First aid because the stress point of the injured person is mostly on the top of the head, sometimes the patient may be unconscious. At the scene, we should first consider whether there are combined injuries of important organs such as the brain. Pay attention to the reasonable protection of the neck when handling, so as not to aggravate the injury.
People with complete spinal cord injury keep the respiratory tract unobstructed, especially those with cervical vertebra grade 6 or above, who are more likely to have difficulty breathing due to respiratory muscle paralysis, and lung sputum cannot be coughed up, leading to respiratory failure. If necessary, tracheotomy should be performed as soon as possible and mechanical breathing should be assisted.
To restore the shape of the spinal canal, we should first restore the normal shape of the spinal canal in the shortest time by traction reduction or surgical prying, eliminate the compression on the spinal cord, avoid aggravating the degeneration and edema of the spinal cord, and maintain the opposition through traction.
Although the stress-inducing factors in the spinal canal can be eliminated by traction to restore the line of force, the spinal fracture, lamina collapse and intervertebral disc tissue kyphosis may still continue to invade the spinal canal, which constitutes the compression of the spinal cord. All compression patients diagnosed by CT and MRI should be removed as soon as possible, and anterior or posterior surgery should be selected according to the compression direction. The operation should be performed under traction. However, the general condition is not good, and those who are completely paralyzed can be suspended.
Promote the recovery of spinal cord function. On the basis of decompression, spinal edema and traumatic reaction should be eliminated as soon as possible. The use of dehydrated diuretics and a large number of hormones has a certain effect. Early hyperbaric oxygen therapy also has certain effect. Drugs such as naloxone and ganglioside are still in the experimental and clinical trial stage, and the effect needs to be confirmed. At present, neurotrophic agents and drugs to improve blood circulation are often given. Patients with complete spinal cord injury should focus on the recovery and reconstruction of hand function, including nerve root decompression (wrist should be partially preserved) and tendon transfer surgery. Sometimes spinal canal decompression is not helpful to the recovery of complete spinal cord injury, but local decompression is expected to reduce the level of spinal cord injury 1 ~ 2 segments and improve the function of the hand.
In the later stage, surgical resection is mainly used to remove the stressors of bone and soft tissue that hinder the further recovery of spinal cord function. Functional reconstruction using residual function of limbs.
Fracture and dislocation of cervical spine is the most serious injury among all kinds of lower cervical spine injuries. Because it is often accompanied by serious spinal cord injury, the prognosis is poor, except for the so-called "lucky injury" without spinal cord injury.
The purpose of surgical treatment after cervical fracture is to restore the normal curvature and stability of the cervical spine, completely decompress the spinal canal, relieve the compression of the spinal cord, and provide a prerequisite for the recovery of spinal nerve function. However, sometimes simple anterior or posterior surgery can not completely relieve the compression of the spinal cord from both sides at the same time, and can not correct the anterior and posterior deformities at the same time, which affects the recovery of spinal nerve function. From 1999 1 to June 2000, we treated 7 cases of cervical spine fracture1with good results. The report is as follows.
1 data and methods
1. 1 general information 17 cases in this group, including male 13 cases and female 4 cases. 18 ~ 43 years old, with an average of 3 1 year. Among them, there were 5 cases of fracture dislocation with joint dislocation (C54 cases, C6 1 case), 6 cases of burst fracture (C5-7 cases), 2 cases of vertebral fracture with primary spinal stenosis (C5, C7 cases), and 4 cases of lamina fracture with acute disc herniation (C5/63 cases, C6/7 1 case). There were 8 cases of falling injuries and 9 cases of traffic accidents. 9 cases were operated within 24 hours and 8 cases were operated within 2 ~ 5 days. According to Frankel classification, there were 4 cases of grade A, 6 cases of grade B, 5 cases of grade C and 2 cases of grade D.
All patients were examined by X-ray, CT and MR before operation to determine the degree of cervical fracture and dislocation, the degree of cervical spinal canal stenosis and the scope of cervical spinal cord injury.
Methods All patients were treated with posterior decompression, anterior decompression, bone grafting and anterior plate internal fixation. After general anesthesia with tracheal intubation, the skull was pulled, and the injured vertebra, upper and lower laminae and spinous process were exposed by lateral incision. First, the whole lamina of the injured vertebra was removed, and the hematoma, ligamentum flavum and broken bones were removed. Pry the articulated joint to reduce or chisel out the articular process joint that hinders reduction. Decompress the spinal cord upward and downward to normal, and wash it with plenty of saline. After decompression, the spinous process and lamina were made into bone strips and placed around the articular process for bone grafting. If necessary, fix it on the joint capsule of articular process with silk thread 10, and put a drainage tube to suture the knife edge. Then the patient took the supine position, made an oblique incision in the right front of the neck, exposed the anterior cervical fascia layer by layer, determined the intervertebral space that needed decompression with "C" arm fluoroscopy, and took out the bone block and intervertebral disc that pressed the cervical spinal cord in front with trephine and curette. Decompression up and down, then flushing with plenty of salt water, taking out iliac bone pieces from the body and implanting them into decompression space. Orion anterior plate of Sofmmor-Danek was used. According to the physiological curvature of cervical spine, it was pre-bent, then fixed firmly, and skin graft was placed for drainage, followed by suture.
Postoperative routine use of hormones, dehydrating agents, antibiotics and neurotrophic drugs. The neck was fixed with neck brace for 8 ~ 12 weeks, and hyperbaric oxygen therapy was performed on the third day after operation, with 2 ~ 3 courses of treatment 10 times. At the same time, actively prevent complications such as bedsore, lung infection and urinary tract infection.
1.3 Follow-up All patients underwent anteroposterior and lateral X-ray examination with the same magnification within 1 week after operation and at the last 1 follow-up. The height h and H' of C2_-C7 vertebral body were measured on neutral lateral radiograph, and the loss rate (%) of vertebral body height was (H-H')/H * 100%. Finally, X-rays of cervical hyperextension and hyperflexion were taken at 1 follow-up, and the total flexion and extension range of cervical spine was measured [1]α=α 1+α2. Finally, during the follow-up period of 1, the fusion rate was observed on X-ray films. The recovery of spinal nerve function was evaluated according to Frankel classification.
Bear fruit
All 17 patients were followed up for 36 ~ 48 months, with an average of 42 months. The average recovery of spinal nerve function was improved by 65438 0.8 grades. The average extension and flexion range of cervical spine after operation was 65438 06? To compare the range of motion of cervical spine after simple posterior double door opening, 16.5? [3] Similar. The loss of vertebral height was 65438 0.7%, and the fusion rate was 65438 000%. See figure 1, figure 2.
No axial symptoms such as neck and shoulder pain [4] occurred, no steel plate fracture and screw loosening, no esophageal injury and irritation symptoms.
Fig./preoperative x-ray, CT and MR of kloc-0/C5 fracture.
Figure 2 X-ray film after cervical vertebra 5 fracture Figure 2 X-ray film after C5 fracture.
3 discussion
3. 1 surgical indications We list the cases where complete decompression or satisfactory reduction cannot be achieved by simple anterior and posterior surgery as surgical indications. ① Burst fracture involves both the anterior column and the posterior column. There are bone fragments and ruptured intervertebral discs in front of the spinal canal, and articular processes and lamina fractures with hematoma and yellow ligament shrinkage in the back. Decompression, fusion and fixation should be carried out simultaneously from front to back, so as to obtain complete decompression and firm fusion; ② Developmental spinal stenosis or bone with posterior longitudinal ligament.
After cervical fracture, sufficient buffer space should be obtained from posterior decompression to make anterior bone grafting and fusion safe and easy. ③ Anterior cervical fracture and dislocation with posterior facet atresia.
3.2 Advantages of this operation ① After cervical fracture, decompression and bone grafting were performed first, and then anterior decompression and bone grafting and fusion plate internal fixation were performed. On the one hand, anterior decompression and posterior decompression are carried out at the same time, and the decompression is complete. At the same time, washing the injured spinal cord with normal saline, cooling and removing endotoxin, reducing the secondary injury to the marginal spinal cord tissue [5], is conducive to the recovery of spinal nerve function; ② Simultaneous anterior and posterior bone grafting, full bone grafting and plate fixation, with high fusion rate and good stability. It avoids kyphosis and secondary nerve injury caused by the loss of intervertebral height and the collapse of intervertebral space after operation [6]; ③ After cervical fracture, the cervical spinal cord was obviously compressed, ischemic and edematous, and the volume of spinal canal was obviously reduced. If decompression is performed only through the anterior approach, any stimulation of surgical instruments on the spinal cord will aggravate the spinal cord injury, and the postoperative symptoms may be aggravated due to the deep surgical approach. Posterior decompression of spinal canal can obviously expand the effective volume of spinal canal, increase the buffer space of cervical spinal cord and improve the safety of anterior surgery. ④ The average range of flexion and extension is similar to that of simple posterior decompression laminoplasty [3], indicating that simultaneous anterior and posterior surgery does not seriously affect the range of motion of cervical spine. Due to the simultaneous anterior and posterior bone grafting and anterior plate internal fixation, the fusion rate is obviously improved and the long-term stability is good. Discectomy plus laminectomy can cause obvious three-dimensional motion instability [5], and anterior and posterior bone grafting plus plate internal fixation can obviously stabilize the cervical spine. Therefore, the anterior and posterior surgery has well reconciled the contradiction between motion and stability after cervical surgery; ⑤ One operation through anterior and posterior approach not only satisfies the thoroughness of spinal canal decompression, but also obtains the long-term stability of cervical vertebra, and reduces the incidence of axial symptoms of cervical vertebra. In addition, one-time completion of anterior and posterior surgery shortens the hospitalization time compared with separate anterior and posterior surgery.
3.3 Matters needing attention and problems to be solved During the operation, the articular process should be unlocked one by one to make it reset. After laminectomy, decompression and bone grafting, anterior decompression and internal fixation should be performed. When the posterior joint is locked, it will be difficult to restore the normal sequence of cervical spine by simple anterior surgery without chiseling or prying the superior articular process to restore it. The operation must be carried out under the traction of skull. When changing from lateral position to supine position, it is necessary to protect the neck and prevent the fracture and dislocation of cervical spine from aggravating. After operation, the neck was fixed with neck brace for 8 ~ 12 weeks. Because the bone structure of cervical spine is obviously destroyed after one anterior and posterior operation, its stability mainly depends on steel plate fixation, so reliable external fixation is needed for a period of time after operation. After 8 ~ 12 weeks, the cervical fracture can be initially healed before the gradual neck movement can begin. In addition, the first-stage anterior and posterior surgery for cervical spine fracture is traumatic, so it is necessary to pay close attention to the changes of the condition after surgery, keep the respiratory tract unobstructed and strengthen systemic nutrition. The long-term complications and curative effect of this operation need further observation.
Minimally invasive treatment of the first cervical fracture in China.
The Second Affiliated Hospital successfully carried out minimally invasive surgery for the treatment of old neck fracture and dislocation. The patient under general anesthesia was fixed on the operating table. The chief surgeon Chi Yonglong made two 5 mm incisions in front of his neck, inserted a small catheter along the incision and placed an endoscope. Dr. Chi watched the TV monitor to remove the bones and scars that oppressed the spine, loosen the soft tissue in front of the neck, reset it at the same time, and finally fix it with screws. The whole operation lasted more than 3 hours, and the patient's bleeding during the operation was only about 20 ml. It is reported that this is the first case in China.
Source: China Health Network Release Date: April 2, 2006114: 42: 53.
Fracture and dislocation of cervical spine:
1, cervical subluxation: more common. It can be caused by the sudden braking of the car, and the passenger's head is used to it, which is caused by a sudden forward movement. This kind of injury is easy to be ignored and will lead to paraplegia.
2. Fracture of cervical vertebra: It mostly occurs in cervical vertebra 5 ~ 7, which is caused by excessive flexion. Often combined with dislocation and acute disc herniation, causing spinal cord injury.
3, cervical dislocation: mostly caused by flexion injury. After the imaginary edge of the next vertebral body is compressed, the dislocated vertebral body moves forward, one or two intervertebral joints can be locked, and the spinal cord is often bruised or compressed.
4. Atlanto-axial fracture and dislocation: When the cervical vertebra is buckled, the transverse ligament of Atlanto-axial fracture and Atlanto-axial dislocation forward. Fracture of the base of the odontoid process of the axis and annular anterior dislocation can also occur. Both of these conditions can lead to spinal cord injury. However, because the odontoid process of the fracture moves forward together with the annular vertebra, the risk of spinal cord compression is small. When the odontoid process of the axis is fractured at the base, because the displacement of the annular vertebra is not obvious at that time, the fracture can not be fixed in time, and it may be ignored because it does not heal or delay healing. Later, the symptoms were relieved, and when the patient began to move, delayed dislocation or delayed paraplegia of the annular vertebra could occur. Extensional fracture and dislocation, odontoid basal fracture, atlantoaxial posterior dislocation and ligamentum flavum squeezing into spinal canal can also occur, resulting in spinal cord injury. Violent blows to the head vertically downward, squeezing the lateral mass to separate it to both sides, and the anterior and posterior arches of the annular vertebrae are weak, which may lead to fractures.
clinical picture
(1) Having a history of serious injuries, such as falling from high altitude, heavy objects hitting the head, neck, shoulders or back, diving injuries, being buried by mud and ore in landslide accidents, etc.
(2) When the cervical vertebra is injured, headache and neck pain occur, and the wounded often hold their heads in their hands.
Emergency treatment
(1) Use wooden boards or door panels for handling.
(2) First straighten the injured lower limbs and put the upper limbs aside. This board is placed on the side of the wounded, and two or three people support the trunk of the wounded, making it roll over and move to the board. Be careful not to twist the trunk. Or three people at the same time hold the wounded with their hands and go straight to the board. It is forbidden to cuddle or raise your head and feet, because these methods will increase the curvature of the spine and aggravate the injury of vertebrae and spinal cord.
(3) For the wounded with cervical spine injury, there should be a special person to hold the head and pull it slightly along the longitudinal axis to make the head and neck roll with the trunk. Or the injured person holds his head with his own hands and moves slowly. It is forbidden to forcibly move the head at will. After sleeping on the board, put sand bags or folded clothes on both sides of the neck to fix it.
treat cordially
(a) if there are other serious compound injuries, should actively rescue, save the lives of the wounded.
(2) Fracture or dislocation of cervical vertebra
1. If the compression or displacement is light, use the jaw pillow sling for traction and reduction in the prone position. The traction weight is 3 ~ 5 kg. After reduction, the neck was fixed with plaster for about 3 months. The plaster immediately hardened and buckled.
2. If there is obvious compression or displacement, or barrel dislocation, continuous skull traction is used for reduction. The traction weight is 3 ~ 5 kg, which can be increased by 6 ~ 10 kg if necessary. X-rays should be taken in time for review. If it has been reset, it should be fixed with head, neck and chest plaster at the same time.
3. Patients with cervical spine fracture and dislocation and articular process lock have higher recurrence rate and greater risk. Closed or open reduction is required, but special care should be taken.
paraplegia
Fracture of vertebral body or appendix, displaced vertebral body or bone fragments protruding into spinal canal can compress spinal cord or cauda equina nerve, causing different degrees of injury. Symmetrical sensation, movement and reflex disappear completely below the injured plane and below the bilateral chest and abdomen, and the bladder and anal sphincter function are completely lost, which is called complete paraplegia, while some functions exist, which is called incomplete paraplegia. After cervical spinal cord injury, those who have neurological dysfunction of both upper limbs at the same time are quadriplegia, referred to as quadriplegia for short. After spinal cord injury, systematic nervous system examination should be carried out, including sensory, motor, reflex, sphincter function and autonomic nerve function examination.
Principles of treatment:
(1) Early release of the compression on the spinal cord is the primary problem to ensure the recovery of spinal cord function. Spinal fracture or fracture dislocation should be restored as soon as possible. Patients with incomplete paraplegia can recover spinal cord function to varying degrees after correct treatment.
(2) electroacupuncture and massage therapy: electroacupuncture, massage and massage can promote the recovery of nerve function, paralyze the passive contraction of limb muscles, promote blood and lymphatic circulation, and help avoid muscle atrophy, limb edema and joint stiffness and deformity.
(3) Functional exercise
Prevention and treatment of complications
1, prevention and treatment of bedsore 2, prevention and treatment of urinary tract infection and calculus 3, treatment of constipation: abdominal massage, 3-4 yuan can eat a single rhubarb, or take Maren pills, or enema. 4, prevention and treatment of respiratory infections: often pay attention to turn over, encourage patients to take a deep breath, cough according to the abdomen, help discharge secretions or suck out with an aspirator. 5. Treatment of body temperature disorder: When the cervical spinal cord is injured, the wounded often have high fever or low temperature, which is mainly caused by the dysfunction of the autonomic nervous system and the inability to adjust and adapt to the change of environmental temperature. An abnormal body temperature is a sign of danger. The mortality rate is high. The treatment is mainly aimed at high fever, taking physical cooling, such as ice compress, alcohol bath, ice water enema and so on. Drug cooling is ineffective. At the same time, we should adjust the room temperature, treat complications, use antibiotics, infusion and other measures.