bubble_chart Overview

Spinal cord injuries often occur in industrial and mining accidents, as well as traffic accidents, and can occur in large numbers during wartime or natural disasters. The injuries are severe and complex, often involving multiple or compound injuries, with many complications. When combined with spinal cord damage, the prognosis is poor, potentially leading to lifelong disability or even life-threatening conditions.

bubble_chart Pathogenesis

1. Spinal shock Early spinal injury is often accompanied by spinal shock, manifested as complete loss of sensation, motor function, and sphincter control below the injury level. Simple spinal shock may resolve spontaneously within weeks. The reappearance of the bulbocavernosus reflex or deep tendon reflexes marks the end of spinal shock.

2. Spinal contusion and laceration This can range from grade I hemorrhage and edema to complete spinal cord crushing or transection. In the late stage [third stage], cystic degeneration or atrophy may occur.

3. Spinal cord compression Displaced vertebral bodies, bone fragments, herniated discs, or other tissues intruding into the spinal canal can directly compress the spinal cord, leading to hemorrhage, edema, ischemic degeneration, and other changes.

The clinical manifestations of spinal injury caused by the above pathologies may range from complete paralysis to incomplete paralysis, depending on the severity of the injury.

bubble_chart Clinical Manifestations

(1) Spine Fracture

1. There is a history of severe trauma, such as falling from a height, heavy objects hitting the head, neck, or shoulders/back, collapse accidents, traffic accidents, etc.

2. The patient experiences localized pain at the injury site, restricted neck movement, muscular rigidity in the back muscles, and inability to turn over or stand up. A localized posterior protrusion deformity can be palpated at the fracture site.

3. Due to the stimulation of the autonomic nerves by retroperitoneal hematoma, intestinal peristalsis slows down, often leading to symptoms such as abdominal distension and fullness, abdominal pain, etc. Sometimes, it needs to be differentiated from injuries to abdominal organs.

(2) Combined Spinal Cord and Nerve Root Injury

After spinal cord injury, motor, sensory, reflex, sphincter, and autonomic nerve functions below the injury level are impaired.

1. Sensory impairment: Pain, temperature, touch, and proprioception below the injury level are weakened or lost. The spinal cord injury level can be determined by referring to the dermatomal distribution of spinal nerves (Table 3-13-1).

Table 3-13-1 Skin Landmarks of Spinal Cord Sensory Levels

Cervical Cord	Thoracic Cord	Lumbar Cord	Sacral Cord
C5 Anterolateral shoulder	T4 Nipple line	L2 Inner thigh	S1 Lateral foot
C6 Thumb	T6 Xiphoid process	L3 Inner knee	S2 Posterior thigh
C7 Middle finger	T10 Umbilicus	L4 Inner ankle
C8 Little finger	T12 Upper edge of pubis	L5 Dorsum of foot	S3,4,5 Perianal area

2. Motor impairment: During spinal shock, flaccid paralysis and absent reflexes are observed below the spinal cord injury level. After the shock period, if the spinal cord is completely transected, upper motor neuron paralysis occurs, characterized by increased muscle tone, hyperreflexia, patellar and ankle clonus, and pathological reflexes. The muscle landmarks of spinal cord motor levels are shown in Table 3-13-2.

Table 3-13-2 Muscle Landmarks of Spinal Cord Motor Levels

Cervical Cord	Muscle weakness	Lumbar Cord	Muscle weakness
C3-4	Diaphragm	L2	Iliopsoas
C5	Biceps brachii	L3	Quadriceps femoris
C6	Wrist extensors
C7	Triceps brachii	L4	Tibialis anterior
C8	Intrinsic hand muscles	L5	Dorsiflexors
T1	Abductor digiti minimi	S1	Gastrocnemius

3. Sphincter dysfunction During the spinal shock phase, it manifests as urinary retention due to detrusor muscle paralysis leading to an atonic bladder. After the shock phase, if the spinal injury is above the sacral level, an automatic reflex bladder may form, with residual urine less than 100ml, but voluntary urination is impossible. If the spinal injury involves the conus medullaris or sacral nerve roots, urinary incontinence occurs, and bladder emptying requires increased abdominal pressure (e.g., manual abdominal compression) or catheterization. Similarly, bowel dysfunction presents as constipation and incontinence.

4. Incomplete spinal cord injury When partial preservation of motor or sensory function remains below the injury level, it is termed incomplete spinal cord injury. Clinically, it can be classified into the following types:

(1) Anterior cord syndrome: Characterized by loss of voluntary movement and pain sensation below the injury level. Since the posterior columns are intact, the patient retains touch, position sense, vibration sense, motion sense, and deep pressure sensation.

(2) Central cord syndrome: More common in cervical spinal cord injuries. Presents with loss of upper limb motor function while lower limb motor function is preserved or significantly less impaired. Tendon reflexes are absent at the injury level but hyperactive below it.

(3) Brown-Sequard syndrome: Manifests as loss of pain and temperature sensation on the contralateral side below the injury level, with ipsilateral loss of motor function, position sense, motion sense, and two-point discrimination.

(4) Posterior cord syndrome: Characterized by loss of deep sensation, deep pressure sense, and position sense below the injury level, while pain/temperature sensation and motor function remain entirely normal. This is commonly seen in patients with vertebral lamina fractures.

bubble_chart Auxiliary Examination

1. X-ray examination Routine anteroposterior and lateral views of the spine are taken, and oblique views if necessary. During film reading, measure the height of the anterior and posterior parts of the vertebral body compared with adjacent vertebrae; measure the interpedicular distance and vertebral body width; measure the interspinous distance and intervertebral disc space width compared with adjacent intervertebral spaces. Measure the pedicle height on anteroposterior and lateral views. X-rays can basically determine the location and type of fracture.

2. CT examination Helps assess the degree of displacement of fracture fragments into the spinal canal and detect bone fragments or intervertebral discs protruding into the canal.

3. MRI (Magnetic Resonance Imaging) Highly valuable for evaluating spinal cord injury. MRI can reveal early edema and hemorrhage in spinal cord injury and display various pathological changes, such as spinal cord compression, transection, incomplete injury, atrophy, or cystic degeneration.

4. SEP (Somatosensory Evoked Potentials) A test to evaluate the conduction function of the somatosensory system (mainly the posterior spinal cord). It provides some assistance in determining the severity of spinal cord injury. MEP (Motor Evoked Potentials) is now also available.

5. Jugular vein compression test and myelography The jugular vein compression test has some reference value in assessing spinal cord injury and compression. Myelography is useful for diagnosing chronic traumatic spinal canal stenosis. {|104|}

bubble_chart Diagnosis

There is a history of severe trauma, and the diagnosis can be confirmed by X-ray examination.

bubble_chart Treatment Measures

(I) First Aid and Transportation

1. Spinal cord injuries may sometimes be accompanied by severe cranial brain injury, thoracic or abdominal organ injuries, or limb vascular injuries, which can be life-threatening. In such cases, immediate rescue measures should be prioritized.

2. For any patient suspected of having a spinal fracture, the spine should be maintained in its normal physiological curvature. Avoid any movement that hyperextends or hyperflexes the spine. The patient should be lifted and placed onto a wooden board by three people simultaneously, ensuring no rotational force is applied to the spine. If fewer people are available, a rolling method may be used.

For patients with cervical spine injuries, one person should specifically support the mandible and occipital bone, applying slight axial traction to keep the neck in a neutral position. After placing the patient on the wooden board, sandbags or folded clothing should be placed on both sides of the head and neck to prevent rotation and maintain airway patency.

(II) Treatment of Simple Spinal Fractures

1. Grade I compression fractures of the thoracolumbar spine are considered stable. The patient may lie flat on a hard bed with the lumbar region elevated. Back extensor exercises can begin within a few days. Functional therapy can help the compressed vertebra self-reduce and return to its original shape. With the protection of a thoracolumbar brace, the patient can start ambulating after 3–4 weeks.

2. For Grade III thoracolumbar compression fractures where compression exceeds one-third of the vertebral height, closed reduction should be performed. The two-table hyperextension reduction method can be used: two tables with a height difference of about 30 cm, each with a soft pillow, are arranged. The patient lies prone with the head on the higher table, hands gripping the table edge, and thighs on the lower table, leaving the sternum and pubic symphysis suspended. The suspended body weight gradually achieves reduction. After reduction, a plaster vest is applied for fixation for 3 months.

3. For unstable thoracolumbar spinal fractures where vertebral compression exceeds one-third, the deformity angle is greater than 20°, or dislocation is present, open reduction and internal fixation may be considered.

4. For cervical vertebral fractures or dislocations with mild compression or displacement, mandibulo-occipital bandage traction can be used for reduction, with a traction weight of 3–5 kg. After reduction, a head-thoracic plaster cast is applied for 3 months. For severe compression or displacement, continuous skull traction may be used, with the weight increased to 6–10 kg. X-ray follow-up is required. If reduction is successful, a head-thoracic plaster cast or brace is applied for 3 months. If traction reduction fails, open reduction and internal fixation are necessary.

(III) Spinal Fractures with Spinal Cord Injury

The functional recovery of spinal cord injury primarily depends on the severity of the injury, but early relief of spinal cord compression is the most critical factor. Surgical treatment is an essential part of comprehensive rehabilitation for spinal cord injury patients. The goals of surgery are to restore the normal spinal axis, regain the spinal canal diameter, directly or indirectly relieve compression from fracture fragments or dislocation on the spinal cord and nerve roots, and stabilize the spine (through internal fixation and bone grafting). Surgical methods include:

1. Anterior Cervical Decompression and Bone Graft Fusion

For cervical fractures below C3, traction reduction, anterior decompression, or subtotal vertebrectomy with bone graft fusion may be performed, using plate and screw internal fixation or a cervical collar for external fixation. Patients with significant instability may require continued skull traction or head-thoracic plaster fixation.

2. Posterior Cervical Surgery

For cases primarily involving dislocation, posterior metal clamp internal fixation and bone graft fusion may be performed after traction reduction. Alternatively, wire spinous process internal fixation with bone graft fusion may be used. If necessary, posterior decompression with plate and screw internal fixation and bone graft fusion may be performed.

3. Anterior Surgery for Thoracolumbar Fractures

For thoracolumbar burst or comminuted fractures, anterior decompression, bone graft fusion, and plate and screw internal fixation are often performed. For old fractures, anterolateral decompression may be considered.

4. Posterior Surgery for Thoracolumbar Fractures

Posterior surgery includes laminectomy decompression, reduction with pedicle screw plates or rods for internal fixation, and, if necessary, bone graft fusion. Harrington rods or Luque rods with wire internal fixation may also be used.

(IV) Comprehensive Therapy

1. Dehydration Therapy: Administer 20% mannitol, 250 ml twice daily, to reduce spinal cord edema.

2. Hormone Therapy Administer dexamethasone 10–20mg intravenously once daily. This has certain significance in alleviating the traumatic response of the spinal cord.

3. The use of some free radical scavengers such as vitamins E, A, C, and coenzyme Q, calcium channel blockers, lidocaine, etc., is considered beneficial in preventing secondary damage after spinal cord injury.

4. Drugs that promote nerve function recovery, such as cytidine disodium triphosphate, vitamins B1, B6, B12, etc.

Supportive therapy: Pay attention to maintaining the water and electrolyte balance of the injured, as well as the supplementation of calories, nutrition, and vitamins.

bubble_chart Complications

bedsore; urinary tract infection; joint stiffness and deformity; prevention and treatment of respiratory infections; autonomic nervous system dysfunction; constipation