Early treatment
Early treatment of spinal injury includes on-site rescue, emergency treatment and early specialist treatment. Whether the early treatment measures are correct or not directly affects the life safety of patients and the recovery of spinal cord function.
Early evaluation of patients with various injuries should start from the injury site. Patients who are unconscious or unconscious usually cannot complain about pain. Patients with craniocerebral injury, severe laceration of face or scalp and multiple injuries should be suspected of spinal cord injury, and further damage to nerve tissue should be reduced through orderly rescue and transportation.
Follow the principle of ABC rescue, that is, keep airway unobstructed, restore ventilation and maintain stable blood circulation. It is necessary to distinguish between nervous shock and hypotension caused by hypovolemic shock caused by blood loss. Neurogenic shock refers to the interruption of sympathetic output signal (T 1-L2) and the disorder of vagus nerve activity after cervical or upper thoracic spinal cord injury, which leads to hypotension and bradycardia. Hypotension complicated with tachycardia is mostly due to insufficient blood volume. Whatever the reason, hypotension must be corrected as soon as possible to avoid further spinal cord ischemia. Actively transfuse blood to replenish blood volume, and perform emergency surgery on life-threatening bleeding when necessary. When there is still hypotension with bradycardia after volume expansion, pressor and sympathomimetic drugs should be used.
2. Drug therapy
When patients with spinal cord injury are satisfied, the main treatment task is to prevent further injury of the injured spinal cord and protect normal spinal cord tissue. To do this, restoring the spinal sequence and stabilizing the spine are the key links. In terms of treatment, drug therapy may be the fastest way to reduce the degree of spinal cord injury.
(1) The corticosteroid methylprednisolone (MP) is the only drug approved by FDA to treat spinal cord injury (SCI). It is recommended to give the medicine within 8 hours. Methylprednisolone is recommended as a treatment option rather than a standard or recommended treatment. In addition, the research results of a few scholars show that MP is ineffective in the treatment of acute spinal cord injury and can cause serious complications.
MP is not effective for patients with spinal cord rupture, and mild spinal cord injury can recover without MP. Complete spinal cord injury and severe incomplete spinal cord injury are the goals of MP treatment. However, it should be noted that high-dose MP may cause pulmonary and gastrointestinal complications, and the elderly are prone to respiratory complications and infections. In a word, we should pay attention to the prevention of complications during MP treatment. Dexamethasone can also be used and stopped for 5 days to avoid complications caused by long-term high-dose use of hormones.
(2) Ganglioside is a kind of sialic acid with sugar ester, which widely exists in mammalian cell membrane and has a high concentration in the outer cell membrane of the central nervous system, especially in the synaptic region. Patients with spinal cord injury were treated with GM- 1 and followed up after 1 year, and the curative effect was better than that of the control group. Although their real function is not clear, experimental evidence shows that they can promote axon regeneration and germination mediated by nerve exogenesis and synaptic transmission, reduce nerve degeneration after injury, and promote nerve development and shaping. It is considered that GM- 1 is usually administered 48 hours after injury, lasting for 26 days on average, and methylprednisolone has the best effect within 8 hours after injury. Some scholars believe that GM- 1 can not stop the process of secondary injury. At present, ganglioside has been used in the treatment of spinal cord injury, but its mechanism of action is still unclear, and the research is still going on, so its wide clinical application is also limited.
(3) Scopolamine can regulate microcirculation, improve microcirculation disturbance caused by capillary rupture, bleeding and blockage after spinal cord injury, reduce spinal cord ischemia and necrosis, and is beneficial to the recovery of spinal cord function. The sooner you use it, the better. It should be used the day after the injury.
(4) Mecobalamin, a neurotrophic drug, is coenzyme B 12, and its central cobalt atom is bound with active methyl, which is easy to be absorbed, so that the concentration of vitamin B 12 in serum is increased and further transported to the organelles of nerve tissue. Its main pharmacological effects are: enhancing the synthesis of nucleic acid and protein in nerve cells; Promoting the synthesis of lecithin, the main component of myelin sheath, is beneficial to the repair of damaged nerve fibers.
(5) Mannitol is commonly used to relieve spinal edema. Patients with cardiac insufficiency, coronary heart disease and renal insufficiency may suffer from fatal diseases if they drip too fast. For the elderly or potential renal insufficiency, we should closely observe the changes of urine volume, urine color and urine routine. If the daily urine output is less than 1500ml, it should be used with caution. Water and electrolyte should be properly supplemented to prevent dehydration and insufficient blood volume, and water, electrolyte and renal function should be monitored.
3. Treatment of complications
The death of patients with spinal cord injury can be divided into early and late stages. Early death occurred within 1 ~ 2 weeks after injury, mostly in cervical spinal cord injury. The cause of death is persistent high fever, low temperature, respiratory failure or heart failure. Late death occurs several months or years later, which is mostly caused by pressure sore, urinary tract infection, respiratory tract infection and malnutrition. Late death may occur in cervical spinal cord and thoracolumbar spinal cord injuries. There is no certain boundary between early death and late death, and most patients with spinal cord injury die of complications. However, if prevention and good rehabilitation can be given, patients can not only survive for a long time, but also sit, stand, walk and even take part in work, which shows the importance of prevention and treatment of complications.
(1) Dysuria after spinal cord injury and its treatment. The main purpose of treating dysuria is to improve urination function, reduce the inconvenience in daily life, make patients urinate regularly, have no catheter, have little or no residual urine, have urinary incontinence, prevent urinary system infection and restore normal bladder function.
1) Continuous drainage and bladder exercise in the early stage of spinal cord injury, bladder detrusor weakness, urine can not be discharged due to internal sphincter, indwelling catheter drainage is the best treatment. Generally, rubber catheter or silicone rubber catheter with smaller diameter should be retained, and bladder emptying should be maintained at first to facilitate the recovery of detrusor function. 1 ~ 2 weeks later, the tube was opened every four hours and kept open after falling asleep at night. When the catheter is opened, train the patient to massage the bladder with both hands and squeeze out urine as much as possible.
2) Prevention of urinary tract infections and stones Due to bladder paralysis and urinary retention, it is necessary to use indwelling catheters for a long time, but bladder contracture, urinary tract infections and stones are prone to occur. Over time, infection will be difficult to control, which will seriously damage the kidney and lead to renal failure. ① Raising the bedside is beneficial to the urine drainage from the kidney to the bladder through the ureter, reducing the chance that pyelonephritis, hydronephrosis and pyelonephritis will eventually damage the renal function. ② The daily water consumption of patients who drink more water should be kept above 2500m 1, so that they can urinate more and have the function of mechanical flushing. In summer, patients can be encouraged to eat more watermelons for the same reason. (3) Flush the bladder under strict aseptic operation, and use the catheter for a short time or intermittently to make urination smooth. Rinse the bladder with normal saline, 3% boric acid solution or 0. 1-0.05% nitrofuracilin solution twice a day. (4) after cleaning urethral orifice and indwelling catheter, secretions often accumulate at urethral orifice due to the stimulation of catheter, which is easy to breed bacteria and should be removed every day. ⑤ Replacing the catheter for too long can easily lead to infection and stone formation, so it should be replaced regularly. Ordinary rubber catheters are generally replaced every 1 ~ 2 weeks. If the plastic pipe with less irritation and smaller outer diameter and inner diameter of 1.5 ~ 2mm is used, it can be replaced every 2 ~ 3 weeks. Urine should be emptied as much as possible before changing the tube so that the urethra can rest for several hours after extubation. During this time, the patient can try to urinate. If urination is successful, intubation is not needed. Urine can overflow around the catheter on weekdays, indicating that the bladder has resumed urination function, which is an indication of extubation.
3) Drug treatment ① Urinary retention stimulates parasympathetic nerve to enhance detrusor strength, and opens internal sphincter to restore urination function. Inhibition of sympathetic nerve makes the internal sphincter not tense to facilitate urination, and adrenergic receptor inhibitors can be used. Use drugs to inhibit urethral and sphincter spasm. ② Urinary incontinence and bladder detrusor spasm: Atropine drugs can be used. Internal sphincter weakness: Ephedrine can be used in combination with ethinylestradiol. Relaxation of internal sphincter of bladder: the effect of western medicine is not good, so you can try Chinese medicine Suoquan Pill or Suoquan Decoction.
4) Surgical treatment According to the different conditions of patients, the following surgical methods can be selected: ① patients with dysuria due to exercise bladder after internal urethral sphincter incision, who still cannot urinate on their own for half a year after injury; Transurethral sphincterotomy for patients with upper motor dysuria, increased tension of internal sphincter of bladder and increased urination resistance, which can not be relieved for a long time. ② External urethral sphincterotomy can't be controlled because of long-term dysuria or urinary tract infection, and it is feasible to perform external urethral sphincterotomy when it is confirmed that the main resistance of dysuria comes from external urethral sphincter. (3) Ileal bladder replacement is feasible for patients with bladder contracture caused by long-term indwelling catheter or long-term chronic urinary tract infection, which can expand bladder muscle capacity, eradicate bladder infection and reduce urination times. ④ Suprapubic cystostomy is feasible due to long-term dysuria and indwelling catheter. The general condition of patients is poor, and nephrostomy is feasible for those with urinary tract obstruction complicated with hydronephrosis, pyelonephritis and renal failure. Ureterostomy is feasible if ileum cannot be used instead of bladder for bladder contracture for some reason.
(2) Abnormal body temperature and its treatment
1) high fever, high fever beard and infection. Because the sympathetic nerve has been paralyzed, it is useless to use drugs to cool down. If there is air conditioning equipment, the room temperature can be controlled between 20 ~ 22℃. Prevention and treatment are mainly based on physical cooling, and alcohol rubbing bath or ice pack is used in the running parts of big blood vessels such as neck, armpit and groin.
2) Patients with cervical spinal cord transection have hypothermia and heart failure. Because of systemic sympathetic paralysis, the subcutaneous vascular network expands and cannot contract. Therefore, if the injury occurs in the dead of winter and the patient fails to keep warm after long-distance transportation, a large amount of body temperature will be emitted in the body, and the body temperature will drop to 32℃. At this time, the patient's expression is indifferent, and the speed will slow down, only more than 50 degrees per minute. If the body temperature continues to drop to 30℃ or below, it will cause arrhythmia and die of heart failure. The main treatment methods are artificial rewarming, raising room temperature, hot water bag method (40℃), electric blanket method, preheating imported blood and liquid, etc. The temperature should not rise too fast or too high. Slowly raise the temperature to 34℃, and then raise it to 36℃ through clothes insulation, preferably not exceeding 37℃.
4. Pressure ulcer and its treatment
Pressure ulcer is a common complication of paraplegia patients. The most common parts are sacrum, spinous process, scapula, greater trochanter, heel and fibula. Severe pressure ulcers can directly reach the bones, causing osteomyelitis. Large-area and deep necrotic pressure ulcers can make patients lose a lot of protein, resulting in malnutrition, anemia and hypoproteinemia. They can also cause high fever, loss of appetite, toxemia and even sepsis due to secondary infection, leading to the death of patients.
(1) Prevention of pressure ulcers ① Turn over to strengthen nursing, turn over frequently, once every 2 hours, and stick to it day and night. The upper and lower parts of the fracture plane should be turned over as a whole at the same time, and the patient's body should not be distorted. Turn over often, with a small amplitude, that is, turn 45 degrees left and right to meet the needs. ② When the patient turns over, 50% alcohol or other compound liniment should be applied to the bony protrusion that is easy to be oppressed. Massage while painting to promote local blood circulation. Then, apply talcum powder or Liuyisan. Massage gently, not too hard, so as not to scratch the skin. ③ It is best to use pure cotton for clothes and quilts of pollution-proof patients, so as to avoid skin pollution by feces and urine.
(2) Treatment of bedsore ① Mattress should be soft, flat, clean and dry, and inflatable bedsore pad should be used. Strengthen nursing, turn over frequently, try to make the pressure sore no longer under pressure and create conditions for healing. ② Improve the general condition, increase the intake of protein and vitamins, properly transfuse blood, adjust the balance of water and electrolyte, and apply antibiotics.
(3) Treatment of local wounds ① First-degree pressure ulcers increase the number of patients turning over, keep local skin and sheets dry, wipe them with talcum powder or 50% alcohol, and do light massage. ② If the blister of the second degree pressure sore is not broken, clean the water with an empty needle after strict disinfection. For those who have formed wound surface after blister rupture, apply 1% gentian violet or 10% ~ 20% mercuric tincture locally and irradiate with infrared rays every day. ③ Surgical methods were used to remove the third degree pressure sore, and local dressing change was used to remove the residual necrotic tissue. Skin grafting is feasible when granulation grows healthily. ④ If the drainage of grade IV pressure sore is not smooth, it is necessary to open the wound to expand drainage, and try to remove necrotic tissue including bones with osteomyelitis. If the granulation has aged, the wound edge has been scarred, and the wound has not healed for a long time, the wound should be cut radially to facilitate the growth of fresh granulation. For patients with clean but large wounds, local skin flap transfer can be done.
5. Prevention and treatment of dyspnea and pulmonary complications
(1) insist on turning over for patients every 2 ~ 3 hours.
(2) Give the patient an oral expectorant.
(3) Choose effective antibiotics for systemic application or mix them with α-chymotrypsin, and inhale them by atomization.
(4) Encourage patients to cough. It can press the abdomen to help cough.
(5) Ask patients to take deep breaths frequently.
(6) cut the trachea. Those whose paraplegia plane is above the fourth and fifth cervical vertebrae have weak breathing and small gas exchange. If the vital capacity is less than 500ml, preventive tracheotomy can be done; The paraplegia plane is low, and the patient's breathing becomes difficult during the observation process, and it is gradually aggravated, or secondary lung infection and increased tracheal secretions affect gas exchange, and the vital capacity drops below 1000ml. Tracheotomy should be done as soon as possible. Tracheotomy can ensure airway patency, reduce respiratory resistance, reduce dead space and facilitate sputum aspiration, and can be administered directly through incision. Generally, the medicine given is a mixed solution of diluted antibiotics, chymotrypsin and isoproterenol, which has antibacterial, spasmolytic, expectorant and moist respiratory tract functions. When the patient stops breathing, artificial respiration can be performed through tracheotomy, or automatic respirator can be used to assist breathing. With pulmonary infection, standard wood can be taken from tracheotomy for sputum culture to find out the pathogenic bacteria and effective antibacterial drugs. The route of administration is not only intravenous drip, but also direct drip through tracheotomy.
6. Defecation disorder and its treatment
(1) Defecation disorder in patients with spinal cord injury When paraplegia occurs in spinal cord injury, the random control of external anal sphincter and defecation reflex of rectum disappear, intestinal peristalsis slows down, and rectal smooth muscle relaxes, so feces remain, which is called constipation because of long-term absorption of water. If there is diarrhea, it is manifested as fecal incontinence. Constipation is the most common among paraplegic patients. When constipation occurs, patients will have symptoms such as abdominal distension, loss of appetite and decreased digestive function due to the absorption of toxic substances.
(2) Treatment of constipation in paraplegic patients ① Diet and medication recipes contain more water, vegetables and fruits. Laxatives and stool softeners can be taken orally. Analgesics and alkaline drugs can inhibit gastrointestinal peristalsis and should be avoided as much as possible. ② Soap water or normal saline can be used for enema. ③ Acupuncture or stimulating the trigger point, such as hammering the sacrococcygeal region. (4) Hand-pulling method uses gloved fingers to reach into the anus and pull out the hard stool. This method is more suitable for patients with bedsore in coccyx, because it can avoid stool pollution of the wound. ⑤ Training defecation reflex: Patients with advanced paraplegia who have been injured for 2 or 3 months should sit up every day, increase abdominal pressure and give appropriate stimulation regularly, such as pressing anus and lower abdomen, so as to train defecation reflex.
7. Spasm and its treatment
Spasm is due to the loss of central command at the transport end of the injured spinal cord, but the connection between the cerebellum and muscles in the anterior horn remains intact. The reflex arc below the injury plane is highly excited, and the basic spinal cord reflex (including stretch reflex, flexor reflex, blood pressure reflex, bladder reflex, defecation reflex and penile erection reflex) is hyperactive. After the shock stage, patients with spinal cord injury gradually developed spasms 1 ~ 2 months after injury, and reached moderate spasms 3 ~ 4 months after injury. Severe spasm often suggests that the body below the injury plane has lesions, such as urinary tract infection, stones, perianal abscess, anal fissure, pressure sore and so on.
(1) Preventive measures Pay attention to the position of paralyzed limbs in the early stage of spinal cord injury, promote limb extension reflex and avoid flexion spasm. For example, prone position, passive limb movement and training to restore upright position are all conducive to promoting traction reflex. Relieve the mental stress of patients. Actively treat urinary tract infection, bedsore and other complications. Avoid convulsions caused by drastic changes in room temperature, tight clothes, shoes and hats, and bladder and rectum filling. Helping patients to do cycling can obviously relieve spasticity.
(2) Treatment of Spasm ① Drug therapy is beneficial to relieve pain. ② Perform functional electrical stimulation on the antagonistic muscles of spastic muscles once a day. ③ Obturator neurotomy and adductor neurotomy can relieve severe adductor spasm. ④ Anterior rhizotomy is suitable for spasms ranging from the tenth thoracic spinal nerve to the first sacral spinal nerve. ⑤ Anterior combined spinal cord amputation should be limited to the range from the tenth thoracic spinal cord to the first sacral spinal cord, and attention should be paid to preserving the cone and its important reflex function.
8. Rehabilitation treatment
(1) The injured in ideological education suddenly changed from a healthy person to a disabled person, and their psychological trauma was extremely serious. During the period of treatment and rehabilitation, patients often have anxiety and pessimism because of the lack of treatment methods, slow effect and long course of treatment. Medical staff should do ideological work with their families, give full play to patients' subjective initiative to overcome disability, and minimize disability.
(2) Physiotherapy ① Massage lightly, massage all parts of limbs from far to near, with the purpose of preventing muscle atrophy and joint stiffness, improving local blood circulation and promoting lymphatic reflux. Massage, rubbing and deep pressing with the palm along the direction of gastrointestinal peristalsis can promote gastrointestinal peristalsis and help digestion. Massage along the direction of colon peristalsis can promote defecation; Massage along pubic bone can promote urination. Massage the lower limbs, starting from the toes, followed by flexion and extension of the ankle joint, knee joint and hip joint, adduction, abduction and elevation of the hip joint, with one heel on the opposite knee, and then the lower leg slides down to the ankle. Upper limb massage, passive finger flexion and extension, fist clenched, assisting wrist, elbow and shoulder joint activities. When doing passive activities on spastic limbs, be patient and slow, and avoid being rude, so as to avoid soft tissue injury, leading to bleeding and ectopic osteogenesis in the future. ② Electrotherapy For patients with flaccid paralysis, induction electrotherapy can prevent muscle atrophy and fibrosis, improve muscle nutrition and maintain muscle function. Electrotherapy is not suitable because it is ineffective for patients with spastic paralysis. (3) Spa and hot water bath are helpful to stretch tendons, muscles and ligaments, improve joint mobility, reduce spasms and soften tissues.
(3) After functional exercise fracture healing, patients can sit up, stand and even walk with the help of bedstead, support, crutches and other instruments.
(4) Functional electrical stimulation Functional electrical stimulation is also called artificial spinal cord. Its basic principle is to make muscles or limbs reproduce functional activities through appropriate doses of electrical stimulation. Stimulation can act directly on muscles or nerves. Electrical stimulation can enhance the aerobic metabolism of muscle, release more active enzymes, increase the cross-sectional area of muscle and increase the percentage of myofibrils, thus enhancing muscle strength; It can also increase the contraction speed of muscles and enhance the endurance in muscles. In addition, more channels can be opened between the central nervous system and muscles to strengthen their ability to control movement. ① Stimulate the quadriceps femoris and leave the negative electrode at the junction of the upper and middle part of the front thigh. Intermittent contraction of the quadriceps femoris can be seen in the induction period, but it is obviously powerful in the strengthening period and standing period. ② Stimulating the femoral nerve and placing the negative electrode outside the femoral inguinal artery can lead to contraction of quadriceps femoris. Although the intensity is low, the effect is good and the urination function can be improved. ③ Stimulate the common peroneal nerve and place the negative electrode under the fibular capitulum and the positive electrode on the abdomen of the extensor muscle outside the calf to correct foot drop and make the ankle joint stretch backward, so as to prepare for standing and walking. ④ Stimulate the lumbosacral spinous muscle, and place electrodes on both sides of the lumbosacral spinous muscle below the sensory plane to contract the lumbosacral muscle and maintain the standing posture of the human body. ⑤ Stimulate the median nerve, with the negative electrode placed in the middle of the cubital fossa and the positive electrode placed on the flexion side of13 under the forearm. ⑥ Stimulate ulnar nerve, place the negative electrode on the back of elbow and the positive electrode on the flexion side of the junction of middle and lower forearm 1/3. ⑦ Stimulate the radial nerve. The negative electrode is placed outside the cubital fossa, and the positive electrode is placed at the elbow flexion point at the junction of the middle and lower forearm 1/3.
Prevention and treatment of disability
(1) To prevent deformity, the patient should keep the hip joint and knee joint slightly flexed when taking the lying position, and support the soles and toes with soft pillows or tripods, or support them with leg protectors and plaster to prevent foot drop deformity caused by quilt pressing the feet. In addition, frequent massage of paralyzed limbs and passive movement of joints can also reduce the occurrence of deformity.
(2) Deformity correction
1) Patients with mild deformity can be treated by passive joint movement, skin traction and drug symptomatic treatment.
2) Surgical treatment For those with severe deformity, the following surgical methods can be selected according to the situation. ① Treatment of moderate foot drop by cutting or lengthening Achilles tendon. ② Talus resection or triple arthrodesis for severe foot drop. ③ Interdigital joint resection and fusion for claw toe. ④ Treatment of adduction deformity of hip joint with adduction tendon amputation or obturator nerve amputation. ⑤ Release tensor fascia lata, sartorius muscle and iliopsoas muscle to treat hip flexion deformity. ⑥ hamstring amputation for knee flexion deformity. ⑦ Severe spasm was treated by spinal cord scar excision, neurolysis or anterior rhizotomy.
After operation, it is generally necessary to protect the affected limb with plaster and bracket in functional position, so as to achieve the purpose of sitting up, standing, walking for a short distance and basically taking care of themselves in the future. However, for patients with high degree of spinal cord injury and late functional exercise, but poor physique, weak will and lack of perseverance, the treatment effect is not ideal.