Spinal cord injury

Introduction to spinal cord injury The number of patients with spinal injuries is increasing, depending on the mechanism of damage, and the classification is different. Therefore, it is difficult to diagnose, but in fact, as long as the local pathological anatomical features can be grasped, the history of trauma, symptoms and signs are collected. Under the premise of seeing it, it is not difficult to obtain a correct diagnosis for most cases. On this basis, the treatment problem is also easy to solve. For some patients with clinical difficulties, CT, MRI, CT plus myelography, CTM and other imaging methods can be used. basic knowledge Proportion of disease: the incidence of spinal fracture and dislocation is about 17% Susceptible people: no specific population Mode of infection: non-infectious Complications: respiratory infections acne

Cause of spinal cord injury

Causes:

Due to various spinal fractures, dislocation and injury.

Pathogenesis:

1. Spinal fractures and dislocations of spinal injury can occur in any vertebral section, but 60% to 70% of cases occur in the chest 10 to the waist 2, of which the chest 12 to the waist 1 is more high, About 80% of them; cervical 4-6 vertebrae and neck 1~2 are secondary multiple areas, accounting for about 20% to 25%; the rest of the cases are scattered in other vertebrae.

2. The incidence of spinal cord injury (spinal cord injury (SCI) in the incidence of spinal fracture and dislocation is about 17%, of which the incidence of cervical segment is the highest, followed by the thoracic and lumbar segments, neck 1 ~ 2 and occipital neck injury is easy to cause death, and most of the time at the injury site, from the way of violence, the highest proportion of direct violence, especially the firearms through the injury, almost 100%, followed by overextension injury, For example, from the type of fracture, the rupture of the vertebral body is more common. Of course, the incidence of fracture combined with spinal cord injury is higher. Clinically, the vertebral injury can be severe, but there is no obvious spinal cord injury. The case of the so-called "lucky spine fracture" is mainly due to the wider spinal canal.

3. Pathological anatomical features of various types of fractures

(1) Stretched fracture: mainly manifested as a collapse of the articular process or a laminar fracture in the direction of the spinal canal. The formation of the dural sac is oppressive, the light has a sensory disturbance, and the severe one can cause paraplegia, accompanied by a vertebral body. The inter-articular joint is separated from the front or the middle part of the vertebral body is relatively rare. The anterior longitudinal ligament can be completely ruptured, but it is rare in clinical practice. Even if the spinous process fracture is found and collapsed to the front, many lines directly act on the spinous process. Caused by violence, at this time, there are many soft tissue contusions. The symptoms of articular protrusion are common in the cervical vertebrae, followed by the thoracic vertebrae, which is very rare in the lumbar segments.

(2) vertebral compression fracture: vertebral compression fracture is the most common in spinal fractures. When the anterior edge of the vertebral body is compressed more than 1/2 of the vertical diameter, an angular deformity of about 18° appears in the segment; When the front edge of the vertebral body is compressed by 2/3, the angle can reach about 25°; when the leading edge of the vertebral body is fully compressed, the angle can reach 40°. Therefore, the more the number of compressed vertebral bodies, the heavier the degree, the angle The bigger the problem, the following consequences:

1 The sagittal diameter of the spinal canal is reduced: the degree of reduction is proportional to the angle of the deformity, and it is easy to cause spinal cord involvement in the spinal cord tissue and accompanying blood vessels in the spinal canal, especially the posterior small joint loosening. There are severe vertebral instability.

2 spinal canal extension: due to the angular deformity, the posterior wall of the posterior intervertebral facet joint is elongated due to the expansion of the articular capsule, resulting in the spinal canal tissue, especially the posterior ligamentum flavum, the dural wall and The blood vessels are in a state of tension, which is easy to cause damage and affects the spinal cord, especially when the length of the segment exceeds 10%.

3 causes instability of the vertebral node: the more compression of the vertebral body, the worse the stability of the vertebral body, except for the sub-dislocation of the facet joint and the loss of the original anterior longitudinal ligament, the shortening of the vertebral body The angular deformity itself has changed the normal load line of the spine, which is easy to cause vertebral instability.

(3) vertebral burst fracture: this type of fracture vertebral body posterior margin bone fragments are most likely to enter the spinal canal, and it is not easy to be found on X-ray films, often with the following consequences:

1 spinal cord compression: the bones behind the compressed fragmented vertebral body or the bone fragments of the burst fracture are not easy to shift forward, mainly because the anterior longitudinal ligament is strong and affected by the flexion position, and the rear happens to be pressure The lower spinal canal, so that the vertebral body bone piece easily protrudes into the spinal canal and becomes a clinically common frontal spinal cord inducer, and constitutes a pathological anatomical basis for hindering the further recovery of spinal cord function.

2 easy to miss diagnosis: the bone block (slice) protruding in the direction of the spinal canal is not easy to be found on the X-ray film due to the occlusion of various tissues, especially in the thoracic vertebrae segment, so that it is easy to miss the diagnosis and lose the opportunity of early surgical treatment, therefore, CT examination or tomography should be performed on the injured as soon as possible if the condition permits.

3 difficult to repay: when the posterior longitudinal ligament is damaged, if it has not lost the longitudinal connection, the broken bone piece (slice) still adheres to the front of the posterior longitudinal ligament, then the bone can be retracted by traction; but in the case of injury, if When the posterior longitudinal ligament is completely broken, the bone behind the vertebral body is mostly free and loses contact. Even if the vertebral fracture is restored by traction, the bone piece is difficult to return to the original position.

(4) Dissection of the vertebrae: In addition to cervical vertebrae, vertebral dislocation can occur separately. Most of the vertebral dislocations in the thoracic and lumbar segments are associated with various types of fractures, especially in the flexion type, because the lower segment of the upper segment of the vertebral body is in the lower vertebra. The upper edge of the vertebral body slides forward, forming a bony step-like pressure in the spinal canal, which can cause stimulation or compression of the spinal cord or cauda equina, which constitutes the main cause of early spinal cord injury. At the same time, this also hinders the spinal cord. One of the important factors for full recovery of function.

(5) Lateral flexion injury: its pathological changes are similar to those of flexion type, mainly manifested by lateral compression of one vertebral body, more common in the chest, lumbar, lateral flexion injury, and the same violence. In the case, it is lighter than the front flexion type.

(6) Other types: including the more commonly found acute disc herniation (especially seen in the cervical vertebrae, simple spinous process fractures and transverse process fractures, etc., most of the lesions are limited, the degree of damage is also light, through the middle of the vertebral body to the rear The horizontal fracture of the lamina, etc., has not been clinically seen in recent years.

4. Pathological changes of spinal cord injury Because the spinal cord tissue is very delicate, any impact, pulling, squeezing and other external forces can cause more serious damage than imagined. The pathological changes are mainly spinal concussion, spinal cord. There are three states of parenchymal injury and spinal cord compression, but they are often divided into the following six types in clinical practice.

(1) Oscillation: It is the lightest type of spinal cord injury, similar to concussion. It is mainly transmitted through the back of the spine to the spinal cord, and there are transient sexual loss of several minutes to tens of hours. See, this type of spinal cord injury usually begins with the lower limbs. Since there is no visible pathological change in the morphology of the spinal cord, its physiological dysfunction can be recovered and is reversible.

(2) Spinal cord hemorrhage or hematoma: refers to intraspinal hemorrhage, which is more likely to occur in vascular malformations, ranging from subtle point-like hemorrhage to hematoma formation. A small amount of hemorrhage may be partially obtained after hematoma absorption. Or most of the recovery; severe hematoma is prone to poor prognosis due to scar formation.

(3) Spinal cord contusion: The degree of spinal cord contusion varies greatly, ranging from very mild spinal cord edema, punctate or flaky hemorrhage to extensive spinal cord contusion (softening and necrosis), and over time, due to nerves Changes in glial and fibrous tissue hyperplasia, which in turn leads to scar formation and atrophy of the spinal cord, causing irreversible consequences.

(4) Spinal cord compression: extramedullary tissue, including fracture fragments, prolapsed nucleus pulposus, invaginated ligaments, hematoma and later osteophytes, bone spurs, adhesive bandages, scars, etc. and foreign bodies in vitro (shrap, internal fixation) Physical and bone grafting, etc.) can cause direct compression of the spinal cord tissue, which can cause local ischemia, hypoxia, edema and congestion, which can change and aggravate the degree of spinal cord damage.

(5) Fracture: In addition to firearm injuries, when the spinal dislocation exceeds a certain limit, the spinal cord may also be partially or completely broken, resulting in the loss of most or all of the spinal cord conduction function. In appearance, the dural sac remains mostly intact; A severe type of fracture dislocation is very obvious, and the dural sac can also be broken at the same time.

(6) ridge shock: different from spinal cord turbulence, ridge shock is not caused by violence directly on the spinal cord, its clinical manifestations are reduced muscle tension below the vertebral ganglia, limbs are flaccid paralysis, sensory and skeletal muscle reflex disappears, can not be drawn Pathological reflex, fecal incontinence and urinary retention, this performance is essentially the result of loss of high-level central control of the spinal cord below the injured section, generally lasting 2 to 4 weeks, the duration of the co-infected person is prolonged, and the recovery of the spinal cord after the sacral shock disappears Depending on the degree of injury, the movement, sensory and shallow reflex function of the transected spinal cord injury do not recover, hyperreflexia, and pathological reflexes occur; the spinal cord function of the incompletely injured person can be obtained mostly, part Or a little recovery.

The above are the types of spinal cord injury, but the pathological changes in the spinal cord vary depending on the length of time after injury. The substantial spinal cord injury can be divided into early, middle and late stages, and within 2 weeks after the early finger injury, the main performance is The autolysis process of the spinal cord reaches its peak within 48 hours after injury, and the mid-term is 2 weeks to 2 years after injury. It is mainly manifested by the process of regression and repair of acute process. Because the growth rate of fibroblast tissue is faster than that of spinal cord tissue, The fractured spinal cord is difficult to recanalize. In the later stage, the degeneration of the spinal cord tissue is mainly manifested. The change time is longer, generally starting from 2 to 4 years after injury, and lasting for more than 10 years, in which microcirculation changes play an important role.

Spinal spinal cord injury prevention

Spinal spinal cord injuries are common in houses collapsed, high places fall, car accidents, etc., resulting in closed spinal compression fractures, fracture dislocation, spinal cord injury, and even paraplegia in different parts. Bone and traumatic diseases. Firearm spine, spinal cord injury often combined with chest, abdomen and pelvic organ injury, severe injury, high incidence of shock. At the same time, once the wound is contaminated, suppurative meningitis can occur. So avoid the best preventive measures for this disease when an accident occurs.

Spinal cord injury complications Complications, respiratory tract infections, acne

Common complications are respiratory infections, urinary tract infections, hemorrhoids, and deep vein thrombosis.

Spinal cord injury symptoms Common symptoms Dyspnea, sensory disturbance, Abdominal muscle tension, Passive position, Acute urinary retention

1. Clinical features of spinal cord injury According to the location, extent, extent, time and individual specificity of spinal injury, clinical symptoms and signs are quite different, and the common symptoms are now described.

(1) General characteristics:

1 Pain: It has severe pain unique to patients with fractures. Except for cases of coma or severe shock, almost every case occurs, especially when moving the trunk. It is often unbearable. Therefore, patients take passive positions. Instead of doing any activities, try to alleviate this symptom when checking and moving.

2 tenderness: pain and conduction pain: localized fractures have obvious tenderness and pain (the latter is generally not checked, so as not to increase the patient's pain), and consistent with the fracture site, simple vertebral fractures, deep tenderness In the main, through the spinous process, the tenderness of the lamina and spinous process fractures is superficial. In addition to simple spinous processes and transverse process fractures, there are generally indirect ankle pains, and the pain site is consistent with the injury site.

3 Restricted activities : no matter what type of fracture, the spine has obvious activity limitation. During the examination, it is forbidden to let the patient sit up or twist the body to prevent the spinal canal and spinal nerve root damage caused by deformation of the spinal canal; The patient should not be allowed to do activities in all directions (both active and passive), so as not to aggravate the displacement of the fracture and cause secondary damage, or even paraplegia.

(2) Neurological symptoms:

The neurological symptoms here refer to the symptoms of spinal cord, cauda equina or nerve root involvement.

1 high cervical spinal cord injury: high cervical spinal cord injury refers to cervical medullary injury caused by neck 1-2 or occipital neck fracture and dislocation. If the life center of this place is directly oppressed and exceeds its compensation limit, the patient will die immediately. Fortunately, the sagittal diameter of the spinal canal is large, there are still a certain number of survivors, but it can also cause quadriplegia and accidents due to complications.

2 lower cervical spinal cord injury: the lower cervical spinal cord injury refers to the cervical spinal cord injury below the neck 3, severe cases, not only quadriplegia, and the chest respiratory muscles are more involved, only the abdominal breathing is retained, complete paralysis, below the injury plane Sexuality.

3 thoracic or lumbar spinal cord injury: Thoracic or lumbar spinal cord injury is more common with complete injury, especially in the thoracic segment, below the plane of injury, movement and bladder and rectum function disorders.

4 horsetail injury: the range of visual impairment is different, the symptoms of horsetail injury are quite different, in addition to lower limb movement and feeling different degrees of obstacles, the rectum, bladder function can also be affected.

5 root damage: root damage and spinal cord symptoms occur at the same time, often caused by intense compression of nerve roots, especially in patients with complete spinal cord injury, and often become one of the main reasons for this type of surgery.

(3) Clinical judgment of the plane of spinal cord injury:

The plane of the spinal cord injury is generally consistent with the plane of the fracture, but the order of the number of the spinal cord is different from that of the lower end of the first lumbar vertebrae. The order of the plane of the spinal cord injury is different. The upper thoracic vertebra +2, the lower thoracic vertebra +3, the cone is located between the chest 12 and the waist 1 , in addition, clinically, the damaged plane of the spinal nerve root can be inferred according to the part of the affected muscle, see Table 1.

(4) Other symptoms:

Depending on the location of the fracture, the degree of injury, the involvement of the spinal cord, and many other factors, some other symptoms and signs may occur in patients with spinal cord injury, including:

1 Muscle spasm: refers to the defensive contracture of the paravertebral muscles of the damaged vertebrae. In essence, it fixes and brakes the fractured vertebrae.

2 abdominal muscle spasm or pseudo acute abdomen: common in the chest, lumbar fractures, the main reason is due to vertebral fractures caused by retroperitoneal hematoma stimulate local nerve plexus, causing reflex abdomen tension or paralysis, individual cases may even appear It is similar to the symptoms and signs of acute abdomen, so that it is diagnosed by misdiagnosis. Finally, it is only caused by retroperitoneal hematoma.

3 fever reaction: more common in patients with high spinal cord injury, mainly due to the body's thermal response imbalance, but also with central reflex, metabolic product stimulation and inflammatory response.

4 acute urinary retention: In addition to spinal cord injury, patients with simple chest, lumbar fractures can also occur acute urinary retention, the latter is mainly due to retroreflective reactions caused by retroperitoneal hemorrhage.

5 systemic reactions: In addition to systemic traumatic reactions, other such as shock, traumatic inflammatory response and other various complications may occur, should be fully observed.

2. Determination of the degree of spinal cord injury

(1) Standards for general judgment:

The general criteria for the degree of spinal cord injury vary from country to country. In the country, according to the movement, feeling and urination function of the injured person, the degree of spinal cord injury is divided into 6 levels according to whether it is a partial disorder or a complete disorder. Although it is simple and easy to implement, it is difficult to accurately reflect the degree of injury of the patient. It needs further improvement and improvement. The foreign classification criteria are widely used in foreign countries, which are divided into five levels, namely:

Class A: No sensory or motor function below the damaged plane.

Class B: There is a feeling below the damaged plane, but there is no motor function.

Grade C: There is muscle movement but no function.

Class D: There are useful motor functions, but not resistance.

Class E: Exercise and feeling are basically normal.

It has also been proposed to divide it into four categories: complete spinal cord injury, Brown-Séguard syndrome, acute spinal cord injury and acute cervical spinal cord syndrome.

(2) Identification of complete and incomplete spinal cord injury:

The identification of complete and incomplete spinal cord injury is generally more difficult,

(3) Identification of severe incomplete spinal cord injury and spinal cord transection injury: this identification is a major clinical problem, and it is difficult to distinguish it with special examinations such as MRI and myelography. The author believes that during clinical examination, The following points may be helpful in identifying the two.

1 A toe with autonomous micro-motion indicates an incomplete spinal cord injury (.

2 The saddle area has a sensory person with incomplete spinal cord injury.

3 The anterior reflexes are mostly incomplete spinal cord injury in the acute phase.

4 urethral bulbar body reflexes are mostly incomplete spinal cord injury.

5 toe residual position sensory is incomplete spinal cord injury.

6 stimulation of the soles of the feet, the toes have a slow flexion and extension of multiple spinal cord complete injuries.

3. Characteristics of defects in different damage planes

From the brain to the cauda equina, the extent and characteristics of the different planes are different, especially the symptoms and signs of the motor nervous system are more conducive to the determination of the affected part, which is summarized below.

4. Identification of sputum caused by upper motor neurons and lower motor neurons

Each clinician should have a clear understanding of the different sputum characteristics of upper and lower neuron damage for easy identification.

Spinal spinal cord injury

1. X-ray and CT examination

X-ray examination is the most basic examination method. The orthotopic position should be observed whether the vertebral body is deformed, the upper and lower spinous process gaps, the pedicle spacing, etc., or the lateral position should be observed whether the spinous process gap is increased or not.

1 degree of vertebral compression;

2 degree of dislocation;

3 posterior arch angle of the spine, the normal posterior arch angle of the thoracic spine is not >10°, and the cervical spine and lumbar vertebrae are physiologically protruding.

According to the extent of X-ray dislocation, the degree of spinal cord injury is indirectly evaluated. In the thoracic vertebrae, the dislocation of the spine is more than 1 degree, mostly complete spinal cord injury, and there is little recovery. In the cervical and lumbar spine, the severity of the X-ray film and the degree of spinal cord injury can be Not exactly the same.

After the acute phase, in order to check the stability of the spine, the lateral flexion and posterior extension of the spine should be photographed. The displacement of the leading or trailing edge of the adjacent vertebral body as described above is >3 mm, which is an unstable sign.

CT examination showed the presence or absence of lamellar fracture subsidence, articular process fracture, burst fracture fracture block into the spinal canal, the ratio of the anterior and posterior diameter of the spinal canal occupied by the fracture block, accounting for 1/3 of the stenosis, 1/2 Those with a degree of stenosis, greater than 1/2 are III degree stenosis, II degree, III degree stenosis and more compression of the spinal cord.

2. Magnetic resonance imaging (MRI) examination

It can clearly show the changes of spine, intervertebral disc, ligamentum flavum, intraspinal hemorrhage and spinal cord, spinal fracture and dislocation, and MRI of spinal cord injury have the following three aspects:

(1) Factors and locations showing compression of the spinal cord: Common compression factors are:

1 The fracture piece of the burst fracture is displaced backward or the posterior edge of the vertebral body below the dislocation vertebra.

2 disc herniation, in about half of the cases, the upper disc of the compression fracture vertebrae protruded backward to oppress the spinal cord.

3 compression of the fracture of the vertebral body of the posterior horn into the spinal canal to compress the spinal cord, often incomplete paraplegia, relieve compression to help recovery.

4 The lamina is depressed and the spinal cord is rarely seen.

(2) shows the degree of spinal stenosis: in the sagittal position, the degree of spinal stenosis, that is, the degree of compression of the spinal cord, especially the posterior arch angle of the spinal cord, and the compression of the spinal cord, and the extent and extent of compression, as a decompression Guidance.

(3) shows changes in spinal cord injury:

1 There are three types of MRI manifestations of acute spinal cord injury:

A. Hemorrhagic type: There is a large central low signal area in spinal imaging, indicating deoxyhemoglobin in gray matter hemorrhagic cells, surrounded by a high signal area, indicating spinal edema.

B. Edema type: The spinal cord injury area presents a consistently high signal.

C. Mixed type: manifested as mixed high and low unevenness signals in the spinal cord.

Among the above three types, the edema type injury was lighter, and the recovery rate was higher (60% or more), while the mixed type recovered significantly at 38%, and the bleeding type had the lowest recovery rate of only 20%.

2 Old spinal cord injury: histological changes in the late stage of spinal cord injury, different in MRI, cystic cavity in the spinal cord, MRI also showed cystic cavity; necrosis in the spinal cord, glial tissue loose, MRI T1 is low signal; white matter in the spinal cord Tissue gelatinization and softening lesions are mixed, MRI is a spot uneven signal; spinal cord ischemic gliosis and atrophy, MRI is near normal normal high signal, but thinner than normal spinal cord (Figure 20), Table 5 shows a group The relationship between MRI findings and neurological function in 76 old spinal cord injuries.

The relationship between MRI findings and prognosis of spinal cord injury: those with normal spinal cord signals but being oppressed can recover most after decompression; if the spinal cord signal is not uniform, decompression therapy can restore Frank 1; low signal thickening, very low signal The spinal cord atrophy and thinning were not restored; the cystic cavity did not recover significantly after treatment.

The judgment of the degree of spinal cord injury and the evaluation of prognosis are combined with clinical neurology and evoked potentials and MRI examination, which has the most reference and guiding significance.

Diagnosis and diagnosis of spinal cord injury

Diagnostic criteria

1. Diagnosis of spinal cord injury Under the current equipment conditions, the diagnosis of any type of spinal fracture should not be too difficult. Due to the appearance of MRI, the differential diagnosis of spinal cord injury and spinal shock may have been solved. However, in any case, the clinical diagnosis should still be placed in the first place. Therefore, every injured person is required to check in the formal clinical examination order, and then go to do further special examination after obtaining the initial impression, which is more conducive to diagnosis. Accuracy and timeliness.

(1) Clinical examination: For those who come to the early stage after injury, the following judgments should be made quickly in order:

1 history of trauma: should be brief, simply ask the patient or accompanying person about the patient's injury, the site of the site and the situation after the injury, etc., if the general condition is unclear, you should check the medical history.

2 Consciousness: Unconsciousness indicates that the brain has multiple combined injuries and is life-threatening. Priority should be given to the treatment. At the same time, the pupils of the eyes should be quickly examined and the light reaction should be observed, and the cerebrospinal fluid and blood flow out of both ears and nostrils should be noted.

3 cardiopulmonary function: check for chest combined injuries, diaphragmatic paralysis, may be caused by more than 4 neck injuries; elevated blood pressure are more likely to have a head injury; those with low blood pressure, more with internal organs, pelvis and severe For limb injuries, the cause should be quickly identified.

4 local spine: including local tenderness, bilateral iliac spine muscle tension, the location and extent of the spinous process protruding to the back, and conduction pain, etc. are easy to find and determine the diagnosis, avoid turning the patient arbitrarily during the examination to prevent aggravation degree.

5 Feelings and Exercises: Coping with the feelings of the upper limbs, trunk and lower limbs, and performing a comprehensive examination of active movements to infer whether there is spinal cord damage, damaged plane and degree of damage, etc., should not be missed for each patient.

6 Perineal and toe sensation, movement and reflex: For those with spinal cord involvement, especially severe cases, the feeling around the anus and the rectal reflex, the feeling and movement of the toes should be judged, even if there is a little functional residue. However, the sensory movement of the limbs basically disappears, and it is still incomplete spinal cord injury. Therefore, the determination of the degree of spinal cord damage and the identification of complete damage are essential, and should not be ignored.

(2) Imaging examination: In principle, the X-ray film is mainly used, and the CT or MRI is supplemented as appropriate (see other auxiliary examinations).

(3) Other examinations: Clinically, there are also myelography (including cerebrospinal fluid examination), discography, angiography, epidural and spinal nerve root angiography, endoscopic digital subtraction imaging and other electromyography, Cerebral blood flow maps, etc., can be used for diagnosis and differential diagnosis.

2. Localization diagnosis of spinal injury The injury of the vertebral segments should be performed for each case of spinal injury. In particular, the segmentation of the affected spinal cord should be considered.

(1) General positioning of vertebrae: After completing the clinical examination of the patient, according to the characteristics of the vertebrae and the surface markers, it is generally not difficult to locate the affected vertebrae. Individual difficulties may be based on conventional radiographs or other imaging studies. Check for positioning.

(2) Location of spinal cord involvement segment: When the vertebrae have trauma, the damaged segment is consistent with the affected segment of the spinal cord. However, if the large root artery of the spinal cord is involved, the actual segment of the spinal cord is significantly higher than the injured segment. Plane, therefore, when clinically determining the plane of spinal cord involvement, it should not be determined by X-ray film alone, in order to prevent unilateral, the main symptoms of different planes of spinal cord involvement are described separately.

1 Upper cervical spinal cord injury: The upper cervical segment mainly refers to the first and second segments of the cervical vertebra. For the convenience of expression, the cervical spinal cord is divided into two segments: the neck 1~4 and the neck 5-8, and the cervical spinal cord is damaged between 1 and 4. At the time, the condition was more dangerous and the mortality rate was high. About half of the patients died on the scene or on the way of transportation. The main performance was (Figure 21):

A. Respiratory disorders: more obvious, especially when the injury is at the highest position, the patient often dies at the scene. The patient presents with hiccups due to different degrees of sacral nerve damage, vomiting, difficulty breathing or complete paralysis of the respiratory muscles.

B. Movement disorders: finger movements, neck and shoulder lift are limited. Patients with different degrees of spinal cord injury have different limbs and limbs, and muscle tension is significantly increased.

C. Sensory Disorder: Root pain can occur in the damaged plane, mostly in the occiput, posterior or shoulder of the neck, with partial or complete paresthesia or even disappearing below the damaged plane.

D. Reflection: deep reflection hyperthyroidism; shallow reflection, such as abdominal wall reflex, cremaster reflex or anal reflex, and pathological reflex, such as Hoffman sign, Babinski sign and palmar reflex Clinical significance.

2 Lower cervical spinal cord injury: refers to the neck and neck of 5 to 8 segments of the neck, which is more common in clinical practice and the disease is more serious. The main manifestations are as follows (Figure 22):

A. Respiratory Disorder: Lighter because the intercostal muscles are involved but the phrenic nerve is normal.

B. dyskinesia: The main range is the trunk and limbs below the shoulder. The affected part is the lower neuron sputum, while the lower part is the upper neuron sputum, and the forearm and hand muscles are mostly atrophic.

C. Sensory Disorder: Root pain is more common in the lower arm. The distal end of the spinal cord is different in degree of involvement and appears to be paresthesia or completely disappear.

D. Reflex: The biceps and triceps tendon reflexes and tendon reflexes are often affected by abnormalities.

3 Thoracic spinal cord injury: It is not uncommon for the thoracic spinal cord injury to occur. The patient exhibits different degrees of motion and sensory disturbances due to different damaged segments. Under normal circumstances, the affected range is between the lower cervical segment and the thoracolumbar segment.

4 chest and lumbar segment or lumbar pulp enlargement: mainly manifested as spinal cord enlargement or slightly above the spinal cord involvement, the clinical manifestations are as follows:

A. dyskinesia: Most of the hips are peripheral sputum signs, which are characterized by complete or incomplete sputum depending on the degree of spinal cord injury. The weaker ones only weaken the gait, while the severe ones have soft squats.

B. Sensory dysfunction: refers to the buttocks, hips below the temperature, pain and other shallow sensory disturbances, and those with complete spinal cord injury, the lower limbs feel loss.

C. Urinary dysfunction: Because the segment is located above the urinary center, it is characterized by central urinary dysfunction, that is, intermittent urinary incontinence. The bladder has involuntary reflex urination in the case of urinary retention, which is different from peripheral urinary dysfunction. .

5 Conical spinal cord injury: The conus of the spinal cord is located at the end of the spinal cord. Because it is tapered, it is named because it is easy to cause fractures due to the chest 12 to the waist. Therefore, the spinal cord injury here is very common in clinical practice. The main performance is as follows:

A. Exercise: There is no impact.

B. Sensory Disorder: manifested as numbness in the saddle area, allergies and feelings of dullness or disappearance.

C. Urinary dysfunction: Because the conus of the spinal cord is the center of the urination, when the spinal cord is completely damaged, urinary incontinence may occur due to the inability of the urine to stay in the bladder. If it is incomplete, the sphincter still retains part of the function, when the bladder is filled. When the urine droplets appear, there is no urine droplets when the bladder is empty.

6 horsetail damage: horsetail damage is seen in the upper lumbar fracture, clinically more common, its main performance is as follows:

A. dyskinesia: refers to the soft sacral sign of the lower extremities, the degree of optic nerve involvement varies greatly, from the weakening of muscle strength to the complete paralysis of the dominant muscle.

B. Sensory Disorder: The extent and extent of it is consistent with dyskinesia. In addition to feeling abnormalities, it is often accompanied by unbearable root pain.

C. Urinary dysfunction: It is also a peripheral dysuria.

Differential diagnosis

1. The identification of complete and incomplete spinal cord injury is generally more difficult than the identification of incomplete spinal cord injury.

2. The identification of severe incomplete spinal cord injury and spinal cord transection injury is a clinical problem. It is difficult to distinguish with special examinations such as MRI and myelography. The author believes that during clinical examination, the following Points may help identify the two.

(1) Autonomous hyperactivity in the toes indicates incomplete spinal cord injury.

(2) In the saddle area, there is an incomplete spinal cord injury.

(3) The presence of an anal reflex is mostly incomplete spinal cord injury in the acute phase.

(4) Those with urethral bulbal caver reflex are mostly incomplete spinal cord injury.

(5) The residual position of the toe is incomplete spinal cord injury.

(6) Stimulate the sole of the foot, and the toes have slow flexion and extension and multiple spinal cord complete injuries.

3. Identification of sputum caused by upper motor neurons and lower motor neurons Each clinician should have a clear understanding of the different sputum characteristics of upper and lower neuron damage for easy identification.

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