Spinal cord blade injuries

　　One, Etiology

　　Spinal cord blade injuries are mostly caused by crimes, with the victims suffering attacks from behind. The most common weapon is a knife, followed by an axe, and there are also screwdrivers, bicycle spokes, sickles, and sharpened bamboo or wooden sticks, etc. After the injury, the blade can be immediately removed, or it can remain or partially break within the body.

　　1, The ways of blade puncture injury to the spinal cord

　　(1) Through the intervertebral plate gap: This is the most common. The spinous process of the vertebrae projects posteriorly, and the transverse process projects laterally and posteriorly, forming a longitudinal groove between them. The blade is easy to enter the intervertebral plate gap or slide up and down behind the plate, and then enter the gap. Therefore, nearly half of the spinal cord blade injuries are hemisectional injuries.

　　(2) Through the intervertebral foramen: Most of the slender and sharp instruments entering between the vertebrae cause injury to the spinal cord, nerve roots, and blood vessels.

　　(3) Through the vertebral plate: With great force, a sharp blade is inserted into the vertebral plate, causing injury to the blade itself and the fractured fragments of the vertebral plate to the spinal cord.

　　2, The ways of spinal cord injury are divided into two types

　　(1) Direct injury: The blade or bone fragment directly pierces the spinal cord, nerve root, or blood vessel.

　　(2) Concussive injury: The blade enters one side of the spinal canal, pushing the spinal cord towards the opposite side, causing a contusion injury on the opposite side.

　　Two, Pathogenesis

　　Spinal cord blade injuries are rarely fatal, and most do not require surgical exploration, hence the early pathological data is scarce. Autopsies on patients who died from associated injuries show that part or all of the spinal cord may be excised, or it may only be contused, with the断面swelling and inversion, the dura may be damaged, and there may be hematomas within the spinal canal. In cases of root artery injury, the spinal cord may necrose and soften. The sharper the weapon, the greater the possibility of vascular injury.

　　Spinal blade injury often accompanies injuries to other organs. When abdominal organs are injured, it can be missed due to the lack of pain sensation and painful muscle tension. It can also be complicated by Brodie abscess, which is a chronic vertebral abscess caused by the broken tip of the blade left in the vertebral body. It is also known as Brodie bone abscess or osteochondral abscess: it is a bone abscess caused by low-toxicity bacteria infection, commonly occurring at the diaphyseal epiphyses of long bones, with rough rounded erosions, the eroded part filled with pus or connective tissue, which belongs to a localized bone abscess and requires surgical removal.

　　1. Characteristics of the wound

　　The wound is almost always on the back of the body, one-third in the midline or near the midline, and can be single or multiple, but generally only one wound affects the spinal cord. The direction of the wound channel is upward in the thoracic segment, horizontal or downward in the cervical and lumbar segments. The size of the wound is related to the type of blade, with the smallest being only a small hole, which needs to be carefully examined to be found.

　　2. Cerebrospinal fluid leakage

　　4% to 6% of wounds have cerebrospinal fluid leakage, which usually stops within 2 weeks.

　　3. Neurological symptoms

　　According to the statistics of 450 cases by Peacock, the injury location accounts for 63.8% in the thoracic segment, 29.6% in the cervical segment, 6.7% in the lumbar segment, and only 20.9% are complete injuries. Incomplete injuries account for 70%. It presents with typical or atypical Brown-Sequard syndrome. Spinal shock generally recovers within 24 hours. In cases with arterial injury, symptoms are often severe, and the temperature may rise below the injury level due to sympathetic paralysis and vascular dilation.

　　Nursing care for spinal cord injury is also very important. Spinal cord injury must be bed rest, and appropriate dietary restrictions should be made within one week after the injury to avoid bloating affecting breathing. High-protein, high-fat, high-carbohydrate, and vitamin-rich foods should be provided after 2-3 weeks of injury. After surgery, active prevention and treatment of complications should be carried out to keep the respiratory tract unobstructed, prevent pulmonary infection. For paraplegic patients, turning and back patting should be performed regularly to assist in sputum expectoration, prevent skin decubitus ulcers, and use soft pads for protection immediately after the injury. Turning every 2-3 hours should be maintained to keep the bowels smooth. Rehabilitation treatment should start early, the earlier the easier the recovery, but the method must be correct. Junjun's treatment was relatively timely, but it would have been better if he had been carried to the hospital instead of being transported on a flat board.

　　1. X-ray flat film:Large fractured fragments may be found, and the segment of injury can also be identified based on the tip position of the retained blade or the position of the remaining part after fracture. Routine shooting of the anterior and lateral views should be performed. The slender blade parallel to the direction of exposure may appear as a dot, and if it overlaps on the vertebra, it is not easy to find. Pay attention to the presence of pneumothorax, pleural effusion, and free gas under the diaphragm on chest and abdominal X-rays.

　　2. Axial CT:The residual blade or fractured fragment locations, or the presence of intraspinal hematoma, abscesses, and other space-occupying lesions requiring surgery can be clearly displayed, but metallic foreign bodies often produce artifacts that affect observation.

　　3, Magnetic Resonance Imaging:It can clearly show the degree of spinal cord injury, the typical hemisection injury is a transverse defect on one side of the spinal cord in the coronal position, the defect area is long T1, long T2 signal, and if there is metal residue, this examination is generally not performed.

　　4, When the nervous system:If symptoms worsen, surgery should be explored, but it is not convenient to perform CT or MRI at that time, in order to clarify the relationship between the wound channel and the spinal canal, spinal cord iodine water myelography should be performed to understand whether there is compression or obstruction.

　　1,食疗方 for spinal cord blade injuries:

　　Maintain a balanced diet, eat more fruits and vegetables and other high-fiber foods, eat more eggs, soybeans, and other high-protein foods, pay attention to a light diet, and engage in moderate exercise.

　　2, What not to eat for spinal cord firearm injuries:

　　Avoid smoking and drinking, and refrain from spicy, coffee, and other irritant foods.

　　First, Treatment

　　1, Prioritize the treatment of injuries to important organs in the neck, chest, and abdomen.

　　2, Early intravenous application of high-dose antibiotics, intramuscular injection of TAT.

　　3, Wound treatment: Small wounds, if there is no obvious contamination, can only be flushed superficially and then sutured. Larger wounds with tissue necrosis or severe contamination need debridement of the wound channel. Compared with firearm injuries, the treatment of blade injuries is more conservative, but the premise is to use a large amount of broad-spectrum antibiotics.

　　4, Indications for surgery: In the following situations, lumbar laminectomy can be considered:

　　(1) Imaging confirms foreign bodies in the spinal canal, bone fragments exist, and need to be removed.

　　(2) Progressive neurological dysfunction, CT or MRI confirms hematoma in the spinal canal.

　　(3) Cerebrospinal fluid leakage from the wound for more than 3 weeks without healing requires suture repair of the dura mater.

　　(4) There is an abscess or chronic granuloma in the spinal canal, causing symptoms of spinal cord compression.

　　Second, Prognosis

　　The prognosis of blade injuries is better than that of firearm injuries, because the cut edge of the spinal cord is neat, the range of contusion is small, and it is conducive to the repair of nerve tissue. In the 450 cases reported by Peacock, 65.6% recovered well and could walk without or with slight support, 17.1% needed crutches to walk; 17.3% had no recovery, and 9 of the 16 deceased died early from meningitis or thrombosis.