VERTEBRAL AND SPINAL INJURY (grech, trauma a wound, a mutilation) — injury of a backbone and spinal cord. The most frequent reason of P. - page of t. in peace time are: falling about heights, a pridavlivaniye weight, transport injuries. At the same time there is a superflexion or extension of a backbone most often in its most mobile departments (nizhnesheyny, nizhnegrudny and verkhnepoyasnichny) exceeding greatest possible fiziol, volume, as leads to disturbance of an integrity of bone structures of a backbone and injury of a spinal cord.
According to the standard classification all injuries of a backbone and spinal cord divide on closed and opened. On the nature of an injury all closed injuries of a backbone divide into damages of the copular device, fractures of bodies of vertebrae, changes of arches and shoots of vertebrae, dislocation-fractures and multiple damages backbone (see). Depending on the level of damage distinguish injuries of cervical, chest, lumbosacral departments of a spinal cord and roots of a horse tail.
Among the closed injuries of a spinal cord distinguish its concussion, a bruise and a prelum. The concussion of the spinal cord is functionally reversible form which is clinically shown segmented or, more rare, partial conduction disturbances (see. Spinal cord ). The bruise of a spinal cord can lead to its partial damage or an anatomic break that is neurologic shown by partial or full disturbance of conductivity of a brain. The prelum of a spinal cord which is often followed by its bruise can be caused by bone fragments of vertebrae, scraps of soft tissues, an intraspinal hematoma, hypostasis and brain swelling or a combination of these reasons.
Open injuries of a spinal cord can be not fire and fire, not getting and getting, at to-rykh the firm cover of a spinal cord is damaged. These injuries can be also followed by partial injury or an anatomic break of a spinal cord, neurologic shown partial or full disturbance of its conductivity.
Pathoanatomical changes at a bruise of a spinal cord are characterized by existence of primary traumatic necroses in a place of application of the injuring force and the secondary changes connected with circulatory disturbances and circulation of cerebrospinal liquid. The last aggravate hypostasis, ischemia, a hypoxia and an anoxia of tissue of brain and can cause its necrosis. Circulatory disturbances and circulation of cerebrospinal liquid observe at a prelum of a spinal cord more often. In the unimpaired sites of a spinal cord located above and lower than the place of its injury there are phenomena of guarding braking or parabiosis (see) which are supported by different pathogenic irritants in the form of bone fragments, scraps of soft tissues, hemorrhages, commissures, etc. that recovery of functions of a spinal cord can detain for a long time. Therefore, injury of a spinal cord at partial disturbance of its integrity represents a combination of irreversible morphological and reversible functional changes while at morfol, a break of a spinal cord there comes the full softening of its diameter that causes axonal, and at discrepancy of the ends of a spinal cord — an anatomic break.
A clinical picture
During P. - page of t. distinguish 4 periods: acute lasts the first 2 — 3 days, early 2 — 3 weeks, intermediate — up to 2 — 3 months and late — more than 3 months proceed.
Characteristic of P. - page of t. existence of pains in a backbone, decrease in force of muscles and restriction of active movements in joints of hands and legs is up to their full paralysis, disorder of sensitivity and function of pelvic bodies. The concussion of the spinal cord is followed by paresis or paralysis of extremities (see. Paralyses, paresis ), paresthesia (see), a hypesthesia, and sometimes anesthesia on segmented or conduction type (see. Sensitivity, frustration ), short-term disorder of function of pelvic bodies. For a concussion of the spinal cord typically total disappearance of neurologic disturbances in terms from several minutes or hours to 3 — 5 days. The bruise of a spinal cord, especially at its rough damage, in the acute and early periods is followed by spinal shock (see. Diaschisis ) with a syndrome of full disturbance of conductivity, the shown sluggish paralysis of muscles with loss tendon jerks (see), loss of all types of sensitivity on conduction type from top to bottom from the level of damage and disorder of functions of pelvic bodies. The true damage rate of a spinal cord at its bruise usually comes to light only in later terms in process of subsiding of the phenomena of spinal shock when the reflex mocheotdeleniye (one of the first signs of the termination of shock) is recovered, sluggish paralysis of muscles of extremities is replaced spastic with emergence, and then increase in tendon jerks, strengthening of a tone of muscles and development of other symptoms characteristic of injury of a spinal cord of this or that localization (see. Spinal cord, pathology ). The prelum of a spinal cord is expressed in a combination of segmented and conduction frustration. Injury of a horse tail is shown by sluggish paralysis of muscles of the lower extremities (depending on what roots of spinal nerves are damaged), asymmetric disturbance of sensitivity standing in a zone of an innervation of the damaged roots and an incontience of urine. The syndrome of a cone of a spinal cord is characterized by a symmetric anesthesia in a crotch, a true incontience of urine (constant department of urine drops), frequent formation of decubituses at safety of movements in legs. The syndrome of an epikonus is followed by the paralysis of feet of peripheral type dissociated by disorder of sensitivity standing in a crotch and an ischuria.
One of frequent and dangerous complications at injury of a spinal cord are trophic disturbances in a look decubituses (see) and trophic ulcers (see). The disturbance of a trophicity owing to injury of a spinal cord which is aggravated with existence of the centers patol, irritation in the place of an injury of a brain and also disturbance of blood circulation in fabrics owing to their prelum is the cornerstone of their development.
Diagnosis is based on data of the anamnesis, results clinical, first of all neurologic, and also rentgenol, inspections, spinal puncture (see) with tests on passability of subarachnoid space (see. Liquorodynamic tests ), and at indications — and venospondilografiya (see. Flebografiya ), allowing to reveal a prelum of contents of the vertebral channel.
First aid consists in fight against traumatic shock (see), arising almost at a half of such patients, and also with disturbances of the vital functions. At an injury of cervical and verkhnegrudny departments of a spinal cord owing to paralysis of respiratory muscles there can be gross violations of breath up to its dead stop in this connection it is necessary to apply an artificial respiration with the subsequent intubation and transfer of the victim into hardware breath (see. Artificial respiration ).
Transport the victim with P. - page of t. only on a rigid stretcher or on different boards in situation on spin or on a stomach with an immobilization of the damaged department of a backbone. The immobilization at damage of cervical department of a backbone is reliable, edge it is reached by means of the special tire (fig. 1).
The basis of conservative treatment of the patients with the closed spine injury and a spinal cord who are not subject to operational treatment is made by extension on the inclined plane (see. Extension ). As such inclined plane the hard bed or a board with the head end raised on 20 — 30 ° can serve. At the same time extension is carried out at the expense of the sole weight of a body of the patient, to-rogo fix by the head end of a bed by means of wadded and gauze rings for axillary hollows (at a change of chest or lumbar departments of a backbone), or the load fixed for bones of a skull (fig. 2) or for zygomas (at a change of cervical department of a backbone). For reposition of the displaced vertebrae under area of a change enclose a sack with sand or a dense cotton roll. For recovery of the broken function of a spinal cord (in cases of concussion or bruise it) the pharmaceuticals increasing excitability and conductivity of a spinal cord (Dibazolum, prozerin, strychnine, etc.), resorptional means appoint (an aloe, a vitreous, FIBS, a lidaza, pyrogenal, trypsin, iodide drugs, etc.). Much attention is paid to massage, LFK and physical therapy, in particular applications of ozokerite, paraffin, dirt on the field of damage. Apply also longitudinal galvanization of a backbone, an ionophoresis of iodine, novocaine, a prozerin. Actions for prevention of trophic disturbances are important, including: laying of the patient on a mattress from porous rubber, foam rubber or on an air mattress, systematic turning it in beds, the general quartz irradiation.
At a prelum of a spinal cord operational treatment for the purpose of elimination of a prelum of a brain and recovery of normal topo-grafo-anatomic ratios between a backbone and a spinal cord is shown. Operational tactics is defined by character of a prelum and its localization.
By means of the forced closed reposition, by skeletal traction for bones of a skull eliminate deformation of cervical department of a backbone and a bone prelum of a spinal cord. After that with the diagnostic purpose make a spinal puncture with liquorodynamic tests and a venospondilogra-fiya. At detection of disturbances of passability of subarachnoid spaces make laminectomy (see) with audit, elimination of a possible prelum of a spinal cord and simultaneous back fixing of a backbone (see. Spondylodesis ). At identification on venospondilo-grams of the signs of disturbance of a venous blood-groove testimonial of a front prelum of a spinal cord, make removal of a part or all body of the injured vertebra together with one or two adjacent disks (a so-called front decompression) with obligatory fixing of bodies of the next vertebrae by means of bone transplants — korporodez (fig. 3). In some cases in the presence of indications perform open reposition of a dislocation-fracture with the subsequent back fixing of cervical department of a backbone. At dislocation-fractures of chest and lumbar departments of a backbone fixing it is made by means of Tsivyana-Ramikh's fixer coupler or bone transplants stacked on skeletirovanny handles on both sides from acanthas and fixed by silk seams through interspinal sheaves (fig. 4). For fixing of a backbone various metal designs can be used. In the presence of a depressed fracture of an arch of a vertebra the urgent decompressive laminectomy is shown. The deformations of a backbone remaining after elimination signs of a prelum of a spinal cord, and also existence of the getting wound with liquorrhea (see) are the indication to audit of a spinal cord.
Audit of a spinal cord is carried out after a laminectomy and opening of a firm cover of a spinal cord a linear section on the centerline. At the same time delete with a mouse-tooth forceps or wadded balls clots. At damage of substance of a spinal cord make washing of a brain detritis isotonic solution with suction by its aspirator through a wadded and gauze ball (fig. 5). At an anatomic break of a spinal cord delete nekrotizirovanny sites of proximal and distal its departments. Suture for the ends of the interrupted spinal cord was not repaid. At a rupture of roots of a horse tail make sewing together them under operative microscope (see) with use of microsurgical instruments. The section of a firm meninx is carefully sewn up.
At open injuries of a backbone and spinal cord make primary surgical treatment of wounds (see), a laminectomy, removal of bone fragments, available foreign bodys, audit and elimination of a prelum of a spinal cord, and in the presence of the getting wound — mending or plastics of defect of a firm cover of a spinal cord (see. Meninx ).
In postoperative, and also in the late period as closed, and an open injury conduct repeated courses of conservative treatment using the resorptional, stimulating pharmaceuticals and physical therapy. Indications to a late laminectomy with audit of a spinal cord are all types of its prelum, the expressed pain syndrome, and also the permanent disturbances of a trophicity which are not giving in to conservative treatment. Operation in this case consists in separation of the shell unions around a spinal cord and roots of spinal nerves (meningomiyeloradikuloliz) with recovery of passability of the subshell spaces and elimination of a prelum of a brain (fig. 6). Rehabilitation of the broken functions is promoted by a dignity. - hens. treatment in specialized sanatoria for patients with damage of a spinal cord (Saki, Sergiyevskiye mineral waters, Kemeri, etc.), a cut is carried out in the late period of an injury.
Treatment of trophic disturbances is directed to normalization of trophic influence of a nervous system and immediate effect on decubituses and trophic ulcers. An operative measure on a backbone with audit, elimination of a prelum and the centers of irritation of a spinal cord, and also conservative actions for recovery of function of a spinal cord contribute to normalization of trophic influence of a nervous system on fabrics.
Forecast is defined first of all by degree and level of injury of a spinal cord. Danger to life of subjects is more, than the level of an injury is higher and injury of a spinal cord is more considerable. At most of patients with P. - page of t. remain resistant nevrol, disturbances, expressiveness to-rykh also depends on a damage rate of a spinal cord.
Fighting injuries of a backbone and spinal cord
In the period of the Great Patriotic War the closed injuries of a backbone and a spinal cord made 0,2%, and fire — from 0,3 to 1,5% of all fighting damages. Fighting injuries of a backbone and spinal cord are divided into the closed damages, open gunshot wounds, the combined and combined damages. The closed damages in essence do not differ from above described. Gunshot wounds divide into 5 basic groups (fig. 7): 1) through (the wound channel crosses the vertebral channel); 2) blind (the wound channel blindly comes to an end in the vertebral channel); 3) tangent (the wound channel destroys a wall of the vertebral channel, the spinal cord is injured by bone fragments); 4) not getting (damages do not destroy a wall of the vertebral channel and a firm cover; the spinal cord is injured as a result of blow and concussion of surrounding fabrics); 5) juxtaspinal (the wound channel passes about a backbone). The combined defeats are characterized by simultaneous damage of other bodies and systems. the Combined defeats (see) come at influence of several striking factors, napr, in the center of nuclear explosion at the backbone which was injured along with damage and a spinal cord can be burns (see), radiation injuries (see. Radial illness , Beam damages ).
The first medical aid comes down to imposing of an aseptic bandage, administration of anesthetics, according to indications — to an artificial respiration. The carrying out of victims from the battlefield or from the center of defeat whenever possible should be made on a stretcher with a rigid laying.
Pre-medical help (see) on the IFV (see. Battalion medical aid station ) includes correction of a bandage, introduction of cardiovascular and respiratory means, providing reliable transport immobilization (see). The last should be carried out using an individual vacuum stretcher (see. Stretcher ).
First medical assistance (see) on PMP (see. Regimental medical aid station ) includes correction of a bandage, introduction of antishock means, antibiotics, antitetanic serum or tetanic anatoxin, catheterization or a puncture of a bladder with the subsequent first-priority evacuation.
During the rendering the qualified medical care (see) in MSB (see. Medical and sanitary battalion ) or OMO (see. Separate medical group ) in the course of medical sorting of such wounded divide into three groups: seriously wounded (need the surgical help according to vital indications at this stage), wounded, the surgical help the Crimea can be delayed to the following stage, and wounded, the nature of defeats at to-rykh is not compatible to life. Carry wounded to the first group preferential with the combined injury. They are sent to the operating room for elimination pheumothorax (see), productions laparotomies (see), final stop bleedings (see) and other operative measures. In these conditions it is reasonable to carry out at the same time and primary surgical treatment of a wound of a backbone without intervention on a spinal cord. Only the compression of a spinal cord a foreign body or bone fragments can be the indication to economical decompressive laminectomies (see). The second group includes affected hl. obr. with the closed damages and the isolated wounds of a backbone and spinal cord. Such wounded correct a transport immobilization, carry out necessary procedures (catheterization of a bladder) and enter the medicamentous means preventing emergence of complications in the course of evacuation. These wounded are evacuated first of all. To the third group of wounded apply the means alleviating them suffering.
In neurosurgical hospital during the rendering specialized medical care (see) perform surgeries according to indications or carry out conservative treatment (see above). The aftercare of such wounded is carried out in hospitals of the back of the country. In the MSGO system (see. Health service of civil protection ) assistance to victims has no fundamental differences.
Experience of the Great Patriotic War showed that the lethality at fighting injuries of a backbone and spinal cord depends on the nature of damage, a type of a hurting shell, existence of complications. At the isolated wounds of a backbone it made 35,6%, at combined — is much higher; at full disturbance of conductivity of a spinal cord — 94,5%, at partial — 45,3%; at missile wounds — 33,6%, at bullet — 28,3%. Good functional outcomes at not getting wounds of a backbone are noted at 46,1%, at getting - at at 16,8% of wounded.
Bibliography: Babichenko E. I. Classification of an acute spine injury, spinal cord and horse tail, Vopr, neyrokhir., century 4, page 3, 1979; The Multivolume guide to neurology, under the editorship of S. N. Davidenkov, t. 8, page 539, M., 1962; Experience of the Soviet medicine in the Great Patriotic War to a vorsha of 1941 — 1945, t. 11, M., 1952; The Guide to neurotraumatology, under the editorship of A. I. Arutyunov, the p. 2, page 5, 365, M., 1979; Gloomy in V. M. and B and and the p e of N to about E. I. The closed injuries of a backbone and a spinal cord, L., 1973; The Textbook of field surgery, under the editorship of A. N. Berkutov, page 467, L., 1973; Surgery of damages of a nervous system, under the editorship of V. N. Shamov, L., 1959; Hardy A. G. a. Rossier A. Century of Spinal cord injuries, Stuttgart, 1975.
E. I. Babichenko; V. I. Grebenyuk (soldier.).