Spinal cord injury in the elderly: causes, symptoms, diagnosis, treatment

The advanced age of the victims imposes its own characteristics on the mechanism of occurrence, clinical forms and clinical manifestations, course and treatment of spinal trauma.

Due to socio-economic changes in our country, the number of elderly people has increased significantly.

The anatomical and physiological characteristics of the elderly require a special, unique approach to the treatment of injuries encountered in them, including spinal trauma. Along with the changes occurring in all systems and organs of an elderly person, bone tissue and joints undergo very significant changes. It should be borne in mind that involutional processes in the body, including in the musculoskeletal system, occur gradually. These changes are not always equivalent in people of the same age: in some, more elderly, they are less pronounced, in others, less elderly - more. This allows us to talk about premature or late aging, which is why senile involutional processes should not be associated only with a person's age.

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Age-related changes in the spine

Age-related changes in the spine are characterized by senile osteoporosis in the bone elements of the spine and age-related degenerative changes in the intervertebral discs.

Senile osteoporosis is a mandatory symptom of bone aging and occurs in all people over 60-70 years of age. Its essence is a quantitative and qualitative disorder of the protein matrix of the bone in the absence of pronounced disorders of calcium-phosphorus metabolism. Using electron microscopy, Little and Kelly showed that the essence of changes in the bone matrix in osteoporosis comes down to a tighter fit of collagen bundles to each other, to the disappearance of canals, to the transformation of the matrix into a structureless mass. Consequently, the primary cause of osteoporosis is not calcium deficiency in bone tissue, but a protein deficiency.

Clinically, osteoporosis in the spine area manifests itself in the form of various deformations in the spine area. In women, it is expressed as an increase in thoracic kyphosis, in men - as a straightening of the lumbar lordosis, which in essence is also a tendency to develop kyphotic deformation.

The anatomical basis of senile osteoporosis is the progressive transformation of dense bone matter into spongy bone due to an imbalance between osteoblastic and osteoclastic processes in favor of the latter. Thinning and quantitative reduction of bone beams in spongy bone occurs. The complex system of bone beams - the bone architectonics - is simplified due to the disappearance of some bone beams. The degree of thinning of the cortical bone and the quantitative reduction of bone beams reach such limits that they contribute to the appearance of entire territories devoid of bone elements, rarefaction and enlargement of the cells of the spongy substance and weakening of the bone lines of force. A. V. Kaplan, when studying sections of spongy bone, showed that with old age the walls of the cells of the spongy substance become significantly thinner.

All these changes lead to increased fragility of the aged bone, as evidenced by the frequency of fractures in the elderly when exposed to violence, which never causes bone fractures in children, adolescents and middle-aged people.

Much earlier and subtler changes occur in the intervertebral discs. As mentioned earlier, the intervertebral disc consists of a fibrous ring, a pulpous nucleus, and hyaline plates. Histological studies have shown that the fibrous ring consists of dense collagen fibers, which in the outer parts of the fibrous ring are concentrically located plates. The pulpous nucleus consists of an amorphous substance in which collagen fibers and cellular elements are located. The end plates are hyaline cartilage.

Most researchers believe that all tissue components of the intervertebral disc are formed during prenatal life. Fibrous structures of the disc appear in children in the first months of life under the influence of the load on the spine. With age, the disc "dries out", especially its pulpous nucleus. "Drying out" of the disc with age occurs because the pulpous nucleus changes its structure and approaches the structure of the fibrous ring, and in old age - to the structure of hyaline cartilage. With age, the number of cartilaginous cells in the discs increases and they tend to be located in the form of nests. Hyalinization of the fibrous ring occurs, cracks and crevices appear in the hyaline plates.

Based on a biochemical study of intervertebral disc tissue, it has been shown that the nucleus pulposus contains mucopolysaccharides, mainly of the chondroitin sulfate type. With age, the content of mucopolysaccharides decreases, and the concentration of chondroitin sulfates decreases faster than that of keratosulfate.

Histochemical study of polysaccharides in intervertebral discs is represented by isolated studies and was carried out without sufficient histochemical analysis and a small number of methods.

As is known, the nucleus pulposus of the intervertebral disc contains a large amount of fluid, which can be histochemically explained by the high content of acidic mucopolysaccharides in its tissue and their high ability to retain water. A significant decrease in the content of acidic mucopolysaccharides, and possibly a change in their composition towards an increase in keratosulfate, lead to a decrease in the hydrophilic properties of the main substance and a decrease in the water component in the nucleus pulposus. These phenomena, in turn, lead to a slowdown and deterioration of diffusion processes, which are the main factor in the trophism of avascular disc tissues. Probably, the compaction of disc tissues due to an increase in collagen fibers also affects the slowdown of diffusion and a decrease in the supply of nutrients. It should be assumed that deterioration in nutrition affects the state of fine molecular and submicroscopic structures. Apparently, separation of the protein-mucopolysaccharide complex from collagen and disintegration of the latter occur. Collagen fibers, deprived of cementing substance, undergo disorganization and disintegrate into separate fibrils, which are essentially collastromin with or without remnants of precollagen. This is probably associated with the change in picro-fuchsin staining and the increase in argyrophilia in the foci of dystrophy.

It is possible that depolymerization of mucopolysaccharides plays a certain role in the development of dystrophy, since the longer and more polymerized the macromolecules, the more vigorously the gel formed by them retains water. Probably, only the integral structure of the protein-mucopolysaccharide complex determines the characteristic physicochemical and mechanical properties of the intervertebral disc tissue. Enzyme systems are of great importance in the integrity of the protein-mucopolysaccharide complex.

As a result of the biochemical and biophysical changes described above, the elasticity and resilience of the disc decrease, and its shock-absorbing properties weaken.

In the process of studying human intervertebral discs, attention was drawn to some features in the structure of the outer plates of the fibrous ring and the cartilaginous hyaline plate. Both of them almost do not perceive fuchsin when stained according to van Gieson, acidic mucopolysaccharides are very weakly detected in them compared to other zones of the disc, and neutral mucopolysaccharides are presented in large quantities.

Possible causes of structural changes in "old" discs are changes in the nature of the bond between acidic and neutral mucopolysaccharides and proteins, relocation and some change in the composition of acidic mucopolysaccharides. These causes can cause disruption of tissue nutrition processes, collagen formation, elasticity and mechanical strength of the disc, which in turn will inevitably affect the change in the fibrous structures of the intervertebral disc.

The histochemical changes described above schematically correspond to the dynamics of morphological changes.

The nucleus pulposus of the intervertebral disc of a newborn and a child of the first years of life is extremely rich in a substance that has a homogeneous, amorphous appearance under a microscope. This substance is stained pale and is barely noticeable on preparations. Against the background of this structureless mass, thin collagen fibers are found. The cellular elements of the nucleus pulposus are represented by fibroblasts, cartilaginous cells, and groups of cartilaginous cells. Some cartilaginous cells have an eosinophilic capsule. In the nucleus pulposus of the first years of life, there are still many chordal cells, which disappear by the age of 12.

As the child grows and, consequently, the intervertebral disc grows, the collagen fibers in it become denser, and fiber formation in the pulpous nucleus increases. In the 3rd decade of a person's life, the plates and fiber bundles of the fibrous ring in the intervertebral disc become denser and partially hyalinized. The pulpous nucleus consists almost entirely of a fine-fibrous, felt-like network of collagen fibers with a large number of cartilaginous cells and isogenic groups. In adulthood, especially in old age, the hyalinization and coarsening of the bundles and plates of the fibrous ring increases, and the number of cartilaginous elements in the pulpous nucleus increases. In the pulpous nucleus and fibrous ring, foci of granular and lumpy disintegration of the ground substance and its ossification appear. In the thickness of the hyaline plates, there is tissue of the pulpous nucleus in the form of cartilaginous nodules, described by Schmorl. All the described phenomena begin to be observed from the end, and sometimes the beginning of the 3rd decade of a person’s life, progress with age and reach extreme degrees in old age.

The described age-related changes in the vertebral bodies and intervertebral discs lead to the fact that the spine of an elderly person undergoes significant age-related changes. In addition to the above-mentioned clinically detectable deformations of the spine, it becomes rigid, inelastic, less mobile, less resistant to the vertical loads usual for it. This is manifested by a feeling of fatigue, the inability to hold the body in an upright position for a long time. Senile osteoporosis and involutional changes in the intervertebral discs lead to the fact that with age the length of the spine decreases and, as a result, the height of a person as a whole. All these phenomena are aggravated by age-related changes: in the muscular system.

In X-ray examination, age-related changes in the vertebral bodies are manifested as "transparency" of the vertebral bodies, a significant decrease in the intensity of their X-ray shadow. Lumbar vertebrae often acquire the shape of a fish vertebra, between which intervertebral spaces are visible that seem to be significantly increased in height, resembling tight car tires.

Thoracic vertebrae may acquire a wedge-shaped form due to a significant decrease in the height of their ventral sections. Then the intervertebral spaces in the thoracic section are significantly narrowed and sometimes difficult to differentiate. A significant number of osteophytes appear in both the lumbar and thoracic, as well as in the cervical spine, especially in the area of the ventral sections of the vertebral bodies. Osteophytes often arise along the posterior edges of the bodies. In the cervical spine, these osteophytes face the intervertebral openings. An age-related feature of the cervical spine is the development of uncovertebral arthrosis. In the intervertebral synovial joints, a degenerative process develops in the form of spondyloarthrosis, radiologically manifested as uneven joint spaces, increased intensity of the X-ray shadow in the area of the subchondral zones, and accentuation and sharpening of the ends of the articular processes.

Gross changes are detected from the side of the intervertebral discs. As a rule, their height decreases. Straightening of the lumbar lordosis, which occurs with age, leads to the fact that on the anterior spondylograms, the intervertebral spaces are clearly traced and located parallel to each other. In the thoracic region, due to an increase in thoracic kyphosis on the anterior spondylogram, these spaces, on the contrary, are poorly differentiated, and a false impression is created of their absence. In the cervical region of old people, a complete disappearance of the intervertebral spaces can be observed, which creates the impression of the presence of a block of the body of adjacent vertebrae. In the cervical region and somewhat less often in the upper thoracic region, calcification of the anterior longitudinal ligament can be observed up to its complete ossification. The cervical spine also loses its characteristic lordosis with age, acquires a strictly vertical shape, and sometimes even angular kyphotic deformation.

In addition to osteophytes located perpendicular to the long axis of the spine and resulting from degenerative age-related changes in the intervertebral discs, bone growths may be observed within the anterior longitudinal ligament and running strictly parallel to the long axis of the spine. These manifestations of spondylosis are a reflection of local degeneration of the outer sections of the fibrous ring of the intervertebral disc, unlike osteochondrosis, in which primarily degenerative processes occur in the nucleus pulposus.

In the subchondral zones of the vertebral bodies, against the background of osteoporosis, zones of pronounced subchondral sclerosis of bone tissue are clearly defined.

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Symptoms of Spinal Injury in the Elderly

Symptoms of spinal trauma in the elderly and old age are very scarce, which sometimes creates significant difficulties in establishing the correct diagnosis.

The most typical and constant complaints are about local pain in the spine. The pain can radiate along the intercostal spaces, and in case of a fracture of the thoracic vertebral body, to the extremities. The intensity of the pain varies. Usually, this pain is insignificant. The great constancy of this pain and its locality give grounds to suspect the presence of a fracture. A study of the mobility of the spine can add little to substantiate the clinical diagnosis. The spine of an elderly, old person is already slightly mobile, rigid and all types of movement in it are significantly limited. Detection of local pain by palpation also does not allow obtaining clear data, since in elderly and old people palpation of the posterior spine is often painful even without the presence of a fracture. Only pronounced local pain can help substantiate the diagnosis. Axial load on the spine and tapping on the area of the spinous processes provide little information.

Consequently, in the most common compression wedge fractures of the vertebral bodies in elderly and old people, the clinical manifestations and symptoms of these injuries are very scanty and do not have a clear clinical picture. This requires the doctor to pay special attention to the complaints of the victim and the most detailed objective examination.

Clinical forms of spinal trauma in the elderly

Elderly and old people do not have all the diverse clinical forms of spinal trauma that are typical for people of prime and middle age. This is explained by the peculiarity of the rhythm of life and behavior of an elderly and old person. Severe spinal trauma occurs in the elderly and old age mainly in car and train accidents.

Therefore, the first circumstance that limits the possibility of occurrence of various clinical forms of spinal trauma in elderly and old people are the conditions in which they are, their behavior and lifestyle. The second circumstance, no less important, are the age-related changes that occur in the elements of the spine of an elderly person and which we described above.

A typical spinal injury observed in old and senile age is compression wedge-shaped, usually uncomplicated, fractures of the vertebral bodies. One of the features of these injuries is a relatively small degree of reduction in the height of the broken body - compression of the vertebra and the inadequacy of the force causing the injury to the nature of the fracture. A feature of these injuries in older people is that they often go unnoticed and are detected later or during an accidental X-ray examination, or in the late post-injury periods due to the pain that has arisen.

The most common locations of spinal injuries in older people are the middle, lower thoracic and upper lumbar vertebrae. The vertebral bodies located in the transitional thoracolumbar region are especially often damaged.

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Diagnosis of spinal injury in the elderly

X-ray examination is especially important in the diagnosis of spinal fractures in the elderly and old people. However, this method of examination does not always solve the diagnostic difficulties. Due to pronounced senile osteoporosis, it is quite difficult to obtain a high-quality image, especially in elderly obese patients and especially women. The difficulties are aggravated by the presence of age-related changes in the spine. On a profile spondylogram, it is not easy to differentiate an senile wedge-shaped vertebra from a wedge-shaped vertebra that has arisen as a result of a fracture of the vertebral body. Only significant degrees of compression of the vertebral body allow us to consider the suspected diagnosis reliable. With insignificant and mild degrees of compression, this presents certain difficulties. Therefore, reliable spondylography data confirm the diagnosis of a spinal fracture; negative data with corresponding clinical symptoms do not reject it.

The senile spine is characterized by osteophytes of various localizations. These osteophytes can sometimes reach significant sizes.

Careful analysis of spondylograms most often allows for a more precise clinical diagnosis. In some cases, tomography may be useful.

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Treatment of spinal injury in the elderly

When treating spinal fractures in elderly and old people, the goal is usually not to restore the anatomical shape of the broken vertebra and the full function of the spine. The body of an elderly and especially old person undergoes known involutional processes characterized by the inferiority of the cardiovascular and pulmonary systems, hormonal function disorders, gastrointestinal tract function, changes in the excretory system, central and peripheral systems, mental deviations and the above-mentioned changes in the musculoskeletal system. The above changes, a significant decrease in reactivity, the inferiority of reparative processes, changes in the blood and hematopoietic organs, a tendency to thrombosis and other occlusive processes in the vessels, vitamin deficiency, metabolic disorders, a tendency to congestive processes in the lungs, easily occurring decompensation of cardiac activity, etc. make the body of an elderly and old person easily vulnerable. All this forces the doctor to focus his efforts primarily on preventing possible complications and combating them in order to save the patient's life. Understanding should be given to the treatment of senile osteoporosis. This can be achieved to some extent by a full protein diet, the introduction of large doses of vitamin C into the patient's body, and hormone therapy.

Early physical activity of elderly people plays a major role in preventing complications.

For the above reasons, all methods and techniques of treating spinal fractures that involve the victim staying in bed for a long time in a forced position, and treatment methods that involve wearing plaster corsets, are completely unacceptable. They are burdensome for these patients, are poorly tolerated by them, and can cause complications.

Methods of treating spinal fractures in elderly and senile people

The method of treating compression wedge-shaped fractures of the lumbar and thoracic vertebrae in elderly and senile people has the following features. Local anesthesia of the area of the fractured vertebra is usually not performed. Pain is relieved or significantly reduced by the administration of analgesics per os or subcutaneous administration of promedol. If pain relief is necessary, intradermal or paravertebral novocaine blockades give a good effect. The victim is placed on a bed with a firm mattress. Laying him down on a hard board is not always possible due to age-related deformations of the spine. Compliance with this seemingly mandatory provision leads to the fact that the victim's pain increases significantly. Unloading the spine by traction by the armpits and especially by the Glisson loop is not always possible. Therefore, a relatively free regime is prescribed for victims with wedge-shaped compression fractures of the lumbar and thoracic vertebrae. They are allowed to change their position while lying on their back, on their side, and turn onto their stomach. Only in isolated cases is unloading performed using traction or gradual light reclination on a soft hammock, provided that these procedures are well tolerated and do not increase pain. Massage and therapeutic exercises are prescribed early.

By prescribing early therapeutic exercises, we pursue slightly different goals than in young victims. For obvious reasons, we cannot count on creating a muscle corset in elderly and old people. Therapeutic exercises mainly activate these patients, improve breathing and increase their vitality. Such treatment, supplemented by appropriate symptomatic drug treatment, is carried out for 6-8 weeks. After this period, the victim is raised to his feet in a lightweight skeletal removable orthopedic corset or in a soft corset of the "grace" type. He is not allowed to sit for 3-4 weeks. Individually, depending on the conditions and condition of the victim, he spends the last 3-4 weeks in a hospital or at home.

At home after discharge from the hospital, treatment should be carried out aimed at combating senile osteoporosis, as a preventive measure against possible repeated spinal fractures. In case of severe pain, it is useful to wear the "grace" for a long time, especially for obese elderly and old women.

The anatomical results of this treatment method are not always good, but the functional results are quite satisfactory. In severe spinal injuries, all the treatment methods described in the previous chapters are used.