Pediatric Spinal Cord Injury
Introduction
Introduction to spinal cord injury in children Spinal cordinal injury (spinalcordinjury) is caused by external violence directly or indirectly on the spine, causing fractures of the vertebrae or involving the spinal ganglia. It can be divided into two categories: open and closed. basic knowledge The proportion of illness: 0.04%-0.08% Susceptible people: children Mode of infection: non-infectious Complications:
Cause
Causes of spinal cord injury in children
(1) Causes of the disease
Heavy objects impact the back of the back, and the back of the back falls on the raised stones, or the direct violence such as the crush injury on the lower back can cause the spinal cord injury consistent with the external force. It is rare in the clinic; Head striking and over-extension of the spine, overflexion or torsion, resulting in vertebral fractures, dislocation or blood circulation disorders of the spinal cord can cause indirect injury to the spinal cord. The most common cause of spinal cord injury in childhood is fall injury ( 56%), followed by car accidents (23%). In adults, the common site of injury is the thoracolumbar transition, followed by the cervical spine. In children, the most common level of spinal cord injury is cervical cord (57%), followed by In the lumbar region (16.5%), the thoracic spinal cord is protected by ribs and bony thorax, with less chance of injury.
(two) pathogenesis
Pathological changes can be divided into:
Spinal cord concussion
Also known as spinal shock, transient spinal cord function occurs immediately after injury, without visible damage.
2. Spinal cord laceration
The spinal cord is partially or completely broken, with smashing, hemorrhage, edema and liquefaction necrosis. The cerebrospinal fluid is bloody. The stimulation of the blood vessels can cause blood supply to the upper and lower spinal cord segments, so that the damage plane is wider and later, the damage is local. There may be vesicles of liquefaction and necrosis of varying sizes, surrounding glial scars and fibrous tissue hyperplasia, arachnoid adhesions thickening, forming cysts.
3. Spinal cord compression
Fractures that protrude into the spinal canal, dislocated vertebrae, torn ligaments, and hematoma outside the spinal cord can compress the spinal cord and cause neurological dysfunction.
4. Spinal cord ischemia and central hemorrhagic necrosis
The rupture of the microvasculature of the spinal cord, sputum or thrombosis of the blood vessels can lead to ischemic damage of the spinal cord, liquefaction and necrosis, and venous return can also lead to spinal edema. Recent studies have shown that catecholamine neurotransmitters in spinal cord injury Excessive release is likely to cause paralysis of the spinal cord blood vessels, resulting in central hemorrhagic necrosis.
Prevention
Prevention of spinal cord injury in children
Various measures are taken to actively prevent trauma and accidents of children of all ages.
Complication
Pediatric spinal cord injury complications Complications
Spastic sputum, sphincter dysfunction, persistent hyperthermia, soft palate, loss of sensation and movement, etc.
Early death occurred within 1-2 weeks after injury, and was more common in cervical spinal cord injury. The cause of death was persistent high fever, hypothermia, respiratory failure or heart failure. Late death occurs after several months or years, mostly caused by hemorrhoids, urinary tract infections, respiratory infections, nutritional failure, etc., cervical spinal cord, thoracic and lumbar spinal cord injury can occur late death. There are no boundaries between early and late death, and most patients with spinal cord injuries die from complications. However, if it can be given prevention and treatment, and can provide good rehabilitation treatment, the patient can not only survive for a long time, but also can sit, stand, walk, and even participate in work, showing the importance of prevention and treatment of complications.
Symptom
Symptoms of spinal cord injury in children Common symptoms Sensory disorder Motor dysfunction Shallow sensation loss or loss of skin Pale spinal cord anterior horn lesions Spinal shock Sphincter dysfunction Dyspnea Reflex disappears Reflex hyperactivity
Spinal cord concussion
It is characterized by soft limbs such as below the plane of injury immediately after trauma, muscle tension is relaxed, deep and shallow reflex disappears, skin is pale and dry, and urine is retained. Generally, recovery begins after several hours. If there is no other substantial damage, it can be within 2 to 4 weeks. Back to normal.
2. Spinal cord injury
After the spinal shock period, the muscle tension is increased below the injury plane, the sputum reflex is hyperthyroidism, pathological reflex occurs, and the degree of recovery of motor or sensory function depends on the degree of injury. In part of the injury, the limb below the injury plane may still have a part. Exercise and sensation; after complete injury, the limb sensation and movement below the injury plane disappear completely, and some early low-level autonomous reflexes may appear.
The clinical manifestations of different parts of the spinal cord are different:
(1) Spinal cord semi-transverse injury syndrome: manifested as ipsilateral movement and deep sensory disturbance, contralateral pain and temperature disturbance.
(2) Central spinal cord injury: There is a loss of temperature and sensation in the nerve distribution area of the damaged segment, and the tactile and deep sensation exists. The muscle is the lower motor neuron.
(3) In the case of anterior spinal cord injury: the complete iliac crest and the shallow sensation below the injury plane are dull or disappear, and the sacral sensation is preserved, accompanied by sphincter dysfunction.
(4) In the case of posterior spinal cord injury: manifested as the loss of deep sensation (positioning sensation, vibratory sensation) below the injury plane, preservation of pain and temperature, and incomplete muscle spasm.
3. Characteristics of different segments of the spinal cord
(1) High neck (neck 1 ~ 4) injury: severe injury to the neck 1 ~ 2 immediately died; neck 2 ~ 4 damage can cause the phrenic nerve and other respiratory muscles to control nerve paralysis, leading to patients with breathing difficulties, damage The lower limbs of the plane are spastic paralysis and sphincter dysfunction; facial triad nerve spinal cord injury in the upper cervical segment may cause facial "onion skin-like" sensory disturbance (Dejerine syndrome); in autonomic nerve injury, perspiration and blood vessels may occur Persistent high fever caused by motor dysfunction or unilateral or bilateral Homer syndrome.
(2) Injury of neck enlargement (neck 5 to chest 1): dyspnea may occur during intercostal nerve paralysis, loose soft palate in upper limbs, spastic paralysis in lower limbs, deep and shallow sensation below the injury plane, autonomic and sphincter Dysfunction is also very common.
(3) In the middle and lower part of the chest (chest 3 to chest 12) Injury: There is a clear plane of sensory disturbance, the feeling and movement below the plane disappear, and the collection reflex may appear after the spinal shock period (expressed to stimulate the lower extremity muscle spasm, knee Hip flexion, adduction of lower limbs, abdominal muscle contraction, reflex urination and sweating, standing hair reflex); sympathetic nerve dysfunction is also more obvious in thoracic injury.
(4) Lumbar enlargement (waist 2 ~ 2) injury: Corresponding to the chest 10 ~ waist 1 vertebral body, there is a loose soft palate of the lower limb, the abdominal wall reflection exists, and the knee reflex disappears.
(5) Spinal conus injury: There is a spinal urination center. After the injury, there is an autonomous bladder, urinary incontinence and rectal sphincter relaxation. The perineal saddle-shaped sensation disappears, the anus reflex disappears, the knee and achilles tendon reflexes exist, and there is no limb paralysis.
(6) Damage of the cauda equina: mostly incomplete injury, manifested as soft palate of the lower extremities, paralysis of the tendon disappeared, irregular sensory disturbance, and obvious sphincter dysfunction.
4. Physical examination
(1) Local examination: more common deformation, swelling, tenderness and spinous process separation of the injured spine.
(2) The examination of the nervous system: examination of various depth and sensation and motor function, the existence and disappearance of physiological and pathological reflexes, help to determine the plane, location and extent of the injury.
Examine
Examination of spinal cord injury in children
Lumbar puncture: can understand whether the cerebrospinal fluid is bloody, indirectly infer whether there is a spinal cord contusion, and also know whether there is obstruction of the spinal subarachnoid space.
1. Spinal X-ray plain film: visible compression of the vertebral body, fracture of the lamina or articular process, dislocation, stenosis of the intervertebral space or spinal canal, small joint lock, etc., indirectly through changes in bone and vertebral anatomy Estimation of spinal cord injury, but in children, because of the strong elasticity of the spine, the vertebral body can be self-reset after dislocation at the moment of injury, so there can be obvious spinal cord injury and no abnormalities in X-ray plain film.
2.CT: visible fractures of the vertebral body and facet joints of the injured plane. Fracture fragments can protrude into the spinal canal and cause compression displacement of the spinal cord. The spinal cord can be seen with flaky contusion hemorrhage. In severe cases, the spinal cord density is reduced, the shape is swollen, and the arachnoid The lower chamber is compressed and occluded.
3. MRI: It can clearly show the pressure displacement of the spinal cord, contusion bleeding and edema, and has a diagnostic significance for spinal cord injury, but it is difficult to do this examination in the acute phase.
Diagnosis
Diagnosis and diagnosis of spinal cord injury in children
diagnosis
According to a clear history of trauma and characteristic clinical manifestations, the diagnosis is not difficult, but to determine the location and extent of the injury, careful neurological examination and necessary auxiliary examination are required.
Differential diagnosis
Identification with brain trauma, according to clinical manifestations and auxiliary examination can be clear, and the identification of spinal cord contusion, depending on clinical manifestations and whether there is bloody cerebrospinal fluid can help identify.
1. Severe brain trauma can pull, twist or tear nerves, blood vessels and other tissues in the brain. The nerve pathway is damaged, or causes bleeding and edema. Intracranial hemorrhage and cerebral edema increase the contents of the cranial cavity, but the cranial cavity itself cannot be expanded accordingly. As a result, intracranial pressure increases and brain tissue is further damaged. Increased intracranial pressure pushes the brain down, forcing the upper brain tissue and brain stem into the associated pores, a condition called cerebral palsy. The cerebellum and brainstem can be displaced from the hole in the base of the skull to the spinal cord. Because the brainstem has an important function of maintaining breathing and heartbeat, cerebral palsy is often fatal.
2. Acute transverse spinal cord injury immediately causes loss of delirium below the level of damage and loss of all sensory and reflex activities (including autonomic dysfunction) (so-called spinal shock). Within a few hours or days, the loose sputum gradually turns into a tonic paraplegia, which is due to the elimination of the descending inhibition and the normal tendon draft reflex. Later, if the lumbosacral spinal cord function is intact, flexor tendons may occur, and deep sacral reflexes and autonomic nerve reflexes also recover.
Incomplete injury of the spinal cord causes partial movement and loss of sensory function, and disorder of voluntary movement. The specific manifestation of sensory impairment depends on the damaged conduction beam: if the posterior column is damaged, it can cause positional awareness, vibration and loss of light touch. If the spinal thalamus is damaged, pain, temperature and often lightness will occur. Loss of touch or heavy touch. Semi-transverse lesions of the spinal cord cause tonic convulsions in the ipsilateral lower extremities with deep sensory loss and pain and temperature loss in the contralateral lower limbs (Brown-Sequard syndrome). The level of spinal cord damage can be determined based on clinical clues.
