Spinal trauma and back pain

To denote the combined trauma of the spine and the spinal cord, in the literature, along with the term spinal-spinal trauma, its English analogue vertebro-spinal injuries is often used, which leads to certain contradictions. What is meant by the term "spinal trauma"? Trauma of the spinal cord, as is customary in the Russian-language literature, or trauma to the spine, which follows from a literal translation from the English word spine? What is "spinal shock", "traumatic spinal cord disease", what are their characteristics, duration, course, principles of treatment? Apart from possible deepening into the problems of neurosurgery, where spinal cord injuries are usually considered, we will try to highlight only some of the fundamental questions of vertebral-spinal cord injury that are not sufficiently reflected in the special literature.

From the classification of fractures of the sacrum, the most interesting, in our opinion, is a classification based on the evaluation of the ratio of the fracture line to the caudal part of the spinal canal and radicular apertures. Conditionally, in the frontal plane, the region of the sacrum is divided into 3 zones: the zone of the lateral part ("wings") of the sacrum, the zone of the radicular holes and the area of the spinal canal. In oblique and transverse fractures, the type of injury is assessed by the most medial injured department. Fractures that are lateral to radicular apertures are never accompanied by neurological disorders. In turn, explosive fractures of the sacrum are potentially dangerous with regard to compression of the sacral roots, fractures and dislocations - with respect to their rupture. There is also a classification of the sacrum fractures A0 / ASIF, which is based on the determination of the horizontal level of the lesion and distinguishes the fracture of the caudal sacrum (type A), the compression fracture of its cranial section (type B) and the fractured cranial sacrum (type C). A more detailed division of the sacrum fractures into groups is not currently used.

The general structure of closed spinal cord injuries is presented by SA Georgieva et al. (1993). VPBersnev et al. (1998) supplements this scheme with posttraumatic vascular syndromes: myelo-ischemia, hematomia, epidural. Subdural and subarachnoid hemorrhages.

Another option of spinal trauma, not found reflection in the above scheme, is the rupture of the spinal cord. However, a true anatomical gap, accompanied by a divergence of the fragments of the spinal cord and the formation of diastase between them, is observed only in 15% of patients with clinical manifestations of transverse rupture of the spinal cord. In other cases, there is an intralobular or axonal rupture.

F. Denis and L. Krach (1984) distinguish the following clinical variants of spinal trauma:

• spinal shock - complete loss of movement, sensitivity and reflexes of all lumbar and sacral segments with trauma of the cervical and thoracic spinal cord (the authors emphasize localization). The duration of spinal shock is from a few minutes to 24 hours. An indication of an exit from a spinal shock is the appearance of a bulbocavernous reflex;
• complete quadriplegia - complete loss of movement of the upper and lower extremities with trauma of the cervical spinal cord;
• incomplete quadriplegia - partial loss of movements of the upper and lower extremities with trauma of the cervical spinal cord, including:
  • syndrome of the anterior cerebral basin,
  • Brown-Sequarda syndrome,
  • syndrome of the central cerebral basin;
• full paraplegia - complete loss of movement of the lower limbs;
• incomplete paraplegia (paraparesis) - incomplete loss of movements of the lower extremities;
  • false full paraplegia - complete absence of movements of the lower extremities in the trauma of the epiconus and the cone of the spinal cord;
  • ascending paraplegia (in modern literature this type of disorder is described as "ascending myelopathy") - a neurological symptomatology that is growing in dynamics and spreading above the level of vertebral lesion, usually observed in the first 4 days after trauma.

Many neurosurgeons pay attention to the staging of the clinical course of spinal trauma, which is called "traumatic spinal cord disease." In the course of traumatic spinal cord disease, SA Georgieva et al. (1993) distinguish the following periods:

• acute period (duration - up to 2-3 days): clinical manifestations are unstable and mainly characterized by general symptoms of spinal shock;
• early period (duration - 2-3 weeks): clinical manifestations correspond to the local neurological symptoms of spinal shock. For acute and early periods of traumatic spinal cord disease polymorphism and instability of the clinical picture, back pain are characteristic ;
• Intermediate period (duration - 2-3 months): neurological symptoms are unstable, changes in the neurological status are possible both against the background of the natural course of the disease, and under the effect of treatment;
• Late period (starts 3-4 months after the trauma and lasts up to 2-3 years): accompanied by a gradual, more often unidirectional (either improvement or deterioration) changes in the state and the formation of a new level (stereotype) of the patient's life, which corresponds to the period of adaptation to a new state;
• the period of the consequences is characterized by the newly formed level of neurological functions, the nature of which changes little further.

VPBersnev et al. (1998), describing practically the same time periods in the clinical course of a spinal trauma, additionally give the characteristic clinical and morphological features:

• acute period (duration - up to 3 days): morphologically marked edema of soft tissues, primary necrosis and myelo-ischemia of the injury zone; an unstable clinical picture, including symptoms characteristic of spinal shock;
• the early period (2-3 weeks) corresponds to the time of appearance of primary complications: meningitis, myelitis, pneumonia, urosepsis, exacerbation of chronic infectious and inflammatory diseases;
• the intermediate period (up to 3 months) is accompanied by the maintenance of purulent complications, against which cicatrical and fibrous processes develop in the damaged brain tissue, bone callus is formed in fracture zones, decubitus is beginning to heal;
• the late period (from 3 months to 1 year) corresponds to a period of late complications: pyelonephritis, enterocolitis, trophic disorders, pressure sores, sepsis;
• Residual period (more than 1 year after injury) is the period of residual events and consequences.

Spinal trauma can not be described without mentioning the Frankel scale, first proposed for a qualitative assessment of neurological complications of spinal injuries as far back as 1969 and is currently used for an approximate evaluation of myelopathies of various genesis. On this scale, five types of neurological spinal disorders are distinguished: type A - paraplegia with total sensitivity impairment (clinic of complete transverse spinal cord injury); type B - paraplegia with partial sensitive disorders; type C - paraparesis with pronounced impairment of motor functions; type D - paraparesis with insignificant limitation of motor functions; type E - the absence of neurological complications or the presence of minimal neurologic symptoms.

Given the characteristics of pediatric patients, the doctors modified the Frankel scale for use in pediatric practice (Mushkin A.Yu., et al., 1998) and found it possible to classify as E type the complete absence of pathological neurologic symptoms, while the damage to the anterior columns of the spinal cord , detected only with a guided examination of the neurologist and not significantly limiting the patient's arbitrary movements, are referred to us as type D. In addition, the type R-radicular (pain) syndrome is additionally identified.

The Frankel scale is used for qualitative characterization of injuries accompanied by spinal cord lesions below the cervical thickening level. For damage that occurs with the picture of tetraplegia (tetraparesis), the scale of the Japanese orthopedic association JOA is used.

In order to increase the objectivity of the assessment of motor disorders, the American associations for spinal trauma NASCIS and ASIA have introduced quantitative schemes based on the determination of strength in muscles innervated by a certain spinal segment - in so-called "key muscles". Table 30 lists the key muscles, the function of which is evaluated by the NASCIS and ASIA systems.

The strength of each key muscle is estimated on a 5-point scale first proposed by the Nerve Injury Committee in 1943: 0 - paralysis, 1 - palpable or visible muscle contractions, 2 - active movements with incomplete volume under / against gravity, 3 - full volume of movements against gravity, 4 - the total volume of movements with moderate opposition to the investigator, 5 - unlimited movements.

According to ASIA, the function of 10 muscles, estimated from two sides, is summed up, with a maximum total of 100 points. According to NASCIS, the function of 14 muscles is summed from the right side (taking into account the supposed symmetry of neurological disorders). The maximum score is 70.

In 1992, ASIA combined a qualitative assessment of neurological disorders according to the Frankel scale with their partial quantification. According to the combined Frankel / ASIA system, the following types of neurological disorders are distinguished:

A - a complete violation of sensitivity and movements with the preservation of zones innervated by sacral segments S4-5; B - movements below the level of damage are absent, but the sensitivity is preserved; C - movements below the level of damage are preserved, however, the number of "key muscle" retaining function is less than 3; D - movements below the level of defeat are preserved, the number of functioning "key" muscles is more than 3; E is a normal neurological picture.

The NASCIS treatment protocol, recommended for the management of an acute period of spinal trauma. The aim of the protocol is the maximum prevention of the development of irreversible morphological changes in the spinal cord due to a decrease in the prevalence of necrobiotic changes in it, hematomyelia, vacuolization, etc. The protocol is effective only if it is started within the first 8 hours after the injury. The protocol is used in the presence of symptoms of spinal trauma (neurological disorders), as well as in its absence in patients with neurologically unstable trauma of the spine and high risk of myelopathy (for example, in explosive fractures of the thoracic vertebrae without a myelopathy clinic). The items of the protocol include:

• a single (bolus) injection of methylprednisolone (MP) at a dosage of 30 mg / kg;
• the subsequent administration of MP at a dosage of 5.4 mg / kg / hour for 24 hours.

The protocol was proposed in 1992, and in 1996 NASCIS recommended extending it to 48 hours. According to experimental and clinical data, NASCIS protocol application allows to reduce the incidence of irreversible neurological disorders with spinal trauma by almost 30%.

[1], [2], [3], [4], [5]