Spinal cord injury: symptoms, treatment

Treatment of victims with spinal cord injury is an extremely urgent problem of modern medicine. Every year in Ukraine about 2000 people suffer from spinal cord injuries, and these are mainly young people of working age who become disabled of groups I (80%) and II. In the USA, 8000-10 000 cases of this type of injury are registered annually. Spinal cord injury is not only medical, but also social.

For example, the cost of treatment and maintenance of one victim with a spinal cord injury in the USA is estimated at up to 2 million dollars. Spinal fractures with damage to the spinal cord and spinal roots occur with direct exposure to mechanical force (direct injuries), a fall of the victim from a height (catatrauma), with excessive flexion or extension of the spine (indirect injuries), or when diving head first into the water.

Symptoms of Spinal Cord Injury

The severity of spinal cord injury, especially in the early stages after injury, largely depends on the development of spinal shock. Spinal shock is a pathophysiological condition characterized by a disorder of the motor, sensory, and reflex functions of the spinal cord below the level of injury. In this case, the motor activity of the limbs is lost, their muscle tone decreases, sensitivity and the function of the pelvic organs are impaired. Hematomas, bone fragments, and foreign bodies can maintain spinal shock and cause cerebrospinal fluid and hemodynamic disorders. Nerve cells located in the immediate vicinity of the injury are in a state of extreme inhibition.

Among the clinical forms of spinal cord injury are:

1. Spinal cord concussion.
2. Spinal cord contusion.
3. Spinal cord compression.
4. Crushing of the spinal cord with partial or complete disruption of the anatomical integrity of the spinal cord (ruptures, ruptures of the spinal cord).
5. Hematomyelia.
6. Spinal cord root damage.

Spinal cord concussion

Spinal cord concussion is characterized by reversible dysfunction of the spinal cord, unstable symptoms in the form of decreased tendon reflexes, muscle strength, sensitivity in the limbs according to the level of damage. Symptoms disappear within the first 1-7 days after spinal cord injury. Lumbar puncture shows no changes in the cerebrospinal fluid, and the patency of the subarachnoid spaces is not impaired.

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Spinal cord contusion

Spinal cord contusion is a more severe form of spinal cord injury. Clinically, spinal cord contusion is characterized by disorders of all its functions in the form of paresis or paralysis of the limbs with muscle hypotonia and areflexia, sensitivity disorders, and pelvic organ dysfunction. With spinal cord contusion, the symptoms of its injury may regress completely or partially, depending on the degree of injury. With spinal cord contusion, the cerebrospinal fluid is mixed with blood, and there are no cerebrospinal fluid dynamics disorders.

Spinal cord compression

Spinal cord compression may be caused by fragments of the vertebral bodies and arches or their articular processes, damaged ligaments and discs, hemorrhages (hematomas), foreign bodies, cerebral edema-swelling, etc. A distinction is made between dorsal spinal cord compression caused by fragments of the vertebral arches, damaged articular processes, and the yellow ligament; ventral compression resulting from the direct impact of the vertebral bodies or their fragments, fragments of a damaged disc, a thickened posterior longitudinal ligament, and internal compression (due to hematoma, hydroma, edema-swelling of the spinal cord, etc.). Often, spinal cord compression is caused by a combination of several of the above causes.

Spinal cord crush injury

Crushing of the spinal cord with partial disruption of its anatomical integrity (spinal cord rupture) in the first days, weeks and even months after the injury can cause the clinical picture of the so-called physiological transverse rupture of the spinal cord (spinal shock), which is characterized by a decrease in the tone of the muscles 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. With an anatomical rupture of the spinal cord, the syndrome of complete transverse lesion of the spinal cord develops. In this case, all voluntary movements below the level of the lesion are absent, flaccid paralysis is observed, tendon and skin reflexes are not evoked, all types of sensitivity are absent, control over the functions of the pelvic organs is lost (involuntary urination, impaired defecation), vegetative innervation is affected (sweating and temperature regulation are impaired). Over time, flaccid paralysis of the muscles can be replaced by spasticity, hyperreflexia, and automatisms of the pelvic organ functions often develop.

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Hematomyelia

Hematomyelia is a hemorrhage into the spinal cord substance. Most often, hemorrhage occurs when vessels rupture in the area of the central canal and posterior horns at the level of the lumbar and cervical thickenings. Clinical manifestations of hematomyelia are caused by compression of the gray matter and posterior horns of the spinal cord by the spilled blood, spreading to the 3-A segment. In accordance with this, segmental dissociated disturbances of sensitivity (temperature and pain) arise acutely, located on the body in the form of a jacket or half-jacket.

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

Spinal cord root lesion

Damage to the spinal cord roots may be in the form of stretching, compression, contusion with intrastem hemorrhage, or tearing of one or more roots from the spinal cord. Clinically, sensitivity disorders, peripheral paresis or paralysis, and autonomic disorders are detected, respectively, in the area of damage.

Objectively, the examination reveals: local pain and deformation of the spine, its pathological mobility; abrasions, bruises, swelling of soft tissues, muscle tension in the form of ridges on both sides of the spinous process - the reins symptom. In the neurological status, there are disturbances of movement and sensitivity in the upper and lower extremities (in case of injury to the cervical spine), in the lower extremities (in case of injury to the thoracic and lumbar spine), dysfunction of the pelvic organs in the form of acute urinary retention.

Symptoms of spinal cord injury depend on the level of damage and manifest as a syndrome of damage to the transverse spinal cord - motor, sensory disorders of the conductive type below the level of damage, dysfunction of the pelvic organs, vegetative-trophic disorders. Disorders of each section of the spinal cord are characterized by certain clinical symptoms.

Thus, traumatic damage to the spinal cord at the level of the upper cervical region (CI-CIV) is characterized by radicular pain in the neck and occipital region, forced position of the head with limited range of motion in the cervical spine. Spastic tetraplegia (or tetraparesis) develops, all types of sensitivity below the level of damage are impaired, and brainstem symptoms (breathing disorders, swallowing, cardiovascular activity) are added. With damage to the middle cervical segments (CIV-CV), diaphragmatic breathing is impaired.

Lesions of the lower cervical segments (CV-CVIII) are characterized by 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). When the ciliospinal center (CVIII-ThII) is damaged, Bernard-Horner syndrome (ptosis, miosis, anophthalmos) is added.

Trauma to the thoracic spinal cord leads to the development of the syndrome of transverse spinal cord damage in the form of lower spastic paraplegia (paraparesis), impaired sensitivity by the conductive type below the level of damage, and the occurrence of trophoparalytic syndrome.

Cardiac dysfunction can be observed when the process is localized at the level of ThIV-ThCI segments. For damage to the ThVII-ThII segments, the absence of all abdominal reflexes is characteristic, at the ThIX-ThX level - the absence of middle and lower abdominal reflexes, the absence of only lower abdominal reflexes is specific for damage to the ThXI-ThXII segments. The main landmarks in determining the level of spinal cord damage are: the zone of sensitivity impairment, radicular pain and the level of reflex loss, motor disorders. The localization of the process can be determined by the level of sensitivity impairment: ThIV - nipple level, ThII - costal arches, ThX - umbilicus level, ThXII - inguinal ligament level.

When the lesion is at the level of the lumbar thickening, lower flaccid paraplegia develops with the absence of reflexes and atony of the muscles of the limbs, dysfunction of the pelvic organs. Impaired sensitivity is noted below the inguinal ligament.

In case of injury to LI-LII, at the level of which the cone (SIII-SV and the epicone) are located, sensitivity in the perineum and in the genitals (in the form of a saddle) is impaired, dysfunction of the pelvic organs occurs such as urinary and stool incontinence, sexual weakness.

Damage to the equine tail is accompanied by intense radicular pain syndrome with a causalgic tint, peripheral paralysis of the lower extremities, and dysfunction of the pelvic organs such as incontinence. Sensory disturbances are characterized by uneven hypoesthesia in the area of the shins, groans, back of the thighs (unilateral or bilateral), and buttocks.

In children, spinal cord injuries are quite common (18-20%) without radiographic changes in the skeletal system.

The characteristics of spinal cord injury in children are determined by the anatomical and physiological structure of their spine:

1. Increased mobility of the cervical spine.
2. Weakness of the ligamentous apparatus, underdevelopment of the neck muscles and back muscles.
3. Horizontal orientation of the articular surfaces of the vertebrae.
4. Incomplete ossification of the vertebrae with incomplete formation of the Luschka joints.

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

Spinal Cord Injury: Types

A distinction is made between closed (without breaking the integrity of the skin) and open injuries of the spine and SM, in which the site of injury to soft tissues coincides with the site of injury to the spine and this creates conditions for infection of the spinal cord and its membranes. Open injuries can be penetrating and non-penetrating. The criterion for penetrating injuries of the spine is a violation of the integrity of the inner wall of the spinal canal or damage to the dura mater.

Types of Spinal Cord and Spine Injuries

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

Depending on the nature of the spinal injury, the following are distinguished:

1. Damage to the ligamentous apparatus (ruptures, tears).
2. Damage to the vertebral bodies (cracks, compression, comminuted, transverse, longitudinal, explosive fractures, endplate tears); dislocations, fracture-dislocations of the vertebrae.
3. Fractures of the posterior semicircle of the vertebrae (arches, spinous, transverse, articular processes).
4. Fractures of bodies and arches with or without displacement.

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

• Flexion lesions.

As a result of sharp bending, the posterior ligaments (posterior longitudinal, yellow ligaments, interspinous) are torn; dislocation most often occurs between the CV-CVI or CVII vertebrae.

• Hyperextension lesions.

As a result of sudden extension, a rupture of the anterior longitudinal ligament occurs, which is accompanied by compression of the spinal cord, disc protrusion, and dislocation of the vertebral body.

• Vertical compression fractures.

Sharp vertical movements lead to a fracture of one or more vertebral bodies and arches. Spinal cord compression can be caused by fracture-dislocations of both vertebral bodies and arches.

• Lateral flexion fractures.

A distinction is made between unstable and stable spinal injuries.

Unstable spinal injuries include multi-fragmentary (burst) fractures of the vertebral bodies, rotational injuries, dislocations of the vertebrae, fractures and dislocations of the articular processes, ruptures of the intervertebral discs, which are accompanied by a violation of the anatomical integrity of the ligamentous apparatus and in which repeated displacement of the spinal structures with injury to the spinal cord or its roots is possible.

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

A distinction is made between gunshot and non-gunshot injuries. Depending on the relationship of the wound canal to the spine and spinal cord, the following injuries are distinguished: through (the wound canal crosses the spinal canal), blind (ends in the spinal canal), tangential (the wound canal passes, touching one of the walls of the spinal canal, destroys it, but does not penetrate the canal), non-penetrating (the wound canal passes through the bone structures of the vertebra, without damaging the walls of the spinal canal), paravertebral (the wound canal passes next to the spine, without damaging it).

According to localization, there are injuries to the cervical, thoracic, lumbar, lumbosacral spine and the roots of the equine tail.

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

Diagnosis of spinal cord injury

The patient must be examined by a neurosurgeon. The functional state of patients with spinal cord injury should be assessed according to Frankel:

• Group A - patients with anesthesia and plegia below the level of the lesion;
• Group B - patients with incomplete sensory impairment below the level of traumatic injury, no movement;
• Group C - patients with partial sensory impairment, weak movements, but insufficient muscle strength for walking;
• Group D - patients with incomplete sensory impairment below the level of traumatic injury, movements are preserved, muscle strength is sufficient for walking with assistance;
• Group E - patients without sensory and motor impairments below the level of injury.

The American Spinal Injury Association (ASIA scale; 1992) proposed a system for assessing neurological impairment in spinal cord injury. This system assesses muscle strength in ten important paired myotomes on a six-point scale:

• 0 - plegia;
• 1 - visual or palpable muscle contractions;
• 2 - active movements that cannot counteract the force of gravity;
• 3 - active movements that can counteract the force of gravity;
• 4 - full range of active movements that can counteract moderate resistance;
• 5 - full range of active movements that can counteract strong resistance.

Motor functions are assessed by testing muscle strength in ten control muscle groups and in relation to spinal cord segments:

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

The maximum score on this scale is 100 points (normal). All scores are recorded in the medical form.

The most informative methods for examining the spine and spinal cord at present are MRI and CT, which allow us to identify not only gross structural changes, but also small foci of hemorrhage in the substance of the spinal cord.

X-ray (spondylography) of the spine allows us to detect: dislocations, fracture-dislocations of the vertebrae, fractures of the arches, spinous and transverse processes, fracture of the odontoid process of the C1 vertebra, and also to obtain information about the condition of the intervertebral joints, the degree of narrowing of the spinal canal, and the presence of foreign bodies.

In case of suspected spinal cord compression, patients with spinal cord injury undergo a lumbar puncture, during which the cerebrospinal fluid pressure is measured, and cerebrospinal fluid dynamics tests (Queckenstedt, Stukey) are performed, which allow determining the patency of the subarachnoid spaces. Impaired patency of the subarachnoid spaces indicates compression of the spinal cord, which necessitates immediate decompression of the spinal cord. In case of cervical spinal cord injury, cerebrospinal fluid dynamics tests are of relative importance, since even with severe dorsal or ventral compression of the brain, the patency of the subarachnoid spaces may be preserved due to the presence of cerebrospinal fluid "pockets" on the sides of the spinal cord. In addition, cerebrospinal fluid dynamics tests do not provide information on the localization and cause of spinal cord compression.

In addition to cerebrospinal fluid dynamics tests, myelography using radiopaque agents (omnipaque, etc.) is of great importance in determining the patency of the subarachnoid spaces and the state of the spinal canal, as it allows one to clarify the level of spinal cord compression.

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Pre-hospital care for spinal cord injury

Treatment of spinal cord injury at the prehospital stage includes monitoring and ensuring vital functions (respiration, hemodynamics), immobilization of the spine, stopping bleeding, administration of neuroprotectors (methylprednisolone), analgesics and sedatives. In case of urinary retention, catheterization of the bladder is performed.

At the site of injury, medical personnel pay attention to the position of the victim, the presence of wounds, local changes (limited mobility in the spine, swelling, pain during palpation and percussion of the vertebrae). The doctor evaluates the patient's neurological status, checks the motor function of the upper and lower extremities, impaired sensitivity in them, muscle tone and reflexes. To prevent wound infection, anatoxin and antitetanus serum are administered, and broad-spectrum antibiotics are used.

Reliable immobilization of the spine to prevent repeated displacement of bone fragments is a mandatory condition when transporting victims to a specialized neurosurgical department.

Patients must be transported to the hospital on a rigid stretcher or on a shield. Victims with thoracic and lumbar spinal cord injuries must be placed on their stomachs, with a pillow or bolster under their head and shoulders.

The victim must be placed on a stretcher with the help of three or four people. In case of damage to the cervical spine, the patient must lie on his back, to create moderate extension of the neck, a small bolster is placed under the shoulders.

Immobilization of the cervical spine is performed using a Kendrick splint, a Shantz collar, a CITO splint, or a cardboard, plaster, or cotton-gauze collar. Such tactics reduce mortality in spinal and spinal cord injuries by 12%.

Respiratory disorders are eliminated by clearing the oral cavity of foreign bodies, vomit and mucus; by moving the lower jaw forward without extending the neck using artificial ventilation of the lungs. If necessary, an airway is inserted and tracheal intubation is performed.

It is necessary to stabilize cardiac activity. Instability of the cardiovascular system, which can manifest itself as traumatic sympathectomy, signs of spinal shock (bradycardia, arterial hypotension, warm lower limbs symptom), is typical for damage to the cervical and upper thoracic spinal cord (as a result of circulatory disorders in Clark's lateral columns). Arterial hypotension can also develop as a result of blood loss, but in this case tachycardia and cold clammy skin will be observed.

In case of spinal shock, atropine, dopamine are prescribed, saline solutions (3-7% sodium chloride solution), rheopolyglucin, hemodez are administered, and elastic bandaging of the lower extremities is performed.

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Treatment of spinal cord injury

In the acute period of spinal cord injury, intensive conservative therapy is indicated simultaneously with determining the severity and nature of the injury and establishing indications for surgical treatment.

It is shown to use large doses (30 mg/kg) of methyl prednisolone intravenously in the first 8 hours after injury, another 15 mg/kg in the next 6 hours, then 5.0 mg/kg every 4 hours for 48 hours. Methylprednisolone as an inhibitor of lipid peroxidation is more effective than regular prednisolone or dexamethasone. In addition, methyl prednisolone inhibits lipid hydrolysis, improves blood supply to spinal cord tissues and aerobic energy metabolism, improves calcium removal from cells, enhances neuronal excitability and impulse conduction. To eliminate cerebral edema, saluretics are used together with hypertonic sodium chloride solution. Vitamin E is used as an antioxidant (5 ml 2-3 times a day). Diphenin, seduxen, and relanium are prescribed to increase the brain's resistance to hypoxia. Early use of calcium antagonists (nimodipine - 2 ml), magnesium sulfate is mandatory. Drug treatment of spinal cord injury increases the brain's resistance to hypoxia, but does not eliminate its compression.

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

Indications for surgery for spinal cord injury

1. Compression of the spinal cord or cauda equina roots, confirmed by CT, MRI, spondylography or myelography.
2. Partial or complete blockade of cerebrospinal fluid pathways during lumbar puncture with cerebrospinal fluid dynamics tests.
3. Progression of secondary respiratory failure due to ascending edema of the cervical spinal cord.
4. Instability of the spinal motor segment, which threatens to increase neurological symptoms.

Spinal cord injury: surgical treatment includes:

1. Spinal cord decompression.
2. Restoration of normal anatomical relationships between the spine, spinal cord, membranes and roots. Creation of conditions for improving cerebrospinal fluid circulation, blood supply to the spinal cord.
3. Stabilization of the spine.
4. Creating conditions for the restoration of impaired functions of the spinal cord.

The choice of the method of spinal cord decompression depends on the level of its damage and the nature of the injury. Decompression is performed by repositioning, cornectomy (removal of the vertebral body), laminectomy (removal of the vertebral arch, spinous process). The operation is completed by stabilization (immobilization) of the spine - interbody, interspinous or interarch spondylodesis (corporodesis).

In case of cervical spine injury, skeletal traction is performed by the parietal tubercles or zygomatic arches, halo devices are applied, which helps to reduce spinal cord compression (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 with subsequent fixation of the damaged segment with a metal structure for the articular processes, arches or spinous processes. In case of fractures of the cervical vertebral bodies and damage to the intervertebral discs, anterior pretracheal access is used, spinal cord decompression is performed by cornectomy, discectomy followed by anterior spondylodesis using a bone autograft, titanium cage, metal plate on screws, etc.

Complications of spinal cord injury and their treatment

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

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

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

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

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

1. necrosis (characterized by tissue breakdown);
2. formation of granulations (necrosis slows down and granulation tissue is formed);
3. epithelialization;
4. trophic ulcer (if the regeneration process does not end with scarring of the bedsore).

To prevent bedsores, the patient is turned over every hour with 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 bags or cotton rolls are placed. In case of deep bedsores (stages 3-4), only surgical intervention is indicated, aimed at creating conditions for the fastest possible cleansing of the wound from necrotic tissue.

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

The early ones include:

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

Late ones include:

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

Dysfunction of the pelvic organs is manifested by retention or incontinence of urine and stool. The following forms of neurogenic bladder are distinguished:

1. normoreflexive;
2. hyporeflexive (characterized by low intravesical pressure, decreased detrusor strength and a slow urination reflex, resulting in overstretching of the bladder and accumulation of a large amount of residual urine);
3. hyperreflexive (emptying the bladder occurs automatically and is accompanied by urinary incontinence);
4. areflexic (with the absence of a bladder reflex, overstretching 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 done using catheterization; the bladder can be washed using the Monroe system with antiseptic solutions (rivanol, furacilin, collargol, protargol).

Conservative therapy plays an important role in the prevention and treatment of urinary tract infections. Furagin, furazolidone, furadonin, 5-NOC, nevigramon are used. When determining the sensitivity of microorganisms to antibiotics, broad-spectrum antibiotics are used: cephalosporins of the first, second and third generations, fluoroquinolones, etc.

Patients with urinary retention syndrome against the background of an areflexic or hyperreflexic bladder are prescribed anticholinesterase drugs (galantamia, proserin, kalimin), adrenergic blockers (phentolamine), cholinomimetics (carbachol, pilocarpine, aceclidine), strychnine group drugs (strychnine, securinine). Patients with urinary incontinence syndrome against the background of a hyperreflexic bladder are treated with anticholinergic drugs (atropine, belladonna, platifillin, metacin), antispasmodics (papaverine, no-shpa), muscle relaxants (baclofen, mydocalm), ganglionic blockers (benzohexonium). Patients with urinary incontinence against the background of hypo- or areflexia of the bladder are prescribed ephedrine.

Changes in the musculoskeletal system are manifested by various deformations of the spinal column, directly related to the mechanism of spinal cord injury. In addition, contractures of the limbs, paraarticular and paraosseous ossifications may develop, for the prevention of which the correct positioning of the limbs, massage and therapeutic gymnastics are important.

Prevention of contractures should begin from the first day after the injury. At least twice a day, gymnastics should be performed to ensure full range of motion in the joints. The ankle joints should be maintained in a flexed position to prevent extension contractures.

Patients with spinal cord injury have a significant risk of thromboembolic complications (deep vein thrombosis of the lower leg, pulmonary embolism). To prevent these complications, bandaging of the lower extremities, massage, early activation of the victims, administration of fraxiparine - 0.3 ml 2 times a day, then ticlid is prescribed - 1 tablet 2 times a day for 2-3 months.

In case of purulent complications, toxic-septic condition to eliminate secondary immunodeficiency, T-activin is prescribed (1 ml of 0.1% solution subcutaneously or intramuscularly every other day, total dose - 500 mcg) and in combination with immunoglobulin (25 ml by drip at intervals of 24 and 48 hours), 75 ml per course of treatment.

To reduce spasticity in spinal patients, mydocalm, baclofen, sirdalud, and transcutaneous electrical neurostimulation are used.

In the more distant period, comprehensive medical and social rehabilitation of the victims is carried out. Exercise therapy, limb massage, physiotherapeutic methods (iontophoresis of lidase, proserin; electrical stimulation of the bladder) are widely used. Preparations that improve microcirculation, nootropics, B vitamins, neuromidin, biostimulants, etc. are indicated. In the future, the victims are recommended to undergo treatment in specialized sanatoriums (Saki, Slavyanok in Donetsk region, Solenyi liman in Dnepropetrovsk region, etc.).

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