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. These injuries are severe and complex, frequently involving multiple or compound injuries with many complications. When combined with spinal cord damage, the prognosis is poor, often leading to lifelong disability or even life-threatening conditions.

bubble_chart Etiology

1. Spinal shock: Early stages of spinal injury are often accompanied by spinal shock. It manifests as complete loss of sensation, motor function, and sphincter control below the level of injury. Simple spinal shock can resolve on its own 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 changes or atrophy may occur.
3. Spinal cord compression: Displaced vertebral bodies, bone fragments, herniated discs, or other tissues protruding into the spinal canal 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, being struck by heavy objects on the head, neck, or shoulder/back, collapse accidents, or traffic accidents.
2. The patient experiences localized pain at the injury site, restricted neck movement, and muscular rigidity in the back, making it difficult to turn over or stand up. A localized posterior protrusion deformity may be palpable at the fracture site.
3. Due to the stimulation of the autonomic nerves by retroperitoneal hematoma, intestinal motility slows down, often leading to symptoms such as abdominal distension, fullness, and abdominal pain. These symptoms sometimes need 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 disturbances:** Pain, temperature, touch, and proprioception below the injury level are weakened or lost. The level of spinal cord injury can be determined by referring to the dermatomal distribution of spinal nerves.
2. **Motor disturbances:** During the spinal shock phase, flaccid paralysis and loss of reflexes are observed below the injured spinal segment. After the shock phase, 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.
3. **Sphincter dysfunction:** During the spinal shock phase, urinary retention occurs due to an atonic bladder caused by detrusor muscle paralysis. After the shock phase, if the spinal cord 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 injury involves the conus medullaris or sacral nerve roots, urinary incontinence occurs, requiring increased abdominal pressure (manual abdominal compression) or catheterization to empty the bladder. Similarly, constipation and fecal incontinence may also occur.
4. **Incomplete spinal cord injury:** When some motor or sensory functions are preserved below the injury level, it is termed incomplete spinal cord injury. Clinically, the following types are observed:
   1. **Anterior cord syndrome:** Characterized by loss of voluntary movement and pain sensation below the injury level. Since the posterior columns are unaffected, the patient retains touch, position sense, vibration sense, kinesthesia, and deep pressure sensation.
   2. **Central cord syndrome:** More common in cervical spinal cord injuries. It manifests as loss of upper limb motor function while lower limb motor function is preserved, or upper limb motor loss is significantly more severe than lower limb loss. Tendon reflexes are absent at the injury level but hyperactive below it.
   3. **Brown-Sequard syndrome:** Characterized by loss of pain and temperature sensation on the contralateral side below the injury level, and loss of motor function, position sense, kinesthesia, and two-point discrimination on the ipsilateral side.
   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 intact. This is often 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 are obtained when necessary. During film reading, measure the height of the anterior and posterior parts of the vertebral body and compare it with adjacent vertebrae; measure the interpedicular distance and vertebral body width; measure the interspinous distance and intervertebral disc space width and compare them with adjacent intervertebral spaces. Measure the pedicle height on anteroposterior and lateral views. X-rays can essentially determine the location and type of fracture.
2. CT examination: Helps assess the degree of displacement of fracture fragments into the spinal canal and identify bone fragments or intervertebral discs protruding into the canal.
3. MRI (Magnetic Resonance Imaging) examination: Highly valuable for evaluating spinal cord injury conditions. MRI can reveal early edema and hemorrhage in spinal cord injuries, as well as various pathological changes such as spinal cord compression, transection, incomplete injury, atrophy, or cystic degeneration.
4. SEP (Somatosensory Evoked Potential): A test that measures the conduction function of the somatic sensory system (primarily the posterior columns of the spinal cord). It provides some assistance in determining the severity of spinal cord injury. MEP (Motor Evoked Potential) is now also available.
5. Jugular vein compression test and myelography: The jugular vein compression test offers some reference value in assessing spinal cord injury and compression. Myelography is meaningful for diagnosing chronic traumatic spinal canal stenosis.

bubble_chart Diagnosis

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

bubble_chart Treatment Measures

1. First Aid and Transportation

1. Spinal cord injuries are sometimes accompanied by severe cranial brain injury, thoracic or abdominal organ injuries, or limb vascular injuries. When the patient's life is at risk, immediate rescue measures should be prioritized.
2. For any suspected spinal fracture, the patient's spine should be kept in its normal physiological curvature. Avoid any hyperextension or hyperflexion movements during transportation. The spine should be lifted and placed onto a wooden board by three people simultaneously without rotational force. If fewer people are available, a rolling method can be used.

For patients with cervical spine injuries, a dedicated person should 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 head rotation and ensure airway patency.

2. Treatment of Simple Spinal Fractures

1. Grade I compression fractures of the thoracolumbar spine are considered stable. The patient can lie flat on a hard bed with the lumbar region elevated. Back extensor exercises can begin within a few days. Functional therapy allows the compressed vertebrae to self-reduce and return to their 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 exceeding one-third of the vertebral height, closed reduction should be performed. The two-table hyperextension method can be used: two tables with a height difference of about 30 cm, each with a soft pillow, are used. 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 weight of the suspended body gradually achieves reduction. After reduction, a plaster vest is applied for fixation for 3 months.
3. For unstable thoracolumbar spinal fractures with vertebral compression exceeding one-third, a deformity angle greater than 20°, or accompanying dislocation, open reduction and internal fixation may be considered.
4. For cervical vertebral fractures or dislocations with mild compression displacement, mandibulo-occipital bandage traction can be used for reduction with a weight of 3–5 kg. After reduction, a head-thoracic plaster cast is applied for 3 months. For severe compression displacement, continuous skull traction may be used with weights increased to 6–10 kg. X-rays should be reviewed post-reduction, and a head-thoracic plaster cast or brace is applied for 3 months. If traction reduction fails, open reduction and internal fixation are required.

3. Spinal Fractures with Spinal Cord Injury

Functional recovery of spinal cord injuries 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, reconstruct the spinal canal diameter, directly or indirectly relieve compression from fracture fragments or dislocations on the spinal cord and nerve roots, and stabilize the spine (via internal fixation and bone grafting). Surgical methods include:

1. - **Anterior cervical decompression and fusion**: For cervical fractures below C3, traction reduction, anterior decompression, or subtotal vertebrectomy with bone grafting and fusion can be performed, using plate-screw internal fixation or a cervical collar for external fixation. Patients with significant instability may require continued skull traction or a head-thoracic plaster cast.
2. - **Posterior cervical surgery**: For dislocations, after traction reduction, posterior metal clamp internal fixation with bone grafting or spinous process wiring with bone grafting can be performed. If necessary, posterior decompression with plate-screw internal fixation and bone grafting may be done.
3. - **Anterior thoracolumbar surgery**: For thoracolumbar burst or comminuted fractures, anterior decompression, bone grafting, and plate-screw internal fixation are often performed. For old fractures, anterolateral decompression may be considered.
4. - **Posterior thoracolumbar surgery**: Posterior approaches include laminectomy decompression, reduction with pedicle screw plates or rods, and internal fixation. If necessary, bone grafting and fusion may be performed, or Harrington/Luque rod wiring may be used.

4. 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. It has certain significance in alleviating the traumatic response of the spinal cord.
3. Some free radical scavengers: such as vitamin E, A, C, and coenzyme Q, calcium channel blockers, lidocaine, etc., are considered to have certain benefits in preventing secondary damage after spinal cord injury.
4. Drugs that promote neurological recovery: such as cytidine disodium triphosphate, vitamin 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

Prevention and treatment of bedsores, urinary tract infections, joint stiffness and deformities, respiratory infections, autonomic nervous system dysfunction, and constipation.