Spinal trauma and back pain

In literature, along with the term spinal cord injury, its English analogue, vertebrospinal injuries, is often used to denote combined trauma of the spine and spinal cord, which leads to certain contradictions. What should be understood by the term "spinal injury"? Spinal cord injury, as is customary in Russian literature, or spinal injury, which follows from the literal translation from English of the word spine? What is "spinal shock", "traumatic disease of the spinal cord", what are their characteristics, duration, course, principles of treatment? Without considering it possible to delve into the problems of neurosurgery, where spinal cord injuries are usually considered, we will try to highlight only some fundamental issues of spinal cord injury that are insufficiently reflected in the specialized literature.

Of the classifications of sacral fractures, the most interesting, in our opinion, is the classification based on the assessment of the fracture line relationship to the caudal part of the spinal canal and the root foramina. Conventionally, in the frontal plane, the sacral region is divided into 3 zones: the zone of the lateral part ("wings") of the sacrum, the zone of the root foramina, and the spinal canal region. In oblique and transverse fractures, the type of injury is assessed by the most medial injured section. Fractures located lateral to the root foramina are never accompanied by neurological disorders. In turn, burst fractures of the sacrum are potentially dangerous in terms of compression of the sacral roots, fracture-dislocations - in terms of their rupture. There is also a classification of sacral fractures A0/ASIF, which is based on the definition of the horizontal level of damage and distinguishes a fracture of the caudal part of the sacrum (type A), a compression fracture of its cranial part (type B) and a fracture-dislocation of the cranial part of the sacrum (type C). A more detailed division of sacral fractures into groups is not currently used.

The general structure of closed spinal cord injuries is presented by S. A. Georgieva et al. (1993). V. P. Bersnev et al. (1998) supplements this scheme with post-traumatic vascular syndromes: myeloischemia, hematomyelia, epidural, subdural and subarachnoid hemorrhages.

Another type of spinal injury that is not reflected in the diagram above is a spinal cord rupture. However, a true anatomical rupture, accompanied by the divergence of spinal cord fragments and the formation of a diastasis between them, is observed in only 15% of patients with clinical manifestations of a transverse rupture of the spinal cord. In other cases, an intrathecal or axonal rupture occurs.

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

• spinal shock - complete loss of movement, sensitivity and reflexes of all lumbar and sacral segments due to injury to the cervical and thoracic spinal cord (the authors particularly emphasize localization). The duration of spinal shock ranges from several minutes to 24 hours. The appearance of the bulbocavernous reflex is considered a sign of recovery from spinal shock;
• complete quadriplegia - complete loss of movement of the upper and lower limbs due to injury to the cervical spinal cord;
• incomplete quadriplegia - partial loss of movement of the upper and lower limbs due to injury to the cervical spinal cord, including:
  • forebrain basin syndrome,
  • Brown-Sequarda syndrome,
  • central cerebral basin syndrome;
• complete paraplegia - complete loss of movement of the lower limbs;
• incomplete paraplegia (paraparesis) - incomplete loss of movement of the lower limbs;
  • false complete paraplegia - complete absence of movement of the lower limbs due to injury to the epiconus and conus of the spinal cord;
  • ascending paraplegia (in modern literature this type of disorder is described as “ascending myelopathy”) - neurological symptoms that increase dynamically and spread above the level of the vertebral lesion, usually observed in the first 4 days after the injury.

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

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

V.P. Bersnev et al. (1998), describing practically the same time periods in the clinical course of spinal injury, additionally cite the clinical and morphological features characteristic of them:

• acute period (duration - up to 3 days): morphologically, soft tissue edema, primary necrosis and myeloischemia of the damaged area are noted; unstable clinical picture, including symptoms characteristic of spinal shock;
• the early period (2-3 weeks) corresponds to the time of occurrence 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 persistence of purulent complications, against the background of which cicatricial-fibrous processes develop in the damaged brain tissue, bone callus forms in the fracture areas, and bedsores begin to heal;
• the late period (from 3 months to 1 year) corresponds to the period of late complications: pyelonephritis, enterocolitis, trophic disorders, bedsores, sepsis appear;
• residual period (more than 1 year after injury) - the period of residual effects and consequences.

It is impossible to describe spinal trauma without mentioning the Frankel scale, first proposed for a qualitative assessment of neurological complications of spinal trauma back in 1969 and currently used for an approximate assessment of myelopathies of various origins. This scale distinguishes five types of neurological spinal disorders: type A - paraplegia with complete sensory impairment (clinical presentation of complete transverse spinal cord injury); type B - paraplegia with partial sensory impairment; type C - paraparesis with severe motor impairment; type D - paraparesis with minor motor impairment; type E - no neurological complications or minimal neurological symptoms.

Taking into account the characteristics of pediatric patients, doctors modified the Frankel scale for use in pediatric practice (Mushkin A.Yu. et al., 1998) and considered it possible to classify the complete absence of pathological neurological symptoms as type E, while damage to the anterior columns of the spinal cord, detected only during a directed examination by a neurologist and not significantly limiting the patient's voluntary movements, was classified by us as type D. In addition, type R was additionally identified - radicular (pain) syndrome.

The Frankel scale is used to qualitatively characterize injuries involving the spinal cord below the level of the cervical enlargement. For injuries occurring with a picture of tetraplegia (tetraparesis), the JOA scale is used.

In order to improve the objectivity of the assessment of movement disorders, the American associations for spinal injury NASCIS and ASIA have introduced quantitative schemes based on the determination of strength in the muscles innervated by a certain spinal segment - in the so-called "key muscles". Table 30 lists the key muscles whose function is assessed according to the NASCIS and ASIA systems.

The strength of each key muscle is assessed using 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 limited range of motion under/against gravity, 3 - full range of motion against gravity, 4 - full range of motion with moderate resistance from the examiner, 5 - unlimited motion.

The ASIA sums the function of 10 muscles assessed bilaterally, with a maximum total score of 100. The NASCIS sums the function of 14 muscles on the right side (taking into account the assumed symmetry of neurological disorders). The maximum score is 70.

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

A - complete impairment of sensitivity and movement with preservation of zones innervated by sacral segments S4-5; B - there are no movements below the level of damage, but sensitivity is preserved; C - movements below the level of damage are preserved, but the number of “key muscles” that retain function is less than 3; D - movements below the level of damage are preserved, the number of functioning “key” muscles is more than 3; E - normal neurological picture.

The NASCIS treatment protocol recommended for the acute period of spinal injury. The goal of the protocol is to maximally prevent the development of irreversible morphological changes in the spinal cord by reducing the prevalence of necrobiotic changes, hematomyelia, vacuolization, etc. The protocol is effective only if it is started in the first 8 hours after the injury. The protocol is used in the presence of symptoms of spinal injury (neurological disorders), as well as in its absence in patients with neurologically unstable spinal injury and a high risk of myelopathy (for example, with burst fractures of the thoracic vertebrae without clinical myelopathy). Protocol points include:

• single (bolus) administration of methylprednisolone (MP) at a dosage of 30 mg/kg;
• 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 its implementation to 48 hours. According to experimental and clinical data, the use of the NASCIS protocol allows to reduce the frequency of irreversible neurological disorders in spinal trauma by almost 30%.

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