Spinal cord injuries. Traumatic spinal cord disease

Spinal cord injury is currently one of the most pressing medical problems. Although such injuries are less common than traumatic brain injuries, more than three-quarters of injured people become disabled. Injury to the spine and spinal cord is most often an indirect injury.

Structure and functions of the spinal cord

The spinal cord is a cylindrical cord that runs in the spinal canal. It is part of the central nervous system, which carries out impulses from the brain to all organs, muscles, and skin. On a section it consists of white and gray matter. Gray matter is represented by a large number (about thirteen million) neurons. It is surrounded by white matter - these are the roots that carry commands from the brain directly to the organs.

Mechanism of spinal cord injury

Spinal cord injury occurs:

• isolated - damage to the spinal cord only;
• combined - with thermal, chemical and radiation damage to the body;
• combined - with involvement and damage to internal organs.

There are closed injuries and open ones - with damage to the skin, and a closed injury can be more serious in severity than an open one.

Spinal cord injury most often occurs in men 18-45 years of age. In this case, damage to the spinal cord, bones, joints of the spine, nerve endings and blood vessels. Basic mechanisms of injury:

• mechanical damage- compression by ligaments, bones, hematoma, foreign body;
• impaired blood supply due to damage to the arteries;
• edema;
• stretching

A spinal cord injury can result from contusion, crushing, concussion, compression, hemorrhage, or several causes.

Clinical picture

Symptoms of spinal cord injury depend on the severity, type of injury, level and extent of injury.

There is partial and complete damage to the spinal cord according to the degree of conduction of nerve impulses. If the damage is incomplete, the spinal cord may conduct some impulses. The patient has some sensitivity and preserved physical activity below the affected area, although not completely. In this case, there is a possibility of restoration of lost functions.

Complete - implies a conduction disorder in which there is no chance of restoring sensitivity and motor activity. In this case, the spinal cord is not necessarily anatomically completely cut.

Main signs of spinal cord injury:

• sharp or Blunt pain with a burning sensation due to damage to nerve fibers;
• impairment of motor activity - partial or complete;
• inability to feel touch, cold or heat;
• spasms or reflex activity;
• difficulty breathing or cough that does not bring relief;
• pain, irregularities in the heart area;
• inability to control urination and bowel movements;
• loss of sexual sensitivity and fertility.

Critical signs

Symptoms that suggest spinal cord injury after a head injury:

• short-term loss of consciousness;
• pain or feeling of pressure along the spine;
• inability to breathe normally;
• loss of sensation in the distal parts of the upper and lower extremities;
• involuntary urination or defecation;
• incorrect position of the back or neck;
• unsteady gait or loss of balance.

Clinical forms

Spinal cord injury occurs after exposure to a damaging factor and manifests itself in the following forms:

• shake;
• compression;
• injury;
• crushing in the form of tears or ruptures;
• hemorrhage in the spinal cord;
• radicular damage.

A concussion is characterized by reversible dysfunction of the spinal cord that resolves within a week. The integrity of the spinal cord is not compromised.

Compression injury has three types: damage to the spinal cord at the time of injury is acute, a few hours after it is early, and a few months later it is late. Acute occurs from compression by bone fragments, intervertebral discs, early - after displacement of the vertebrae or their parts due to improper transportation, later - due to the development of a scar-adhesive process or circulatory disorders. In all cases, ischemia of the conducting fibers occurs, and then their death.

Contusion and crushing of the spinal cord leads to complete or partial damage to the substance and rupture of the conductors. If at least some reflexes, sensitivity are preserved, or functional restoration is observed in the first hours or days, this is a good prognostic sign.

Hemorrhage leads to ischemia or death of neurons and the conduction system of the spinal cord, most often at the level of the cervical and lumbar regions and can involve several segments.

A distinctive feature is the preservation of deep and disappearance of superficial sensitivity.

Primary damage to the roots occurs as a result of exposure through the skin with a sharp object, and secondary damage occurs when a fragment of a vertebra or intervertebral disc is damaged. Most often, the following lesions of the spinal cord roots are identified morphologically: stretching, compression, bruise with hemorrhage, separation of one or more roots. Clinically: sensory disturbances, paresis or paralysis, autonomic disorders.

The most unfavorable localization of a spinal cord injury is up to the 4th cervical vertebra. Respiratory function, all types of sensitivity and movement of the limbs are impaired, a violation occurs pelvic functions. Such patients require constant care and artificial ventilation.

Damage at the level of 5-7 cervical vertebrae is manifested by partial paresis of the upper and lower extremities, severe pain, decreased or absent functions of the pelvic organs.

Localization at the level of 3-4 thoracic vertebrae leads to impaired breathing and cardiac activity; 5-9 vertebrae - to spastic paraparesis of the lower extremities and dysfunction of the pelvic organs; and sometimes to partial immobility, while maintaining deep sensitivity on one side and reducing sensitivity on the other.

Trauma in the lower thoracic region leads to flaccid paralysis of the legs, sensitivity disorder of the lower half of the body, urinary retention, and the formation of bedsores.

Lesion in the sacral and coccygeal regions leads to impaired sensitivity, sometimes flaccid paralysis, radicular pain and in rare cases- disorders of the pelvic organs.

Terrible complications

Trauma to the brain and spinal cord in the first minutes is complicated by traumatic shock or collapse, which can lead to the death of the injured person.

When bladder function is impaired and urine stagnates, cystitis and pyelonephritis develop, which can lead to urosepsis.

Trauma in the upper spine can lead to pneumonia, pulmonary edema due to respiratory distress and degenerative disorders in the lung tissue.

Trauma in lower parts- leads to dysfunction of the digestive organs. Stasis occurs, paralysis of the intestines and gives a picture of an acute abdomen.

Thrombosis of the deep veins of the pelvis and lower extremities is asymptomatic, but in 5% of cases it leads to pulmonary embolism and fatal outcome.

Pathological processes provoked by spinal cord injury:

• atrophy, cystic lesion, circulatory disorder of the spinal cord;
• trophic disorders - bedsores, ulcers, hard swelling of the legs, ossification and immobility of large joints;
• spinal deformity - dislocations, pathological fractures, degenerative changes;
• traumatic disease of the spinal cord.

The concept of traumatic illness

Spinal cord injury leads to the development of traumatic disease. This is a complex of all changes (reversible and irreversible) that occur after damage to the spinal cord itself, its membranes, vessels and roots and affect all organs and systems.

Depending on the time, several periods are distinguished.

1. The acute period lasts for the first three days. Sensitivity, reflexes, and motor activity are reduced, as is general muscle tone.
2. The early period lasts up to three weeks and is characterized by a gradual restoration of muscle tone, reflexes, the appearance of hyperreflexia and pathological reflexes due to the weakening of the inhibitory influence of the brain.
3. The interim period lasts up to three months. Muscle tone occurs with a predominance of either flexion or extensor; spasticity, muscle wasting, joint contractures.
4. The late period (up to a year) is characterized by improvement or deterioration of the condition.

During the residual period, new neurological functions are formed that will remain with the patient for life.

Pre-hospital first aid

Before the doctor arrives, it is necessary to control breathing, heart function, and ensure the immobility of the spine.

During the examination, the emergency doctor determines what kind of injury, the location of the spinal lesion, stops bleeding if necessary, immobilizes the spine and catheterizes the bladder for acute urinary retention, administers painkillers, sedatives and neuroprotectors. The spine is palpated and examined to identify wounds, swelling, and hematomas. Sensitivity, reflexes, motor activity, muscle tone are checked. It is necessary to carry out antishock therapy and bandaging the lower extremities with elastic bandages to prevent thromboembolism.

The patient is transported on a rigid stretcher. In case of injury to the thoracic or lumbar regions, the patient is placed on his stomach with a cushion placed under his head. If the injury to the cervical spine is on the back, the cushion is placed under the shoulders. The injured cervical spine is immobilized using a plaster or cotton-gauze collar. The mouth must be freed from foreign bodies or vomit and removed lower jaw and insert an airway or intubate the trachea. Trauma to the thoracic region leads to disturbances in cardiovascular activity: decreased blood pressure, rare pulse, symptom of warm lower extremities, therefore cardiac medications, atropine, and dopamine are administered.

Diagnosis and treatment

Brain and spinal cord injuries are diagnosed and treated by a neurosurgeon together with a neurologist. The main and informative surveys are:

• radiography;
• CT scan;
• lumbar puncture;
• myelography with the introduction of a contrast agent.

X-ray allows you to see damaged vertebrae, the site of the fracture, and narrowing of the spinal canal, but computed tomography will show all the changes more clearly. Magnetic resonance imaging will show swelling of the spinal cord, the presence of damage to the intervertebral discs, hemorrhages and hematomas. During lumbar puncture, cerebrospinal fluid pressure is measured and the patency of the subarachnoid spaces is assessed. Myelography is performed if spinal cord compression is suspected.

The need for surgery

Currently, the indications for surgical treatment spinal cord injuries, but only half of the patients require surgery. Many doctors believe that the earlier surgery is performed, the better the prognosis for the injured person and the greater the chance for recovery and restoration of function. During the operation, bleeding is stopped, bone fragments, hematomas, foreign bodies, and intervertebral disc herniation are removed, and the spine is stabilized with metal implants.

After surgical treatment, constant monitoring and careful care are necessary to prevent complications: deterioration of the patient's condition, contractures, urinary tract infections, thromboembolism, bedsores. It is recommended to carry out the prevention of bedsores and blood clots, exercises for paralyzed limbs, light rubbing, assistance with urination and defecation.

After discharge from hospital, long-term medical and social rehabilitation will be required in order to develop activity, mobility and adapt to daily activities. For medications, nootropics, vitamins, and immunostimulants are used; for physiotherapy, lidase iontophoresis, ozokerite and mud applications, and electrical stimulation of the bladder are used. Exercise therapy, massage, and spa treatment are indicated.

Full recovery is possible if the injury was of mild severity and all neurological functions have been restored to maintain normal functioning of the body.

About 6 million injuries involving the nervous system are recorded annually in the world, which accounts for approximately 6-8% of all neurological morbidity. spinal cord lesions have a relatively low proportion in general structure nervous system injuries – about 12%. From 80% to 100% of patients with this pathology become disabled or die.

Spinal cord injuries are usually associated with damage to the spine. Most often the lower cervical, lower thoracic and lumbar spine are injured.

Classification. Spinal cord injuries are divided into open and closed, penetrating and non-penetrating, with and without damage to the spine.

Open injuries include those in which a connection between the spinal canal and the external environment is formed through damaged soft tissue, vertebrae and dura mater.

The main clinical forms of closed spinal cord injuries are: concussion, contusion, compression, hematomyelia (bleeding into the brain substance) and hematorahis (bleeding into the membranes).

In the development of traumatic disease of the spinal cord, acute, intermediate or recovery, and late periods are distinguished. The acute period lasts approximately 1-2 months after the injury and is characterized by necrosis of spinal neurons and their processes in places of direct traumatic impact, as well as the development of diaschisis (spinal shock). Spinal shock is a nonspecific reaction of nerve cells and conductors of the spinal cord in response to injury, manifested in the form of limitation of their functions to the framework of maintaining basic life support processes with reversible blocking of other properties nerve tissue(excitability, conductivity).

Recovery period, lasting up to a year from the moment of injury, is characterized by relief of the phenomena of spinal shock, the beginning of the formation of a post-traumatic scar and the development of regenerative and reparative processes. During this period, the true extent of the spinal cord lesion and the possibility of restoring the existing morphofunctional defect are determined.

In the late period, the formation of secondary necrosis, cysts, edematous melting of nervous tissue comes to the fore, rough collagen scars are formed, ascending and descending degeneration of spinal conductors occurs, and infectious-trophic complications develop.

Etiology and pathogenesis . Spinal cord injuries occur at home, at work, in car accidents, during sports, and as a result of iatrogenic influences. The increase in the number of injuries is facilitated by the increasing mechanization of work and life, non-compliance with safety regulations in the workplace, and the constant increase in the number Vehicle coupled with the lack of discipline of drivers and pedestrians, a high rhythm of life, leading to the development of physical fatigue and neuropsychic stress, alcoholism and drug addiction.

Mechanical and vascular factors play a leading role in the pathogenesis of spinal cord injury. The mechanical factor is understood as morphological and functional changes in the tissues of the spinal cord directly related to the direction and intensity of the traumatic impact in the form of necrosis of nerve cells and conductors, changes in the intracellular structure with impaired speed metabolic processes etc. Blood supply disturbances and swelling that occur at the site of injury and nearby areas are decisive factors for the subsequent development of spinal cord TB.

Clinic . Damage to the spinal cord is clinically manifested by a symptom complex of motor, sensory and autonomic disorders. Some of them are due to the death of spinal structures, and some are due to varying degrees of damage to these structures and their functional inferiority. A common variant of reversible morphofunctional defect is spinal shock, which is typical for the acute period of spinal cord injury of any severity. Clinically, it manifests itself as paralysis of the limbs and anesthesia below the level of injury, retention of urination and defecation. The phenomena of spinal shock are observed within several hours and sometimes several weeks, after which the clinical picture of spinal cord injury is determined by neurological disorders varying degrees severity depending on the severity of the damage.

Spinal concussion– most light form traumatic injuries, which manifests itself predominantly as sensory disorders of the conduction type below the level of damage, most often in the form of hypoesthesia and paresthesia. Pain at the site of injury, numbness. Motor disorders are represented by mild weakness in the arms and/or legs, depending on the location of the injury. Sometimes pelvic disorders are detected in the form of constipation, urinary retention or increased frequency. All clinical manifestations regress without a trace within 2-3 weeks.

Spinal cord contusion accompanied by more severe neurological disorders. With this form, fractures of the vertebral bodies and arches with displacement into the spinal canal and compression of the spinal cord are often observed. As the phenomena of spinal shock regress, pronounced motor disorders are determined in the form of central and peripheral paresis or paralysis. Below the site of injury, sensory disturbances of the conductive type are observed in the form of hypoesthesia and anesthesia. When the roots are damaged, victims complain of shooting pains in the corresponding areas. Severe disorders of the functions of the pelvic organs, primarily urination, are determined by the peripheral or central type. After a few weeks, bedsores form on the sacrum, heels, iliac crests and other areas where soft tissue can be compressed by bony protrusions. Infection of bedsores often leads to sepsis and death. Urosepsis and pneumonia are also fatal. Recovery of functions after a spinal cord injury occurs at a slow pace throughout the year and is never complete.

Spinal cord compression caused by bone fragments of the vertebrae, fragments of ligaments and discs, intravertebral hematoma, edema-swelling and a combination of these reasons.

Compression of the spinal cord, which occurs acutely, most often occurs from fragments of the vertebrae and a prolapsed disc and develops at the time of injury. Motor and sensory disturbances occur below the level of damage, and dysfunction of the pelvic organs occurs. A gradual increase in neurological symptoms is characteristic of an epidural hematoma due to damage to the epidural veins. A hematoma can develop 2-3 weeks after injury as a late traumatic hemorrhage. In this case, victims develop radicular pain, reflex muscle tension in the area of ​​hematoma projection, and disturbances in the statics and dynamics of the spine.

In cases of complete interruption of the spinal cord, trophic disorders (extensive bedsores, hard swelling of the legs) are detected already in the first days. The presence in the acute period of at least one reflex with complete areflexia, the early appearance of Babinski's symptom, and the preservation of sensitivity in the perineal area make it possible to exclude a complete break of the spinal cord.

Hematomyelia- hemorrhage in the spinal cord.

The clinical picture is determined by the location of the hemorrhage. Most often, the gray matter of the spinal cord is affected in the area of ​​the cervical and lumbar thickenings. In the zones of innervation of the affected segments immediately after injury, flaccid paresis, dissociated disorders of superficial sensitivity while maintaining deep sensitivity. With massive hemorrhages, the white matter of the spinal cord is involved in the pathological process, which is manifested by moderately pronounced conduction disorders - spastic paresis, disorders of the pelvic organs. The outcome of the injury depends on the volume and location of the hemorrhage, but the death of neurons in the gray matter of the spinal cord predetermines incomplete recovery of functions.

Hematorahis– hemorrhage into the membranes of the spinal cord, occurs with traumatic injuries to the vertebrae.

Clinical picture of subarachnoid hemorrhage as in vascular diseases of the central nervous system. Neurological symptoms with epidural hematoma occur after a short (several hours) “light” interval. Subsequently, conduction disturbances occur below the lesion in the form of paresis, disorders of sensitivity and functions of the pelvic organs. Clinical symptoms increase over time. At the location of the hematoma, pain is detected when tapping the spinous processes of the vertebrae, reflex tension of the paravertebral muscles, and pathological fixation of nearby motor segments.

Diagnostics: spondylography, positive and pneumomyelography, CT, MRI. Lumbar puncture.

Treatment . Urgent Care: - immobilization of the spine: the victim is placed on a flat board, which, if necessary, can be replaced with improvised means (tree branches, boards, etc.);

Transport only in a supine position;

In the presence of open wound a bandage is applied, 1 million units of sodium or potassium salt of benzylpenicillin is injected intramuscularly;

Victims with pain syndrome are prescribed analgesics (analgin, promedol);

Bladder catheterization is mandatory.

Qualified care: primary surgical treatment of the wound. The indication for urgent surgery is compression of the spinal cord by a displaced vertebra, hematoma or foreign body.

Conservative treatment: enzymes, corticosteroids; drugs that prevent maturation connective tissue: pyrogenal, lidase, ribonuclease, vitreous, aloe. Immunomodulators (pentoxylo, methyluracil, 6-mercaptopurine, methotrexate) and synthesis stimulants nucleic acid and proteins (B vitamins, folic and orotic acids, alpha-tocopherol, Keltican).

For concussions and bruises, trental, agapurin, and cavinton are used.

From the first days, great importance is attached to the prevention of the development of bedsores, urosepsis, and pneumonia.

Intestinal paresis is treated using laxatives, siphon enemas, anticholinesterase drugs (prozerin, galantamine).

Electrical stimulation of the bladder and intestines.

To prevent pneumonia, breathing exercises are prescribed (inflating balloons, exercises with forced breathing), exercise therapy - an important element of which is giving the body vertical position, which increases the excursion of the chest, normalizes the functioning of the heart and intestines. Strength training is important for initial stages development of the disease, however, do not lose their relevance in the late period of spinal cord injuries.

Physiotherapeutic procedures, massage, and electrical stimulation of the spinal cord and its roots are important for the correction of movement disorders.

Control questions:

1.What is the pathogenesis of a brain tumor?

2. List the focal symptoms characteristic of tumors of the frontal, temporal, parietal and occipital lobes.

3. Name the symptoms of hypertension.

Medical and social examination and disability in spinal cord injuries

Definition
Spinal cord injury (spinal cord injury - spinal cord injury) - mechanical damage to the spine and (or) the contents of the spinal canal (spinal cord, membranes, vessels, spinal nerves), manifested by spinal and radicular symptoms caused by primary structural and functional changes, and subsequently pathophysiological and pathomorphological processes.

Epidemiology
Traumatic lesions of the spinal cord are one of the most severe types of injuries and a serious medical and social problem. The incidence of PSMT is 2.6-14.5 per 100,000 population; in the general structure of injuries from 0.7 to 4%, and among victims with CNS trauma - up to 10%. It is 3-4 times more common among men.
The social significance of SCI is determined by high mortality (17-23% in the acute period of injury), severe and persistent consequences that dramatically change social status injured. 70-80% of them become disabled, with disability groups I and II predominating. In the structure of all primary neurological disability, spinal injury accounts for 5.7-5.9%. In more than half of the cases, injuries occur to persons under the age of 45, i.e., the most active in social, labor and military terms.
The most common causes of spinal injuries in peacetime are road accidents (35%) and falls from a height (32%). Sports injuries account for about 10% (diving, jumping, wrestling), industrial injuries (compression, blockages, blow to the spine) - about 20%.
The complexity of the problem of acute trauma lies in the fact that victims need the help of specialists different profiles- traumatologist, neurosurgeon, neurologist, urologist, etc. The share of complicated spinal injuries in the structure of all bone injuries reaches 17.7%. Neurological pathology almost always occurs with trauma to the cervical and upper thoracic spine and in 30-70% of patients with damage to the lumbar and lower thoracic vertebrae (Livshits A.V., 1990). Bone damage is absent in only 6.1% of victims (Ruchkin B.F., 1989).

I. Periods during traumatic disease of the spinal cord
1. Acute lasting from several days to 3-
4 months depending on the severity and nature of the injury.
2. Intermediate (restorative). Duration 1-2 years.
3. Late. May continue indefinitely.

II. Classification of the acute period of SCI:
1. Open - with a violation of the integrity of the skin at the level of damage to the spine, spinal cord or cauda equina roots: a) depending on the damage to the wall of the spinal canal - penetrating and non-penetrating; b) gunshot and stab wounds.
2. Closed - without violating the integrity of the skin:
a) with damage to the spine (ligaments, discs, bone structures, multiple); stable and unstable;
b) without damage to the spine; c) according to clinical form: spinal cord concussion; spinal cord contusion (mild, moderate and severe); spinal cord compression.
3. By location of the lesion (closed and open injury):
a) spinal cord (cervical, thoracic, lumbosacral regions); b) roots of the horse's tail.

III. Classification (clinical and morphological) of the late period of closed PSCI(Makarov A. Yu., Amelina O. A., 1992):
1. Without compression of the spinal cord: a) with reversible morphological and functional changes; b) with irreversible spinal and radicular morphological changes.
2. With compression of the spinal cord: a) with irreversible spinal and radicular morphological changes;
b) with progressive morphological changes (myelopathy, arachnoiditis.

Pathogenesis, pathomorphology
Currently, they are considered on the basis of intravital MRI-detected morphological changes in the spinal cord, adjacent bone structures and soft tissues: vertebral fractures, rupture of the ligamentous apparatus, post-traumatic disc herniation, as well as congenital pathology, primarily stenosis of the cervical spinal canal (Maravilla, Cohen , 1991; Kholin A.V., 1992, etc.).

1. In the acute period of SCI. Possibility of damage to the spinal cord and roots: extreme degrees of flexion, extension, compression due to fracture of both the body and vertebral arches. Some pathogenetic mechanisms: 1) vascular insufficiency due to narrowing or compression of the effective radiculo-medullary arteries, especially when the general
hemodynamics (with a focus of softening); 2) hematomyelia (point or confluent). It is 5 times more common in patients with spinal cord compression than without it, and is typical of open injuries such as stab wounds. According to MRI data, regression of morphological changes within several weeks, in the late period - cystic changes or atrophy of the spinal cord;
3) spinal cord contusion. Depending on the severity and presence of concomitant compression: swelling below the level of compression can last up to 2 months, in its absence it disappears within a few days, which is accompanied by restoration of impaired functions; primary traumatic necrosis of the spinal cord with a large spread in its diameter and relatively less in length; 4) complete transverse lesion with uneven edges of brain tissue and late formation of scars.

2. In the intermediate and late periods of PSMT the main pathogenetic factors leading to the progressive course of the disease with worsening of existing neurological deficits or the appearance of new symptoms are (Makarov A. Yu., Amelina O. A., 1994):
1) persistent compression of the spinal cord (impaired patency of the subarachnoid space, compression of the brain, its deformation);
2) a progressive adhesive membrane process (obliteration of the subarachnoid space, cysts), which is one of the factors of discirculatory myelopathy;
3) progressive myelopathy. Variants of clinical and morphological manifestations:
a) spinal cord atrophy (local or diffuse);
b) myelomalacia (foci of necrosis, edema, gliosis, microcysts), more often after a severe injury with a syndrome of complete or partial disruption of spinal cord conduction;
c) cystic degeneration: microcystic and macrocystic (syringomyelitic syndrome);
d) discirculatory myelopathy;
e) a combination of these manifestations.

Clinic and diagnostic criteria
I. In the acute period of SCI:
1. Associated spinal injuries:
a) stable fractures. There is no damage to the “posterior supporting complex,” i.e., the intervertebral joints, supraspinous and yellow ligaments, which provide the static function of the spine. Restoration of its functions occurs within a period of 7 to 8, at most up to 12 months. In the late period of injury it is compensated;
b) unstable fractures. Extensive damage to the vertebral bodies, comminuted fractures with an Urban wedge, compression fractures of the vertebral bodies (usually C5-C6 and Th12-L1) with a decrease in the height of the bodies by 1/2 or more, elements of dislocation with damage to the ligamentous apparatus and disruption of anatomical relationships are observed in various combinations in the segment, which in some cases can progress and cause neurological disorders along with decompensation of spinal function. There is no clear parallelism between the severity of injury to the spine and the spinal cord, although spinal cord injury is accompanied by damage to various spinal structures in 30-40% of cases. The clinical and occupational prognosis is usually poor. Surgeries that stabilize the spine are indicated, sometimes with decompressive laminectomy and subsequent corrodesis; the time frame for restoring spinal function often takes up to 2 years.
In 40% of cases, SCI is combined with other bone injuries - limbs, pelvic bones, rib fractures, closed head injury, and damage to internal organs. The localization and nature of the combined pathology are taken into account when judging the prognosis and the degree of limitation of the life activity of the victims.

2. Clinical forms of acute spinal cord injury. Damage to the spinal cord usually leads to the development of spinal shock syndrome complete violation conductivity: flaccid paralysis muscles distal to the site of injury, atony of paralyzed muscles, loss of reflexes and all types of conduction-type sensitivity. Neurological disorders are reversible; their usual duration is from 2-4 to 5-7 weeks, depending on the severity of the injury. Shock can be maintained and aggravated in the presence of spinal cord compression, circulatory disorders and liquor circulation. Subsequently, the clinical picture depends on the level, extent and nature of the spinal cord injury:
a) spinal cord concussion. Clinically manifested by segmental disorders in the form of short-term muscle weakness, decreased reflexes, loss of sensitivity, sometimes in combination with mild conduction disorders in the form of urinary retention, pyramidal signs. These symptoms almost completely disappear within the first 5-7 days;
b) spinal cord contusion. It is characterized by a combination of functional and morphological changes in the form of foci of contusion and softening. For mild bruises, segmental neurological symptoms combined with partial conduction disorder syndrome. They last for more than 7 days, the restoration of functions is almost complete and occurs within a month. Injury medium degree manifests itself as a syndrome of partial or complete conduction disturbance with incomplete restoration of functions within 2-3 months. A severe contusion occurs when there is significant anatomical or axonal (when the integrity of the spinal cord is externally preserved) damage to the brain. The true extent of partial damage can only be revealed several months after the injury. There may be a slight improvement or persistence of the complete conduction disorder syndrome.
With spinal cord contusions, blood is often found in the cerebrospinal fluid. Due to the involvement of blood vessels in the process (angiospasm, compression), mild injuries can be accompanied by severe damage to the spinal cord; sometimes the level of injury does not correspond to the border of neurological disorders or two lesions are detected.
Traumatic hematomyelia occurs in 90% of cases at the level of the cervical and only in 10% of cases at the lumbar thickening. As a rule, it manifests itself as sharp girdling pain in the corresponding segments, impaired superficial sensitivity, segmental paresis, and sometimes impaired pelvic functions. Hemorrhage usually involves the gray matter over 3-4 segments; the spilled blood does not enter the white matter, but compresses it from the inside; as a result, the clinical picture includes, along with segmental and conduction symptoms. As the blood is absorbed, conduction disorders disappear, a cavity or glial scar is formed, often with a characteristic syringomyelitic syndrome. Functional restoration requires from several weeks to 4 or more months;
c) compression of the spinal cord is always accompanied by a moderate or severe contusion with foci of primary and secondary softening. There are compression by fragments or vertebral bodies, discs, damaged ligaments, epi- or subdural hematoma. Neurological symptoms are usually severe, with partial or complete disruption of conduction. The prognosis depends on timely surgical treatment;
d) features of open spinal cord injury; absence of traumatic injury to the spine (except for gunshot wounds); the possibility of partial damage to the spinal cord, most often manifested by Brown-Séquard syndrome.

II. In the intermediate and late periods of PSMT:
1. Syndrome of complete disruption of spinal cord conduction (in 30% of patients).
2. Disorders that arose in the acute period and regress to varying degrees in the future. The severity and nature of the neurological deficit depend on the level of damage:
a) at the cervical level, with the syndrome of partial conduction disturbances, mixed upper and spastic lower paraparesis is formed, sensory disorders of the segmental type in the arms and conductive type below the level of the lesion occur, with dysfunction of the pelvic organs of the central type, radicular pain in the upper extremities radiating to the back of the head , neck. With high cervical localization, brainstem symptoms are common, predominantly bulbar, vestibular dizziness, and sometimes a disorder of superficial sensitivity on the face of the bulbous type;
b) at the thoracic level: spastic lower paraparesis or paraplegia, conduction hypo- or anesthesia, disorders of the pelvic functions of the central type;
c) at the level of the lumbar enlargement of the spinal cord: flaccid paralysis of the lower extremities, loss of tendon and superficial reflexes, anesthesia below the level of injury, urinary and stool retention with periodic incontinence;
d) with spinal conus syndrome, there are no paresis, anesthesia in the anogenital zone, true urinary and fecal incontinence are observed;
e) damage to the roots of the cauda equina: flaccid paresis of the distal parts of the lower extremities, usually asymmetrical, accompanied by atrophy of the corresponding muscle groups. Depending on the degree of damage to the roots, sensitivity disorders are observed in the form of hypo-, anesthesia, and more often hyperesthesia with severe pain. Oppression tendon reflexes asymmetrically, pelvic disorders of a peripheral type.
3. Clinical syndromes caused by the progressive course of a traumatic disease:
a) progressive post-traumatic myelopathy (in 28% of patients). Syndromes:
- syringomyelitic;
- amyotrophic lateral sclerosis;
- spastic lower paraplegia;
- discirculatory myelopathy, rarely - acute cerebrospinal circulation disorder in the lower arterial basin.
Factors contributing to the development of post-traumatic myelopathy: congenital spinal canal stenosis, meningeal adhesions, reactive hyperplasia of the posterior longitudinal ligament of the spine, traumatic disc herniation with prolapse into the lumen of the spinal canal, as well as deformation of the vertebral segments and spinal cord;
b) spinal arachnoiditis with obliteration of the subarachnoid space, cysts (in 7% of cases). Most often local in the area of ​​bruise, compression of the spinal cord. However, a widespread adhesive process is possible, clinically manifested by sensory-motor disorders that occur 1.5-10 years after SCI, aggravating the severity of its direct consequences. Clinically: polyradicular pain syndrome, conductive sensory disorders (at a distance from the site of injury), worsening of existing pyramidal and flaccid paresis. Symptom instability, remission, exacerbation are typical;
c) degenerative-dystrophic process in the form of deformation of the vertebral bodies, osteochondrosis in the area of ​​the affected segments with persistent radicular pain syndrome; deforming spondylosis.

III. Additional research data:
1. Spondylography. Depending on the location of the lesion in the anteroposterior, lateral and oblique projections, if necessary, tomography. Fractures, fracture-dislocations, and dislocations of the vertebrae are clearly identified.
2. CT scan - visualizes bone structures, spinal canal, small bone fragments, arch fractures.
3. MRI - allows you to obtain a multidimensional image of the spinal cord, identify morphological changes in other soft tissue structures of the spine (traumatic disc herniations, hematomyelia, epidural hematoma, etc.). Morphological changes in the spinal cord are clearly visualized in the acute period of SCI, can be traced in the intermediate period and are recorded during the progressive course of traumatic disease of the spinal cord, which makes it possible to objectify the morphological basis clinical syndrome, described above (Makarov A. Yu. et al., 1995). The ability to assess the condition of the spinal canal, the nature and degree of spinal cord compression determines the indications, scope and tactics of neurosurgical intervention.
4. Lumbar puncture with determination of the patency of the subarachnoid space, examination of the cerebrospinal fluid (admixture of blood in the acute period, increase in protein content).
5. Myelography with water-soluble contrasts (if it is impossible to perform MRI and CT).
6. Examination by a surgeon, traumatologist, therapist (concomitant damage to internal organs and other bone structures).
7. EMG to objectify the syndromes of progressive myelopathy and radicular lesions.
8. Thermal imaging (clarification of the level of damage to the spinal cord, vascular disorders).
9. Urological examination: cystometry, cystoscopy, EMG assessment of the innervation of the striated sphincter of the bladder (objectification of the nature and degree of dysfunction).

Differential diagnosis
1. In the acute period of SCI (in the absence of data on concomitant spinal injury, in the case of concussion by a blast wave and in other situations): a) with an acute disorder of spinal circulation, in particular acute radiculomyeloischemia; b) hematomyelia with vascular malformation.
2. In the late period of traumatic disease of the spinal cord (mainly with a progressive course), the differential diagnosis is carried out:
a) with myelopathy of spondylogenic, vascular and mixed origin;
b) with a spinal cord tumor;
c) with amyotrophic lateral sclerosis;
d) with syringomyelia;
e) with spinal amyotrophy and some progressive degenerative diseases of the spinal cord.
It must be taken into account that these diseases, for example vascular lesions, may first appear or clearly progress under the influence of SCI, both in the acute period and subsequently.

Course and prognosis
1. Main factors determining clinical prognosis, degree of disability in case of post-traumatic stress injury: type of injury (open, closed); localization, clinical form and severity of damage; the presence of complications (severe pelvic, trophic disorders), the combined nature of the injury, the effectiveness of treatment and rehabilitation measures, social and labor rehabilitation.
2. In general terms, it is advisable to distinguish (Ugryumov V.M., 1973) three groups of patients: a) with reversible changes - complete or almost complete restoration of spinal cord functions; b) with a combination of reversible and irreversible changes - partial restoration of spinal cord functions; c) with irreversible changes (anatomical or axonal break of the spinal cord or cauda equina roots) - there is no recovery, and for some functions it may be due to compensatory devices, regeneration after suturing the cauda equina roots.
According to the literature, recovery after SCI is observed in 17-32%, improvement - in 32-42%, condition without changes - in 7-50% of patients.
3. The greatest changes in the neurological picture occur during the first and second years after the injury, with 70% of victims experiencing partial or complete restoration of function, 21% of the condition does not change significantly, and only 9% deterioration. In subsequent years (from 2 to 45 years after the injury), in 50% of patients the neurological deficit remains stably, in 30% slow improvement and adaptation to the defect continues, and in 20% the neurological picture worsens (Amelina O. A., 1992). The main reasons for the progressive flow are stated above.
4. The labor prognosis is more favorable in the case of early recovery and stabilization of the anatomical and physiological relationships of the spinal segments by surgical or (better) conservative means.

Principles of treatment in acute and intermediate periods of SCI
1. Stages and continuity therapeutic measures:
a) first aid at the scene of an incident - immobilization, gentle transportation, anti-shock measures, catheterization, etc.; b) hospitalization in a traumatology, neurosurgical, specialized department; V) further treatment in the rehabilitation therapy department, rehabilitation center(specialized department of neurorehabilitation), sanatoriums of the corresponding profile, on an outpatient basis.
2. Conservative therapy in the acute period: correction of vital dysfunctions, prevention of further damage to the spinal cord - naloxone, methylprednisolone; drugs that improve microcirculation and tissue metabolic processes (Cerebrolysin, anabolic hormones, nootropics, etc.); treatment of bedsores, urinary infection, prevention and treatment of adhesive membrane process (pyrogenal, lidase), etc. With increased muscle tone - baclofen, sirdalud and other muscle relaxants; acupressure, subsequently physical therapy, physiotherapy.
3. Surgical treatment of patients with complicated spinal injuries. A functionally conservative method is traction. For unstable fractures and spinal cord compression - surgical treatment. The main task is decompression of neurovascular formations (spinal cord, roots) followed by spinal fusion of damaged motor segments. Fixation or resection of vertebral bodies with autotransplantation and other modern methods are used. In the future, according to indications, orthopedic treatment.
In case of gunshot wounds, the volume and nature of surgical intervention are determined by the characteristics of the injury and the condition of the victim. In cases of penetrating injury to the spine and spinal cord, early surgery is usually necessary.
4. Compliance with the length of stay in the hospital. They are purely indicative and depend on the characteristics of bone injuries, the need for repeated surgical interventions, injuries, complications, and the combined nature of the injury. If we take into account only damage to the spinal cord, then in case of a concussion, the duration of inpatient treatment should be at least 1.5-2 weeks; for mild bruise - 3-4 weeks, bruise moderate severity- 1.5-2 months, severe bruise 3-4 months.

Medical and social examination Criteria of VUT
1. In the acute and intermediate periods of SCI:
a) with simultaneous damage to bone structures:
- in the case of a stable fracture (without disruption of the “posterior supporting complex”), the duration of life is up to 4 months, for people with manual labor, continued treatment on sick leave for up to 8-10 months;
- in the case of an unstable VL fracture, up to 8-12 months.

When deciding on the need for referral to
BMSE and continuation of treatment on sick leave must also take into account the prognosis for the restoration of spinal cord functions;
b) without damage to bone structures:
- in case of concussion and slight contusion of the spinal cord - VL for at least 1-1.5 months. Patients whose work involves long walking and significant physical stress should be provided with temporary relief of working conditions according to the conclusion of the CEC;
- with a moderate injury, in particular accompanied by hematomyelia, the duration of life is usually 3-4 months. If by the 4th month the restoration of impaired functions continues and further improvement can be expected, which will allow the patient to return to work or be assigned disability group III instead
Group II, then it is advisable to continue VL for another 2-3 months. Many patients who have started work also need to create easier working conditions according to the decision of the Institution of Internal Affairs;
- in case of severe contusion, complete or partial transverse injury of the spinal cord due to an unfavorable clinical and work prognosis, continuation of VL for more than 3 months is usually inappropriate. They must be examined by the BMSE;
- in case of injury to the cauda equina, especially accompanied by hemorrhage in this area, the timing of VL depends on the results of surgical treatment, usually they are at least 2-3 months. With persistent pain, motor and pelvic disorders, patients should be referred to BMSE;
- in case of open spinal cord injury, the duration of VL is determined mainly by the severity of the spinal cord injury (partial, complete interruption), the volume and results of the surgical treatment performed. Usually VN is at least 2-3 months.

2. In the late period of PSMT:
a) in case of decompensation during a traumatic illness, the need for repeated inpatient examination, treatment of VN - 1-2 months, including for working disabled people;
b) in case of revealed functional insufficiency of the spine, in particular after surgical treatment; need for orthopedic care; exacerbation of radiculopathy due to developed osteochondrosis of the spine (duration of VL depending on the degree of dysfunction, effectiveness of therapy);
c) with progressive post-traumatic myelopathy, exacerbation of spinal arachnoiditis (during diagnosis, inpatient and outpatient treatment). In case of an unfavorable prognosis, patients are referred to BMSE in order to determine or strengthen the disability group.
The main causes of disability in the late period of post-acute spinal cord injury
1. Motor disorders: central, less often flaccid mono-, para-, tetraparesis, the degree of which is aggravated by changes in muscle tone (spasticity, atony), secondary muscle contractures, tendon retractions. Characteristics of disability depending on the location and degree of motor defect. Concomitant vegetative and trophic disorders, observed in 24% of patients, also affect their vital functions, but they are usually combined with paresis, which are leading in assessing work capacity.
2. Pelvic disorders occur in 86% of patients. There are three degrees of severity of pelvic dysfunction (compensated, decompensated, severe). Depending on the level of injury and the extent of damage to the spinal cord, possible Various types urination disorders: reflex, hyporeflex, hyperreflex, atonic and mixed (Livshits A.V., Vishnevsky A.V., 1974). Pelvic and motor disorders are usually combined, therefore, they jointly affect the vital functions and ability to work of patients, but they can also be leading. Moderate urinary retention and infrequent urgency usually have a lesser impact on quality of life than incontinence. The need to control urination, defecation, and use of a urine bag eliminates physical stress, constant presence at the workplace, and complicates constant presence in a team. All this limits the possibilities of work in normal production conditions.
3. Sensitivity disorders in some cases significantly aggravate the severity of disability due to radicular pain syndrome and especially after injury to the cauda equina. Depending on the persistence and severity of the pain syndrome, it affects the ability to work to varying degrees. It is mainly limited or lost in professions that require a load on the spine, a forced position of the torso and limbs, prolonged standing, and walking. At the same time, disruption of the static-dynamic function of the spine due to the consequences of fractures may be significant. In rare cases, sensory ataxia leads to limitation of life activity.
- closed spinal injury with compression fracture Th6. Moderate spinal cord contusion with moderately severe lower paraparesis and dysfunction of the pelvic organs. Acute stage;
- SCI with compression fracture of the C5-C6 vertebral bodies, severe contusion of the spinal cord, moderate upper flaccid paraparesis and severe spastic paraparesis of the lower extremities, moderate pelvic disorders, mild radicular pain syndrome. Late period;
- consequences of closed spinal cord injury (brain contusion at the Th4-Th5 level). Progressive myelopathy (microcystic degeneration) with moderate lower spastic paraparesis, mild pelvic disorders of the central type.

Contraindicated types and working conditions
1. Associated with static load, sudden and constant movements upper limbs, V various departments spine, with a forced position of the body, etc.
2. Associated with physical stress (features depending on the location and extent of paresis). For example, with moderate atrophic paresis of the distal upper limbs, fine coordinated movements of the fingers are necessary.
3. In case of dysfunction of the pelvic organs: requiring constant presence at the workplace (operator, assembler on a conveyor belt, etc.).
4. General - exposure to adverse meteorological factors (especially cooling), toxic substances.

able-bodied patients
1. Those who have suffered a concussion, a slight contusion of the spinal cord with full restoration of function, not complicated by a spinal fracture, or with a stable fracture, rationally employed (sometimes after a long-term VL).
2. After a mild or moderate contusion of the spinal cord, the motor defect has been largely compensated, without other complications of the injury, if the necessary facilitated working conditions can be provided according to the conclusion of the VC.

Indications for referral to BMSE
1. Unfavorable clinical and work prognosis due to significant dysfunction and social impairment due to severe posttraumatic injury and slow recovery, despite active treatment.
2. Inability to return to work in the specialty due to the characteristics of the motor defect and other dysfunctions.
3. Progressive course of traumatic disease of the spinal cord, late functional failure and osteochondrosis of the spine with pain, other complications (with combined injury).

Minimum required examination when referring to BMSE
1. Spondylography data, myelography.
2. Results of lumbar puncture.
3. CT, MRI (if possible).
4. EMG, ENMG (if necessary).
5. Results of urological examination.
6. EMG of the striated sphincter of the bladder (to objectify pelvic disorders).
7. Data from examination by a traumatologist, neurosurgeon.
8. General clinical tests of blood and urine.

Disability criteria

Group I: pronounced limitation of life activity - inability to move, severe impairment of the functions of the upper extremities (according to the criteria for impairment of the ability to move and self-care of the third degree).

Group II: severe limitation of life activity: a) pronounced upper or lower paraparesis, less often hemiparesis, as well as moderate but widespread motor disorders (tri-, tetraparesis); significant dysfunction of the pelvic organs, persistent severe radicular pain syndrome (according to the criteria of impairment of the ability to move, self-care of the second degree, and ability to work of the second and third degrees); b) progressive course of traumatic illness with the development of severe post-traumatic myelopathy;
c) complex-comminuted and compression fractures of the vertebrae with a decrease in the height of the vertebrae by 1/2 or more and instability in the vertebral segments; d) unclear clinical prognosis in case of planned surgical treatment, long period of repair and reconstruction of the graft; e) severe combined injury with combined defects (the criteria for limiting the ability to move and self-care of the second degree are used).

Group III: moderate limitation of life activity: a) motor disorders partially limiting the ability to move, perform applied actions (moderate, less often mild mono-, para-, tri-, tetraparesis); moderate pain syndrome and dysfunction of the pelvic organs, if they interfere with work in the main profession, as well as subject to a decrease in qualifications or a decrease in the volume of production activity (according to the criteria for impairment of the ability to move and work activity of the first degree).
The dynamics of disability depending on the severity of the injury and the nature of the dysfunction: in 15% of patients the disability group worsens, in 54% the disability remains stable for a long time, and in 31% of cases partial or complete rehabilitation is carried out.

In the case of severe dysfunction of the spinal cord, if rehabilitation measures are ineffective, the disability group is determined indefinitely (after 5 years of observation).

Causes of disability: 1) general disease; 2) injury received during the period military service; 3) work injury. In this case, the BMSE determines the degree of loss of professional ability to work; 4) disability since childhood.
The basis for recognizing a child who has suffered a spinal cord injury as disabled is: a) for two years - the need for long-term treatment and rehabilitation; b) before reaching the age of 18 - paralysis or deep paresis of one or more limbs.

Prevention of disability
1. Primary prevention: prevention of SCI, in particular industrial and sports.
2. Secondary prevention: a) compliance with the terms of inpatient treatment, the optimal volume of treatment and rehabilitation measures, including orthopedic and surgical treatment; b) dispensary observation after hospitalization: for those who have suffered severe post-traumatic injury, the frequency of examinations is at least 2 times a month, then at least 3-4 times a year; after minor injury- once a month for 3 months, then once every 3 months; with severe persistent dysfunction - once a year; c) compliance with VN deadlines; d) extension of treatment on sick leave for follow-up treatment of victims with ongoing restoration of functions; e) creation of easier working conditions based on the conclusion of the VC.
3. Tertiary prevention: a) timely identification and treatment of patients with progressive post-traumatic myelopathy, arachnoiditis, decompensation of spinal function; b) rational employment of disabled people of group III; c) reasonable and timely determination of disability.

Rehabilitation
The basic principles are the same as for TBI.
An individual rehabilitation program for a victim with SCI is a continuous, long-term process aimed at maximizing restoration and compensation of impaired functions, and, consequently, the degree of disability and social consequences of the injury. The program is drawn up taking into account the predicted level of rehabilitation: full, partial, household.
The rehabilitation potential of patients with partial disruption of spinal cord conduction is generally good. In this case, the preservation of intelligence and the possibility of active participation of the patient should be taken into account. Rehabilitation activities in addition to the medical, they should include social, professional and psychological aspects (Kogan O. G., Naidin V. JL, 1983). However, the effectiveness of restorative treatment is insufficient. Unsatisfactory results from various sources are observed in 16-47% of patients, although optimal and satisfactory compensation is possible in 30-60% of cases.

1. Medical rehabilitation includes rehabilitation measures that should be carried out step by step in a hospital, a specialized rehabilitation center, a sanatorium of the appropriate profile, as well as on an outpatient basis (in a clinic, at home, at work). The complex of therapeutic and rehabilitation treatment, in addition to drug therapy, involves stimulation of the spinal cord using implanted electrodes and hyperbaric oxygenation.
One of the most important conditions for medical rehabilitation of victims is the restoration of independent function of urination and defecation. Various methods of electrical stimulation of the bladder are used to restore active urination. A method has been developed for the treatment of patients with urinary incontinence by transurethral electrical stimulation of the striated sphincter of the bladder, combined with training of sphincter contraction through biological feedback in the form of a recorded electromyogram (Amelina O. A., Pavlov V. S., 1992). The method is effective in 30% of patients with urinary incontinence with partial denervation of the sphincter.
At the final stage of rehabilitation treatment, special attention should be paid to strengthening compensatory mechanisms. Complexes of therapeutic exercises, massage, and acupuncture are used to increase muscle strength and prevent atrophy and contractures. Special methods are used to restore the ability to move independently and develop everyday self-care skills.

2. Vocational rehabilitation includes the psychological aspect, vocational training (retraining), rational employment. The most important stage of a comprehensive rehabilitation system is training disabled people in accessible professions. Opportunities for acquiring a new profession are used directly in production or in specialized educational institutions(boarding colleges, vocational schools).
Disabled people of group III have access to light types of work that do not require a forced position of the body or long periods of standing on their feet. The employment recommendation must take into account the nature and extent of the motor defect and other impairments, professional training, personal wishes and objective opportunities for employment of the disabled person. All types of administrative and economic work are possible, the work of a fitter-assembler of small-sized equipment, a computer operator, a cutter, a photographer, a laboratory assistant, a librarian, an archivist, etc. The optimal nature of the work should correspond to a light and moderate degree of severity. For disabled people of groups I and II, work in specially created conditions at work, as well as home work, may be recommended. All types of mental labor are available to them with appropriate education or after training (scientist, translator, lawyer, etc.), as well as a wide range of professions of light manual physical labor (knitter, draftsman, watchmaker, radio assembler, bookbinder, etc.) . Involvement in labor activity disabled people due to SCI, especially groups I and II, helps to improve their general condition and is a tangible psychological factor that has a positive effect on the quality of life. In this regard, sports are also very important.

3. Social rehabilitation. One of the important measures social assistance, which contributes to the rehabilitation of disabled people, is to supply them with bicycle strollers, wheelchairs (paralysis and paresis of both lower extremities with the absence or significant limitation of active movements in the proximal parts; paralysis or severe paresis of one lower extremity; diseases, spinal deformities that significantly complicate standing and walking) , work and household devices, in particular urinals, provision of technical means of rehabilitation, such as exercise equipment, adaptation of the apartment to the needs of a disabled person also greatly contribute to reducing the degree of social disability of patients with the consequences of SCI.

Although methods for diagnosing and providing assistance for injuries of the spine and spinal cord were given in the Egyptian papyri and the works of Hippocrates, for a long time a spinal injury with neurological disorders was considered practically a death sentence. Back in the First World War, 80% of those wounded in the spine died within the first 2 weeks. Progress in the treatment of spinal cord injury (SCI), based on an improved understanding of its pathogenesis and the development of radically new treatment methods, began only during the Second World War and in the post-war years. Today, SCI remains a severe, but usually not fatal, type of injury, and a significant contribution to minimizing its consequences is made by the timely and adequate provision of first, qualified and specialized medical care to victims.

Traumatic injuries of the spine and spinal cord are much less common than TBI. In adults, the incidence of SMT is 5 per 100 thousand population per year, in children it is even lower (less than 1 per 100 thousand population per year), but in children SMT is more often associated with polytrauma and is more severe, with a worse prognosis. In Russia, approximately 80% of victims are men under 30 years of age. Since today the majority of victims even with severe STS survive, the number of people with consequences of STS in the population of developed countries is approximately 90 per 100 thousand population (for Russia today this is approximately 130 thousand people, of which 13 thousand are with paraplegia or tetraplegia) . Social significance the problems cannot be overestimated.

The main cause of SMT is road traffic accidents (50% of cases). This is followed by sports and related injuries. active recreation(25%, of which 2/3 are injuries to the cervical spine and spinal cord caused by diving in a shallow place). Approximately 10% each are industrial injuries and those received as a result of illegal actions, and 5% are received when falling from a height, in natural disasters, etc.

Most often the cervical spine is damaged (55%), less often - the thoracic (30%), even less often - the lumbosacral

Damage to the spinal cord and its roots occurs in approximately 20% of cases of SCI. Such injuries are called complicated.

Damage Level(defeats) spinal cord assessed by the lower segment, in the dermatome of which sensitivity and at least minimal voluntary movements have been preserved. Often, but not always, this level corresponds to the established level of spinal injury. In assessing the level of spinal cord damage, one should not rely on pathological reflexes (Babinsky, Rossolimo, Oppenheim, defensive and synkinesis); their reflex arc may pass below the level of complete spinal cord damage.

Highlight complete And incomplete spinal cord injury. With complete damage (group A on the Frankel scale, Table 12.1), there is no sensitivity and voluntary movements below the level of the lesion. Usually in such a situation the spinal cord is anatomically destroyed. With incomplete damage (groups B, C, D on the Frankel scale), disturbances in sensitivity and movement are expressed to a greater or lesser extent; group E corresponds to the norm.

Injuries to the spine and spinal cord are divided into open, in which the integrity of the skin and underlying soft tissues is compromised, and closed, in which these damages are absent. In peacetime, closed

Table 12.1. Spinal Cord Disability Rating Scale (Frankel)

Complete defeat		No voluntary movement or sensation below the level of the lesion
Only sensitivity is preserved		Below the level of the lesion there are no voluntary movements, sensitivity is preserved
Movements intact but non-functional		Below the level of the lesion there are voluntary movements, but without useful function. Sensitivity may or may not be preserved.
Movements are intact and functional		Useful voluntary movements below the level of the lesion are functional. Various sensitivity disorders
Normal motor function		Movements and sensitivity below the level of the lesion are preserved, pathological reflexes are possible

Closed injuries of the spine and spinal cord

Spinal injuries. Closed spinal injuries occur under the influence of excessive flexion, extension, rotation and axial compression. In many cases, a combination of these mechanisms is observed (for example, with the so-called whiplash injury of the cervical spine, when flexion of the spine is followed by its extension).

As a result of the influence of these mechanical forces, various changes in the spine are possible:

Sprain and rupture of ligaments;

Damage to intervertebral discs;

Subluxations and dislocations of the vertebrae;

Vertebral fractures;

Fracture-dislocations.

The following types of vertebral fractures are distinguished:

Fractures of vertebral bodies (compression, comminuted, explosive);

Fractures of the posterior half ring;

Combined with simultaneous fracture of the bodies, arches, articular and transverse processes;

Isolated fractures of the transverse and spinous processes.

It is of fundamental importance to classify spinal injury as stable or unstable. The stability of the spine is understood as the ability of its structures to limit their mutual displacement so that, under physiological loads, it does not lead to damage or irritation of the spinal cord and its roots. Unstable spinal injuries are usually associated with rupture of ligaments, fibrous ring, multiple destruction of bone structures and are fraught with additional trauma to the spinal cord even with minor movements in the affected segment.

It is easier to understand the causes of spinal instability if we turn to the concept of Denis (Fig. 12.1), who identifies 3 support systems (pillars) of the spine: front the supporting complex (column) includes the anterior longitudinal ligament and the anterior segment of the vertebral body; average the column unites the posterior longitudinal ligament and the posterior segment of the vertebral body; rear column - articular processes, arches with yellow ligaments and spinous processes with their ligamentous apparatus. Violation of the integrity of two of the mentioned supporting complexes (pillars), as a rule, leads to instability of the spine.

Rice. 12.1. Denis’s diagram: the anterior, middle and posterior supporting complexes (pillars) of the spine are highlighted; instability of the spinal segment develops when two of them are affected in any combination

Spinal cord injuries. Based on the type of spinal cord injury, it is classified as concussion, bruise, compression And violation of anatomical integrity(partial or complete rupture of the spinal cord); often these mechanisms are combined (for example, a bruise with vascular rupture and hemorrhage - hematomyelia, causing direct damage to the axons and cells of the spinal cord). The most severe form of local damage to the spinal cord is its complete anatomical break with diastasis of the ends at the site of damage.

The degree of damage to the spinal cord and its roots is of primary importance for the fate of the patient. This damage can occur both at the time of injury (which is incurable) and in the subsequent period, when prevention of secondary spinal cord injuries is potentially possible.

Currently, there are no methods to restore the function of anatomically damaged neurons and cells of the spinal cord. The goal of treating STS is to minimize secondary damage to the spinal cord and provide optimal conditions for the restoration of neurons and axons caught in the zone of impaired blood supply - the “ischemic penumbra.”

A frequent and dangerous consequence of spinal cord injury is edema, caused both by an increase in tissue osmotic pressure during the destruction of cell membranes and by disorders venous outflow due to compression of the spinal veins (hematomas, bone fragments, etc.) and their thrombosis. An increase in the volume of the spinal cord as a result of edema leads to an increase in local hypertension and a decrease in perfusion pressure, which, according to the principle of a vicious circle, leads to a further increase in edema, ischemia and can lead to irreversible damage to the entire diameter of the spinal cord.

In addition to the listed morphological changes, functional disorders caused by disturbances at the cellular level are also possible. Such spinal cord dysfunctions regress, as a rule, within the first 24 hours after injury.

Clinical picture of spinal injury. The main manifestation of a spinal fracture is local pain, which increases significantly with load (standing up, bending and even turning in bed). Spinal damage may also be indicated by:

Abrasions and hematomas;

Swelling and local tenderness of soft tissues in the paravertebral region;

Pain on palpation of the spinous processes;

Different distances between the apices of the spinous processes, displacement of one or more of them anteriorly, posteriorly or to the side from the midline;

Angular change in the spinal axis (traumatic scoliosis, kyphosis or lordosis).

With a fracture of the lower thoracic and lumbar spine, even without damage to the spinal cord, intestinal paresis may develop due to a retroperitoneal hematoma (compressing the vessels and nerves of the mesentery).

Clinical picture of spinal cord damage in spinal injury

The clinical symptoms of a complicated spinal fracture are determined by a number of reasons, primarily the level and degree of damage to the spinal cord.

There are syndromes of complete and partial transverse spinal cord lesions.

At complete transverse spinal cord syndrome down from the level of the lesion, all voluntary movements are absent, flaccid paralysis is observed, deep and cutaneous reflexes are not evoked, all types of sensitivity are absent, control over the functions of the pelvic organs is lost (involuntary urination, defecation disorders, priapism); autonomic innervation suffers (sweating and temperature regulation are impaired). Over time, flaccid muscle paralysis can be replaced by spasticity, hyperreflexia, and automatisms in the functions of the pelvic organs are often formed.

Features of the clinical manifestations of spinal cord injury depend on the level of damage. If the upper cervical part of the spinal cord is damaged (C I-IV at the level of the I-IV cervical vertebrae), tetraparesis or spastic tetraplegia develops with the loss of all types of sensitivity from the corresponding level. If there is concomitant damage to the brain stem, bulbar disorders appear (dysphagia, aphonia, respiratory and cardiovascular disorders).

Damage to the cervical enlargement of the spinal cord (C V -Th I at the level of the V-VII cervical vertebrae) leads to peripheral paraparesis of the upper extremities and spastic paraplegia of the lower extremities. Conduction disorders of all types of sensitivity occur below the level of the lesion. There may be radicular pain in the arms. Damage to the ciliospinal center causes the appearance of Horner's symptom, decreased blood pressure, and slowed pulse.

Trauma to the thoracic part of the spinal cord (Th II-XII at the level of I-IX thoracic vertebrae) leads to lower spastic paraplegia with the absence of all types of sensitivity, loss of abdominal reflexes: upper (Th VII-VIII), middle (Th IX-X) and lower (Th XI-XII).

If the lumbar thickening (L I S II at the level of the X-XII thoracic and I lumbar vertebrae) is damaged, peripheral paralysis of the lower extremities occurs, anesthesia of the perineum and legs downward from the inguinal (pupart) ligament occurs, and the cremasteric reflex falls out.

In case of injury to the conus of the spinal cord (S III-V at the level of the I-II lumbar vertebrae), there is a “saddle-shaped” anesthesia in the perineal area.

Damage to the cauda equina is characterized by peripheral paralysis lower extremities, anesthesia of all types in the perineum and legs, sharp radicular pain in them.

Spinal cord injuries at all levels are accompanied by disorders of urination, defecation and sexual function. With transverse damage to the spinal cord in the cervical and thoracic parts, dysfunction of the pelvic organs appears, such as the “hyper-reflex neurogenic bladder” syndrome. At first after the injury, urinary retention occurs, which can last for a very long time (months). The sensitivity of the bladder is lost. Then, as the segmental apparatus of the spinal cord disinhibits, urinary retention is replaced by spinal automaticity of urination. In this case, involuntary urination occurs when there is a slight accumulation of urine in the bladder.

When the conus of the spinal cord and the roots of the cauda equina are damaged, the segmental apparatus of the spinal cord suffers and the syndrome of “hyporeflex neurogenic bladder” develops: urinary retention with paradoxical phenomena is characteristic.

noi ischuria - the bladder is full, but when the pressure in it begins to exceed the resistance of the sphincters, part of the urine flows out passively, which creates the illusion of intact urinary function.

Defecation disorders in the form of stool retention or fecal incontinence usually develop in parallel with urination disorders.

Damage to the spinal cord in any part is accompanied by pressure sores that occur in areas with impaired innervation, where bony protrusions are located under the soft tissues (sacrum, iliac crests, heels). Bedsores develop especially early and quickly with severe (transverse) damage to the spinal cord at the level of the cervical and thoracic regions. Bedsores quickly become infected and cause the development of sepsis.

When determining the level of spinal cord damage, the relative position of the vertebrae and spinal segments must be taken into account. It is easier to compare the location of the spinal cord segments with the spinous processes of the vertebrae (with the exception of the lower thoracic region). To determine the segment, add 2 to the vertebral number (so, at the level of the spinous process of the third thoracic vertebra the fifth thoracic segment will be located).

This pattern disappears in the lower thoracic and upper lumbar regions, where at the level of Th XI-XII and L I there are 11 segments of the spinal cord (5 lumbar, 5 sacral and 1 coccygeal).

There are several syndromes of partial spinal cord damage.

Half spinal cord syndrome(BrownSequard syndrome) - paralysis of the limbs and impairment of deep types of sensitivity on the affected side with loss of pain and temperature sensitivity on the opposite side. It should be emphasized that this syndrome in its “pure” form is rare; its individual elements are usually identified.

Anterior spinal syndrome- bilateral paraplegia (or paraparesis) combined with decreased pain and temperature sensitivity. The reason for the development of this syndrome is a violation of blood flow in the anterior spinal artery, which is injured by a bone fragment or a prolapsed disc.

Central spinal cord syndrome(more often occurs with a sharp hyperextension of the spine) is characterized mainly by

paresis of the arms, weakness in the legs is less pronounced; Sensory disturbances of varying severity below the level of the lesion and urinary retention are observed.

In some cases, mainly with trauma accompanied by sharp flexion of the spine, it may develop dorsal cord syndrome- loss of deep types of sensitivity.

Damage to the spinal cord (especially when its diameter is completely damaged) is characterized by disturbances in the regulation of the functions of various internal organs: respiratory disorders with cervical lesion, intestinal paresis, dysfunction of the pelvic organs, trophic disorders with the rapid development of bedsores.

IN acute stage injury, the development of “spinal shock” is possible - a decrease in blood pressure (usually not lower than 80 mm Hg) in the absence of signs of polytrauma and internal or external bleeding. The pathogenesis of spinal shock is explained by the loss of sympathetic innervation below the site of injury while maintaining parasympathetic innervation (causes bradycardia) and atony of skeletal muscles below the level of injury (causes deposition of blood in the venous bed with a decrease in circulating blood volume).

Clinical forms of spinal cord injury

Spinal concussion is very rare. It is characterized by damage to the spinal cord of a functional type in the absence of obvious structural damage. More often, paresthesia and sensory disturbances below the injury zone are observed, less often - paresis and paralysis, and dysfunction of the pelvic organs. Occasionally, clinical manifestations are severe, up to the picture of complete damage to the spinal cord; The differential diagnostic criterion is complete regression of symptoms within 24 hours.

The cerebrospinal fluid is not changed during a concussion of the spinal cord, the patency of the subarachnoid space is not impaired. Changes in the spinal cord are not detected by MRI.

Spinal cord contusion - the most common type of lesion in closed and non-penetrating spinal cord injuries. A bruise occurs when a vertebra is fractured with its displacement, prolapse of the inter-

vertebral disc, vertebral subluxation. When a spinal cord injury occurs, structural changes in the substance of the brain, roots, membranes, vessels (focal necrosis, softening, hemorrhages).

The nature of motor and sensory disorders is determined by the location and extent of the injury. As a result of a spinal cord contusion, paralysis, changes in sensitivity, dysfunction of the pelvic organs, and autonomic disorders develop. Trauma often leads to the appearance of not one, but several areas of injury. Secondary disorders of the spinal circulation can cause the development of foci of softening of the spinal cord several hours or even days after the injury.

Spinal cord contusions are often accompanied by subarachnoid hemorrhage. In this case, an admixture of blood is detected in the cerebrospinal fluid. The patency of the subarachnoid space is usually not impaired.

Depending on the severity of the injury, restoration of impaired functions occurs within 3-8 weeks. However, with severe bruises that cover the entire diameter of the spinal cord, the lost functions may not be restored.

Spinal cord compression occurs when a vertebrae is fractured with displacement of fragments or when there is a dislocation or herniation of an intervertebral disc. The clinical picture of spinal cord compression can develop immediately after injury or be dynamic (increasing with spinal movements) if it is unstable. As in other cases of SMT, symptoms are determined by the level of damage, as well as the severity of compression.

There are acute and chronic compression of the spinal cord. The latter mechanism occurs when the compressing agent (bone fragment, prolapsed disc, calcified epidural hematoma, etc.) persists in the post-traumatic period. In some cases, with moderate compression, after the acute period of SMT has passed, a significant or complete regression of symptoms is possible, but their reappearance in the long term due to chronic trauma to the spinal cord and the development of a focus of myelopathy.

There is a so-called hyperextension injury of the cervical spine(whiplash injury) that occurs when

car accidents (rear impact with incorrectly installed head restraints or their absence), diving, falling from a height. The mechanism of this spinal cord injury is a sharp hyperextension of the neck, exceeding the anatomical and functional capabilities of this section and leading to a sharp narrowing of the spinal canal with the development of short-term compression of the spinal cord. The morphological focus that forms in this case is similar to that of a bruise. Clinically, hyperextension injury is manifested by spinal cord lesion syndromes of varying severity - radicular, partial dysfunction of the spinal cord, complete transverse lesion, anterior spinal artery syndrome.

Hemorrhage in the spinal cord. Most often, hemorrhage occurs when blood vessels rupture in the area of ​​the central canal and posterior horns at the level of the lumbar and cervical thickenings. Clinical manifestations of hematomyelia are caused by compression of the posterior horns of the spinal cord by gushing blood, spreading to 3-4 segments. In accordance with this, segmental dissociated disturbances of sensitivity (temperature and pain) acutely occur, located on the body in the form of a jacket or half-jacket. When blood spreads to the area of ​​the anterior horns, peripheral flaccid paresis with atrophy is detected, and when the lateral horns are affected, vegetative-trophic disorders occur. Very often in the acute period, not only segmental disorders are observed, but also conduction sensitivity disorders, pyramidal symptoms due to pressure on the lateral cords of the spinal cord. With extensive hemorrhages, a picture of complete transverse lesion of the spinal cord develops. The cerebrospinal fluid may contain blood.

Hematomyelia, if not combined with other forms of structural damage to the spinal cord, is characterized by a favorable prognosis. Neurological symptoms begin to regress after 7-10 days. Restoration of impaired functions may be complete, but more often certain neurological disorders remain.

Hemorrhage into the spaces surrounding the spinal cord can be either epidural or subarachnoid.

An epidural spinal hematoma, unlike an intracranial hematoma, usually occurs as a result of venous bleeding (from

venous plexuses surrounding the dura mater). Even if the source of bleeding is an artery passing through the periosteum or bone, its diameter is small and the bleeding quickly stops. Accordingly, spinal epidural hematomas rarely reach large sizes and do not cause severe compression of the spinal cord. The exception is hematomas caused by damage vertebral artery with a fracture of the cervical spine; such victims usually die from circulatory disorders in the brain stem. In general, epidural spinal hematomas are rare.

The source of a subdural spinal hematoma can be both the vessels of the dura mater and spinal cord, and the epidural vessels located at the site of traumatic damage to the dura mater. Subdural spinal hematomas are also rare; usually bleeding inside the dural sac is not limited and is called spinal subarachnoid hemorrhage.

Clinical manifestations. Epidural hematomas are characterized by an asymptomatic interval. Then, a few hours after the injury, radicular pain appears with varying irradiation depending on the location of the hematoma. Later, symptoms of transverse compression of the spinal cord develop and begin to increase.

The clinical picture of intrathecal (subarachnoid) hemorrhage in spinal cord injury is characterized by acute or gradual development of symptoms of irritation of the membranes and spinal roots, including those located above the site of injury. Intense pain in the back and limbs, stiffness of the neck muscles, and Kernig's and Brudzinski's symptoms appear. Very often they are accompanied by paresis of the limbs, sensory conduction disturbances and pelvic disorders due to damage or compression of the spinal cord by gushing blood. The diagnosis of hemorrhachis is verified by lumbar puncture: the cerebrospinal fluid is intensely stained with blood or xanthochromic. The course of hemorrhachis is regressive, and complete recovery often occurs. However, hemorrhage in the cauda equina area can be complicated by the development of an adhesive process with severe neurological disorders.

Anatomical spinal cord injury occurs at the time of injury or secondary spinal cord injury

a wounding object, bone fragments, or when it is overstretched and ruptured. This is the most severe type of SMT, since the recovery is anatomically damaged structures spinal cord never occurs. Occasionally, anatomical damage is partial, and Brown-Séquard syndrome or another of those described above develops, but more often such damage is complete. Symptoms are determined by the nature and level of the lesion.

Objective diagnosis

Radiography. Direct radiological signs of a spinal fracture include disturbances in the structure of the bodies, arches and processes of the vertebrae (discontinuity of the external bone plate, the presence of bone fragments, a decrease in the height of the vertebral body, its wedge-shaped deformation, etc.).

Indirect radiological signs of SMT - narrowing or absence, less often - widening of the intervertebral space, smoothing or deepening of natural lordoses and kyphosis, the appearance of scoliosis, changes in the axis of the spine (pathological displacement of one vertebra relative to another), changes in the course of the ribs due to trauma to the thoracic region, as well as poor visualization spinal structures in the area of ​​interest even with targeted images (caused by paravertebral hematoma and soft tissue edema).

X-ray examination makes it possible to detect bone-destructive changes and metal foreign bodies with sufficient reliability, but provides only indirect, unreliable information about the state of the ligamentous apparatus of the spine and intervertebral discs, hematomas and other factors of spinal cord compression.

To identify the condition of the spinal cord and its roots, as well as to assess the patency of the spinal subarachnoid space, previously myelography- X-ray examination of the spine after introducing a radiopaque substance into the subarachnoid space of the lumbar or occipital cistern, contouring the spinal cord and its roots. Various preparations were proposed (air, oil and aqueous solutions of iodine salts), the best in terms of tolerability and quality of contrast were non-ionic water solutions.

suitable radiopaque agents. With the advent of CT and MRI, myelography is practically not used.

CT- the main method for diagnosing the condition of the bone structures of the spine. Unlike spondylography, CT is good at detecting fractures of the arches, articular and spinous processes, as well as linear fractures of the vertebral bodies, which do not lead to a decrease in their height. However, before a CT scan, X-ray or MRI of the spine is mandatory, since it allows you to establish “areas of interest” in advance and thereby significantly reduce the radiation dose. Three-dimensional reconstruction of spinal structures obtained from spiral CT helps plan surgical intervention. CT angiography provides visualization of the internal carotid and vertebral arteries, which can be damaged by trauma to the cervical spine. A CT scan may be performed if there are metallic foreign bodies in the wound. The disadvantage of CT is unsatisfactory visualization of the spinal cord and its roots; some assistance in this may be provided by the introduction of a radiopaque substance into the subarachnoid space of the spinal cord (computed myelography).

MRI- the most informative method for diagnosing SMT. It allows you to assess the condition of the spinal cord and its roots, the patency of the spinal subarachnoid space and the degree of compression of the spinal cord. MRI clearly visualizes intervertebral discs and other soft tissues, including pathological ones, and obvious bone changes. If necessary, MRI can be supplemented with CT.

The functional state of the spinal cord can be assessed using electrophysiological methods- studies of somatosensory evoked potentials, etc.

Algorithm for providing medical care for spinal cord injury

1. At the scene of injury, as with TBI, the DrABC algorithm works (Danger remove, Air, Breathing, Circulation). That is, the victim must be moved from the place of maximum danger, ensure patency respiratory tract, mechanical ventilation for breathing problems or in patients in stupor and coma and maintaining adequate hemodynamics.

Rice. 12.2. Philadelphia collar; Various modifications are possible (a, b)

The victim has unconscious and if there are complaints of pain in the neck or weakness and/or numbness in the limbs, external immobilization of the cervical spine is necessary with a Philadelphia collar (included in the set of external emergency orthoses) - Fig. 12.2. The trachea can be intubated in such a patient after applying the specified external cervical orthosis. If damage to the thoracic or lumbosacral spine is suspected, no special immobilization is carried out; the patient is carefully placed on a stretcher and, if necessary, fixed to it.

The main thing at this stage is to ensure arterial normotension and normal arterial blood oxygen saturation, which, as with TBI, prevents the development of secondary consequences of TBI. In the presence of external and/or internal injuries, among other things, compensation for blood loss is necessary.

There is no specific drug treatment for STS. Glucocorticoids may inhibit lipid peroxidation at the site of injury and may reduce secondary spinal cord injury to some extent. There are recommendations for administration high doses methylprednisolone (30 mg per 1 kg of body weight as a bolus in the first 3 hours after SMT, then 5.4 mg per 1 kg of body weight per hour for 23 hours); The effectiveness of this regimen has not yet been confirmed in independent studies. Other previously proposed drugs (“nootropic”, “vascular”, “metabolic”) are ineffective.

2. Inpatient (hospital) stage of medical care. Assessment of the condition of the spine is necessary in all victims with TBI of any severity, in victims with neurological symptoms that appeared after the injury (impaired sensitivity, movements, sphincter function, priapism), in persons with multiple injuries to the skeletal bones, as well as in cases of complaints of back pain in the absence of noticeable damage and neurological deficits.

In victims with clinical manifestations or a high risk of STS (see below), one or more objective neuroimaging studies are required.

Algorithm of actions in the emergency room. First of all, the severity of the patient’s condition is assessed using the GCS, hemodynamic parameters, pulmonary ventilation are determined and, if necessary, taken emergency measures for their correction. At the same time, the presence and nature of combined injuries to internal organs and extremities are assessed, and signs are identified combined lesion(thermal, radiation, etc.) and determine the order of therapeutic and diagnostic measures.

All patients with clinical signs of SMT or in an unconscious state must have a permanent urinary catheter and nasogastric tube installed.

The general rule is to eliminate the most life-threatening factor first. However, even if SMT is not leading in the severity of the patient’s condition or is only suspected, all diagnostic and therapeutic measures should be carried out with maximum immobilization of the spine.

In victims with mild TBI (15 GCS points) in the absence of complaints and neurological symptoms, assessing the condition of the spine using physical methods is sufficient. Obviously, in such victims the likelihood of SMT is extremely low, and the patient can be released under the supervision of a family doctor. Neuroimaging studies are usually not performed in these cases.

In the absence of signs of TBI or SCI, but with multiple bone injuries, a thorough neurological and physical assessment of the condition of the spinal cord and spine is necessary. In such a situation, even in the absence of clinical signs of STS, radiography of the cervical spine is advisable, and in patients with in serious condition- and the entire spine.

Radiography is performed by most victims (only with closed SMT and, accordingly, confidence in the absence of metallic foreign bodies in the patient’s body, is it possible to refuse radiography in favor of MRI).

In patients with impaired consciousness, radiography of the cervical spine is required in at least a lateral projection

Rice. 12.3. Compression fracture of the VII cervical vertebra with retrolisthesis (“diver’s fracture”); spondylogram, lateral projection: a - before stabilization; b - after it

(Fig. 12.3); For the remaining victims with complaints of back pain or neurological symptoms, radiography of the presumably damaged part of the spine is performed in 2 projections. In addition to radiography in standard projections, if necessary, radiography is performed in special settings (for example, if there is a suspicion of injury to the 1st and 2nd cervical vertebrae, pictures through the mouth).

When identifying radiological signs spinal injuries (direct or indirect), the diagnosis is verified using MRI or CT (Fig. 12.4). As already mentioned, with closed SMT, it is possible to abandon radiography in favor of MRI.

Rice. 12.4. Fracture of the odontoid process of the II cervical vertebra: a - MRI; b - CT; due to the loss of the supporting function of the odontoid process as a result of a fracture, the first cervical vertebra is displaced anteriorly, the spinal canal is sharply narrowed

Assessment of the functional state of the spinal cord using electrophysiological methods is usually performed in a hospital on a routine basis.

Algorithm of actions in the hospital. After the diagnosis of STS and associated injuries is established, the patient is hospitalized in the department according to the profile of the main (most life-threatening) pathology. From the first hours of SMT with spinal cord injury, complications are prevented, the main of which are bedsores, urinary tract infections, deep vein thrombosis of the legs and pelvis, intestinal paresis and constipation, gastric bleeding, pneumonia and contractures.

Measures to prevent bedsores - use of an anti-bedsore mattress, hygienic skin care, frequent change position of the patient in bed and in the absence of spinal instability - early (after 1-2 days) activation of the victim.

Urinary infection develops in almost all patients with spinal cord injury, and the “trigger” is the resulting acute urinary retention, leading to overstretching of the bladder, ureters and renal pelvis, circulatory disorders in their walls and retrograde spread of infection due to vesicoureteral reflux . Therefore, perhaps earlier, such patients undergo catheterization of the bladder with preliminary introduction into the urethra of a solution or gel of an antiseptic and anesthetic (usually chlorhexidine with lidocaine); If possible, the permanent catheter is removed after a few days and periodic catheterization of the bladder is performed (once every 4-6 hours; to prevent overdistension of the bladder, the volume of urine should not exceed 500 ml).

Deep vein thrombosis of the legs and pelvis develops in 40% of patients with spinal cord injury and often occurs without clinical manifestations, but in 5% of cases it leads to pulmonary embolism. The greatest risk of deep vein thrombosis is in the first 2 weeks after injury with a maximum on the 7-10th day. Prevention consists of the use of periodic pneumatic compression of the legs and/or stockings with graduated compression, passive exercises and early activation (for stable or surgically stabilized spinal injuries);

in the absence of contraindications, low molecular weight heparin preparations are prescribed.

Intestinal paresis develops in the majority of victims with STS and can be caused by both central and peripheral mechanisms(compression of the mesentery with the vessels and nerves passing through it by a retroperitoneal hematoma that occurs during a fracture of the lumbar and sometimes thoracic spine). Therefore, on the first day, such victims are fed parenterally and then gradually increase the amount of food with sufficient fiber content; If necessary, laxatives are prescribed.

In many patients, on the 1st day after SMT, erosions of the mucous membrane of the stomach and duodenum occur, leading to gastric bleeding in 2-3% of cases. Therefore, victims are given a nasogastric tube and H2 blockers (ranitidine, famotidine) are prescribed; taking them during the first 7-10 days reduces the risk stomach bleeding up to 1%.

Violations of pulmonary ventilation are caused by impaired innervation of the intercostal muscles, pain with concomitant rib fractures and immobilization with the development of congestion in the posterior parts of the lungs. Prevention consists of breathing exercises, anesthesia for rib fractures, and early activation of the patient. In case of injury to the cervical spine, there is a need for periodic sanitation of the upper respiratory tract, sometimes using a bronchoscope. Mechanical ventilation is carried out with a periodic increase in end-expiratory pressure; if long-term mechanical ventilation is necessary, a tracheostomy is performed.

Prevention of contractures begins on the 1st day after SMT and consists of active and passive gymnastics at least 2 times a day; to prevent contractures in ankle joints the feet are fixed in a flexed position using pillows or external orthoses.

It should be borne in mind that even if immediately after the injury the clinical picture of complete spinal cord damage is determined, in 2-3% of victims, a greater or lesser recovery of impaired functions is observed after a few hours. If the clinical picture of complete spinal cord injury persists after 24 hours from the moment of SMT, the chances of further neurological improvement are extremely low.

Until the nature of the lesion is clarified and an adequate treatment method is selected, external immobilization is maintained. Algorithm for the treatment of spinal cord injury

The treatment algorithm for STS is determined by the nature of the damage to the spine (stable or unstable) and spinal cord (complete or incomplete).

For stable damage indications for urgent surgery rarely arise, only when there is compression of the spinal cord or spinal root. Limiting the load on the affected segment is usually sufficient. To do this, in case of damage to the cervical spine, external orthoses (“head holders”) are used; in case of stable fractures of the thoracic and lumbar spine, various corsets are used or simply prohibiting heavy lifting, bending, and sudden movements for 2-3 months. With concomitant osteoporosis, calcium supplements with ergocalceferol and, if necessary, synthetic calcitonin are prescribed to accelerate fracture healing.

For unstable damage immobilization is necessary - external (using external devices) or internal, carried out during surgery. It should be noted that even with complete damage to the spinal cord and instability of the spine, its stabilization is necessary - this improves the possibilities of rehabilitation.

Treatment of complicated spinal fractures

The main goals that are pursued when providing care to patients with a complicated spinal fracture are the elimination of compression of the spinal cord and its roots and the stabilization of the spine.

Depending on the nature of the injury, this goal can be achieved in different ways:

Surgical method;

Using external immobilization and repositioning of the spine (traction, neck collars, corsets, special fixing devices).

Spinal immobilization prevents possible dislocation of the vertebrae and additional damage to the spinal cord, creates conditions for eliminating existing spinal deformation and fusion of damaged tissues in a position close to normal.

One of the main methods of immobilizing the spine and eliminating its deformation is traction, which is most effective for cervical trauma.

Traction is carried out using a special device consisting of a bracket fixed to the skull and a system of blocks that perform traction (Fig. 12.5).

The Crutchfield clamp is fixed to the parietal tuberosities with two screws with sharp ends. Traction using weights is carried out along the axis of the spine. At the beginning of traction, a small load is usually installed (3-4 kg), gradually increasing it to 8-12 kg (in some cases - more). Changes in spinal deformation under the influence of traction are monitored by repeated radiography.

The disadvantage of traction is the need for the victim to stay in bed for a long time, which significantly increases the risk of developing bedsores and thromboembolic complications. Therefore, recently, implantable or external immobilizing devices that do not interfere with the early activation of the patient have become increasingly widespread.

In case of damage to the cervical spine, immobilization of the spine can be carried out using a device consisting of a special corset such as a vest, a metal hoop rigidly fixed to the patient’s head, and rods connecting

Rice. 12.5. Skeletal traction for a fracture of the cervical spine using a Crutchfield clamp

wearing a hoop with a vest (halo-fixation, halo vest- rice. 12.6). In cases where complete immobilization is not required for injuries to the cervical spine, semi-soft and hard collars are used. Corsets of a special design are also used for fractures of the thoracic and lumbar spine.

When using external immobilization methods (traction, corsets), it takes a long time (months) to eliminate spinal deformity and heal damaged structures in the required position.

In many cases, this method of treatment is unacceptable: first of all, if it is necessary to immediately eliminate compression of the spinal cord. Then there is a need for surgical intervention.

The purpose of the operation is to eliminate compression of the spinal cord, correct spinal deformity and reliably stabilize it.

Surgery. Various types of operations are used: approaching the spinal cord from behind through laminectomy, from the side or from the front with resection of the vertebral bodies. To stabilize the spine, a variety of metal plates, bone screws, and occasionally wire are used. Resected vertebral fragments are replaced with bone fragments taken from the patient's ilium or tibia, special metal and polymethyl methacrylate prostheses. You should know that stabilizing systems provide only temporary immobilization of the damaged part of the spine for up to 4-6 months, after which, due to osteoporosis around the screws embedded in the bone, their supporting function is lost. Therefore, implantation of a stabilizing system is necessarily combined with the creation of conditions for the formation of bone fusions between the above and underlying vertebrae - spinal fusion.

Indications for surgery for spinal and spinal cord injuries

When determining surgical indications It must be taken into account that the most dangerous spinal cord injuries

Rice. 12.6. Halofixation system

occur immediately at the time of injury and many of these injuries are irreversible. So, if a victim immediately after an injury has a clinical picture of a complete transverse lesion of the spinal cord, then there is practically no hope that an urgent operation can change the situation. In this regard, many surgeons consider surgical intervention in these cases to be unjustified.

However, if there are symptoms of a complete break in the spinal cord roots, despite the severity of the damage, surgery is justified primarily due to the fact that it is possible to restore conductivity along the damaged roots, and if they are ruptured, which is rare, a positive result can be obtained with microsurgical suturing ends of damaged roots.

If there are at least the slightest signs preservation of some of the functions of the spinal cord (slight movement of fingers, the ability to determine a change in the position of a limb, perception of strong pain stimuli) and at the same time there are signs of compression of the spinal cord (presence of a block, displacement of the vertebrae, bone fragments in the spinal canal, etc.), surgery is indicated.

In the late period of injury, surgery is justified if compression of the spinal cord persists and the symptoms of its damage progress.

The operation is also indicated for severe deformation and instability of the spine, even with complete transverse damage to the spinal cord. The purpose of the operation in this case is to normalize the supporting function of the spine, which is an important condition for more successful rehabilitation of the patient.

The choice of the most adequate treatment method - traction, external fixation, surgery, a combination of these methods is largely determined by the location and nature of the injury.

In this regard, it is advisable to separately consider the most typical types of injury to the spine and spinal cord.

Cervical spine injury

The cervical region of the spine is the most susceptible to damage and the most vulnerable. Cervical injuries are especially common in children, which can be explained by weakness of the neck muscles, significant extensibility of the ligaments, and large head size.

It should be noted that injury to the cervical vertebrae is more often than other parts of the spine accompanied by damage to the spinal cord (up to 40% of cases).

Damage to the cervical vertebrae leads to the most severe complications and more often than with injury to other parts of the spine, to the death of the patient: 25-40% of victims with injury localized at the level of the 3 upper cervical vertebrae die at the scene of the incident.

Due to the unique structure and functional significance of the 1st and 2nd cervical vertebrae, their damage should be considered separately.

The first cervical vertebra (atlas) can be damaged alone or together with the second vertebra (40% of cases). Most often, as a result of injury, the atlas ring ruptures in its different parts. The most severe type of SMT is atlanto-occipital dislocation - displacement of the skull relative to the first cervical vertebra. In this case, the area of ​​transition of the medulla oblongata into the spinal cord is injured. The frequency of this type of SMT is less than 1%, mortality is 99%.

When the second cervical vertebra is damaged (epistrophy), a fracture and displacement of the odontoid process usually occur. A peculiar fracture of the second vertebra at the level of the articular processes is observed in hanged people (“hangman’s fracture”).

The C V -Th I vertebrae account for over 70% of injuries - fractures and fracture dislocations with accompanying severe, often irreversible damage to the spinal cord.

For fractures of the first cervical vertebra, traction by rigid external stabilization using halo fixation is usually successfully used. For combined fractures of the 1st and 2nd cervical vertebrae, in addition to these methods, surgical stabilization of the vertebrae is used, which can be achieved by tightening the arches and spinous processes of the first 3 vertebrae with wire or fixing them with screws in the area of ​​the articular processes. Fixing systems have been developed that allow maintaining a certain range of movements in the cervical spine.

In some cases, to eliminate compression of the spinal cord and medulla oblongata by the broken off odontoid process of the second cervical vertebra, anterior access through the oral cavity can be used.

Surgical fixation is indicated for fracture-dislocations of the vertebrae C In -Th r Depending on the characteristics of the damage, it can be performed using various implanted systems. In case of anterior compression of the spinal cord by fragments of a crushed vertebra, a prolapsed disc, or a hematoma, it is advisable to use an anterior approach with resection of the body of the affected vertebra and stabilization of the spine with a metal plate fixed to the vertebral bodies, with the installation of a bone graft in place of the removed vertebra.

Trauma to the thoracic and lumbar spine

Injuries to the thoracic and lumbar spine often result in compression fractures. More often, these fractures are not accompanied by spinal instability and do not require surgical intervention.

With comminuted fractures, compression of the spinal cord and its roots is possible. In this case, indications for surgery may arise. To eliminate compression and stabilize the spine, complex lateral and anterolateral approaches, including transpleural ones, are sometimes required.

Conservative treatment of patients with consequences of spinal cord injury

The main thing in the treatment of patients with complete or incomplete spinal cord injury is rehabilitation. The goal of rehabilitation treatment carried out by professional rehabilitation specialists is the maximum adaptation of the victim to life with an existing neurological defect. For these purposes, special programs are used to train intact muscle groups and teach the patient techniques that ensure the maximum level of independent activity. Rehabilitation provides for the victim to achieve the ability to take care of himself, move from a bed to a wheelchair, go to the toilet, take a shower, etc.

Special devices have been developed that allow victims, even with severe neurological impairments, to perform

socially useful features and serve yourself. Even with tetraplegia, it is possible to use tongue-activated manipulators, voice-controlled computers, etc. The most important role is played by the help of a psychologist and social rehabilitation - training in a new, accessible profession.

Methods of conservative and surgical treatment of the consequences of SMT are auxiliary, but sometimes essential.

One of the common consequences of spinal cord injury is a sharp increase in tone in the muscles of the legs and torso, which often complicates rehabilitation treatment.

To eliminate muscle spasticity, drugs that reduce muscle tone (baclofen, etc.) are prescribed. For severe forms of spasticity, baclofen is injected into the spinal subarachnoid space using implantable, programmable pumps (see Chapter 14, Functional Neurosurgery). Surgical interventions described in the same section are also used.

For persistent pain syndromes, more often occurring with damage to the roots and the development of adhesions, there may be indications for pain interventions, also described in Chapter 14 “Functional Neurosurgery”.

The effectiveness of many drugs previously used to treat SMT (and TBI) - “nootropic”, “vasodilator”, “rheological”, “metabolic”, “neurotransmitter” - has been called into question by the results of independent studies.

Open injuries to the spine and spinal cord

In peacetime, open wounds with penetration of a wounding object into the cavity of the spinal canal are rare, mainly in criminal SMT. The frequency of such injuries increases significantly during military operations and anti-terrorist operations.

The incidence of military injuries to the spine approximately corresponds to the length of each section and is 25% for the cervical spine, 55% for the thoracic spine and 20% for the lumbar, sacral and coccygeal spine.

Features of mine-explosive and gunshot injuries of the spine and spinal cord are:

Open and often penetrating nature of the wounds;

High frequency and severity of damage to the spinal cord and its roots, caused by the high energy of the traumatic agent (causing a shock wave and cavitation);

Long up to hospital stage medical care;

High frequency of combined injuries (multiple wounds, fractures, dislocations, bruises, etc.);

High frequency of combined (with burns, compression, potentially radiation and chemical damage) injuries.

The principles of first aid are the same as for any type of injury (DrABC). A special feature is attention to preventing secondary wound infection by antiseptic treatment its edges and application of an aseptic dressing; if there is moderate bleeding, the wound should be packed with a hemostatic sponge containing gentamicin (and then applied with an aseptic dressing).

Transportation of the wounded is carried out according to the same principles. Cervical immobilization is necessary but performed whenever possible. In the absence of a stretcher, it is better to carry a wounded person with suspected STS on a board made of boards, etc.

At the stage of qualified care, anti-shock measures are carried out (if they are not started earlier), stopping bleeding, external immobilization of the damaged part of the spine, primary surgical treatment of the wound, administration of tetanus toxoid, catheterization of the bladder, installation of a nasogastric tube. They determine the leading damage in the clinical picture and ensure prompt transportation of the wounded person to the appropriate specialized or multidisciplinary medical institution (hospital or civilian hospital). Immobilization of the spine during transportation is mandatory.

At the stage of specialized medical care, carried out at a certain distance from the war zone, the algorithm for diagnostic and therapeutic measures for STS is similar to that in peacetime. Peculiarities:

Even if MRI is available, preliminary radiography is required to identify metallic foreign bodies;

The use of glucocorticoids (methylprednisolone or others) is contraindicated;

High incidence of wound liquorrhea and infectious complications;

The rarity of spinal instability.

It should be borne in mind that unnecessarily extensive surgical interventions with resection of bone structures, especially those performed before the stage of specialized medical care, significantly increase the incidence of spinal instability.

Indications for surgery for wartime STS

Tissue damage (primary surgical treatment of the wound is required, in the absence of liquorrhea it is carried out according to the usual principles).

Massive tissue damage with crush areas and hematomas. Excision and closed external drainage are performed to reduce the risk of infectious complications.

Wound liquorrhea. It sharply, approximately 10 times, increases the risk of meningitis with the development of a cicatricial adhesive process, often leading to disability and sometimes death of the victim. To relieve liquorrhea, a wound revision is performed with detection and suturing of the dura mater defect (if it is impossible to compare the edges, a graft from local tissues is sutured into the dura mater defect) and careful layer-by-layer suturing of the wound (preferably with absorbable polyvinyl alcohol sutures). Sutures on the dura mater can be strengthened with fibrin-thrombin compositions.

Epidural hematoma. In the absence of the possibility of objective diagnosis, the likelihood of developing an epidural hematoma is indicated by the increase in local neurological symptoms that began several hours after the injury. The operation significantly improves the prognosis.

Compression of the nerve root(s) by a wounding agent or hematoma, bone, cartilage fragments, etc. It manifests itself as pain in the area of ​​innervation of the root and motor disturbances. The operation is indicated even with the assumption of complete anatomical damage, because the ends of the roots can sometimes be compared and sutured; in any case, decompression usually leads to the disappearance of pain.

Damage to the roots of the cauda equina. To decide on surgery in this case, it is desirable to verify the nature of the damage using CT or MRI, but even in the case of an anatomical break, microsurgical suturing of the roots can be beneficial; The greatest difficulty is in identifying the ends of the torn roots, which is problematic even in peaceful conditions.

Damage to blood vessels (vertebral or carotid arteries) is an absolute indication for surgery, during which it is possible to remove the accompanying epidural hematoma.

The presence of a copper-jacketed bullet in the spinal canal. Copper causes an intense local reaction with the development of a scar-adhesive process. It should be understood that the type of bullet can be established in case of criminal wounds in peacetime during operational search activities; during hostilities this is very problematic.

Spinal instability. As mentioned, it is rare with gunshot and mine-explosive wounds; If there is instability of the spine, its stabilization is required. In cases of open wounds, external stabilization (halo-fixation or other) is preferable, since implantation of a stabilizing system and bone grafts significantly increases the risk of infectious complications.

Compression of the spinal cord with the clinical picture of incomplete damage. As already mentioned, due to the high energy of the traumatic agent, even anatomically incomplete spinal cord damage in these situations is usually severe, and the prognosis for recovery is unfavorable. However, if there is at least minimal preservation of neurological function below the level of compression, decompressive surgery is sometimes beneficial.

To prevent infectious complications in case of penetrating wounds, reserve antibiotics are immediately prescribed - imopenem or meropenem with metrogyl, tetanus toxoid is necessarily administered (if not previously administered), and if an anaerobic infection is suspected, hyperbaric oxygenation is performed.

Indications for surgical treatment in the long-term period of gunshot and mine blast wounds are:

Pain syndromes - in order to eliminate them, devices are implanted for delivering painkillers to the central nervous system or systems for analgesic neurostimulation (see section “Functional neurosurgery”).

Spasticity - the same treatment methods are used as for closed SMT.

Migration of a traumatic agent with the development of neurological symptoms (rare).

Spinal instability. More often it is caused by inadequate primary surgical intervention (laminectomy with resection of the articular processes). Requires surgical stabilization.

Lead intoxication (plumbism). A very rare condition caused by the absorption of lead from a bullet located in the intervertebral disc. Lead bullets encapsulated anywhere outside the joints do not cause lead toxicity. Manifested by anemia, neuropathy (motor and/or sensory), intestinal colic. The operation involves removing the bullet; usually performed under X-ray television control. To accelerate the removal of lead residues from the body, calcium trisodium pentetate is used in a high dose (1.0-2.0 g intravenously slowly every other day, a total of 10 to 20 injections).

Rehabilitation of victims does not differ from that for other types of SMT. Psychological rehabilitation for wartime STS is less complex (due to obvious motivation), but physical rehabilitation tends to be a more significant challenge due to the greater severity of the neurological deficit.

Public opinion and government policy of assistance to persons with disabilities are of great importance for the psychological and social adaptation of persons with consequences of SMT of any origin. Similar programs have now achieved great success in developed countries.

Minor damage to the vertebral body (fractures), often unnoticed, can later become a source of serious spinal disease. After an initial mild and short course and a subsequent long (several months or more) period of apparent recovery, the mobility of the spine is limited, girdle pain, local kyphotic curvature, and sometimes symptoms of brain compression appear. These phenomena depend on the subsidence of the vertebra, which occurred as a result of secondary softening of the damaged bone substance of the vertebral body. The x-ray shows a wedge-shaped flattening of one vertebra (Fig. 105). No osteoporosis. Intervertebral cartilages are not flattened.

In case of traumatic spondylosis, a plaster and then a leather corset is applied for several months, or osteoplastic fixation of the spine is performed according to Albee or Vreden.

Working capacity is restored after 3-4 months.

SPINAL CORD INJURY

The spinal cord is damaged by both closed and open spinal injuries, i.e. sprains, bruises, dislocations, fractures and various kinds wounds. Brain damage is possible without compromising the integrity of the spine. Spinal cord injuries range from molecular changes to complete brain rupture.

A distinction is made between concussion, compression, contusion, hematomyelia, partial disruption of the integrity and complete transverse break of the brain. The roots of the spinal cord are also subject to compression and rupture.

Spinal concussion(spinal shock) is a companion to a variety of injuries: air contusion due to explosions or explosions of firearms (air wave vibrations are transmitted to the brain through the cerebrospinal fluid), a blow to the back, wounds and damage to the vertebrae and the contents of the spinal canal without direct damage to the brain. The anatomical changes that occur in the brain tissue during a concussion are insignificant and consist of swelling of the brain, edema of the brain and pia mater, the largest in pinpoint hemorrhages and necrotic lesions that can be opened with a microscope.

Spinal cord concussion syndrome consists of motor and sensory disturbances that appear immediately after injury and tend to disappear soon. Movement disorders take the form of paraplegia or paraparesis. With paraplegia and paraparesis, movements quickly, in the coming weeks or even days, begin to be restored, and the patient soon recovers. However, recovery is not always complete. The sluggish nature of paraplegia, dysfunction of the pelvic organs, the appearance of bedsores indicate a severe organic damage brain In spinal shock, if involvement of the medulla oblongata or the brain is excluded, the patient does not lose consciousness. Symptoms of a concussion are a very important and, moreover, almost obligatory component of the clinical picture of all types of spinal cord injuries.

With a spinal cord contusion, different degrees of damage to brain tissue occur - from pinpoint hemorrhages to significant hematomas. Brain contusion is possible without damage to the dura mater.

Spinal cord compression is caused by a fragment of a broken vertebral arch, a displaced vertebral body, a foreign body, or a collection of blood. Bleeding into the spinal canal comes from either the venous plexus located extradurally or the veins of the arachnoid, and sometimes both. Blood pouring out from damaged vessels does not meet much resistance in the loose extradural tissue and in the intradural space and flows down, sometimes going down to the bottom of the dura mater sac. Sometimes blood accumulates in the spinal canal in the form of a hematoma and compresses the spinal cord and its roots.

Clinically, traumatic compression of the spinal cord manifests itself as spastic paraplegia with mild disorders of the pelvic organs and occurs without bedsores. Complete paraplegia due to compression caused by hemorrhage often does not develop immediately after the injury, but gradually, as blood accumulates.

Hematomyelia- hemorrhage into the brain substance - complicates both closed and open injuries of the spine and spinal cord. Blood flows from the small blood vessels of the brain, spreading mainly through gray matter and, descending down along the brain in its tissue, it sometimes spreads to several segments of the brain, squeezing and destroying its elements.

The clinical picture of hematomyelia, due to the different location and different distribution of hemorrhage both along and across the brain, is very diverse. Movement disorders consist of paraplegia or paralysis of certain muscle groups, sensitivity disorder (in the form of impaired temperature and pain sensitivity while maintaining tactile sensitivity). These nervous disorders appear either immediately after injury or develop gradually, increasing as blood penetrates the brain tissue. The blood that permeates the medulla can be resorbed, after which the lost function returns. In other cases, the area of ​​the brain soaked in blood softens, is replaced by a scar or cyst, and its function is completely lost. The prediction for hematomyelia depends on the degree of destruction of the brain matter and the size of the affected area.

Violation of the integrity of the spinal cord by a foreign body inserted into the spinal canal, a displaced bone fragment or vertebra, in most cases is partial. Partial spinal cord injuries, depending on the location and degree of damage, give a very diverse clinical picture.

In connection with concussion, brain contusion, hematomyelia accompanying any violation of the integrity of the spinal cord, even with partial damage to it, at first there is almost always a picture of a complete break of the spinal cord. Subsequently, with these injuries, paralysis spreads only to separate groups muscles and partial loss of sensitivity. Partial restoration of seemingly completely lost functions retroactively confirms the partial nature of the damage.

A break in one half of the spinal cord gives the classic picture of Brown-Sequard paralysis, i.e. paralysis on the side of the injury and loss of sensitivity on the opposite side. In peacetime, Brown-Séquard palsy is observed with stab wounds to the back. The knife penetrates between the arches into the spinal canal and cuts half of the brain. In wartime, similar brain damage occurs with gunshot wounds to the spine.

With a complete traumatic interruption of the spinal cord, flaccid paralysis immediately occurs, which later turns into spastic paralysis. In addition, a complete interruption of the spinal cord is characterized by the absence of tendon reflexes, a positive Babinski sign, urinary and fecal incontinence, early appearance and rapid increase in bedsores and total loss sensitivity, upper limit which does not change.

Complete anatomical interruption of the spinal cord rarely occurs, for example, with dislocations of the cervical vertebrae, with fractures of the spine with significant displacement, or with gunshot wounds. Much more common is a physiological, functional break, which is caused by compression, bruise, cerebral edema, hematomyelia or spinal shock. With both types of break, the clinical picture is initially the same, but later, sometimes soon, with a physiological break, partial restoration of lost functions begins; recovery may be complete. Complete paralysis during a physiological break does not always occur immediately.

The clinical picture of spinal cord injuries, in addition to the form and degree of anatomical disorders, also depends on the level of damage. The higher the damage is located, the larger the affected area and the more severe the clinical picture and course (Fig. 107).

When the brain is damaged in the area of ​​the lower cervical vertebrae, paralysis occurs in the form of quadriplegia and anesthesia of the entire body except the head. If damage occurs in the area of ​​the upper cervical vertebrae, this is accompanied by paralysis of the diaphragm ( n. phrenicus), which almost always entails the death of the victim.

With brain damage at the level of the thoracic vertebrae and L 1, paraplegia occurs with dysfunction of the pelvic organs; When the brain is damaged in the area of ​​the upper thoracic vertebrae, paraplegia with dysfunction of the pelvic organs is accompanied by paralysis of the abdominal muscles and most of the intercostal muscles with breathing problems.

Brain damage at level L 2 and below gives the picture of damage to the cauda equina. The ponytail consists of peripheral nerves, so the paralysis has a flaccid character. The paralysis extends to the nerves of the sacral plexus, sometimes limited to sciatic nerve. Loss of sensitivity or pain is localized in the anus, buttocks, etc. (Fig. 108).

The described types of spinal cord injuries and their characteristic syndromes represent only patterns that are rarely encountered in real life. pure form, but are usually combined with each other. Therefore, the clinical pictures observed in reality do not completely coincide with the described schemes, but are incomparably more complex.

In recognizing spinal cord injuries, radiography plays a huge role, with the help of which the doctor can determine the nature of bone damage and the presence of foreign bodies and bone fragments in the spinal canal. In doubtful cases, it is recommended to resort to a trial laminectomy.

Spinal cord injuries cause high mortality. Immediately after the injury, death occurs due to the severity of the injury; in the near future, as a result of a wound infection complicated by meningitis; later, as a result of an ascending urinary tract infection and bedsores. The majority of those who survive remain with irreparable dysfunction and pain. In general, the prognosis for spinal cord injuries is worse the higher the severity of the injury.

The treatment method for closed spinal cord injuries depends on the nature and extent of the injury. For minor injuries, concussions, bruises, and hematomyelia, conservative treatment is indicated. For more severe injuries, early surgical intervention is indicated in the form of opening the spinal canal with removal of the vertebral arch, especially if clinical and radiological studies indicate damage to the brain by a bone fragment or compression by a displaced vertebra. Treatment usually begins with realignment of the spine. If reduction is unsuccessful or spinal cord symptoms worsen, laminectomy becomes mandatory. If the spinal cord is completely interrupted, surgery is contraindicated.

In case of urinary retention, a suprapubic urinary fistula is applied.

In the late stage, surgery is performed when the spinal cord or its roots are compressed by a bone, scar or arachnoid cyst.