What is Spinal Rehabilitation?

The principle of spinal fracture rehabilitation is to promote fracture healing, restore the stability and flexibility of the spine, prevent muscle atrophy, chronic pain, and eliminate the adverse effects of long-term bed rest on the body. Early rehabilitation and treatment go hand in hand to prevent complications and promote the maximum recovery of residual functions; on the basis of maintaining residual functions, retrain the command and control functions of the nervous system and retrain the original functions of residual muscles to compensate Some functions have been lost; according to the anatomical and physiological basis, the level of injury and the degree of injury, a gradual and systematic rehabilitation training is conducted to achieve functional independence and return to society.

Spinal fracture rehabilitation

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The principle of spinal fracture rehabilitation is to promote

Patients with suspected spinal fractures should not be moved arbitrarily. They must be treated in accordance with the first-aid method of spine fractures, so as not to cause fracture displacement and aggravate spinal cord injury, resulting in irreparable consequences. First aid principles are:

1. It should be fixed at the injury site and sent to the hospital as soon as possible;

2. Take correct fixing and handling methods

(1) Handling with wooden boards or door panels, do not use soft stretchers;

(2) Rolling method should be adopted when carrying: first straighten the lower limbs of the injured person, straighten both upper limbs on the side of the body, place the wooden board on the side of the injured person, and support the injured person's head, trunk, and pelvis by 3-4 people And both lower limbs, so that the head, neck, torso and lower limbs are rolled and moved to the wooden board as a whole. The spine is always maintained in a neutral position during transportation. It is forbidden to embrace, back or lift one's head or one's legs to prevent spinal fractures and rotations. Displacement and injury to the spinal cord.

(3) When a cervical spine fracture or dislocation is suspected, someone must support the head and pull slightly along the longitudinal axis. The cervical spine maintains a neutral position, so that the head, neck and torso roll as a whole onto the hard board. Sandbags or clothing, cushions, etc. are stuffed on the sides to restrict head and neck movements; it is strictly forbidden to forcibly move the head;

3. Pay attention to whether the airway is obstructed and remove it in time ^[3]

1. Simple spinal fracture: Reduction, fixation and functional exercise should be performed according to the general principles of fracture, and care should be taken to avoid causing spinal cord injury;

2. Unstable spinal fracture with spinal cord injury:

(1) Surgery should be performed immediately after the injury to restore the sequence and stability of the spine, to completely decompress, to relieve the pressure on the spinal cord and horsetail, and to create conditions for the recovery of nerve function; firm internal fixation allows patients to get the opportunity of early turning activities To reduce local re-injury;
(2) Active prevention of various complications, of which respiratory and urinary tract infections, bedsores, and venous thrombosis should be particularly noted.

(3) Rehabilitation treatment should be carried out in time to promote the recovery of nerve function.

1. Stable spinal fractures: Promote fracture healing, restore the stability and flexibility of the spine, prevent muscle atrophy, chronic pain, and eliminate the adverse effects of long-term bed rest on the body;

Rehabilitation of thoracolumbar fracture and dislocation

(I. Overview

The thoracolumbar vertebra is the transition area of the thoracic and lumbar spine. It is located between the thoracic vertebra with low mobility and strong stability and the lumbar vertebra with high mobility and relatively poor stability. The stress concentration produced makes the thoracolumbar vertebra easily damaged .

1. Damage mechanism: It is often caused by indirect violence. The damage mechanisms mainly include axial compression, axial distraction, axial rotation and horizontal shear force. Some of the thoracolumbar fractures have a single function, while others have a combination of several mechanisms. Experimental studies have shown that different compression conditions of the vertebral body directly affect the fracture type, axial compression causes burst fractures, and forward flexion loading produces compression fractures. The three-dimensional finite element analysis revealed that the injury mechanism of burst fractures was related to the stress concentration of the pedicle, the posterior and upper vertebral body, and the adjacent parts of the pedicle. The morphology, thickness, vertebral trabecular bone density, arrangement direction, and anatomical structure of the vertebral venous foramen are the basis of the tissue structure of the spinal canal bone mass. The instantaneous pressure and residual pressure in the spinal canal during burst fracture formation are important factors that cause spinal nerve tissue damage and prevent the recovery of nerve tissue function.

2. Three-column classification concept of thoracolumbar fracture and dislocation

With the development of CT technology and injury mechanism research, Dennis proposed the concept of three pillars of spine classification in 1983. He believed that the thoracolumbar spine could be divided into anterior, middle, and posterior columns. The anterior column included the anterior longitudinal ligament and the anterior 1/2 of the vertebral body. The front part of the intervertebral disc, the middle column includes the posterior longitudinal ligament, the posterior half of the vertebral body and the posterior part of the intervertebral disc. The posterior column includes the vertebral arch, yellow ligament, intervertebral facet joint and interspinous ligament. The stability of the spine depends on the integrity of the middle column. In 1984, Ferguson further perfected Denis's three-column concept. He believed that the posterior column includes the supraspinous ligament, the interspinous ligament, the ligamentum flavum, the articular process, and the articular capsule. The anterior column includes the anterior 2/3 and anterior longitudinal ligaments of the vertebral body and disc. According to the three-column theory, the key to the stability of the spine is the middle column. Anyone who destroys the middle column is an unstable fracture.

Denis believes that stable fractures refer to: (1) all mild fractures, such as transverse process fractures, articular process fractures, or spinous process fractures. (2) Light or moderate compression fracture of the vertebral body.

Unstable fractures are divided into 3 degrees; (1) I degree: those who may undergo spinal curvature or angulation under physiological load are mechanically unstable, such as severe compression fractures; (2) II degree: unreduced burst fracture Secondary advanced nerve injury; (3) Degree III: fracture dislocation and severe burst fracture combined with nerve injury.

In addition, it is also related to the location of the injury. The thoracic spine injury is mostly stable. If the same injury occurs in the lumbar spine, it may be unstable.

3. Clinical classification of thoracolumbar fractures and dislocations

Many researchers have proposed a variety of classification methods for thoracolumbar fractures based on clinical surgery and experimental anatomy. However, so far, no classification method for thoracolumbar fractures has been applied worldwide. At present, the classification methods with greater impact and wider clinical application are Denis classification and McAfee classification.

(1) Denis classification: Denis proposed to divide thoracolumbar fractures into four categories based on the concept of three columns:

Type A: compression fracture; Type B: burst fracture; Type C: seat belt fracture; Type D: fracture dislocation. Class B is divided into five subtypes: upper and lower middle plate type; upper end plate type; lower end plate type; burst rotation type; burst lateral flexion type. Type C fractures are divided into single-horizontal and bi-horizontal fracture lines, and each type is divided into bone injury and soft tissue injury, which are classified as type 4. Type D has 3 types: flexion and rotation fracture dislocation; shear fracture dislocation; flexion stretch fracture dislocation.

(2) McAfee classification: McAfee and others analyzed the CT performance of 100 patients with thoracolumbar fractures and the condition of the middle column force, and proposed to divide thoracolumbar fractures into 6 categories:

Simple wedge compression fracture: This is the result of anterior spinal column injury. Violence comes from the force of rotation along the X axis, causing the spine to flex forward, the rear structure is rarely affected, and the vertebral body is usually wedge-shaped. This type of fracture does not damage the middle column, and the spine still maintains its stability. It is usually a fall injury, with the feet and hips on the ground, and the body flexes violently, resulting in compression of the front half of the vertebra.

Stable burst fracture: It is the result of spinal anterior and middle column injuries. The violence comes from the axial compression of the Y axis. Usually it is also a fall injury, the feet and hips are on the ground, the spine remains upright, the vertebral body of the thoracolumbar spine receives the most stress, and is broken due to compression. Because there is no rotational force, the back of the spine is not affected, so it remains Although the spine is stable, broken vertebral bodies and discs can protrude in front of the spinal canal, and damage the spinal cord to produce neurological symptoms.

Unstable burst fracture: It is the result of simultaneous injury of the front, middle and back three columns. Violence comes from the axial compression of the Y axis and clockwise rotation, and may also involve the rotational force along the Z axis, which also causes the posterior column to break. Due to spinal instability, post-traumatic spinal process and progressive neurological symptoms may occur. .

Chance fracture: It is common to wear high-speed car waist belts. At the moment of a collision, the upper part of the patient's body moves forward sharply and bends forward. The front pillar is the hub, and the rear pillar and the middle pillar are stretched and pulled apart. This is called a Chance fracture. The fracture line traverses the injured spinous process, lamina, pedicle and vertebral body. It may also be through the rupture of the ligament structure, that is, the supraspinous, interspinous ligament and the ligamentum flavum rupture, the articular process is separated, and the fibrous ring at the back of the disc is ruptured. This type of injury is also seen in fall injuries.

Flexion-stretch injury: The flexion crankshaft is behind the anterior longitudinal ligament. The anterior column is damaged due to compressive force, while the middle and posterior columns are injured due to the tensile force of tension. Part of the injury of the central column is the capsular capsule Dislocation, subluxation, or fracture of the articular process, this kind of injury often involves the participation of Y-axis rotational force, so this type of injury is often a potentially unstable fracture, due to the ligamentum flavum, interspinous ligament, and superior spinal ligament. There are tears.
Displacement injury: including Slice fracture, rotational fracture dislocation and simple dislocation. Violence comes from the Z axis. For example, in a car accident, the violence comes directly from the back of the back, or when bending down to work, a heavy object falls directly at the back and hits the back. Under the action of strong violence, the alignment of the spinal canal has been completely destroyed, and the injury plane The vertebral body is displaced along the horizontal axis. Usually the three columns are destroyed by shear force. The injury plane usually passes through the disc and the participation of rotational force. Therefore, the dislocation is more serious than the fracture. When the articular process is completely dislocated, the lower joint The process moves to the front of the articular process on the next vertebra and blocks each other. It is called interlocking of the articular process. It is a very serious spinal injury with a poor prognosis. In addition, there are some simple attachment fractures, such as laminar fractures and transverse process fractures, which do not cause instability of the spine. They are called stable fractures, especially transverse process fractures, which are often caused by violent contraction of the lumbar muscles after the back is hit. Avulsion fracture.

(B) clinical treatment principles

1. Treatment of simple wedge compression fracture

The spinal stability of this type of fracture is not affected, and the spinal cord is not damaged, and conservative treatment is used. Try to restore the height of the anterior edge of the injured vertebra to normal, correct the kyphosis, restore the weight-bearing function, and avoid complications such as traumatic spondylitis and sequelae. There are roughly two approaches to clinical management:

(1) Rest on a hard plank bed and start back muscle exercises after 1 week of pain relief. It is suitable for those who have a slight degree of vertebral compression, who are old and frail and cannot tolerate reduction and fixation;

(2) Those whose vertebral compression height is less than 1/5, lie supine on a rigid bed with a thick pillow at the fracture site to make the spine overextend. At the same time, instruct the wounded to start the back muscle exercise 3 days later. After 3 months, the fracture basically healed. During the third month, he could go to the ground for a little activity, but still mainly rest in bed. After 3 months, he gradually increased the time to go to the ground.

(3) Adolescents and middle-aged injured with a vertebral compression height of more than 1/5 should be reset, fixed with plaster vests and back muscle exercises. Double ankle suspension method or double table method can be used to fix the plaster vest for 3-4 months after one-time reset. After the plaster is dried, the wounded are encouraged to get up and stay for about 3 months. During the fixed period, insist on doing back muscles every day. Work out and increase exercise time every day.

2. Treatment of burst fractures

(1) For stable burst fractures without neurological symptoms, who have been confirmed by CT to have no bones squeezed into the spinal canal, can be reduced by the double ankle suspension method. Because of its large longitudinal traction, it is safer, but caution is required. ;

(2) Unstable burst fractures with neurological symptoms and fractured pieces squeezed into the spinal canal should not be reduced. Surgical treatment should be performed for this type of wounded. The lateral anterior approach is used to remove protruding fractures and intervertebral disc tissue in the spinal canal. Then, an intervertebral bone graft fusion is performed, and an anterior internal fixation can be placed if necessary, and a posterior internal fixation is necessary if the posterior column is damaged.

3 Chance fractures, flexion-stretch injuries, and displacement injuries are unstable fractures. Anterior or posterior reduction and internal fixation are required to restore the normal alignment and stability of the spine, and provide ideal for the recovery of nerve tissue. Environment, reducing complications and increasing injury recovery rates.

(Three) rehabilitation treatment of thoracolumbar fracture and dislocation

1. Stable thoracolumbar fracture

The purpose of rehabilitation is to prevent trunk muscle atrophy, promote fracture healing, restore stability and flexibility of the spine, and prevent lower back pain.

(1) Stage 1: Within 1 week after injury. Without reduction and fixation of stable fractures, bed rest should be started until local pain is relieved. Exercises on the back and abdominal muscles should be started when the local pain is alleviated. When the plaster vest is fixed, the exercises on the back and back muscles should be performed after the plaster is dry. At this stage, painless back muscle isometric contraction training is mainly used to increase the strength around the spine and stabilize the spine through the isometric contraction of the back muscles. At the same time, the tension of the anterior longitudinal ligament and the anterior fibrous ring of the intervertebral disc is increased to promote the compression of the spine. The leading edge of the body gradually opens. At the same time can be supplemented by active movements of the limbs. The training intensity and time should be gradually increased, and avoid local obvious pain, and avoid spinal forward flexion and rotation during training.

(2) Stage 2: 2-3 weeks after the injury, at this time the pain basically disappeared, and began to do isotonic contraction exercises and turn-over exercises of the trunk muscles. Improve spine stability by increasing trunk muscle strength, reduce tissue fibrosis or adhesions, prevent osteoporosis, disuse atrophy of lower back muscles and chronic chronic lower back pain.

The isotonic exercises of the lumbar and back muscles begin from the supine position to support chest movements and gradually increase to bridge exercise; those with plaster can do exercises such as supine lifting, leg lifting, and hip lifting in the plaster. When turning over, the waist should be maintained in an extended position. Shoulder and pelvis are aligned in a straight line to perform an axial turn. After turning over, you can do waist extension exercises in the prone position. Starting from the prone lifting movement, you can gradually increase the prone leg raising exercise to increase when painless. Prone "Yan Fei" practice.

Chest press in supine position: With the legs in a supine position, the legs are naturally straightened, hands are placed on the side of the body, and the head, shoulders, and feet are used as support points. Drop at the same time

Bridge movement: supine position, legs flexed, feet on the bed, hands on the side of the body, with the head, elbows, and feet as support points, lift the back of the waist off the bed, hold for 6 seconds, lay down. Be careful not to hold your breath. After breathing is even, take the next shot. If the action can be easily completed, put your hands on the abdomen and perform bridge movements with head and feet support; or put one lower limb on the other side for single bridge exercise to increase the difficulty;

Prone "Yan Fei" action: Turn the shaft to the prone position, and use the abdomen as a support point to lift your head, upper chest, upper limbs, and legs as much as possible, and keep it down for 6 seconds. If the action cannot be completed, a disassembly action can be performed, such as a prone head-up action or a prone leg-up action.

In addition, the abdominal muscles play a special role in maintaining the stability and movement of the spine. The weakness of the abdominal muscles can increase the physiological lordosis and the instability of the lower lumbar spine caused by the pelvic tilt. Therefore, it is very important to enhance the strength of the abdominal muscles. In sports training, in order to prevent abdominal muscles from increasing the spine load and causing pain, the following actions can be performed: during abdominal exercises, supine knee flexion, raising the head and shoulders in the hip flexion posture, or raising the head and posture in the supine posture Shoulder to horizontal position.

(3) Stage 3: About 4-5 weeks after injury. At this time, if there is no pain when doing lying position exercises, you can get up and walk under the protection of plaster or braces. When standing from the supine position, first prone on the edge of the bed, one leg down to the ground, then support the upper body, and then lower the other leg to support the upper body to form a standing position without passing through the middle to avoid waist flexion. Reverse order when standing from a standing position. Standing time can be gradually increased. After the fracture has basically healed, you can take a seated position. You still need to maintain the lordosis of the lumbar spine to avoid a bent posture.

(4) Stage 4: About 8-12 weeks after injury. At this point, the fracture is basically healed. After the plaster is removed, the strength of the lumbar and abdominal muscles can be further increased, and the lumbar spine flexibility can be increased. Lumbar and back muscle exercises should be combined with abdominal exercises to maintain the flexion and extensor balance and improve the stability of the lumbar spine. When the fracture is left with an angular deformity, the abdominal muscles should be strengthened after the healing is firm, so as to control the lumbar lordosis and prevent lower back pain. The training of the lumbar spine is mainly flexion, extension, and lateral flexion. On this basis, the training of rotation movements can be appropriately increased. After the thoracolumbar fracture, you need to pay attention to the correct posture of the lower back for various related movements for life.

2. Unstable thoracolumbar fracture and dislocation

Thoracolumbar fractures and dislocations that are unstable or with neurological dysfunction require surgery. Due to the rapid development of spine surgery theory and technology, modern spinal surgery has a very different mentality and surgical method than 10 years ago. It can achieve complete decompression and sufficient stability. Generally, there is no need for postoperative surgery. Fix with plaster.

The stages of rehabilitation are related to the speed and extent of nerve damage and recovery.

(1) For those without nerve damage or with only partial neurological dysfunction, the first week after surgery is the first stage. Isometric contraction exercises of abdominal and back muscles and active movement of the limbs are performed; 2-3 after surgery Zhou pain has basically disappeared. Entering the second stage, a small-scale isotonic exercise of abdominal and back muscles can be performed, but active turning is still prohibited. This movement will cause spine rotation and affect the stability of internal fixation; 4 weeks after surgery After entering the third stage, you can start to get out of bed gradually under the protection of the brace. The action of getting out of bed is the same as the previous conservative treatment, and it increases the active isotonic contraction of the abdominal muscles. However, it must be noted that within 3 months after surgery, spinal mobility exercises should still be controlled within a small range, and active and passive spinal rotations are still prohibited. After the fracture has healed, a large-scale spine mobility training and rotation exercise can begin.

(2) Unstable fractures with spinal cord injury, stage 1-2 after surgery, stage 2 after 3-12 weeks, and stage 3 after 12 weeks. After the fracture heals, you can get out of bed under the protection and help of braces or other instruments. The remaining principles of rehabilitation training will be discussed in detail in spinal cord injury.

Rehabilitation of cervical fracture and dislocation

Cervical spine fractures and dislocations refer to injuries to the cervical vertebrae, joints, and related ligaments caused by direct or indirect violence, and are often accompanied by spinal and spinal nerve root injuries. They are mostly unstable fractures and are one of the more serious types of spinal injuries. Common in the lower cervical spine (C3-C7).

(I. Overview

1. Injury mechanism: It can be caused by vertical compression, flexion, distraction, rotation or shear force. Flexural violence is the main cause of cervical spine fracture and dislocation. Fractures and dislocations cause localized narrowing of the cervical spinal canal, which can easily damage the spinal cord, especially fractures and dislocations in cervical swellings of 5 to 7 necks, which are more likely to be associated with spinal cord injury. During normal anatomy, the sagittal diameter of the spinal canal of the necks 3 to 7 is about 14 mm. If it is 12 mm or less, the spinal cord will be oppressed. Therefore, when the vertebral body is moved forward to 1 / 3-1 / 2 of the vertebral sagittal diameter during fracture and dislocation, spinal cord compression is difficult to survive.

2. Classification of cervical spine fractures and dislocations

There are 7 types of cervical fractures and dislocations:

(1) Teardrop-like type: if a C5 compression fracture with a teardrop-like tear in the upper corner of the vertebra is a stable fracture of the anterior column; in severe cases, such as avulsion fractures in the central vertebra, The spinal cord is compressed with an unstable fracture;

(2) Incomplete compression fracture type: such as comminuted fracture of the anterior edge of the C5 vertebra, the fracture passes through the upper vertebral endplate and part of the lower endplate. Generally, the spinal canal is less involved, which is a stable fracture of the middle and front column. ;

(3) Complete compression fracture type: if the C5 fracture passes through the upper and lower endplates of the vertebra, the cortex behind the vertebra is not broken, and the spinal dura mater is compressed, which is an unstable fracture of the mid-anterior column;

(4) Burst type of vertebral body: The vertebral body is a comminuted fracture that protrudes to the front and back of the vertebral body, the upper and lower endplates, and the intervertebral disc are damaged. Unstable anterior column fracture

(5) Flexion type: it is the result of anterior column compression and posterior column injury. The anterior, middle, and posterior columns are involved. If it can be reduced and fixed internally, it is a stable fracture.

(6) Extension type, which is caused by the damage of extension and axial load, with multi-segment lamina fracture, belongs to three-pillar unstable fracture;

(7) Facet joint dislocation interlocking type: It is caused by the forward force of the cervical spine acting on the upper vertebral body, the facet joint capsule ruptures, and the joint process jumps to cause facet joint interlocking.

(B) clinical treatment principles

1. Stability cervical fracture: Reduction, fixation and functional exercise. Once diagnosed, the cervical spine cannot be stretched to prevent cervical spinal cord injury. Occipital jaw traction or skull traction should be applied. The direction of traction makes the cervical spine slightly flexed. The traction weight starts from 2 to 3 kg and gradually increases under close observation. Once reset, the cervical vertebra is maintained in a physiological position, and after 3 weeks, it is fixed with a head, neck, chest, plaster or brace for 3 months. After the plaster is dry, you can get up and move. If there are nerve stimulation or compression symptoms during traction, adjust the traction weight and direction. If the symptoms do not disappear or there is a tendency to aggravate, the traction should be stopped immediately, and the spinal cord cannot be damaged for reduction. If the compression fracture is obvious and there is bilateral intervertebral joint dislocation, you can use continuous skull traction reduction and X-ray review in time. If it has been reset, it can be fixed with head, neck and chest plaster after 2-3 weeks of traction. The fixation time is about 3 month. Patients with symptoms of spinal cord injury and traction failure must undergo surgical reduction. If necessary, the interlocking joint process can be removed to obtain a good reduction.

2. Unstable cervical fractures and dislocations: Early surgery should be performed. The purpose of surgery is to regain the stability of the cervical spine and restore or expand the spinal canal of the injured segment, relieve the compression of the spinal cord by fracture fragments and disc fragments, and reduce spinal edema Reduce the internal pressure of the spinal cord, improve the blood circulation of the spinal cord, avoid and reduce secondary injuries to the spinal cord, and create conditions for spinal cord function recovery.

(1) Burst fracture with spinal cord injury: In principle, early surgical treatment should be used. Usually, anterior surgery, resection of bone fragments, decompression, bone graft fusion and internal fixation are usually used. However, most of these cases are seriously ill. Severe concomitant injuries require surgery after stabilization if necessary.

(2) Stretch injury: Department of unstable fracture, should be treated early. The posterior lateral plate steel screw internal fixation is an effective and safe method.

(Three) rehabilitation treatment of cervical fracture and dislocation

Fracture of cervical spine

Generally, conservative treatment of traction reduction + fixed + functional exercise is adopted. Rehabilitation should begin as soon as possible without affecting neck stability.

(1) Stage 1: Within 3 weeks after the injury, the patient is usually bedridden for cervical traction. Active and passive movements of the limbs can be performed to maintain joint mobility, improve blood circulation, prevent muscle atrophy, and prevent bedcomplications.

(2) Stage 2: 3 weeks to 3 months after injury. At this stage, the patient's cervical spine was successfully reset, and he had been treated with plaster or braces. He could gradually move under the protection of external fixation. The active movement of the limbs would restore muscle strength and endurance. At the same time, he would gradually increase the isometric contraction training of the neck and shoulder muscle groups. For mild cervical fractures around 2 months after the injury, the external fixation can be removed daily for lying-down weight loss of the neck muscle group.

(3) Stage 3: Three months after the injury, the external fixation of the cervical spine of the patient has been removed, and the isotonic contraction exercise of the neck muscle group can be increased, and the exercise intensity is gradually increased; at the same time, the recovery of the neck joint mobility is started. The training is mainly for cervical spine flexion, extension and lateral flexion, and proper rotation is performed to restore the flexibility and flexibility of the head and neck.

2. unstable cervical fracture and dislocation

This type of cervical spine fracture should be treated as soon as possible to restore the stability of the cervical spine and relieve spinal cord compression. The rehabilitation treatment should focus on the recovery and reconstruction of spinal cord function.

(1) Bed rest period: the brace protects the cervical spine, correct body position, and prevents bed rest complications; breathing training to maintain lung function; passive exercise to prevent muscle atrophy and maintain joint mobility of paralyzed limbs

Do active activities to maintain and enhance residual muscle strength when the cervical spine is stable; feasible isometric muscle strength training for the neck muscle group;

(2) Recovery period: During this period, the cervical spine basically recovers stability. After the removal of the brace, the isotonic muscle training of the cervical muscle group and the training of cervical spine flexibility and mobility are gradually started. The emphasis is different, see the spinal cord rehabilitation article.