Trauma of the spinal cord: symptoms, treatment

Treatment of victims with a spinal cord injury is an extremely topical problem of modern medicine. Every year in Ukraine, spinal cord injuries are received by about 2000 people, mostly young people of working age who become disabled I (80%) and II groups. In the United States, 8,000-10,000 cases of this type of injury are recorded each year. Trauma of the spinal cord is not only medical, but also social.

For example, the costs of treatment and maintenance of one injured with spinal cord and spinal cord injury in the US are estimated at $ 2 million. Spine fractures with spinal cord injuries and spinal cord injuries occur when the mechanical force (direct injuries) is directly affected, the victim falls from the height (catatrauma) , with excessive flexion or extension of the spine (indirect damage), when diving into the bottom upside down.

Symptoms of spinal cord injury

The severity of the trauma of the spinal cord, especially in the early stages after trauma, is largely dependent on the development of spinal shock. Spinal shock is a pathophysiological condition characterized by impaired motor, sensory, reflex function of the spinal cord below the level of damage. At the same time, the motor activity of the limbs is lost, their muscle tone is reduced, the sensitivity, the function of the pelvic organs is impaired. Hematomas, bone fragments, foreign bodies can support spinal shock, cause disorders of liquor and hemodynamics. Nerve cells, located in the immediate vicinity of the lesion, are in a state of prohibitive inhibition.

Among the clinical forms of spinal cord injury are:

1. Concussion of the spinal cord.
2. Contusion of the spinal cord.
3. The compression of the spinal cord.
4. Crushing of the spinal cord with partial or complete disruption of the anatomical integrity of the spinal cord (tears, ruptures of the spinal cord).
5. Hematomyelia.
6. Lesions of the roots of the spinal cord.

Concussion of the spinal cord

Concussion of the spinal cord is characterized by reversible impairments in the functions of the spinal cord, unstable symptoms in the form of a decrease in tendon reflexes, muscle strength, sensitivity in the limbs according to the level of damage. Symptoms disappear within the first 1 - 7 days after a spinal cord injury. With lumbar puncture - the cerebrospinal fluid without changes, the patency of the subarachnoid spaces is not disturbed.

[1], [2], [3]

Spinal cord injury

A spinal cord injury is a more severe form of spinal cord injury. Clinically, with injury of the spinal cord, there are violations of all of its functions in the form of paresis or paralysis of the limbs with muscle hypotension and areflexia, a sensitivity disorder and violations of the function of the pelvic organs. With a spinal cord injury, the symptoms of its damage can regress fully or partially - depending on the degree of damage. Liqvor with a spinal cord injury with an admixture of blood, liquorodynamic disturbances are absent.

Spinal cord compression

The compression of the spinal cord can be caused by splinters of the bodies and arcs of the vertebrae or their articular processes, damaged ligaments and discs, hemorrhages (bruises), foreign bodies, edema-swelling of the brain, etc. Dorsal compression of the spinal cord caused by fragments of arcs of vertebrae damaged by articular processes , yellow ligament; ventral, formed as a result of direct action of the vertebral bodies or their fragments, fragments of the damaged disc, thickened posterior longitudinal ligament, and internal (due to hematoma, hydroma, edema-swelling of the spinal cord, etc.). Often, compression of the spinal cord causes a combination of several of these reasons.

Crushing injury of the spinal cord

Crushing of the spinal cord with partial disruption of its anatomical integrity (spinal cord injury) in the first days, weeks and even months after trauma can cause a clinical picture of the so-called physiological transverse spinal cord break (spinal shock), which is characterized by a decrease in the muscle tone of the paralyzed limbs and the disappearance of both somatic, and vegetative reflexes, carried out with the participation of the caudal segment of the spinal cord. At an anatomical break of a spinal cord the syndrome of a full transverse lesion of a spinal cord develops. At the same time, all voluntary movements are not down from the level of the lesion, sluggish paralysis is observed, tendon and skin reflexes are not caused, all kinds of sensitivity are lost, control of the pelvic organs functions (involuntary urination, violation of defecation), vegetative innervation (sweating, temperature regulation ). Over time, flaccid paralysis of muscles can be replaced by their spasticity, hyperreflexia, and automatic forms of pelvic organs are often formed.

[4], [5], [6], [7]

Hematomyelia

Hematomyelia - a hemorrhage into the substance of the spinal cord. The most common hemorrhage occurs when the vessels are ruptured in the region of the central canal and hindbones at the level of the lumbar and cervical thickenings. Clinical manifestations of hematomyelia are caused by compression of the gray matter and hindbones of the spinal cord with blood flowing out to the 3-A segment. In accordance with this acute, there are segmental dissociated sensitivity disorders (temperature and pain), located on the body in the form of a jacket or semi-jacket.

Very often in an acute period, not only segmental disorders are observed, but also conductive sensitivity disorders and pyramidal symptoms due to compression of the spinal cord. With extensive hemorrhages, a picture of total transverse damage to the spinal cord develops.

Hematomyelia is characterized by a regressive course. Neurological symptoms of spinal cord injury begin to decrease after 7-10 days. Restoration of impaired functions can be complete, but neurological disorders remain more often.

Lesions of spinal cord roots

The defeat of the roots of the spinal cord is possible in the form of stretching, compression, bruising with an intra-stem hemorrhage, detachment of one or more roots from the spinal cord. Clinically, there are disorders of sensitivity, peripheral paresis or paralysis, vegetative disorders, respectively, to the site of damage.

Objectively, the examination reveals: local soreness and deformity of the spine, its pathological mobility; abrasions, bruising, swelling of soft tissues, muscle tension in the form of ridges on both sides of the spinous process - a symptom of the reins. In the neurological status, there are violations of movement and sensitivity in the upper and lower extremities (with injury of the cervical region), in the lower extremities (with trauma of the thoracic and lumbar spine), impaired function of pelvic organs in the form of acute retention of urination.

Symptoms of a spinal cord injury depend on the level of the lesion and are manifested as a syndrome of damage to the diameter of the spinal cord - motor, sensitive disorders but the conductor type below the level of damage, violations of the pelvic organs, vegetative-trophic disturbances. Violations of each part of the spinal cord is characterized by a certain clinical symptomatology.

Thus, traumatic lesion of the spinal cord at the level of the upper cervical region (CI-CIV) is characterized by radicular pain in the neck and occiput, forced head position with limited movement in the cervical spine. Spastic tetraplegia (or tetraparesis) develops, all kinds of sensitivity below the level of damage are violated, stem symptomatology is added (respiratory, swallowing, cardiovascular disorders). When the middle cervical segments (CIV-CV) are affected, diaphragmatic respiration is impaired.

The defeat of the lower cervical segments (CV-CVIII) is characterized by the symptoms of damage to the brachial plexus in the form of peripheral paresis (paralysis) of the upper limbs, the development of lower spastic paraparesis (paraplegia). With the defeat of the ciliary spinal center (CVIII-ThII) Bernard-Horner syndrome (ptosis, miosis, anophthalmus) joins.

Injury of the thoracic spinal cord leads to the development of the syndrome of the spinal cord defect in the form of lower spastic paraplegia (paraparesis), a violation of the sensitivity of the conductor type below the level of damage, the emergence of trophoparality syndrome.

Violation of cardiac activity can be observed when the process is localized at the level of ThIV-ThCI segments. For damage to the non-ThVII-ThII segments, the absence of all abdominal reflexes is typical, at the ThIX-ThX level - the absence of middle and lower abdominal reflexes, the absence of only lower abdominal reflexes is specific for ThXI-ThXII lesions. The main guidelines for determining the level of damage to the spinal cord are: the zone of sensitivity disorders, radicular pain and the level of prolapse of reflexes, motor disorders. By the level of sensitivity impairment, the localization of the process can be determined: ThIV - the level of the nipples, ThII - the rib arches, Thx - the level of the navel, ThxII - the level of the inguinal ligament.

When lesions at the level of lumbar thickening develops inferior flaccid paraplegia with lack of reflexes and atony of the muscles of the extremities, dysfunction of the pelvic organs. Disturbance of sensitivity is noted below the puarth ligament.

With trauma LI-LII at the level of which the cone is located (SIII-SV and epiconus, sensitivity in the perineum and in the genitals (in the form of the saddle) is disrupted, dysfunction of the pelvic organs arises according to the type of incontinence of urine and stool, sexual weakness.

Damage to the horse's tail is accompanied by intense radicular pain syndrome with a causal shade, peripheral paralysis of the lower limbs, impaired pelvic function as an incontinence. Sensitive disorders are characterized by uneven hypostasis in the region of the shins, groans, hamstrings (one- or two-sided), buttocks.

In children quite often (18-20%) traumas of a spinal cord without x-ray changes of an osteal apparatus are found out.

Features of spinal cord injury in children are due to the anatomical and physiological structure of their spine:

1. Increased mobility of the cervical department.
2. Weakness of the ligamentous apparatus, underdevelopment of the muscles of the neck and back muscles.
3. The horizontal orientation of the articular surfaces of the vertebrae.
4. Unfinished ossification of vertebrae with incomplete joint formation Luschka.

Elasticity of the spine in children makes it more resistant to fractures, dislocations, but does not exclude the possibility of damage to the spinal cord with excessive sharp flexion or extension in the cervical spine.

Trauma to the spinal cord: Species

There are closed (without compromising the integrity of the skin) and open spine and CM lesions, in which the wound site of soft tissues coincides with the site of spinal injury and conditions for infection of the spinal cord and its membranes. Open lesions can be penetrating and non-penetrating. Criterion for penetrating wounds of the spine is a violation of the integrity of the internal wall of the spinal canal or damage to the dura mater.

Types of damage to the spine and spinal cord

1. Damage to the spine without damage to the spinal cord.
2. Damage to the spinal cord without spinal injury.
3. Damage to the spine with damage to the spinal cord.

According to the nature of spinal injury,

1. Damage to the ligamentous apparatus (ruptures, tears).
2. Damage to vertebral bodies (cracks, compression, fragmentation, transverse, longitudinal, explosive fractures, detachment of the closing plates); dislocations, fracture of the vertebrae.
3. Fractures of the posterior half-ring of vertebrae (arcs, spinous, transverse, articular processes).
4. Fractures of bodies and arches with or without bias.

According to the mechanism of origin, traumatic spinal cord injuries and spinal cord injuries, according to Harris classification, are divided into:

• Flexion defeats.

As a result of sharp flexion, the posterior ligaments (posterior longitudinal, yellow ligaments, interstitial) break, the dislocation most often occurs between CV-CVI or CVII vertebrae.

• Hyperextension lesions.

As a result of a sharp extension, the anterior longitudinal ligament ruptures, which is accompanied by compression of the spinal cord, protrusion of the disc, dislocation of the vertebral body.

• Vertical compression fractures.

Sharp vertical movements lead to fracture of one or more bodies of vertebrae and arches. Compression of the spinal cord can cause fractures of both the body and the arcs of the vertebrae.

• Fractures due to lateral flexion.

Isolate unstable and stable injuries of the spine.

Unstable injuries of the spine include multisplaced (explosive) vertebral fractures, rotational injuries, vertebral dislocations, fractures and dislocations of the articular processes, ruptures of the intervertebral discs, which are accompanied by a violation of the anatomic integrity of the ligamentous apparatus and in which the spinal structures can be displaced again with spinal cord trauma or roots.

Stable spinal injuries are most often observed with wedge-shaped compression fractures of vertebral bodies, vertebral arches fractures, transverse and spinous processes.

There are gunshot and non-fire damage. In relation to the wound canal, the following injuries are distinguished from the spinal cord and the spinal cord: through (the wound channel crosses the vertebral canal), the blind (ends in the vertebral canal), tangents (the wound channel passes, touching one of the walls of the spinal canal, destroys it, does not penetrate into the channel), non-penetrating (the wound channel passes through the bone structures of the vertebra, without damaging the walls of the spinal canal), paravertebral (the wound channel passes next to the spine without damaging it).

Localization distinguishes the damage to the cervical, thoracic, lumbar, lumbosacral spine and roots of the horse tail.

The frequency of damage to the spine depends on the anatomical and physiological features of the spine, ligaments and its mobility. Damage to the cervical spine occurs in 5-9% of cases, thoracic - in 40 - 45%, lumbar - in 45-52%. V, VI and VII vertebrae are most often damaged in the cervical, XI and XII in the thoracic, I and V in the lumbar spine. Accordingly, at these levels, the spinal cord is damaged.

Diagnosis of spinal cord injury

The neurosurgeon necessarily examines the patient. Evaluation of the functional state of patients with spinal cord trauma should be carried out according to Frankel:

• group A - patients with anesthesia and a plague below the level of the lesion;
• group B - patients with incomplete sensitivity disorder below the level of traumatic lesion, there are no movements;
• group C - patients with incomplete sensitivity disorder, there are weak movements, but muscle strength is insufficient for walking;
• group D - patients with incomplete sensitivity disorder below the level of traumatic lesion, movements are preserved, the muscle strength is sufficient for walking with outside help;
• group E - patients without sensitive and motor disorders below the level of damage.

The American Spinal Ingidence Association (ASIA Scale, 1992) proposed a system for assessing neurological disorders in spinal cord trauma. This system evaluates muscle strength in the important ten pair myotomes on a six-point scale:

• 0 - plethysy;
• 1 - visual or detected palpable muscle contractions;
• 2 - active movements that can not counteract the gravitational force;
• 3 - active movements that can counteract the gravitational force;
• 4 - active movements in full, which can resist moderate resistance;
• 5 - active movements in full volume, which can resist strong resistance.

Motor functions are evaluated when testing muscle strength in ten control muscle groups and in relation to the segments of the spinal cord:

• C5 - bending at the elbow (biceps, brachioradialis);
• C6 - extension of the wrist (extensor carpi radialis longus and brevis);
• C7 - Extension in the elbow (triceps);
• C8 - flexion of the fingers of the hand (flexor digitorum profundus);
• Th1 - reduction of the little finger (abductor digiti minimi);
• L2 - hip flexion (iliopsoas);
• L3 - knee extension (quadriceps);
• L4 - rear extension of the foot (tibialis anterior);
• L5 - extensor of the big toe (extensor hallncis longus);
• S1 - back folding of the foot (gastrocnemius, solens).

The maximum score for this scale is 100 points (norm). All indicators are entered in the medical form.

The most informative methods for examining the spine and the spinal cord are now MRI and CT, which can reveal not only gross structural changes, but also small foci of hemorrhage into the substance of the spinal cord.

Radiography (spondylography) of the spine can detect: dislocations, fractures of the vertebrae, fractures of arcs, spinous and transverse processes, fracture of the dentate process of the CI vertebrae, as well as information on the state of the intervertebral joints, the degree of narrowing of the spinal canal, and the presence of foreign bodies.

In case of suspicion of compression of the spinal cord, the victims with spinal cord trauma are subjected to a lumbar puncture, during which the liquor pressure is measured, and liquorodynamic samples (Quecenstedt, Stukei) are performed, which determine the patency of the subarachnoid spaces. Violation of the patency of subarachnoid spaces indicates a compression of the spinal cord, which necessitates an immediate decompression of the spinal cord. With trauma of the cervical spinal cord, liquorodynamic tests have a relative value, since even with pronounced dorsal or ventral compression of the brain, the permeability of subarachnoid spaces can be maintained due to the presence of liquor "pockets" on either side of the spinal cord. In addition, liquorodynamic tests do not provide information about the location and cause of compression of the spinal cord.

Important in determining the patency of subarachnoid spaces and the state of the spinal cord, in addition to liquorodynamic samples, myelography using radiopaque substances (omnipak, etc.), which allows you to clarify the level of compression of the spinal cord.

[8], [9], [10], [11]

Assisting with spinal cord injury in the prehospital stage

Treatment of spinal cord injury at the prehospital stage includes monitoring and providing vital functions (breathing, hemodynamics), immobilization of the spine, stopping bleeding, administration of neuroprotectors (methylprednisolone), analgesics and sedatives. When the urine is delayed, the bladder is catheterized.

At the injury site, medical personnel pay attention to the victim's situation, the presence of wounds, local changes (limitation of mobility in the spine, swelling, soreness in palpation and percussion of the vertebrae). The doctor evaluates the neurological status of the patient, checks the motor function of the upper and lower extremities, a violation of sensitivity in them, muscle tone and reflexes. For the prevention of wound infection, toxoid and anti-tetanus serum are administered, broad-spectrum antibiotics are used.

Reliable immobilization of the spine in order to prevent repetition of bone fragments is a prerequisite for transporting the victims to a specialized neurosurgical department.

Transportation of patients to the hospital is necessary on a rigid stretcher or on a shield. Victims with trauma of the thoracic and lumbar spinal cord should be placed on the stomach, placing a pillow or roller under the head and shoulders.

Lay on the stretcher of the victim is necessary with the help of three or four people. In case of damage to the cervical spine, the patient should lie on the back, to create a moderate extension of the neck under the shoulders, place a small cushion.

Immobilization of the cervical spine is performed with the help of the Kendrick tire, the Shantz collar, the CITO bus, or with a cardboard, gypsum or cotton-gauze collar. This tactic makes it possible to reduce the lethality in the trauma of the spine and spinal cord by 12%.

Liquidation of respiratory disorders is carried out by cleansing the oral cavity from foreign bodies, vomit and mucus; deducing the mandible anteriorly without unbending the neck with the help of artificial ventilation. If necessary, enter the duct, conduct intubation of the trachea.

It is necessary to stabilize cardiac activity. The instability of the cardiovascular system, which can be manifested by traumatic sympathectomy, signs of spinal shock (bradycardia, arterial hypotension, a symptom of warm lower limbs), is typical for damage to the cervical and upper thoracic parts of the spinal cord (as a result of circulatory disturbances in the lateral columns of Clarke). Arterial hypotension can also develop as a result of blood loss, but tachycardia, cold, sticky skin will be observed.

In the case of development of spinal shock, atropine, dopamine are prescribed, saline solutions (3-7% sodium chloride solution), rheopolyglucin, haemodesis, elastic bandage of the lower extremities.

[12], [13], [14]

Treatment of spinal cord injury

In the acute period of the spinal cord injury intensive conservative therapy is shown simultaneously with the definition of the severity and nature of the trauma, the establishment of indications for surgical treatment.

The use of methyl prednisolone intravenously for the first 8 hours after the trauma of a large dose (30 mg / kg), and 15 mg / kg for another 6 hours, then 5.0 mg / kg every 4 hours for 48 hours. Methylprednisolone as an inhibitor lipid peroxidation is more effective than conventional prednisolone or dexamethasone. In addition, methyl prednisolone inhibits hydrolysis of lipids, improves blood flow to the spinal cord and aerobic energy metabolism, improves the excretion of calcium from cells, enhances neuronal excitability and impulses. Salaries are used to eliminate brain edema along with hypertonic sodium chloride solution. As an antioxidant apply vitamin E (5 ml 2-3 times a day). To increase the resistance of the brain to hypoxia prescribe diphenin, seduxen, Relanium. Obligatory is the early use of calcium antagonists (nimodipine - 2 ml), magnesium sulfate. The drug treatment of spinal cord injury increases the resistance of the brain to hypoxia, but does not eliminate its compression.

In the case of compression of the spinal cord should be as soon as possible to perform decompression of the spinal cord, which is a prerequisite for the successful treatment of patients with spinal cord injury. It should be noted that the most effective is the early surgical intervention (in the first 24 hours after the injury), when the impaired functions of the spinal cord can still be restored.

Indications for surgery for spinal cord injury

1. The compression of the spinal cord or roots of the horse tail, which is confirmed by the results of CT, MRI, spondylography or myelography.
2. Partial or complete blockade of the CSF when performing lumbar puncture with liquorodynamic assays.
3. Progression of secondary respiratory failure due to ascending edema of the cervical spinal cord.
4. Instability of the vertebral-motor segment, which threatens the growth of neurological symptoms.

Injury of the spinal cord: surgical treatment includes:

1. Decompression of the spinal cord.
2. Restoring normal anatomical relationships between the spine, spinal cord, membranes and roots. Creation of conditions for improvement of liquor circulation, blood supply of the spinal cord.
3. Stabilization of the spine.
4. Creation of conditions for the restoration of impaired functions of the spinal cord.

The choice of the method of decompression of the spinal cord depends on the level of its damage and the nature of the injury. Decompression is performed by repositioning, cornorectomy (removal of the vertebral body), laminectomy (removal of the vertebra artery, spinous process). Complete the operation by stabilizing (immobilizing) the spine - interbody, interstitial or intercostal spondylodesis (corpodrose).

With a trauma of the cervical spine, skeletal traction is carried out beyond the parietal knolls or behind the zygomatic arches, halocytes are applied, which helps reduce the compression of the spinal cord (in 80% of cases). In some cases, when there are contraindications to skeletal traction, surgical intervention is performed to decompress the spinal cord, remove bone fragments and then fix the damaged segment with a metallic construction beyond the articular processes, arcs or spinous processes. At fractures of the cervical vertebral bodies and damage to the intervertebral discs, anterior pre-tracheal access is used, spinal cord decompression is performed by cornorectomy, discectomy followed by anterior spondyloarthrosis with bone autograft, titanium cage, metal plate on screws, etc.

Complications of spinal cord injury and their treatment

Untimely conduct of surgical intervention in the compression of the spinal cord is unacceptable and dangerous for the patient, as early signs of multiple organ failure develop - bedsores, infectious and inflammatory complications from the urinary, respiratory systems, etc. Develop.

Complications that develop as a result of a spinal cord injury are divided into:

1. trophic disorders;
2. infectious and inflammatory processes;
3. violations of the pelvic organs;
4. deformation of the musculoskeletal system.

Trophic disorders in the form of bedsores and ulcers occur due to damage to the spinal cord, as well as a violation of blood circulation in tissues when they are compressed.

All decubituses, regardless of the time and place of their formation, go through the stages:

1. necrosis (characterized by tissue decay);
2. formation of granulations (necrosis slows down and granulation tissue is formed);
3. epithelization;
4. trophic ulcers (if the process of regeneration does not end with scarring of decubitus).

For the prevention of pressure sores, the patient is turned over every hour with a simultaneous massage of the skin and muscles, after which the skin is wiped with disinfectants. In places of physiological protrusions (under the shoulder blades, sacrum, heels), special pouches or cotton swabs are placed. With deep bedsores (3-4 stages), only surgical intervention is shown, aimed at creating conditions for the fastest possible cleansing of the wound from necrotic tissues.

Infection-inflammatory complications are a consequence of the development of infection and are divided into early and late.

To the early are:

1. purulent epiduritis (the inflammatory process extends to the epidural cellulose);
2. purulent meningomyelitis (the inflammatory process develops in the spinal cord and its membranes);
3. abscess of the spinal cord.

Late are:

1. chronic epidurit (the course of the disease without a pronounced temperature reaction);
2. arachnoiditis (the course of the disease as a chronic productive inflammatory process with compression of the spinal cord).

Violation of the function of the pelvic organs is manifested by a delay or incontinence of urine, stool. The following forms of the neurogenic bladder stand out:

1. normoreflectory;
2. hyporeflective (characterized by low intravesical pressure, decreased detrusor strength and delayed urinary reflex, resulting in overextension of the bladder and a large amount of residual urine accumulated);
3. hyperreflective (bladder emptying is automatic and accompanied by urinary incontinence);
4. areflex (with no bubble reflex, overgrowth of the bladder or true urinary incontinence). Dysfunction of the bladder is complicated by the development of infection in the urinary tract, which, against the background of dystrophic changes in the bladder mucosa, leads to the development of urosepsis.

Emptying the bladder is carried out with the help of catheterization, it is possible to wash the urinary bladder with the Monroe system using antiseptic solutions (rivanol, furacilin, collargol, protargol).

An important role in the prevention and treatment of urinary tract infections belongs to conservative therapy. Use furagin, furazolidon, furadonin, 5-NOK, nevigramon. When determining the sensitivity of microorganisms to antibiotics, antibiotics of a wide spectrum of action are used: cephalosporins of the 1st, 2nd and 3rd generations, fluoroquinolones, etc.

Patients with urinary retention syndrome in the background of an areflector or gyrereflectory urinary bladder are prescribed anticholinesterase drugs (galantamines, proserine, kalimine), adrenoblockers (phentolamine), cholinomimetics (carbachol, pilocarpine, acetylidine), strychnine (strychnine, secyrinin) drugs. Anticholinergic drugs (atropine, belladonna, platifillin, metacin), spasmolytics (papaverine, no-sppa), muscle relaxants (baclofen, midocalm), ganglioblocators (benzogexonium) are used to treat patients with urinary incontinence syndrome in the hyperreflexive urinary bladder. Patients with urinary incontinence on the background of hypo- or areplexia of the urinary bladder are prescribed ephedrine.

Changes and the musculoskeletal apparatus are manifested by various deformations of the spine, connected directly with the mechanism of spinal and spinal trauma. In addition, the development of limb contractures, paraarticular and paraossal ossification may occur, for the prevention of which proper placement of the limbs, massage and therapeutic gymnastics are important.

Prevention of contractures should start from the first day after the injury. At least twice a day should be performed gymnastics with the full volume of movements in the joints. Ankle joints should be maintained in the flexion position to prevent extensor contractures.

In patients with spinal cord injury, there is a significant risk of thromboembolic complications (deep vein thrombosis of the lower leg, pulmonary embolism). To prevent these complications, bandage of the lower extremities, massage, early activation of the affected, the introduction of fractiparin - 0.3 ml 2 times a day, then appoint a tiklid - 1 tablet 2 times a day for 2-3 months.

In purulent complications, toxic-septic state for the elimination of secondary immunodeficiency, T-activin is prescribed (1 ml of 0.1% solution subcutaneously or intramuscularly every other day, the total dose is 500 μg) and combination with immunoglobulin (25 ml drip at intervals of 24 and 48 h), for the course of treatment 75 ml.

To reduce spasticity, spinal patients are treated with midocals, baclofen, sirdalud, and percutaneous electroneurostimulation.

In the more distant period they carry out complex medical and social rehabilitation of the victims. Widely used LFK, massage of the extremities, physiotherapy methods (iontophoresis lidazy, proserina, electrostimulation of the bladder). The drugs that improve microcirculation, nootropics, B vitamins, neuromidine, biostimulators, etc. Are shown. In the future, the treatment is shown in specialized sanatoriums (Saki, Slavyanok, Donetsk region, Salty estuary of the Dnepropetrovsk region, etc.).

[15], [16],