Spinal Trauma

Spinal cord injury may be

When spinal trauma can cause injury to the spinal cord and / or vertebrae. Occasionally, the spinal nerves are affected. The anatomy of the spine is covered in another section. Spinal cord injury may be total Incomplete etiology spinal cord injury Average occur annually to about 11,000 spinal cord injuries in the United States. The most common causes of spinal cord injuries are motor vehicle accidents (48%) falls (23%) The rest of spinal cord injury is to physical assaults disputes (14%), sports injuries (9%) and accidents back. About 80% of patients are male. In the elderly, falls are the leading cause. Osteoporotic bone and degenerative joint disease may increase the risk of cord injury at lower impact velocities, due to angulation, which is formed by the degenerate joints, osteophytes the spinal cord and brittle bones that allow a simple fracture by critical structures. Spinal cord injuries occur when a blunt force damages the vertebrae, ligaments or intervertebral discs of the spine and for pinching, compression or laceration of the spinal cord tissue leads and if the spinal cord z. B. penetrated by a gunshot or stab injury. Such injuries can also be accompanied by vascular damage leading (typically extradural) for ischemia or hematoma formation, pulling further damage to himself. All injuries can lead to, which further obstructs blood flow and oxygenation a Rückenmarködem. The damage is increased by excessive release of neurotransmitters from the damaged cells by an inflammatory response with cytokine release by accumulation of free radicals and by Apoptose.Wirbelverletzung Vertebral injuries can be fractures that the vertebral body, the lamina and spinous processes, and the cross can affect and spinous process. Dislocations, which usually affect only the facet joints. Subluxations, which can cause a ligament without bony injury. Neck fractures of the posterior elements and dislocations can damage the vertebral arteries and cause a insultartiges syndrome in the brain stem area. Of an unstable vertebral injury occurs when the bony and ligamentous integrity is so far destroyed that free movement is possible that pinch the spinal cord itself or its blood flow and lead to severe pain and potentially to a significant worsening of neurological functions. Such vortices may even when a change in the patient position (z. B. in the ambulance or during the initial investigation) can occur. Stable fractures can tolerate such movements. Specific injuries typically depend on the mechanism of injury. Flexionstraumen can cause wedge fractures of the vertebral body or fractures of the spinous process. A greater flexion may require bilateral Facettenluxationen or when the force impinging on the amount of C1 or C2, lead to a fracture of the odontoid, a subluxation of the atlanto to an atlantoaxial subluxation or to a fracture with subluxation. A rotation injury can lead to a unilateral Facettendislokation. An extension trauma can often cause a posterior fracture of the vertebral arch. Compression trauma eventually lead to a burst fracture of the Wirbelkörper.Schädigung the cauda equina The lower end of the spinal cord (Conus medullaris) is usually located at the height of the L1 vertebra. Below this level, the spinal nerves form the cauda equina. Findings in spinal injuries below this level may be spinal cord injuries similar, especially the Conus medullaris Syndrome. Symptoms and complaints The main feature of a spinal cord injury is an injury level above which the neurological functions are intact and under which they are missing or significantly weakened. The muscle strength is determined by using the default scale of 0 to 5. Specific symptoms depend on the exact level see Table: Effects of spinal trauma on the location), and whether the spinal cord injury is complete or incomplete. In the acute phase of spinal cord injury priapism may occur. In addition to motor and sensory function upper motor neuron signs are an important finding in cord injury. These characters include increased deep tendon reflexes and muscle tone, a plantar response of the extensor (righting toe), clonus (is most commonly found on the ankle by rapid upward bending of the foot) and a Hoffman reflex (a positive response is flexion of the distal phalanx of the thumb to snap the middle finger nail). A vertebral injury, like other fractures and dislocations also, usually painful, but sue the patient may not know when they z. For example, by more painful injuries (z. B. fracture) or are deflected by a clouded by intoxication or head trauma of consciousness. Effects of spinal trauma on the location site of injury * † Possible effects on or above C5 respiratory paralysis and quadriplegia between C5 and C6 paralysis of legs, wrists and hands; weakened shoulder abduction and elbow flexion, lack Brachioradialisreflex between C6 and C7 paralysis of legs, wrists and hands, but the mobility of the shoulder and the elbow flexion is usually possible, lack of biceps jerk reflex between C7 and C8 paralysis of the legs and hands on C8 to T1 with transverse lesions, Horner syndrome (ptosis, miotic pupils, facial anhidrosis), paralysis of the legs between T11 and T12 of the leg paralysis muscles above and below the knee At T12 to L1 paralysis below the knee cauda equina Hyporeflektische or areflektische paresis of the lower extremities, usually pain and hyperaesthesia in the area of ??the nerve roots in question, and in general loss of control of bowel and bladder In S3 to S5 or conus medullaris at L1 complete loss of control of bowel and bladder * the abbreviations relating to the vertebrae; the spinal cord is shorter than the spine, so the vertebral levels and the cord segments soft increasingly interdependent, the further it goes to the lower regions. † priapism, reduced rectal tone and changes the caudal reflexes may occur with injury at any level. Complete spinal cord transection A complete spinal cord injury leads to immediate, complete flaccid paralysis (incl. Loss of anal sphincter tone), the complete sensory loss and an autonomous dysfunction below the injury level. A high Zervikalverletzung (at or above C5) relates to the respiratory muscles and generates a respiratory failure, the ventilation requirement may mean, especially in patients with injuries at or above C3. The autonomic dysfunctions are a Zervikalmarkschädigung bradycardia and hypotension and are called neurogenic shock. Unlike other forms of shock, the skin stays this warm and dry. It can develop in blood pressure instability arrhythmia. People with a high spinal cord injury often die of pneumonia, v. a. when ventilation is compulsory. Flaccid paralysis changed gradually over hours and days in a spastic paralysis with increased deep See reflexes due to a loss of the descending inhibitory pathways. Intact Lumbosakralmark it comes later to a Beugespastik, and the autonomic reflexes return zurück.Unvollständige spinal cord transection An incomplete motor and sensory loss occurs and the tendon reflexes may be hyperactive. Depending on the etiology there is a permanent or temporary partial loss of motor function and sensitivity. The function can temporarily turn out long-term due to a concussion of the spinal cord or a contusion or spinal cord injury. Sometimes, however, a rapid swelling of the spinal cord can lead to a complete neurological dysfunction that is similar to the complete spinal cord injury, which is called spinal shock (and what is not to be confused with the neurogenic shock). The symptoms go over a period of one to several days back, but it often goes back some of the disability. The manifestations depend on which section of the spinal cord is affected. It distinguishes between different syndromes. The Brown-Sequard syndrome occurs at a unilateral spinal cord damage. Patients have an equilateral spastic paralysis distal with disturbance of depth perception and a contralateral disruption of pain and temperature sensation. Front strand Syndrome (v. A. Spinalis anterior syndrome) resulting from direct trauma of the front train or the anterior spinal artery. Patients lose below the lesion, the motor control and pain sensation. The posterior spinal functions (vibration sense, proprioception) are intact. A central spinal cord syndrome is usually for a hyperextension trauma in a narrow spinal canal (congenital or degenerative). The motor function of the arms is more affected than the legs. When the back panels are concerned, the sense of posture, vibration, and touch is deteriorated. When it comes to the spinothalamic pathways, the sensation of pain, temperature and often lost for light or heavy touches goes. Spinal cord hemorrhage (haematomyelia) after trauma are usually limited to the central gray matter, resulting in the symptoms of damage to the lower Motoreuronen, which usually permanently is (muscle weakness and wasting, fasciculations and weakened reflexes on the arms). The motor weakness is usually emphasized proximal and begleitet.Läsionen by selective restriction of pain and temperature sensation of the cauda equina, a loss of motor function or sensor, or both, usually partly occurs in the distal legs. The sensitivity is usually restricted in the perineal region ( “saddle anesthesia”). There may be a dysfunction of bowel and bladder, as either incontinence or retention. Men may have a reduced sexual response erectile dysfunction and women. The anal sphincter tone is weak, but the Bulbocavernosusreflex and anal tone are normal. These findings can those of Conus medullaris, spinal cord injury, similar sein.Komplikationen with spinal cord injury The consequences depend on the severity and location of the damage. Respiration may be affected when the injury is at or above the C5-segment. Reduced motility increases the risk of blood clots, urinary tract infections, contractures, atelectasis, pneumonia and bedsores. It can develop a lead to disability spasticity. In response to trigger stimuli such as pain or pressure, an autonomous dysreflexia can emerge. Chronic neurogenic pain can manifest itself in a burning or stinging character. Diagnostic consideration of injury in high-risk patients, including those without symptoms CT spine injury by trauma are not always obvious reasons. Injuries to the spine and spinal cord must be considered in patients considered with injuries affecting the head pelvic fractures Penetrating injuries of the spine In car accidents suffered injuries Severe blunt injuries injuries associated with falls from height or immersion in water in the elderly a spinal cord injury must be considered even after minor falls. A breach should be considered in patients with an altered sensorium, localized Wirbelsäulendruckschmerzemfpindlichkeit, other painful and thereby distracting injuries or compatible neurological deficits. The motor function is tested in all extremities. The sensitivity test comprises light touch (dorsal column function), pinholes (spinothalamic tract anterior) and examination of the attitude meaning. The identification of the damage levels is best sensory from distal to proximal and testing of the thoracic roots at the back, not to be performed by the innervation of Zervikalmarks astray. Priapism is a spinal cord injury. The Rektaltonus may be reduced and the deep reflexes may be seeing overshoots or weakened. Traditional X-ray images are made by all possibly injured areas. CT images are taken from areas that appear abnormal on x-ray images and sites that are clinically apparent. However, the CT is increasingly used as a primary imaging technique for spinal injuries because it has a better diagnostic accuracy, and is readily available in many trauma centers. An MRI helps identify the type and location of the spinal cord injury, it is the most accurate study for imaging the spinal cord and other soft tissues, but is not always immediately available. The consequences of trauma can be classified with the ASIA scale (American Spinal Injury Association) or similar (see table: Spinal Cord Injury Scale (ASIA scale) *)… Spinal cord injury scale (ASIA scale) * Level A Fully impairment: No motor or sensory function, even in the sacral segments S4-S5. B Incomplete: Sensory but no motor function below the level of the spinal cord, as well as in the sacral segments S4-S5. obtain Motor function below the neurological level, and more than half of key muscles below the level of the spinal cord have a force of <3. D Incomplete: C Incomplete Motor function below the neurological level is obtained, and at least half of the major muscles below the level of the spinal cord have a force ? 3. e normal: motor and sensory function are normal. * According to the American Spinal Injury Association. When a fracture running through the transverse foramen of cervical vertebra, usually a vascular study is recommended (usually, CT angiography) to rule out dissection. Forecast to the cut or degenerated nerves in the spinal cord no longer recover normally, and the functional damage is often permanent. Compressed nerve tissue can regain its function. The return of a movement or sensation in the first week after the injury can hope for a positive recovery. A dysfunction, which is still present after 6 months is likely to be permanent; However, one ASIA grade can improve a degree within one year after the injury. Some new research show the return of some function in recent complete spinal cord injury with spinal cord stimulation. Treatment immobilization maintenance of oxygenation and blood flow to the spinal cord Supportive treatment Surgical stabilization when indicated Long-term symptomatic care and rehabilitation acute care is an important goal is to prevent secondary damage to the spine and spinal cord. In unstable injuries flexion or extension of the spine can squeeze the spinal cord or cut. If injured people are so moved, inadequate handling to para- or quadriplegia or death can result. In patients who may have a spinal injury, the spine should be immobilized immediately; the neck is at the endotracheal intubation manually aligned straight (in-line stabilization). As soon as possible, the spine is fully immobilized on a solid, flat, padded stretcher or similar surface. The position should thereby be stabilized without excessive pressure. A so-called Stiffneck should be applied to immobilize the cervical spine. Patients with thoracic or lumbar spine injuries can be transported in the prone or supine position. In patients with cervical spinal cord trauma that can induce respiratory problems, the transport is in the supine position, which always makes for a dial holding the airway and chest constriction should be avoided. The commitment to a dream center is desirable. The medical treatment is aimed at preventing hypoxia and hypotension, both of which can strain the damaged spinal cord on. When cervical lesions greater than C5 intubation and ventilation are usually required. High doses of corticosteroids starting within 8 hours after spinal cord injury have long been used with the aim to improve the outcome in blunt injuries, but this knowledge has not yet been established and is no longer applicable standard treatment. The injuries are treated by rest, analgesia and muscle relaxation and eventual surgical intervention until swelling and local pain have set. More general treatment of trauma patients is so far necessary provided Unstable injuries are immobilized, are healed by bony and soft tissue injuries in order to ensure proper alignment. Sometimes a surgical bone fusion and internal fixation is required. In contrast, patients may still have significant neurological improvements with incomplete spinal cord injury after decompression. In contrast, a significant return of neurological function with complete injuries below the injury level is unlikely. In a complete spinal cord injury surgery therefore aims to stabilize the spine with the aim of early mobilization. Early surgery allowing early mobilization and rehabilitation. Recent studies suggest that the optimal time of decompression surgery with incomplete spinal cord injuries within 24 hours is after the injury. In complete injuries, surgery is sometimes performed within the first few days, but it is not clear whether this timing has an impact on the result. In the care is paid special attention to the prevention of urinary and respiratory infections and pressure ulcers by the immobilized patient z. B. every 2 h is rotated (if necessary on a Stryker-frame). The prophylaxis of deep vein thrombosis is necessary. For immobile patients can have a vena cava filter thought werden.Langzeitversorgung after spinal cord injury Spasticity some patients responds well to medication. In spasticity following spinal market raumen Baclofen is usually 3 times prescribed 5 mg 3 times daily (maximum of 80 mg over 24 h) and tizanidine 4 mg per day (maximum of 36 mg over 24 h). Intrathecal Baclofengabe of even 50 to 100 mcg once daily may be considered for inefficient oral administration. A rehabilitation is necessary in order to achieve the maximum recovery of the patient. It is best done by a team that combines physical therapy, weight training and consulting, support the social and emotional needs into account. such a team is managed best by a rehabilitation physician. This normally includes nurses, social workers, nutritionists, psychologists, physiotherapists, occupational therapists and a rehabilitation consultant for professional and lifestyle issues. Physiotherapy is focused on strengthening the muscles, passive stretching exercises to prevent convulsions and the use of aids such as orthoses, walkers or wheelchairs, which are intended to increase the mobility. and strategies to control spasticity, autonomic dysreflexia and neuralgia are taught. Occupational therapy focuses on regaining fine motor skills. A bladder and rectum training provides evacuation techniques, intermittent catheterization may be required. Often for defecation a timed Laxanzienstimulation is necessary. Vocational rehabilitation, the assessment of gross and fine motor skills as well as part of the cognitive possibilities to explore the opportunities for meaningful employment. The guidance counselor will then help in defining possible jobs, and determines the necessary support and workplace modifications. A rehabilitation counselor is dedicated to a similar approach to the discovery and design of possible hobbies and sports and other activities. The psychological support to combat the depersonalization and the almost inevitable depression that sets in after the loss of control over the body. It is critical to the success of all other rehabilitation measures. It must be accompanied by efforts to adapt to the new situation of the patient and the active involvement of family and friends suchen.Prüftherapien treatments to promote nerve regeneration and minimize the formation of scar tissue in the spinal cord are still under investigation. Such treatments include injections of autologous incubated macrophages, human embryonic stem cell oligodendrocytes, neural stem cells and trophic factors. Stem cell research is evaluated, many animal studies have shown promising results and there have been several clinical phase I and II studies conducted with people. The implantation of an epidural stimulator is another treatment that is being investigated to improve the voluntary movement after spinal cord injury. During epidural stimulation, electrical pulses to the surface of the spinal cord are given below the injury. Summary spinal cord injuries should be considered in patients consider who had committed prädestinierendes accident scenario have (including smaller falls in the elderly), and an altered sensorium, neurological deficits or localized pressure sensitivity to pain in the spine. To confirm the diagnosis of an incomplete spinal cord injury, motor and sensory functions are checked (including light touch, pinprick and position sensation), and wanted by a disproportionate weakness in the upper extremities. An immediate immobilization of the spine is important in patients who are at risk. Immediate CT or, if available, MRI should be initiated. Surgery within 24 hours after the injury should be scheduled when patients have an incomplete spinal cord injury. Irreversible spinal cord injury are treated with multimodal rehabilitation and drugs of monitoring, manipulating of spasticity. References American Spinal Injury Association Impairment Scale

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