Spinal cord cauda equina involvement
Introduction
Introduction Spinal cord, cauda equina or nerve root involvement is one of the symptoms of spinal cord injury. The number of patients with spinal injuries is increasing, depending on the mechanism of damage, and the classification is also different, so it is also difficult to diagnose. However, in fact, as long as the local pathological anatomical features can be grasped, comprehensive diagnosis and judgment can be made under the premise of comprehensive collection of traumatic history, symptoms and signs, and 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.
Cause
Cause
(1) Causes of the disease:
Due to various spinal fractures, dislocation and injury.
(2) Pathogenesis :
1. The predilection of spinal injury can occur in any vertebrae, but 60% to 70% of cases occur in the chest 10 to the waist 2 segments. Among them, the chest 12 to the waist 1 segment is more high, accounting for about 80%; the neck 4 to 6 vertebrae and the neck 1 to 2 are secondary multiple areas, accounting for about 20% to 25%; the remaining 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 are easy to cause death, and most of the time at the injury site. Observed from the mode of action of violence, the proportion of direct violence is the highest, especially the firearms through the injury, almost 100%, followed by overextension. Such as the type of fracture, it is more common in vertebral burst fractures. Of course, the incidence of fractures associated with dislocation and spinal cord injury is higher. Clinically, cases of so-called "lucky spine fractures" with severe vertebral injury but no obvious symptoms of spinal cord injury can be encountered, mainly due to the wider spinal canal.
Examine
an examination
Related inspection
Spinal MRI
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. Now explain its common symptoms.
(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 more passive positions than any activities. Try to alleviate this symptom during inspection and movement.
2 tenderness, cramps and conduction pain: localized fractures have obvious tenderness and cramps (the latter are generally not checked, so as not to increase the patient's pain), and consistent with the fracture site. In patients with simple vertebral fractures, the tenderness is deeper, mainly through the spinous process. The tenderness of the lamina and spinous process fractures is shallow. 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 Limited activity: 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 from deforming or causing damage to the spinal cord and spinal nerve roots; nor should the patient be allowed to do activities in all directions (both active and passive) to avoid aggravating Dislocation of the fracture and causing secondary damage, and 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 the cervical spinal cord 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, and 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. In severe cases, not only quadriplegia, but also the chest respiratory muscles are more affected, only abdominal breathing is retained. Complete sputum, the sputum is below the damage plane.
3 thoracic or lumbar spinal cord injury: Thoracic or lumbar spinal cord injury is more common with complete injury, especially in the thoracic segment. There are obstacles to the sensation, movement, and function of the bladder and rectum below the injury plane.
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, rectal and 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 spinal cord injury plane: The plane of the spinal cord injury is generally consistent with the fracture plane, but the order number is different from the plane sequence of the spinal cord injury due to the anatomical features of the adult spinal cord ending at the lower end of the first lumbar vertebrae. In the spinal cord injury, the plane of the vertebra should be: cervical vertebra +1, upper thoracic vertebra +2, lower thoracic vertebra +3, and the cone is located between chest 12 and waist 1. In addition, it is clinically possible to infer the damaged plane of the spinal nerve root according to the location of the affected muscle, as shown in Table 1.
(4) Other symptoms: According to the location of the fracture, the degree of injury, the involvement of the spinal cord and other various 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 chest and lumbar fractures. The main reason is that the retroperitoneal hematoma caused by vertebral fractures stimulates local nerve plexus, causing reflex abdomen tension or spasm. Individual cases may even appear as symptoms and signs like acute abdomen, so that they are surgically diagnosed because they are misdiagnosed. Finally, the retroperitoneal hematoma is found during surgery.
3 fever reaction: more common in high spinal cord injury. Mainly due to the imbalance of heat dissipation in the whole body, it is also related to central reflex, stimulation of metabolites and inflammatory reaction.
4 acute urinary retention: In addition to spinal cord injury, patients with simple chest and lumbar fractures can also develop acute urinary retention. The latter is mainly due to the reflex response 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: There are different opinions on the general criteria for the degree of spinal cord injury. 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 grades according to whether it is a partial disorder or a complete disorder. Although this method is simple and easy to perform, it is difficult to accurately reflect the degree of injury of the patient, which needs further improvement and improvement. Foreign countries use the Frank classification standard, which is 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, see Table 2:
(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 authors believe that the following points may be helpful in the identification of the two during clinical examination.
1 A toe with autonomous micro-motion indicates incomplete spinal cord injury (Figure 10).
2 The saddle area has sensory incomplete spinal cord injury (Fig. 11).
3 The anterior reflexes were mostly incomplete spinal cord injury in the acute phase (Fig. 12).
4 Most patients with urethral bulbosaurus reflex are incomplete spinal cord injury (Fig. 13).
5 toe residual position sensory is incomplete spinal cord injury.
6 stimulation of the soles of the feet, toes with slow flexion and extension of multiple spinal cord injury (Figure 14).
3. The characteristics of sputum in different damage planes range from brain to horsetail. 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 parts. 3).
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 in order to facilitate identification (Table 4). .
1. Diagnosis of spinal cord injury Under current equipment conditions, the diagnosis of any type of spinal fracture should be less difficult. Due to the emergence of MRI, the differential diagnosis of spinal cord injury and spinal shock has been possible. But in any case, clinical diagnosis should still be in the first place. Therefore, each 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 the accuracy and timeliness of diagnosis.
(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: You should briefly ask the patient or the accompanying person about the patient's injury, the location of the site, and the post-injury situation. 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. The diaphragmatic paralysis may be caused by more than 4 neck injuries; those with elevated blood pressure are often accompanied by craniocerebral injuries; those with low blood pressure are more complicated with internal organs, pelvis and severe limb injuries. The cause should be quickly identified.
4 local spine: including local tenderness, bilateral sacral spine muscle tension, the location and extent of the spinous process protruding to the back, and conduction pain are easy to find and determine the diagnosis. Do not flip the patient arbitrarily during the examination to prevent the degree of damage.
5 Feeling and exercise: A comprehensive examination of the feelings and active movements of the upper limbs, trunk and lower limbs should be conducted to infer whether there is spinal cord damage, damaged plane and degree of damage, etc., and should not be missed for each patient.
6 Perineal and toe sensation, movement and reflex: For those with spinal cord involvement, especially in severe cases, the feeling around the anus and the reflexion of the anus and the feeling and movement of the toes should be judged. Even if there is a little functional residue, and the sensory movement of the limbs basically disappears, it is still incomplete spinal cord injury. Therefore, the determination of the degree of spinal cord damage and the identification of complete damage is 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: imaging of myelography (including cerebrospinal fluid examination), discography, angiography, epidural and spinal nerve root angiography, digital subtraction of spinal endoscopy, and electromyography, as well as electromyography, are commonly used in clinical practice. 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, it is generally not difficult to make a localization of the affected vertebra according to the characteristics of the vertebrae and the surface markers. Individuals with difficulty can be positioned according to conventional radiographs or other imaging studies.
(2) Localization of the affected segment of the spinal cord: When the vertebra has 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 plane. Therefore, when clinically determining the plane of involvement of the spinal cord, it should not be determined by X-ray film alone to prevent unilaterality. 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 ease of expression, the cervical spinal cord is now divided into two segments: neck 1 to 4 and neck 5 to 8. When the cervical spinal cord is damaged between 1 and 4, the condition is more dangerous, and the mortality rate is high, about half of which is died on the scene or in transit. Its main performance is (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 presented with hiccups, vomiting, difficulty breathing, or complete paralysis of the respiratory muscles due to varying degrees of sacral nerve damage.
B. Movement disorders: refers to the movement of the head, neck and shoulder lift. Patients have different limbs due to different degrees of spinal cord damage, and the muscle tension is significantly increased.
C. Sensory Disorder: Root pain can occur in the damaged plane, mostly in the occiput, the back of the neck or the shoulder. Partial or complete paresthesia occurs below the damaged plane and even disappears.
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: finger neck 5-8 segment of the cervical spinal cord involvement, more common in clinical, and the condition is more serious. Its main performance is as follows (Figure 22):
A. Respiratory Disorder: Lighter because the intercostal muscles are involved but the phrenic nerve is normal.
B. Movement disorders: The main range is the trunk and limbs below the shoulder. The affected part presents a neuronal spasm, while the lower part is an upper neuron. 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 chest and thoracic injury to occur. Patients exhibit different levels of motor and sensory disturbances due to different damaged segments (Fig. 23). Under normal circumstances, the affected range is between the lower neck and the thoracolumbar.
4 chest and lumbar segment or lumbar pulp enlargement injury: mainly manifested as spinal cord enlargement or slightly above the spinal cord involvement, the clinical manifestations are as follows (Figure 24, 25):
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 disturbance: refers to shallow sensory disturbances such as hip and hip, such as temperature and pain. In patients with complete spinal cord injury, the lower extremity feels loss.
C. Urinary dysfunction: Because this segment is located above the urinary center, it is characterized by central urinary dysfunction, which is intermittent urinary incontinence (Figure 26). 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 and is named because it is tapered. Because the chest 12 to the waist 1 is easy to cause fractures, the spinal cord injury here is clinically very common, and the main manifestations of the injury are as follows (Figure 27):
A. Exercise: There is no impact.
B. Sensory Disorder: manifested as numbness, allergies, and feeling sluggish or disappeared in the saddle area.
C. Urinary dysfunction: Because the conus of the spinal cord is the center of the urination, urinary incontinence occurs when the spinal cord is completely damaged due to the inability of the urine to stay in the bladder. In the case of incomplete injury, the sphincter still retains part of the effect. When the bladder is full, urine droplets appear, but when the bladder is empty, there is no urine droplets.
6 horsetail damage: horsetail damage is seen in the upper lumbar fracture, clinically more common, its main performance is as follows (Figure 28):
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.
Diagnosis
Differential diagnosis
1. The completeness of complete and incomplete spinal cord injury and the identification of incomplete spinal cord injury are generally more difficult.
2. The identification of severe incomplete spinal cord injury and spinal cord transection injury is a clinical problem, and it is difficult to distinguish it with special examinations such as MRI and myelography. The authors believe that the following points may be helpful in the identification of the two during clinical examination.
(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) Stimulation of the soles of the feet and toes with multiple flexion and extension of the spinal cord.
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.
