to the medulla.

To assess the severity of the condition in relation to the integrity of the nervous structures, it is worth considering such differences in characteristics:

• Partial compression by a fragment of a vertebra or other bone structure, a foreign body (may get into the spinal canal if there are not only closed injuries). In this case, the symptoms will depend on which part is most damaged.
• Rupture of the spinal cord due to the impact of a sharp object or part of a vertebra, sharp compression (crush), strong stretching in length. The risk of complete rupture is very high if the damaging agent is sharp and large.
• Hematomyelia is bleeding into the gray matter that can compress nerve structures and destroy them.


• Concussion of the spinal cord - most often occurs when a blow to the back without violating the integrity of the bone structures.
• Swelling – may exacerbate symptoms or even cause additional damage. It may be the only consequence of an injury or be combined with mechanical damage.
• Spinal injury. Usually happens with a strong blow. The severity of injuries is different, it is assessed after the elimination of symptoms of spinal shock.
• Contusion. It also manifests itself as spinal shock, but there are still chances for recovery, although in most cases incomplete.
• Spine break. The functions for which he was responsible (mobility or sensitivity) suffer.
• The presence of an infection. The risk is not very great if closed lesions are observed. But if there is an open wound, pathogens could easily get there. It is especially dangerous if the object damaging the spinal cord is a non-sterile foreign body.

It is possible to talk about such characteristics only after the examination. But they are very important to take into account when predicting improvements.

Forecast

The prognosis for and spinal cord depends on the characteristics of the injury, the age and health of the patient, the amount of effort that he and the doctors are willing to make to recover. The rehabilitation period is especially important for relatively minor injuries. In this case, with active timely actions, a complete recovery is possible, and in their absence, a worsening of the condition.

It is possible to note the following patterns of the relationship between the nature of injuries and the possibilities of recovery:

• Weak damage. For example, when hitting the spinal column, a concussion of the spinal cord is possible. Because of this, its edema may develop, symptoms of a violation of the conduction of the spinal cord develop, but there is no mechanical damage, ruptures of the nervous tissue, fractures of bone structures. In this case, all symptoms disappear within a few days.
• Partial damage. When spinal shock develops, an extremely serious condition can be observed, but then the surviving fibers begin to perform their functions again. In addition, sometimes it happens that the surviving areas take on some of the actions that were characteristic of neighboring damaged fibers. Then the mobility and sensitivity of the parts of the body below the site of spinal cord injury can be restored almost completely.
• Complete rupture, crush. In this case, only the formation of new reflex reactions is possible, which will be controlled exclusively by the spinal cord.

In any case, whatever the diagnosis, it is important to cooperate with doctors as much as possible in order to prevent the development of undesirable consequences of improper treatment and not to miss all possible chances for recovery. To do this, you can familiarize yourself with the complex of measures that doctors carry out and find out why each action is needed.

Treatment and rehabilitation

How complete the recovery of the spinal cord will be and how many consequences will remain in the future depends on many factors. Of course, it is very important to consider the severity of the injury and not expect a person to be able to move as before the injury if he is diagnosed with a complete rupture of the brain matter. But a responsible approach and competent actions of the surrounding people, doctors and the patient himself can at least save a life. In addition, it was noted that with a positive attitude of the victims, recovery is faster, the indicators at discharge are better, and the consequences of the injury are minimal compared to others.

Since spinal cord injuries are very dangerous, each period of treatment is associated not only with the restoration of health, but also with saving lives in general. Any wrong action can significantly worsen the condition of the victim. Therefore, even for those who are not connected in any way with medicine, it is important to know what is needed and what cannot be done in such situations.

First steps

How complete the restoration of spinal cord function will be depends largely on what will happen in the first minutes after a person has been injured. In most cases, at this time there are people who are not trained to provide first aid in such situations.

Therefore, it is important for everyone to remember two simple rules that always apply when someone is injured and it is impossible to immediately understand how serious his condition is:

1. Immediately call an ambulance, indicating the details of the reason for the call, the approximate nature of the injury. Be sure to mention that the casualty is unconscious, if so.
2. Do not touch, do not try to move a person or change his posture, do not remove an object that injures him, especially if it is clear that a spinal fracture has occurred. No one knows what condition his spinal cord is in. With an unsuccessful movement, it is easy to turn a partial injury into a complete tear, thereby depriving a person of the hope of being able to walk again. That is, the harm from wrong actions can be greater than from the injury itself.

The rest of the help should be provided by specialists. They have special equipment and tools that will help deliver a person to the hospital without the risk of worsening his condition, fixing the fracture in a stationary state. They also immediately inject neuroprotectors, substances that prevent the self-destruction of the brain substance, which can occur with spinal shock.

In the hospital

Treatment of spinal cord injuries is carried out exclusively in a hospital setting. The patient is usually in intensive care for several days. When a person regains consciousness, he still needs constant care, which can only be provided in a hospital.

An approximate sequence of actions that is necessary for recovery:

• Re-examination (the first is carried out by an ambulance team). The presence of sensitivity and reflexes is checked.
• Administration of painkillers, neuroprotectors, if necessary (eg, if there is an open fracture of the spine) antibacterial drugs.
• Insertion of a catheter into the bladder.
• In most cases it is shown surgical intervention with the restoration of bone structures, if there is a fracture of the vertebra or its arches.
• Care after surgery: massage to prevent contractures, skin care to prevent bedsores, if necessary, assistance with defecation and urination.
• Physiotherapy.
• Limb exercises, passive or active, depending on the patient's capabilities.

After the condition has stabilized and the patient's health has improved so much that he will not need constant health care to restore health, he is discharged home. This happens no earlier than 3 months later.

Discharge is only the first achievement on the road to recovery. You can't stop there.

After discharge

Rehabilitation after a spinal cord injury is a very lengthy process. It lasts at least a year. During all this time, it is important not to miss any rehabilitation measures that will be offered by doctors. This applies to both physical and social recovery. You will need to get used to the fact that some actions will now need to be done in a completely different way. And sometimes it may be necessary to ask for help from someone close to you.

All improvements that come will be gradual. Sometimes at first recovery period a person is weakly given movement even if the necessary nerve fibers are preserved. This is due to the fact that muscles and joints are able to "forget" how to carry out their functions if they have not been used for a long time. You should not be afraid of this, you just need to re-teach them how to work, and after a while the movements will be given without difficulty.

Thank you

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. Expert advice is required!

Spinal Injuries: Prevalence, Causes and Consequences

The prevalence of spinal injuries

According to various authors, spinal injuries account for 2 to 12% of cases of traumatic lesions of the musculoskeletal system.
The average portrait of the victim: a man under 45 years old. In old age spinal injury are observed with equal frequency in both men and women.

The prognosis for spinal injuries associated with spinal cord injury is always very serious. Disability in such cases is 80-95% (according to various sources). One third of patients with spinal cord injuries die.

Especially dangerous damage to the spinal cord in injuries of the cervical spine. Often, such victims die at the scene from respiratory and circulatory arrest. The death of patients in a longer period after the injury is caused by hypostatic pneumonia due to impaired lung ventilation, urological problems and bedsores with a transition to a septic state (blood poisoning).

Injuries of the spinal column and spinal cord in children, including birth trauma of the spine, respond better to treatment and restorative rehabilitation thanks to the great adaptive capabilities of the child's body.

It should be noted that the consequences of spinal injuries are largely determined by the time interval from injury to the start of complex treatment. In addition, very often ineptly rendered first aid significantly aggravates the condition of the victim.

Treatment of spinal injuries is complex and lengthy, often requires the participation of several specialists (traumatologist, neurosurgeon, rehabilitation specialist). Therefore, in many countries, patients with serious injuries of the spinal column are concentrated in specialized centers.

Anatomical structure of the spine and spinal cord

Anatomy of the spinal column

The spine consists of 31-34 vertebrae. Of these, 24 vertebrae are freely connected (seven cervical, twelve thoracic and five lumbar), and the rest are fused into two bones: the sacrum and the rudiment of the human tail - the coccyx.

Each vertebra consists of an anteriorly located body and an arc that limits the posterior vertebral foramen. Free vertebrae, with the exception of the first two, have seven processes: spinous, transverse (2), upper articular (2) and lower articular (2).
The articular processes of neighboring free vertebrae are connected in joints with strong capsules, so that the spinal column is an elastic movable joint.

The vertebral bodies are connected into a single whole with the help of elastic fibrous discs. Each disc consists of an annulus fibrosus, within which is the nucleus pulposus. This design:
1) provides mobility of the spine;
2) absorb shock and load;
3) stabilizes the spinal column as a whole.

The intervertebral disc is devoid of blood vessels, nutrients and oxygen is supplied by diffusion from neighboring vertebrae. Therefore, all recovery processes take place here too slowly, so that with age a degenerative disease develops - osteochondrosis.

Additionally, the vertebrae are connected by ligaments: longitudinal - anterior and posterior, interarticular or "yellow", interspinous and supraspinous.

The first (atlas) and second (axial) cervical vertebrae are not like the rest. They have changed as a result of human upright walking and provide a connection between the head and the spinal column.

Atlas has no body, but consists of a pair of massive lateral surfaces and two arches with upper and lower articular surfaces. The upper articular surfaces articulate with the condyles of the occipital bone and provide flexion-extension of the head, while the lower ones face the axial vertebra.

A transverse ligament is stretched between the lateral surfaces of the atlas, in front of which the medulla oblongata is located, and behind the process of the axial vertebra, called the tooth. The head, together with the atlas, rotates around the tooth, and the maximum angle of rotation in any direction reaches 90 degrees.

Spinal Cord Anatomy

Located inside the spinal column, the spinal cord is covered with three shells, which are a continuation of the shells of the brain: hard, arachnoid and soft. From top to bottom, it narrows, forming a cerebral cone, which at the level of the second lumbar vertebra passes into the terminal thread, surrounded by the roots of the lower spinal nerves (this bundle is called the cauda equina).

Normally, there is a reserve space between the spinal canal and its contents, which makes it possible to painlessly endure the natural movements of the spine and minor traumatic displacements of the vertebrae.

The spinal cord in the cervical and lumbosacral regions has two thickenings, which are caused by the accumulation of nerve cells for the innervation of the upper and lower extremities.

The spinal cord is supplied with blood by its own arteries (one anterior and two posterior spinal arteries), which send small branches into the depths of the brain substance. It has been established that some areas are supplied from several branches at once, while others have only one supply branch. This network is fed by radicular arteries, which are variable and absent in some segments; at the same time, sometimes one radicular artery feeds several segments at once.

With deforming injury blood vessels are bent, squeezed, overstretched, their inner lining is often damaged, as a result of which thrombosis is formed, which leads to secondary circulatory disorders.

It has been clinically proven that lesions of the spinal cord are often associated not with a direct traumatic factor (mechanical trauma, compression by fragments of the vertebrae, etc.), but with impaired blood supply. Moreover, in some cases, due to the peculiarities of blood circulation, secondary lesions can capture fairly large areas beyond the limits of the traumatic factor.

Therefore, in the treatment of spinal injuries complicated by lesions of the spinal cord, the fastest elimination of deformity and restoration of normal blood supply are shown.

Classification of spinal injuries

Spinal injuries are divided into closed (without damage to the skin and tissues covering the vertebra) and open (gunshot wounds, stab wounds, etc.).
Topographically distinguish injuries of different parts of the spine: cervical, thoracic and lumbar.

According to the nature of the damage, there are:

• bruises;
• distortions (tears or ruptures of ligaments and bags of joints of the vertebrae without displacement);
• fractures of the spinous processes;
• fractures of the transverse processes;
• fractures of the vertebral arches;
• fractures of the vertebral bodies;
• subluxations and dislocations of the vertebrae;
• fracture-dislocation of the vertebrae;
• traumatic spondylolisthesis (gradual displacement of a vertebra anteriorly due to destruction of the ligamentous apparatus).

In addition, the distinction between stable and unstable injuries is of great clinical importance.
Unstable spinal injury is a condition in which the resulting deformity as a result of an injury can worsen in the future.

Unstable injuries occur with combined damage to the posterior and anterior sections of the spine, which often occurs with a flexion-rotation mechanism of injury. Unstable injuries include dislocations, subluxations, fracture-dislocations, spondylolisthesis, and shear and sprain injuries.

It is clinically important to divide all spinal injuries into uncomplicated (without damage to the spinal cord) and complicated.

There is the following classification of spinal cord injuries:
1. Reversible functional disorders (concussion).
2. Irreversible damage (bruise or contusion).
3. Spinal cord compression syndrome (may be caused by fragments and fragments of parts of the vertebrae, fragments of ligaments, nucleus pulposus, hematoma, edema and swelling of tissues, as well as several of these factors).

Symptoms of spinal injuries

Symptoms of a Stable Spinal Injury

Stable injuries of the spine include bruises, distortions (rupture of ligaments without displacement), fractures of the spinous and transverse processes, and whiplash injuries.

When the spine is bruised, the victims complain of diffuse soreness at the site of injury. During the examination, swelling and hemorrhage are detected, movements are slightly limited.
Distortions occur, as a rule, with a sharp lifting of weights. They are characterized by acute pain, a sharp limitation of movements, pain when pressing on the spinous and transverse processes. Sometimes the phenomena of sciatica join.

Fractures of the spinous processes are not often diagnosed. They arise both as a result of the direct application of force, and as a result of a strong muscle contraction. The main signs of fractures of the spinous processes: sharp pain on palpation, sometimes you can feel the mobility of the damaged process.

Fractures of the transverse processes are caused by the same causes, but are more common.
They are characterized by the following symptoms:
Payr's sign: localized pain in the paravertebral region, aggravated by turning in the opposite direction.

Stuck heel symptom: when positioned on the back, the patient cannot tear the straightened leg from the bed on the side of the lesion.

In addition, there is diffuse soreness at the site of injury, sometimes accompanied by symptoms of sciatica.

Whiplash injuries of the neck, which are typical for intra-vehicle accidents, are usually referred to as stable injuries of the spine. However, quite often they have severe neurological symptoms. Spinal cord injuries are caused by both direct contusion upon injury and circulatory disorders.

The degree of damage depends on age. In older people, due to age-related changes in the spinal canal (osteophytes, osteochondrosis), the spinal cord is more traumatized.

Signs of injuries of the middle and lower cervical spine

Injuries of the middle and lower cervical vertebrae occur in road accidents (60%), jumping into water (12%) and falls from a height (28%). At present, injuries of these departments account for up to 30% of all spinal injuries, one third of them occur with lesions of the spinal cord.

Dislocations, subluxations and fracture-dislocations are quite common due to the special mobility of the lower cervical spine, and are classified into overturning and sliding. The former are characterized by pronounced kyphosis (posterior bulge) and expansion of the interspinous space due to rupture of the supraspinous, interspinous, interspinous, and posterior longitudinal ligaments. With sliding injuries, a bayonet-like deformation of the spine, fractures of the articular processes are observed. The victims are worried about severe pain and forced position of the neck (the patient supports his head with his hands). Often there are spinal cord injuries, the severity of which largely determines the prognosis.

Isolated fractures of the third-seventh cervical vertebrae are diagnosed quite rarely. characteristic feature: pain in the damaged vertebra with a dynamic load on the patient's head (pressure on the top of the head).

Symptoms of injuries of the thoracic and lumbar spine

For injuries of the thoracic and lumbar spine, fractures and fracture-dislocations are characteristic; isolated dislocations occur only in the lumbar region, and then extremely rarely, due to limited mobility.

There are many classifications of injuries of the thoracic and lumbar spine, but they are all complex and cumbersome. The most simple clinical.

According to the degree of damage, which depends on the magnitude of the applied force directed at an angle to the axis of the spine, there are:

• wedge-shaped fractures (the shell of the vertebral body and part of the substance are damaged, so that the vertebra takes a wedge-shaped shape; such fractures are mostly stable and are subject to conservative treatment);
• wedge-comminuted (the entire thickness of the vertebral body and the upper closing plastic are damaged, so that the process affects the intervertebral disc; the injury is unstable, and in some cases requires surgical intervention; it can be complicated by damage to the spinal cord);
• fracture-dislocations (destruction of the vertebral body, multiple injuries of the ligamentous apparatus, destruction of the fibrous ring of the intervertebral disc; the injury is unstable and requires immediate surgical intervention; as a rule, such lesions are complicated by damage to the spinal cord).

Compression fractures that occur as a result of a load along the axis of the spine should be singled out separately (compression fractures occur in the lower thoracic and lumbar regions when falling on the legs, and in the upper thoracic region when falling on the head). With such fractures, a vertical crack forms in the vertebral body. The severity of the lesion and the tactics of treatment will depend on the degree of divergence of the fragments.

Fractures and fracture-dislocations of the thoracic and lumbar regions have the following symptoms: increased pain in the fracture zone with dynamic load along the axis, as well as when tapping on the spinous processes. The protective tension of the rectus muscles of the back (muscle ridges located on the sides of the spine) and abdomen is expressed. The latter circumstance requires differential diagnosis with damage to internal organs.

Signs of spinal cord injury

Movement disorders

Movement disorders in spinal cord injuries, as a rule, are symmetrical. The exceptions are stab wounds and damage to the cauda equina.

Severe lesions of the spinal cord lead to a lack of movement in the limbs immediately after the injury. The first signs of restoration of active movements in such cases can be detected no earlier than a month later.

Movement disorders depend on the level of the lesion. The critical level is the fourth cervical vertebra. Paralysis of the diaphragm, which develops with lesions of the upper and middle cervical regions of the spinal cord, leads to respiratory arrest and death of the patient. Damage to the spinal cord in the lower cervical and thoracic segments leads to paralysis of the intercostal muscles and respiratory failure.

Sensitivity disorders

Damage to the spinal cord is characterized by violations of all types of sensitivity. These disorders are both quantitative (decrease in sensitivity up to complete anesthesia) and qualitative in nature (numbness, crawling sensation, etc.).

The severity, nature and topography of sensitivity disorders is important diagnostic value, as it indicates the location and severity of the spinal cord injury.

It is necessary to pay attention to the dynamics of violations. A gradual increase in signs of sensory disturbance and movement disorders is characteristic of compression of the spinal cord by bone fragments, fragments of ligaments, hematoma, a shifting vertebra, as well as circulatory disorders due to vascular compression. Such conditions are an indication for surgical intervention.

Visceral-vegetative disorders

Regardless of the localization of damage, visceral-vegetative disorders are manifested primarily in disorders of the pelvic organs (stool retention and urination). In addition, with high damage, there is a mismatch in the activity of organs digestive tract: increased secretion of gastric juice and pancreatic enzymes while reducing the secretion of intestinal juice enzymes.

The speed of blood flow in the tissues is sharply reduced, especially in areas with reduced sensitivity, microlymph outflow is disturbed, and the phagocytic ability of blood neutrophils is reduced. All this contributes to the rapid formation of hard-to-treat bedsores.

Complete rupture of the spinal cord is often manifested by the formation of extensive bedsores, ulceration of the gastrointestinal tract with massive bleeding.

Treatment of injuries of the spine and spinal cord

The basic principles of treatment of injuries of the spine and spinal cord: the timeliness and adequacy of first aid, compliance with all rules when transporting victims to a specialized department, long-term treatment with the participation of several specialists and subsequent repeated courses of rehabilitation.

When providing first aid, much depends on the timely diagnosis of the injury. It should always be remembered that in the case of car accidents, falls from a height, building collapses, etc., the possibility of damage to the spinal column must be taken into account.

When transporting victims with a spinal injury, all precautions must be taken so as not to aggravate the injury. Such patients should not be transported in a sitting position. The victim is laid on a shield. At the same time, an air mattress is used to prevent bedsores. In case of damage to the cervical spine, the head is additionally immobilized with the help of special devices (tires, head collar, etc.) or improvised means (sandbags).

If a soft stretcher is used to transport a patient with a spinal injury, the victim should be placed on the stomach, and a thin pillow should be placed under the chest for additional extension of the spine.

Depending on the type of spinal injury, treatment at the hospital stage can be conservative or surgical.

With relatively mild stable injuries of the spine (distortions, whiplash injuries, etc.), bed rest, massage, and thermal procedures are indicated.

In more severe cases conservative treatment consists in closed correction of deformities (single-stage reduction or traction) followed by immobilization (special collars and corsets).

open surgical removal deformation relieves compression of the spinal cord and helps restore normal blood circulation in the affected area. Therefore, the growing symptoms of spinal cord injury, indicating its compression, are always an indication for urgent surgical intervention.

TO surgical methods are also used in cases where conservative treatment is ineffective. Such operations are aimed at reconstructing damaged segments of the spine. In the postoperative period, immobilization is used, if indicated, traction.

Victims with signs of spinal cord injury are hospitalized in the intensive care unit. In the future, such patients are supervised by a traumatologist, a neurosurgeon and a rehabilitation specialist.

Rehabilitation after injuries of the spine and spinal cord

Recovering from a spinal injury is a lengthy process.
For spinal injuries not complicated by spinal cord injury, exercise therapy is indicated from the first days of the injury: at first it consists of breathing exercises, from the second week limb movements are allowed. Exercises gradually complicate, focusing on general state sick. In addition to exercise therapy for uncomplicated spinal injuries, massage and thermal procedures are successfully used.

Rehabilitation for spinal cord injuries, supplemented electropulse therapy, acupuncture. Drug treatment includes a number of drugs that enhance regeneration processes in the nervous tissue (methyluracil), improve blood circulation (cavinton) and intracellular metabolic processes (nootropil).

Anabolic hormones and tissue therapy are also prescribed to improve metabolism and speed up recovery after injury ( vitreous body and etc.).

Today, new neurosurgical methods are being developed (transplantation of embryonic tissues), methods of performing operations that reconstruct the affected segment are being improved, clinical trials new medicines.

The emergence of a new branch of medicine - vertebrology - is associated with the difficulties of treatment and rehabilitation after spinal injuries. The development of the region has great social significance because, according to statistics, spinal injuries lead to disability of the most active part of the population.

There are contraindications. Before use, you should consult with a specialist.

It is the most dangerous for human life. It is accompanied by many complications and long-term rehabilitation. Injury to the spine threatens with disability and death. The most undesirable damage to the cervical spine. Treatment should begin as early as possible with emergency care, inpatient therapy and recovery course.

Spinal cord injury occurs for the following reasons:

• in road traffic accidents, various injuries occur (bruises, fractures, dislocations, contusion of different parts of the spine);
• falling from height;
• extreme sports (diving, skydiving);
• domestic, industrial injuries;
• gunshot, stab wounds;
• environmental disasters (earthquakes);
• non-traumatic disease disease (cancer, arthritis, inflammation)
• severe injury.

As a result of injury, fractures, vertebral arches, dislocations and displacements, ruptures and sprains, compression, concussion of the spinal cord occur. Damage is divided into closed and open, with or without violation of the integrity of the brain.

Traumatic factors cause pain, swelling, hemorrhage and spinal deformity. General symptoms: loss of consciousness, malfunction of organs (heart, lungs), paralysis, impaired thermoregulation of the body, the occurrence of a shock state, weakness in the muscles, numbness of the limbs, concussion, headache, nausea.

Spinal cord contusion manifests itself as a violation of all types of sensitivity. There is a decrease, loss of sensitivity, numbness of the skin, a feeling of goosebumps. If the signs increase, surgical intervention is necessary (with compression of the brain, hematoma, bone fragments).

Spinal cord injury can cause visceral-vegetative disorders. These include dysfunction of the pelvic organs, gastrointestinal tract (increase or decrease in the formation of digestive enzymes), decreased blood circulation and lymphatic drainage in tissues.

Cervical injuries

They are the most dangerous and more often than other injuries lead to death. This is due to the fact that the centers of respiration and heartbeat are located in the medulla oblongata; in case of damage, the work of these centers stops. There are fractures of the cervical spine during sports, falls, accidents. In case of a fracture of the upper vertebrae death occurs in 30-40%. When the atlas is dislocated, headache, tinnitus, cramps of the upper limbs, sleep disturbance, and back pain occur.

If the cervical spine is injured at the level of C1-C4, dizziness, pain in the upper neck, aphonia, paresis, paralysis, disturbances in the work of the heart, dysphagia, and lack of sensitivity may occur. With dislocation of the C1-C4 vertebrae, radiating pains, difficulty swallowing, and a feeling of swelling of the tongue also occur.

If a fracture or dislocation of the two upper vertebrae occurs, radicular syndrome manifests itself in 25% - pain in the back of the head and neck, partial impairment of brain function (manifested severe pain in the arms, weakness in the legs). In 30%, a symptom of transverse brain damage is manifested in the form of spinal shock (reflexes are absent, sensitivity is lost, the functioning of organs is disrupted).

Spinal shock can be reversible or irreversible. Usually, after the restoration of damaged tissues, the functions return. Allocate acute stage shock (the first 5 days), during which the conduction of impulses stops, there is no sensitivity, reflexes. The subacute stage lasts up to 4 weeks, damaged tissues are restored, cicatricial changes are formed, blood circulation and cerebrospinal fluid movements return to normal. The interim period lasts from 3 to 6 months, there is a restoration of lost functions.

In case of trauma of the cervical spine: fractures, dislocations of the middle and lower cervical vertebrae, cerebral edema, impaired circulation of cerebrospinal fluid, hemorrhages, and hematomas may occur.

Injury to the thoracic and lumbar spine

Symptoms of damage to this department are paralysis of various muscle groups: intercostal (respiratory disorders occur), muscles of the abdominal wall, lower extremities. There is weakness in the legs, a disorder in the functioning of the pelvic organs, sensitivity decreases below the site of injury.

Diagnostics

For diagnosis and diagnosis, it is necessary to conduct a number of studies:

• Radiography is performed for all people with suspected damage, done at least in two projections;
• Computed tomography is a more accurate research method, provides information on various pathologies, reproduces cross-sectional images of the spine and brain;
• Magnetic resonance imaging will help to reveal the smallest details in case of damage (blood clots, splinters, hernia);
• Myelography allows you to accurately see all the nerve endings, which is necessary for proper diagnosis, it can detect the presence of a hematoma, hernia, tumor;
• Vertebral angiography is performed to visualize the vessels of the spine. Check the integrity of the vessels, determine the presence of hemorrhages, hematomas;
• A lumbar puncture is performed to analyze the cerebrospinal fluid. May detect blood, infection, foreign bodies in the spinal canal.
• When making a diagnosis, consider the cause of the injury, the severity clinical symptoms, the effectiveness of first aid, the results of the examination and research methods.

Provision of emergency medical care

• it is necessary to limit mobility: place the victim on a hard surface, fix the injured area;
• prevent further damage to the body;
• if necessary, introduce painkillers;
• control breathing and pulse;
• when diagnosing shock, remove the patient from this state.

When transporting the patient, they try to avoid deformation of the spine so as not to cause further damage. In a medical institution, it is necessary to place the victim on a hard bed or a shield on which bed linen is pulled. The use of the Stricker frame is effective, it provides immobilization and patient care. Further, with the help of orthopedic treatment, deformities are eliminated, fixed, and a stable position of the spine is ensured.

Treatment

Orthopedic treatments include: reduction of fractures, dislocations, traction, long-term immobilization of the spine. In case of damage to the cervical spine, it is recommended to wear a neck brace.

Surgical treatment consists of removing foreign bodies, eliminating pressure on tissues and blood vessels, correcting deformities, restoring the anatomy of the spinal canal and brain, and stabilizing the damaged area.

If necessary surgical treatment in case of spinal cord injury, surgery is performed urgently. 6-8 hours after damage, irreversible changes may occur. For surgical intervention, all contraindications are eliminated with the help of intensive therapy. They optimize disorders of the cardiovascular and respiratory systems, eliminate cerebral edema, and prevent infections.

Medical treatment involves the appointment medicines. They use painkillers, hemostatic, anti-inflammatory drugs, stimulate an increase in immunity and body resistance. With spinal shock, atropine, dopamine, large doses of the hormone methylprednisolone are used. Hormone therapy (dexamethasone, prednisolone) reduces swelling of the nervous tissue, inflammation, and pain. With pathological spasticity of the muscles, muscle relaxants are used. central action(mydocalm, baclofen). To treat or prevent the occurrence infectious diseases broad-spectrum antibiotics are used.

With spinal cord injury, hormones are contraindicated in individual sensitivity, hormone therapy increases the risk of blood clots.

Effective is the use of physiotherapy treatment. Spend massotherapy, electrophoresis, electromyostimulation and biostimulation of body parts with reduced or lost sensitivity. Carry out applications with paraffin and various water procedures.

Complications

Immediately upon injury, bleeding, hematomas, ischemia, a sharp decrease in pressure, the occurrence of spinal shock, and CSF leakage occur.

After a spinal injury, there is a risk of various complications: bedsores, muscle spasticity, autonomic dysreflexia, difficulty with urination and emptying, sexual dysfunction. There may be pain in the area of ​​reduced or lost sensitivity. While caring for the sick, it is necessary to rub the skin, do exercises for the limbs, and help with bowel cleansing.

Rehabilitation

Life after a spinal cord injury can become significantly limited. To restore lost functions, it is necessary to undergo a long rehabilitation, physiotherapists will help restore the strength of the arms and legs, and teach how to perform household tasks. The patient will be taught how to use equipment for the disabled (wheelchair, toilet). Sometimes it is necessary to change the design of the house to create conditions for the patient and facilitate self-care. Modern wheelchairs make life easier for patients.

Medical rehabilitation of people with spinal cord injury involves hormone therapy, for chronic pain - painkillers, muscle relaxants, medicines to improve the functioning of the intestines, bladder, and genital organs.