Thoracic and lumbosacral spine fracture (dislocation): clinical guidelines

List of Abbreviations

AB — antibacterial drugs,

BF — biofeedback,

BoNT-A — botulinum toxin type A-hemagglutinin complex**,

VAS — 10-point visual analogue scale,

HBO — hyperbaric oxygenation,

VC — vital capacity,

CT — computed tomography,

MRI — magnetic resonance imaging,

LF — therapeutic exercise,

MDRT — multidisciplinary rehabilitation team,

MSCT — multislice computed tomography,

NSAIDs — non-steroidal anti-inflammatory and antirheumatic drugs,

FMS — functional spinal unit,

PNF — proprioceptive neuromuscular facilitation,

ASCI — acute spinal cord injury,

VBR — vertebral body replacement,

ACSF — anterior cervical spine fusion,

SCT — spiral computed tomography,

EMS — emergency medical services,

Dura — dura mater,

TPF — transpedicular fixation,

SCI — spinal cord injury,

PE — pulmonary embolism,

UHF — ultra-high-frequency therapy,

UVI — ultraviolet irradiation.

FEV1 — forced expiratory volume in 1 second,

PT — physical therapy,

PRM — physical and rehabilitation medicine,

CVP — central venous pressure,

TENS — transcutaneous electrical nerve stimulation,

EMS – electromagnetic muscle stimulation,

II – image intensifier

Terms and Definitions

Kyphosis – a change in the shape of a spinal segment in the sagittal plane with the formation of a deformity with a posteriorly directed convexity (abnormal kyphosis).

Neurogenic shock – a type of spinal shock occurring in spinal cord injury above the Th6 level, manifested by bradycardia, hypotension, and impaired thermoregulation.

Spinal motion segment instability – a pathological condition characterized by a decreased ability of a spinal motion segment to maintain relationships between vertebrae that prevent irritation of the spinal cord or nerve roots, as well as prevent deformation of the spinal column under physiological loads.

Paraplegia – complete loss of function of the trunk, legs, and pelvic organs resulting from damage to the thoracic, lumbar, or sacral segments of the spinal cord, conus medullaris, or cauda equina roots.

Paraparesis – partial impairment of the function of the trunk, legs, and pelvic organs resulting from damage to the thoracic, lumbar, or sacral segments of the spinal cord, conus medullaris, or cauda equina roots.

Anterior cord syndrome – incomplete spinal cord injury manifesting as impaired motor function, pain, and temperature sensation with preserved proprioceptive sensation.

Spinal motion segment – a functional unit consisting of two adjacent vertebrae, the intervertebral disc connecting them, the zygapophyseal joints, and the muscular-ligamentous apparatus.

Vertebral canal – a canal bounded anteriorly by vertebral bodies and intervertebral discs, posteriorly and laterally by vertebral arches and ligaments connecting them; the contents of the canal include the spinal meninges, epidural/subarachnoid spaces, spinal cord, and its roots.

Postural deformity – a positional, non-structural spinal deformity that occurs upon verticalization.

Brown-Séquard syndrome – an incomplete (hemisection) spinal cord injury characterized by impaired motor function and proprioceptive sensation on the side of the lesion and loss of pain and temperature sensation on the contralateral side.

Conus medullaris and cauda equina syndrome – incomplete injury to the spinal cord and its roots, manifested by flaccid paralysis of the legs, and areflexia of the urinary bladder and rectal sphincter.

Spondylodesis – bony fusion of vertebrae or a surgical procedure creating conditions for such fusion.

Spinal shock – the absence of spinal cord function below the level of injury lasting for 3–30 days as a result of edema, contusion, and supramaximal protective inhibition of nerve cell activity.

Tetraplegia – complete loss of muscle strength in the arms, legs, and trunk, and impaired pelvic organ function resulting from damage to the spinal cord segments at the cervical level.

Tetraparesis – partial impairment of the function of the arms, legs, trunk, and pelvic organs resulting from damage to the spinal cord segments at the cervical level.

Central cord syndrome – incomplete injury to the cervical spinal cord characterized by preserved sensation in the sacral segments and greater weakness in the upper extremities than in the lower ones.

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) – spinal cord injury with no evidence of spinal column damage on radiographs or CT scans.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Spinal cord injury – a pathological condition representing a combination of injuries to the structures of the spinal column and the neurovascular structures of the vertebral canal.

Concussion of the spinal cord – spinal cord injury accompanied by mild neurological disorders, typically resolving within the first 3–7 days, without morphological changes in the spinal cord and its roots.

Uncomplicated spinal injury – a pathological condition arising from a disruption of the anatomical integrity of spinal column structures under the influence of an external force.

Contusion of the spinal cord – spinal cord injury occurring at the moment of trauma and accompanied by complete or partial anatomical destruction of its structure with hemorrhages, areas of ischemia, necrosis, and regional edema. Manifested by neurological disorders lasting more than 7 days.

Vertebral dislocation – a type of spinal injury representing the displacement of a vertebra relative to the underlying vertebrae, during which the articular connection between the dislocated and the inferior vertebra is disrupted.

Vertebral subluxation – a type of spinal injury representing partial displacement and/or rotation of one vertebra relative to another, with disruption of the articular connection between the dislocated and the inferior vertebra in a single joint.

Spontaneous reduction of vertebral dislocation – a type of spinal injury representing the displacement of a vertebra relative to the underlying vertebrae at the time of injury and its return to the anatomical position by the time of examination.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The main causes of spinal and spinal cord injury in adults are: catatropinic injury (about 50% of victims), motor vehicle accidents (about 30% of victims), and diving into shallow water (about 10% of victims). In children, the leading cause of spinal cord injury is motor vehicle accidents (over 50%).

In the structure of spinal injuries in adults, older school-age children, and adolescents, about 90% of injuries occur at the thoracic and lumbar levels, with 68.8% of the total number of injuries accounting for the thoracolumbar junction [1]. For younger and preschool-aged children, cervical spine injuries are predominant due to anatomical and physiological features.

The severity of spinal injury depends on factors such as the severity of wedge deformity and compression of the vertebral body, the degree of destruction and dislocation of its fragments in burst fractures, simultaneous injury to two or more spinal segments, the magnitude of kyphotic deformity, and the presence of osteoporosis [1,2,3].

Mechanisms of neuronal damage in spinal cord injury:

1) primary: acute compression, progressive compression, impact, stretching, tearing, gunshot wound, movement in an unstable spinal segment;

2) secondary: extracellular (hypoxia, microcirculatory disturbance, tissue edema, ischemia, inflammation), intracellular (electrolyte imbalance, reperfusion injury, excess excitatory neurotransmitters, excitotoxic mediators, activation of lipid peroxidation, free radical release, energy metabolism disruption, apoptosis, cellular edema, impaired neurotrophic factor production).

1.3 Epidemiology of the Disease or Condition

The incidence of spinal cord injury worldwide ranges from 15 to 40 per 1 million population per year, and the prevalence is 750 cases per 1 million population [3,6,7]. Uncomplicated spinal injury in a large industrial city is 31.7 per 100,000 population per year and is predominantly represented by the working-age population [8, 41].

Spinal injuries account for 5.5%–17.8% of musculoskeletal injuries. Patients with acute spinal cord injury make up 2%–3% of all patients hospitalized in neurosurgery departments. Spinal injuries in children reach 10% of all spinal injuries [44].

Associated injuries are detected in 28%–50% of patients with spinal cord injury [51].

In the Russian Federation, there are an average of 10.34 ± 11.55 cases of superficial spinal injuries, 4.3 ± 3.9 compression fractures, and 0.2 ± 0.2 unstable and complicated spinal column injuries per 10,000 children [148].

According to statistical data, the most frequent localization of compression fractures in children is the midthoracic spine. This is a fundamental difference from the situation typical for adult patients, in whom vertebral body fractures of the thoracolumbar junction and lumbar spine rank first in frequency [148].

1.4 Features of Coding the Disease or Condition

Fracture of rib(s), sternum and thoracic spine (S22)

M48.3 Traumatic spondylopathy

S22.0 Fracture of thoracic vertebra

S22.1 Multiple fractures of thoracic spine

S23 Dislocation, sprain and strain of joints and ligaments of thorax

S23.0 Traumatic rupture of thoracic intervertebral disc

S23.1 Dislocation of thoracic vertebra

S23.3 Sprain and strain of thoracic spine

S24 Injury of nerves and spinal cord at thorax level

S24.0 Concussion and oedema of thoracic spinal cord

S24.1 Other and unspecified injuries of thoracic spinal cord

S24.2 Injury of nerve root of thoracic spine

S32 Fracture of lumbar spine and pelvis

S32.0 Fracture of lumbar vertebra

S32.1 Fracture of sacrum

S32.2 Fracture of coccyx

S32.20 Closed fracture of coccyx

S33 Dislocation, sprain and strain of joints and ligaments of lumbar spine and pelvis

S33.0 Traumatic rupture of lumbar and lumbosacral intervertebral disc

S33.1 Dislocation of lumbar vertebra

S33.2 Dislocation of sacroiliac and sacrococcygeal joint

S33.3 Dislocation of other and unspecified parts of lumbar spine and pelvis

S34 Injury of nerves and lumbar spinal cord at abdomen, lower back and pelvis level

S34.0 Concussion and edema of lumbar spinal cord

S34.1 Other injury of lumbar spinal cord

S34.2 Injury of nerve root of lumbosacral spine

S34.3 Injury of cauda equina

T91.1 Sequelae of vertebral fracture

1.5 Classification of the disease or condition

Classification of spinal cord injury by timing:

1. Hyperacute period (first 8 hours);

2. Acute period (from 8 hours to 3 days);

3. Early period (from 3 days to 4 weeks);

4. Intermediate period (from 1 to 3 months);

5. Late period (more than 3 months).

Classification of spinal cord injury by integument integrity:

1. Closed;

2. Open;

3. Penetrating.

Classification of spinal cord injury by spinal stability:

1. Stable;

2. Unstable.

Classification of spinal cord injury by presence of neurological deficit:

1. Uncomplicated;

2. Complicated.

Classification of spinal cord injury by type of neural structure damage:

1. Spinal cord concussion;

2. Spinal cord and/or spinal nerve root contusion;

3. Spinal cord and/or spinal nerve root compression;

4. Partial transection of spinal cord and/or spinal nerves;

5. Complete anatomical transection of spinal cord and/or spinal nerves.

Classification of spinal cord injury by compressing substrate:

1. Subdural hematoma;

2. Epidural hematoma;

3. Intramedullary hematoma;

4. Bone or bone fragments;

5. Traumatic disc herniation;

6. Foreign body.

AOSpine Classification:

• Compression injuries (Type A): A0, A1, A2, A3, A4.

• Distraction injuries (Type B): B1, B2, B3.

• Spinal translation (Type C).

ASIA/ISCOS classification of neurological deficit severity (American Spinal Injury Association International Standards for Neurological and Functional Classification of Spinal Cord Injury)

• Grade A

• Grade B

• Grade C

• Grade D

• Grade E

Comment: Injuries to two or more adjacent vertebrae and/or intervertebral discs are classified as multiple spinal column injuries. Injuries to two or more non-adjacent vertebrae and/or intervertebral discs are classified as multilevel spinal column injuries. Multiple vertebral fractures at a single level may be combined with multiple injuries at another level. Such trauma is referred to as multiple multilevel spinal column injuries.

1.6 Clinical presentation of the disease or condition

Injury of the thoracic and/or lumbar spine is characterized by pain in the respective spinal segment, paraspinal muscle spasm, restricted range of motion in the spine and extremities, and frequently by motor dysfunction and sensory disturbances.

The clinical presentation of complicated thoracic and/or lumbar spine injury typically manifests as one of the following syndromes or their combination: radicular syndrome, myelopathy syndrome, central cord syndrome, anterior cord syndrome, Brown-Séquard syndrome, conus medullaris syndrome, cauda equina syndrome, neurogenic shock, spinal shock.

Specific considerations in children and adolescents

A distinctive feature of pediatric age is that minor injuries can present with pronounced complaints, whereas severe traumatic injuries may present with masked and vague symptoms. In addition, the severity of pain syndrome and the nature of complaints depend on the child's psycho-emotional state [148].

During examination, attention should be paid to manifestations of mesenchymal insufficiency in the patient, such as joint hypermobility, telangiectasias in the paraspinal regions, and others, considering the fact that in such children, vertebral injuries occur even with minimal external traumatic forces.

One of the characteristics of vertebral body compression fractures in children is the lack of a clear correlation between the mechanism of injury and the fracture pattern. Even minimal spinal trauma can lead to vertebral body compression and vice versa: significant impact of a traumatic agent may result in minor bone injuries [148].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the disease or condition

1. History that does not rule out spinal cord injury.

2. Appearance of characteristic complaints following the trauma, onset of neurological deficit (if present).

3. Detection of traumatic spinal changes at the corresponding level using instrumental diagnostic methods.

Specific considerations in children and adolescents

A distinctive feature of spinal compression fractures in children is the involvement of multiple vertebral bodies, either adjacent or separated by 1–2 segments. The presence of multiple vertebral body fractures is characteristic of pediatric patients, occurring in 40% of cases involving unstable spinal column injuries. At the age of 5–7 years, the presence of a vertebral body compression fracture more commonly manifests as a loss of height in the injured column with minimal wedge deformity. This is related to the anatomical and physiological features of the trabecular structure of the vertebral body in children of this age group [148].

2.1 Complaints and Anamnesis

When taking the medical history, it is recommended to clarify the mechanism and time of the injury, localization of pain, motor and sensory disorders, and the time of their onset. It is recommended to find out whether the victim could move their legs and arms immediately after the injury and whether they noted any sensory disturbances.

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Comment: Any patient admitted with trauma to the intensive care unit should be evaluated and treated as having a spinal injury until the absence of spinal injury at all levels has been ruled out.

2.2 Physical Examination

• perform a general clinical examination of the patient with assessment of the orthopedic status and skin condition;

• exclude signs of infectious foci;

• identify the relationship between existing limb and chest deformities and the current injury [4, 9, 44, 45, 46, 47].

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Comments: The patient's examination should be performed in the supine position. During this process, it is necessary to identify the localization of injury traces and visible deformities. The physician must examine the entire patient rather than only "profile-specific organs," which will minimize diagnostic errors. The detection of soft tissue edema, as well as retraction of paraspinal tissues, may indicate muscle rupture at the level of the damaged spinal segment. Prominence of the spinous processes combined with widening of the adjacent interspinous spaces and tenderness on palpation at this level is a sign of local injury to the functional spinal unit (FSU). Paraspinal muscle spasm is often present as a reaction to pain. Together, these physical examination findings allow determining the required scope of radiological examination to confirm or exclude spinal and spinal cord injuries. In severe polytrauma, the examination of patients must be performed simultaneously with urgent anti-shock measures.

• Spinal palpation is recommended to be performed with extreme caution [9, 46].

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Comment: performing forced palpation may cause additional injury to the victim.

• When assessing the neurological status in patients with spinal cord injury, it is recommended to use the ASIA/ISNCSCI scale (international standards for neurological and functional classification of spinal cord injury) (APPENDIX G1) [9, 46].

Evidence level 5, Grade of recommendation C

2.3 Laboratory Diagnostics

• All patients diagnosed with a duodenal fracture for whom surgical treatment is planned are recommended to undergo the following laboratory tests:

- complete blood count (CBC);

- urinalysis;

- routine general biochemical blood test;

- blood potassium level testing;

- blood sodium level testing;

- blood chloride level testing;

- determination of ABO blood groups and Rh factor (D antigen) typing;

- hepatitis B surface antigen (HBsAg);

- antibodies to hepatitis C virus (Anti-HCV);

- determination of antibodies to Treponema pallidum in the blood;

- testing for human immunodeficiency virus HIV 1/2 antibodies (IgM, IgG) and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood;

- coagulogram (screening hemostasis test);

- determination of the international normalized ratio (INR) [4, 44, 47].

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2.4 Instrumental Diagnostics

During the diagnostic process, it is recommended to obtain the most accurate information not only regarding the level and nature of the spinal cord injury, but also the type of vertebral injury. This can only be achieved through a comprehensive patient examination that establishes:

I. Level of spinal and spinal cord injury.

II. Nature of the vertebral injury (injuries):

a) number of injured vertebrae;

b) presence and severity of vertebral body injury;

c) fractures of the arches, articular and/or transverse processes, localization of displaced fragments;

d) type of fracture (stable or unstable);

e) injury to the disc(s) and the direction of their displacement;

f) presence of hematomas in the spinal canal, nature of changes in the spinal cord and its roots.

III. Condition of the spinal column:

a) degree and type of spinal deformity (kyphotic, scoliotic);

b) presence and nature of dislocation (bilateral, unilateral, locked, " perched", etc.);

c) presence of rotational, translational, or axial displacement of the spinal column.

d) condition of the ligamentous apparatus.

Based on the obtained data, the following are determined:

1. Indications for surgical or conservative treatment.

2. Timing of surgery depending on the patient's condition and the priority of surgical intervention (in polytrauma with spinal injury);

3. Scope of surgery, its strategy and tactics (one- or two-stage treatment, content of each stage, timing of staged surgeries; the most convenient surgical approach for the given injury that ensures minimal invasiveness and maximum radicality).

• Patients with suspected spinal trauma are recommended to undergo spiral computed tomography (SCT) of the thoracic or lumbar spine (A06.03.058.002 Spiral computed tomography of the spine) [4, 42, 44].

Level of Evidence (LE) 2, Grade of Recommendation (GR) A

• Patients with polytrauma are recommended to undergo SCT of the spine (Spiral computed tomography of all spinal regions) [9, 48].

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• In cases where there are doubts in interpreting the performed studies, or the clinical picture does not match the radiological and/or CT findings, when it is necessary to visualize the spinal cord and/or nerve roots, as well as the soft tissue structures of the spinal column, it is recommended to perform MRI of the thoracic or lumbar spine (Magnetic resonance imaging of the spine [one region]) [49, 50].

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Comment: MRI allows for the evaluation of the soft tissue structures of the spine: ligaments, intervertebral discs, spinal meninges, and the spinal cord itself along with any pathological changes (ischemia, edema, hemorrhage, cyst, extra- and intradural hemorrhages), as well as changes in the vertebral bodies. MRI plays a leading role in the diagnosis of post-traumatic disc herniations. In the presence of compressive radicular or myeloradicular symptoms, when radiographic images show no bone pathology, MR tomograms may reveal a traumatic disc herniation.

• When describing the morphology of a vertebral injury, it is recommended to use the AOSpine classification (APPENDIX G2) [44].

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2.5 Other Procedures

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Comment: Spinal radiography in a number of cases fails to detect all bone injuries and, as a rule, does not provide a complete picture of the fracture characteristics, nor does it allow for the selection of optimal treatment tactics.

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Comment: To determine the lower boundary of the subarachnoid space block, it is recommended to perform ascending myelography (contrast agent is injected into the L4-L5 or L5-S1 intervertebral space) with the head of the X-ray table tilted downward. To determine the upper boundary of the block, descending myelography (contrast injection into the lateral cistern) is recommended.

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• For patients with polytrauma, as part of the preoperative evaluation, it is recommended to perform chest radiography (targeted chest radiography), electrocardiography (decoding, description, and interpretation of electrocardiographic data), echocardiography, ultrasound examination of the abdominal organs, kidneys, and bladder (comprehensive abdominal ultrasound, retroperitoneal ultrasound), spirography (remote monitoring of external respiration parameters), and fibroesophagogastroduodenoscopy (esophagogastroduodenoscopy) [10, 11, 44].

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3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

• To determine the treatment strategy, it is recommended to take into account the TLICS and TL AOSIS scales (APPENDIX G3, APPENDIX G4) [9, 15, 44]

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3.1 Conservative Treatment

3.1.1 Conservative treatment of patients with acute spinal cord injury in a specialized department

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

• For compression fractures of the thoracic and lumbar vertebral bodies of types A1 and A2 with kyphotic deformity greater than 25° (but not exceeding 40°) for the thoracic spine and greater than 10–15° for the lumbar spine, in the absence of spinal cord compression, treatment by one-stage closed reclination on a bolster or using various types of reclinators is recommended. In such injuries, vertebroplasty, kyphoplasty, or vertebral stenting may be used. Bed rest for 2–4 weeks and thoracolumbar external fixation for 1–3 months are recommended [9].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Comments: Spinal injury requires the selection of a pathogenetically substantiated treatment method taking into account the prognosis of the likely outcome. Conservative methods require specific indications and allow achieving favorable functional outcomes in the long term.

1. Soft tissue contusion of the back, distortion of the musculo-ligamentous apparatus of the thoracic and lumbar spine: outpatient treatment, adherence to an orthopedic sparing regimen, and physiotherapy are indicated.

2. Injury to the ligamentous apparatus (isolated ruptures of the supraspinous and interspinous ligaments): conservative treatment is indicated. An analgesic effect can be achieved both by systemic use of analgesics and anesthetics in accordance with their instructions for use and locally by therapeutic blockade (in this case, administration of a local anesthetic into the interspinous space is recommended). Subsequently, in case of severe pain syndrome, spinal immobilization with orthoses for up to 6 weeks is permitted.

3. Fractures of the spinous processes and transverse processes (including multiple ones): adherence to a sparing (load-free) regimen and systemic administration of non-narcotic analgesics in accordance with their instructions for use are recommended. In the acute period of spinal cord injury, a local anesthetic solution can be injected into the fracture zone. If severe pain persists, spinal immobilization with orthoses for up to 3–6 weeks is permitted.

4. For isolated fractures of the articular processes without displacement, as well as isolated fractures of the vertebral arches, immobilization with a rigid, removable fixing orthosis for 3–6 weeks is recommended.

5. For compression fractures of the thoracic and lumbar vertebrae types A1 and A2 (AO Spine), conservative inpatient treatment is recommended: bed rest for 3 to 5 days, pain management with non-narcotic analgesics, physiotherapy, limb massage (massage for spinal disorders), and therapeutic exercise (physical therapy) for spinal injuries. In case of severe localized pain, a paravertebral block with local anesthetics in the area of the vertebral body fracture may be performed. After relief of acute pain, patient verticalization is recommended, along with immobilization using a three-point fixation removable or plaster corset for a period of 16–24 weeks. Fractures of thoracic vertebrae above Th6 require immobilization of the cervical spine as well. Therapeutic exercise should ideally begin on the second day after the injury and be continued throughout the entire period of inpatient and outpatient treatment.

• If the patient refuses surgery or if there are contraindications to surgical treatment, conservative treatment is recommended. The duration of corset immobilization should be determined based on radiological signs of fracture healing (at least 24–28 weeks) with a continuous course of physical therapy and physiotherapy [8, 18, 19, 44, 47].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

3.1.2 Treatment of patients with acute spinal cord injury in resuscitation or intensive care units

All patients with acute complicated or uncomplicated multilevel cervical spine injury, upper thoracic spine injury (up to the Th6 vertebra), and patients with spinal cord injury and associated trauma are recommended to be hospitalized in resuscitation or intensive care units; cardiac and respiratory monitoring is mandatory for the timely diagnosis of cardiovascular and respiratory disorders, along with basic therapy [4, 10, 44].

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Comment: Basic therapy includes: regulation of respiratory and cardiovascular function, correction of biochemical homeostasis parameters, combating spinal cord edema, prevention of infectious complications, pressure ulcers, hypovolemia, and hypoproteinemia; regulation of pelvic organ function via intermittent urinary bladder catheterization; correction of microcirculation disorders; normalization of blood rheological parameters; hyperbaric oxygen therapy sessions, etc.

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

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• The use of methylprednisolone** is not recommended [43, 61].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

• Patients with a neurological deficit are recommended to be prescribed anticoagulants (ATX antithrombotic agents) [3, 61].

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Specific considerations in children and adolescents

1. pain relief,

2. unloading of the anterior spinal segments,

3. restoration of normal blood circulation in the damaged zone of the vertebral motion segment,

4. formation of the muscular corset of the spine,

5. formation of correct posture.

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Comments: The use of a hyperextension corset is an orthopedic tool to influence the restoration of the height and shape of the injured vertebra, which has a wedge-shaped deformity as a result of a compression fracture, during the physiological growth of the child and the act of breathing. This process is ensured by unloading the growth zones of the endplates of damaged and wedge-shaped deformed vertebral bodies, as well as by creating a biomechanically correct direction of forces that allows reliable fixation and unloading of the injured parts of the vertebrae without limiting the rate of natural growth during the active act of breathing.

3.2 Surgical Treatment

3.2.1 Indications and contraindications for surgical treatment of patients with thoracic and lumbar spine injuries

• During preoperative planning, it is recommended to identify absolute and relative indications for emergency and elective surgical treatment, as well as to identify contraindications (within 6 hours for emergency hospitalization, and within 3 days for elective hospitalization) [3, 25, 44, 51].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

• injuries to the thoracic or lumbar spine of types A3, A4, B1–B3, and C (AOSpine) with the appearance and/or progression of a neurological deficit, which is a manifestation of compression of the spinal cord, cauda equina, or nerve roots with a defined compression substrate identified by diagnostic imaging methods, and also caused by instability;

• spinal canal deformations caused by radiopaque compressing substrates (bone fragments, structures of dislocated vertebrae, or due to severe angular deformity exceeding 11° in the cervical, 40° in the thoracic, and 25° in the lumbar spine) or radiolucent compressing substrates (hematoma, traumatic disc herniation, damaged ligamentum flavum, foreign body) in the presence of neurological deficit;

• isolated hematomyelia combined with cerebrospinal fluid pathway block;

• clinical and angiographic signs of compression of the spinal cord master vessel;

• hyperalgic and paralytic forms of spinal nerve root compression;

• unstable injuries of spinal motion segments presenting a risk of displacement of the vertebrae or their fragments and secondary compression of the spinal cord;

• foreign bodies within the spinal structures;

• cerebrospinal fluid leak;

• complicated trauma with damage to the dura mater (in case of stab, incised, and gunshot wounds of the spine) [4, 44, 47].

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• When determining indications for surgical intervention in uncomplicated spinal trauma, it is recommended to be guided by the spinal injury grading system, where conservative treatment is recommended for grade 1 spinal injury; spinal stabilization and, in some cases, decompression of the spinal cord and/or its roots for grade 2; and spinal cord decompression and spinal stabilization for grade 3.

Table 1. Grading of spinal injury severity depending on the number of injured columns, vertebral displacement, and angular deformity of the spinal column.

• In the presence of the following factor(s) (one or more), surgical treatment for patients with spinal trauma is not recommended [4, 25, 44]:

1. Traumatic or hemorrhagic shock with hemodynamic instability.

2. Concomitant internal organ injuries (in case of internal bleeding, risk of peritonitis, cardiac contusion with signs of heart failure, multiple rib fractures with hemopneumothorax and signs of respiratory failure (sO2 on oxygen insufflation less than 85%)).

3. Severe traumatic brain injury with a level of consciousness impairment of less than 10 points on the Glasgow Coma Scale, with suspected intracranial hematoma (APPENDIX G10).

4. Severe concomitant diseases accompanied by anemia (hemoglobin less than 80–90 g/L), cardiovascular, renal (anuria, oliguria, urea > 20 mmol/L, creatinine > 180 mmol/L) and/or hepatic (total protein < 50 g/L, enzyme elevation more than three to four times) failure.

5. Fat embolism, pulmonary embolism, pneumonia, unreduced limb fractures.

6. Gunshot or blast injury of the spinal cord at the C1–C4 segment level with the clinical picture of a complete functional transection of the spinal cord.

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Compensated acute (chronic) diseases or severe structural alterations of internal organs requiring preliminary surgical correction or drug therapy should be considered relative contraindications to surgical treatment in patients with thoracic and/or lumbar spine trauma: acute infectious diseases; cardiac pathology (severe forms of coronary artery disease, complex cardiac arrhythmias); chronic respiratory diseases; kidney diseases with manifestations of renal failure; oncological diseases and other pathological conditions. A history of previous spinal surgeries complicated by suppuration is also a relative contraindication [25, 44].

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

Comments: In cases of spinal trauma with indications for surgical treatment and injuries to organs of other systems (in severe polytrauma), the feasibility of performing decompressive and decompressive-stabilizing surgeries is determined according to damage control principles [11, 13, 36].

3.2.2 Management of patients with spinal cord injury in the absence of bone trauma.

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3.2.3 Treatment methods for thoracic and lumbar spine and spinal cord injuries without neurological deficit.

• For type A2 vertebral fractures with a loss of vertebral body height of less than 50%, conservative therapy or vertebroplasty/kyphoplasty is recommended.

• For type A2 vertebral fractures with a loss of vertebral body height of 50% or more, it is recommended: a) anterior distraction using lift systems (vertebral body replacement prosthesis), autologous bone grafting and titanium plate or anterior rod-based system; or b) within the first 3–7 days in young patients and 3–12 days in elderly patients – posterior transpedicular spinal fusion with reduction of the fractured vertebra and, optionally, a combination with one of the kyphoplasty options [25, 44, 47].

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• Unstable spinal injury: for compression fractures of the thoracic and lumbar spine (A2, A3 types according to AOSpine), it is recommended to perform anterior distraction (preferably using lift systems – vertebral body replacement prostheses), anterior arthrodesis with auto- or allograft and a plate or anterior rod-based system. If bone fragments or intervertebral disc fragments are present in the spinal canal, anterior decompression is mandatory. For type A4 fractures, posterior bisegmental transpedicular spinal fusion with simultaneous reduction of the fractured vertebra is recommended. For injuries of the Th11–L2 vertebrae, placement of a long-segment fixation system is recommended [44, 47, 51].

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Comment: Due to the low level of certainty regarding differences in local deformity correction, functional outcomes, and complications for type A3 and A4 thoracolumbar vertebral fractures, alternative procedures may include: ventral arthrodesis (in the absence of osteoporosis); long-segment transpedicular fixation (with or without vertebral body augmentation); short-segment transpedicular fixation (with vertebral body augmentation); short-segment transpedicular fixation with screw insertion into the fractured vertebra; short-segment transpedicular fixation followed by implant removal upon healing of the injured vertebra [3, 25, 33].

• For unstable distraction fractures (types B1, B2, B3 according to AOSpine), percutaneous (or open) transpedicular spinal fusion (or posterior stabilization with hook or hybrid (transpedicular-hook) systems) is recommended. If the anterior column is disrupted, it is recommended to supplement the surgery with endoscopic or minimally invasive anterior arthrodesis using video assistance or special retractors. It is recommended to maintain bed rest for up to 1–3 days and thoracolumbar sacral external fixation for 1–3 months [44, 47].

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• For unstable rotational injuries of the thoracic or lumbar spine (type C), it is recommended to use posterior open reduction and fixation (transpedicular, laminar, hybrid), and decompression if spinal canal structures are compressed. The second stage, performed simultaneously or after a delay, is endoscopic or minimally invasive anterior arthrodesis [30, 31, 44].

Level of Evidence (LE) 2, Grade of Recommendation (GR) C

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• Vertebral body compression fractures in the setting of osteoporosis are recommended to be treated using vertebroplasty and kyphoplasty only in cases of refractory pain syndrome at 10–15 days post-injury; pharmacotherapy affecting bone tissue remodeling is advisable [37, 38, 39, 40].

Level of Evidence (LE) 2, Grade of Recommendation (GR) A

3.2.4 Treatment methods for thoracic and lumbar spine and spinal cord injuries with neurological deficit

• Stable spinal injury: It is recommended to perform laminectomy, spinal cord revision with local hypothermia. In the presence of kyphotic deformity – reclinatio and posterior stabilization with hook, pedicle screw, or hybrid (pedicle-hook) systems. It is recommended to prescribe bed rest for up to 1–3 days and thoracolumbosacral external fixation for 1–3 months [47].

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• Unstable spinal injury: for AOSpine fracture types A3 and A4, it is recommended to perform an intervention via a posterior approach with indirect (via ligamentotaxis) or direct (via anterior or anterolateral approaches) decompression. When performing decompression via a posterior approach, it is recommended to perform mandatory transpedicular fixation followed by ventral spondylodesis, which can be performed in a delayed manner. The regression of neurological symptoms does not depend on the chosen approach for decompression [29, 30, 31].

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

• For AOSpine type B2 injuries with posterior and/or anterolateral compression, it is recommended to perform surgery via a posterior approach under conditions of transpedicular fixation (TPF). In the presence of anterior compression, elimination of the compression from the posterior approach with preliminary ligamentotaxis is recommended. The performance of ventral spondylodesis may be delayed [30, 31].

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

• For AOSpine type B3 and C injuries, it is recommended to base the choice of approach on the presence and localization of the compressing substrate (disc or ligament elements). In the presence of anterior compression of the dural sac (spinal cord, cauda equina), the surgery is recommended to be performed under TPF conditions in the volume of reduction, laminectomy, and anterior decompression. In case of circular compression of the dural sac (spinal cord, cauda equina), decompression can be performed via a posterior or combined approach [32].

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

Comment: When performing corpectomy, it is advisable to use an isolated bone graft or a vertebral body prosthesis. In all patients with concomitant osteoporosis, posterior fixation is recommended using cannulated screws with simultaneous vertebroplasty. In all patients, posterior transpedicular spondylodesis is recommended to be performed, if possible, using minimally invasive technologies. The priority and advisability of using minimally invasive technologies should be determined by their efficacy in each specific case.

3.2.5 Treatment tactics for patients with stab, gunshot, and blast injuries of the spine

• remove foreign bodies and take cultures from the wound and foreign bodies for microflora and antibiotic sensitivity (examination of wound discharge for aerobic and facultatively anaerobic microorganisms);

• perform meningomyeloradiculolysis;

• restore the lumen of the spinal canal and the integrity of the dura mater;

• in case of unstable spinal injury, perform its stabilization (rigid spinal fixation);

• in case of wound contamination and potential cerebrospinal fluid leak, install a passive drainage via a counter-incision (external lumbar drainage);

• in case of dural tear, install a lumbar drain in the postoperative period for up to 2–5 days (depending on the inflammatory response);

• from the first minutes after hospitalization, prescribe broad-spectrum antibiotic therapy combined with anaerobic infection prophylaxis;

• it is recommended to prescribe hyperbaric oxygen therapy (HBOT), therapeutic exercises, and massage from the first day after surgery (in the absence of other contraindications) [44, 51].

LNC 5 LeC C

3.2.6 Management tactics for patients with multiple and multilevel spinal injuries

• When determining the priority of surgical intervention at different levels, it is recommended to be guided by the following priorities. First of all, the level of complicated trauma should be subjected to surgical intervention, followed by the level of unstable and/or uncomplicated injury. All other things being equal, the cranial level should be operated on first. During surgical treatment, it is recommended to adhere to the following principles:

1. For closely adjacent levels of injury, the surgery is performed from a single approach (if there are 3 or fewer uninjured vertebrae between the damaged ones).

2. If there are 4 or more intact vertebrae between the damaged ones, the approach to each damaged vertebra is performed from separate incisions, avoiding connection of the wounds.

3. In the presence of a complete spinal cord injury at two different levels (clinically and/or according to CT, MRI data), it is recommended to operate on both levels and, at each of them, perform complete decompression of the spinal canal, restoration of CSF circulation (in case of dural damage, perform its plasty), and finish the operation with fixation. Stabilization must be supplemented with anterior spondylodesis [44].

LNC 5 LeC C

• After surgical treatment of a patient with an injury to the thoracic and/or lumbar spine, it is recommended to perform radiological/CT/MRI control (Radiography of the thoracic spine / Radiography of the lumbar spine / Spiral computed tomography of the spine / Magnetic resonance imaging of the spine (one segment)) [10, 44, 47].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Specific considerations in children and adolescents

LNC 5 LeC C

Comment: Such an approach to this type of injury in pediatric patients is carried out in order to minimize the zone of spinal stabilization and the extent of spondylodesis, to allow the continuation of growth processes in the free segment, and to preserve the mobility of the spinal motion segment between the fixed sections of the spinal column.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients after injury to the thoracic and lumbar spine are recommended to undergo early rehabilitation from the first day after surgery. The scope of rehabilitation measures is determined for each patient by the multidisciplinary rehabilitation team (MDRT) specialists together with the attending physician [53].

LNC 5 LeC C

Comments: The rehabilitation program may include muscle electrical stimulation - A17.02, Drug electrophoresis for diseases of the central nervous system and brain - A17.23.001, Local darsonvalization for diseases of the central nervous system and brain - A17.23.002, Spinal cord electrical neurostimulation - A17.23.003, Brain electrical neurostimulation - A17.23.004, Transcranial magnetic stimulation - A17.23.004.001, Percutaneous electrical nerve stimulation for peripheral nervous system diseases - A17.24.001, Galvanization for peripheral nervous system diseases - A17.24.002, Local darsonvalization for peripheral nervous system diseases - A17.24.004; Therapeutic exercises for spinal injury (including robotic mechanotherapy and mechanotherapy with biofeedback) A19.03.001 – A19.03.004.027, Therapeutic exercises for joint diseases and injuries - A19.04.001 – A19.04.001.025, Therapeutic exercises aimed at reducing spasticity - A19.23.001, Therapeutic exercises for peripheral nervous system diseases - A19.24.001, Mud therapy for bone system diseases - A20.03.001, Mud therapy for central nervous system and brain diseases (ozokerite) - A20.23.001, Mud therapy for peripheral nervous system diseases - A20.24.001, Massage for bone fractures - A21.03.001, Manual therapy for joint diseases - A21.04.001, Massage for central nervous system diseases - A21.23.001, Manual therapy for peripheral nervous system diseases - A21.24.001, Low-level laser therapy for muscle diseases - A22.02.001, Intra-articular laser therapy - A22.04.001, Low-level laser therapy for central nervous system and brain diseases - A22.23.001, Low-level laser therapy for peripheral nervous system diseases - A22.24.001; Prescription of medications for central nervous system and brain diseases - A25.23.001.

4.1. General guidelines on the rehabilitation of patients with cervical vertebra dislocation

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Level of Evidence 5, Grade of Recommendation C,

LNC 4 LeC C

LNC 5 LeC C

LNC 5 LeC C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

LNC 5 LeC C

LNC 5 LeC C

LNC 5 LeC C

LNC 5 LeC C

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4.2. Medical rehabilitation in early medical rehabilitation departments (Stage 1)

Depending on the level of spinal cord injury and combination with other injury segments, patients with spinal cord injury during the period of primary conservative and neurosurgical care (stage 1 of treatment) are managed in an intensive care unit (ICU) or specially designated emergency rooms of the traumatology or neurosurgery department with round-the-clock condition monitoring. The need for medical rehabilitation at stage 1 of specialized care is determined by the necessity of treating primary complications of spinal cord injury and preventing the secondary post-intensive care syndrome (PICS), the risk of which is directly related to the duration of ICU stay. The diagnosis of neurological disorders in spinal cord injury is extremely difficult and depends significantly on the phase of the disease. During the period of "spinal shock" (4–12 weeks), it presents a picture of a lower motor neuron lesion, gradually evolving into a true topographically conditioned symptom complex of upper and/or lower motor neuron lesions. This explains the inevitability of a predominantly symptomatic approach to early rehabilitation. The goals of rehabilitation at stage 1 should focus on the prevention of secondary conditions and preparing the patient for the maximum possible participation in rehabilitation.

The scope of rehabilitation measures is determined by the severity and level of the spinal cord injury as well as other associated injuries, the degree of "spinal shock", the overall severity of the condition, and the patient's perioperative status. The individualized program should include (but not be limited to) out-of-bed activities, acquiring tolerance to the upright position, increasing the range of motion (ROM), early strength training, and training in basic self-care.

The standard early rehabilitation program for a patient with spinal cord injury at stage 1 includes the following technological components:

- preoperative immobilization;

- treatment of autonomic dysautonomia;

- prevention and treatment of pain syndrome;

- positioning and mobilization taking into account:

o early spasticity syndrome;

o high risk of developing post-intensive care polyneuropathy combined with lower motor neuron lesions resulting in muscle hypotrophy/atrophy and contracture formation;

- verticalization taking into account orthostatic hypotension;

- prevention of pressure ulcers, urinary tract infections, deep vein thrombosis of the lower leg, including specialized nursing care;

- prevention of early depression;

- training in self-care skills.

The methodological basis of the program is the "ReabIT" rehabilitation treatment complex, supplemented by specific practices for patients with spinal cord injury. In accordance with the federal Procedure for Organizing Rehabilitation Care, the implementation of this program provides for the organization of an early rehabilitation department (ERD). The core of the department is a multidisciplinary rehabilitation team (MDRT), which includes a physical and rehabilitation medicine physician, at least 2 physical rehabilitation specialists, an ergo-rehabilitation specialist, a medical psychologist/psychotherapist, a speech and language therapist, and a medical rehabilitation nurse.

The following recommendations for early rehabilitation contain the basic tenets of the ReabIT program with comments regarding the specifics of its implementation in patients with spinal cord injury and specific recommendations focused exclusively on this pathology.

4.2.1. General provisions

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Comment. More than 50% of all ICU patients demonstrate the development of PICS. Its main component is immobilization syndrome:

- critical illness polyneuropathy (CIP): diffuse decrease in limb strength;

- decreased exercise tolerance (weakness) and shortness of breath with minimal physical activity due to post-pneumonic fibrosis;

- complications of forced positioning ("bed rest" and prone position): brachial plexus injury, foot drop and early plantar flexion contractures, pressure ulcers;

- orthostatic intolerance in the vertical position;

- impaired urinary passage and a tendency toward urolithiasis;

- constipation;

- delirium;

- chronic pain syndrome (musculoskeletal, neuropathic);

- emotional and cognitive impairments (depression, memory impairment);

- dyssomnia.

According to foreign multicenter studies [68], combining PICS symptoms into technological diagnostic and treatment modules—"positioning and mobilization", "prevention of dysphagia and nutritional deficiency", "prevention of emotional-cognitive disorders and delirium", and "prevention of loss of self-care skills"—can provide diagnostic screening and a full range of ICU rehabilitation care.

LNC 5 LeC C

Comments: complications arising in the hyperacute and acute periods of SCI aggravate the disease course, increase hospital stay duration, and may lead to fatal outcomes. Various complications occur in up to 80% of patients with SCI. Knowledge of these complications and the application of preventive and therapeutic measures can reduce their incidence by a factor of 2–3. Early rehabilitation of a patient with SCI begins with prevention.

LNC 5 LeC C

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Comments: the patient's ability to participate in rehabilitation measures depends on the severity of their condition and level of consciousness; therefore, rehabilitation can be carried out in active, passive, and active-passive modes.

The rehabilitation program should include a combination of kinesitherapeutic maneuver techniques (positioning, verticalization and mobility, cycle ergometer loads, and electroneuromyostimulation), as well as practices by clinical psychologists, ergotherapists, and speech-language pathologists. The proportion of kinesiotherapists' time should be at least 50%. Taking into account the specific features of SCI patients regarding the increased risk of immobilization complications,

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Comments. A characteristic feature of SCI is the variety of autonomic nervous system manifestations. Depending on the level of the lesion and the combination of SCI with traumatic brain injury in the hyperacute period, the patient may exhibit symptom complexes of paroxysmal sympathetic hyperactivity and autonomic dysreflexia.

Autonomic dysreflexia is a phenomenon of massive neurosympathetic response occurring in response to spinal cord irritation when the lesion is located above the Th6 segment (rarely seen with lesions below T10), i.e., above the junction of the celiac plexus with the spinal cord. In 48–90% of cases, it occurs after spinal shock when reflexes return. The loss of supraspinal inhibitory control over segmental sympathetic nerves and disruption of intersynaptic connections lead to an imbalance between the sympathetic and parasympathetic nervous systems. At the same time, descending pathways from the vasomotor center, through which impulses normalizing blood pressure could be transmitted, are "blocked" at the level of the spinal cord lesion. The reaction of the vasomotor center in the brainstem activates the vagus nerve and causes bradycardia. Pathological stimulation below the level of the lesion causes massive sympathetic impulses leading to vasoconstriction of arterioles, increased peripheral vascular resistance, and elevated blood pressure due to baroreceptor stimulation in the carotid sinus and aorta. Autonomic dysreflexia (AD) is characterized by a sudden, uncontrolled sympathetic response, usually triggered by a painful or irritating stimulus, leading to a sharp increase in blood pressure combined with bradycardia. In addition, the AD symptom complex includes: throbbing headache, anxiety, facial flushing, nasal congestion, blurred vision, nausea, goosebumps (piloerection), macular rash and hyperemia above the level of the lesion, chills without fever, increased muscle tone, profuse sweating, and bladder spasm.

Paroxysmal sympathetic hyperactivity (PSH) is caused by the loss of excitation inhibition (sympathetic disconnection syndrome) in the sympathetic nervous system without parasympathetic involvement. These mechanisms include the generation of sympathetic tone in the brainstem, hypothalamus, and spinal cord, as well as the inhibition of sympathetic discharge in cortical structures. Disconnection syndromes can develop as a result of structural and/or functional damage. Signs of PSH include typical manifestations of hyperadrenalinemia: tachycardia, elevated blood pressure, hyperhidrosis, increased muscle tone, and hyperthermia. Attacks are provoked by both painful and non-painful stimuli, but can also occur spontaneously.

4.2.2. Positioning and mobilization

Currently, there is no reliable data on the necessity and benefit of using cervical collars to stabilize the injured segment in patients with SCI [72]. Positioning of the patient to achieve sufficient spinal traction must be performed with careful attention to complications, which include exacerbation of neurological damage; increased intra-abdominal pressure and increased risk of hemorrhage; corresponding chest injury, ischemic optic neuropathy, and peripheral nerve injury. In patients with spinal injuries, changes in position can lead to significant hemodynamic changes; a sharp elevation of the head can cause severe hypotension due to impaired cerebral venous drainage, whereas a head-down position can lead to increased intracranial pressure. The rationale for immobilization seems straightforward, and it is widely regarded as the standard of care for patients at risk of spinal injury. Nevertheless, immobilization is not a benign intervention, as it can be complicated by pain, pressure ulcers, and impaired chest excursion in more than 70% of patients; in addition, neck immobilization increases the risk of respiratory disorders, intubation difficulties, gastric content aspiration, and increased intracranial pressure.

Level of Evidence (LE) 3, Grade of Recommendation (GR) C

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

Comment: unlike mobilization, positioning has no absolute contraindications and should be initiated from day 1 by the on-duty medical staff, depending on the extent of other early rehabilitation modalities. The importance of positioning for patients with traumatic spinal cord injury (TSCI) is determined not only by the need to maintain the gravitational gradient, but more so by the necessity to prevent immobilization complications associated with para/tetraplegia. Positioning is used for gravitational stimulation when raising the head of the bed, so the head of the bed must always be elevated by at least 30⁰. Sequential changes in the patient's body position are performed on a 3-section bed, forming a posture in accordance with the verticalization status, striving to have the patient spend as much time as possible in a semi-sitting or sitting position (head of the bed raised, foot of the bed lowered). Patients are assisted in successively assuming lying positions (on the right and/or left side or supine), on an elevated headrest, or sitting. Positioning on the side promotes better drainage function of the bronchi and prevents sputum stasis. Positioning on an elevated headrest and in a fully supported sitting position increases tidal volume and promotes effective coughing. It should be recognized that none of the positioning options is ideal—every position has its indications and contraindications. The task of specialists is to select the optimal postures for a specific situation and ensure their alternation. This helps avoid complications and safely carry out early mobilization and verticalization of the patient. During positioning, it is necessary to consider individual tolerance and the presence of STOP signals (Appendix 3).

Level of Evidence 2, Grade of Recommendation B

Comment: Early mobilization is an element of the rehabilitation process for patients in the ICU. Early mobilization is the process of improving the patient's functional activity, specifically the ability to turn in bed, sit up, stand up, and take steps as early as possible. Minimal yet independent muscle activity prevents the development of muscle atrophy as an early sign of immobilization syndrome. Depending on the patient's degree of participation, rehabilitation mobilization activities in the ICU are divided into active—for those capable of cooperation with multidisciplinary rehabilitation team (MDRT) members, and passive—for patients with a low quantitative and/or altered qualitative level of consciousness. Active mobilization for conscious patients involves non-contact interaction with 1-2 patients, aimed at instructing them to perform independent movements in all joints at a frequency of 10 repetitions once every 2 hours.

Passive mobilization for unconscious patients consists of passive movements in all joints with a very slight stretch at the extreme points of the physiological range of motion, performed by an MDRT specialist. For each segment, 30 repetitions once every 2 hours are sufficient.

When planning daily sessions, MDRT specialists classify the patient's condition using the mRMI-ICU scale (Modified Rivermead Mobility Index) (Appendix 2). The score on this scale indicates the degree of the patient's mobility. Combined with the level of consciousness, this creates a patient model as the basis for developing the mobilization program.

Level of Evidence 2, Grade of Recommendation B

Comment: Mobilization is a type of rehabilitation intervention that facilitates patient movement and energy expenditure in order to improve outcomes. Mobilization optimizes respiration, central and peripheral perfusion, muscle metabolism, and reduces the risk of deep vein thrombosis in the lower extremities. This effect is achieved through active-assisted cycle therapy using a bedside cycle ergometer for the lower/upper extremities with the capability of reverse movement and metered resistance. During passive kinesitherapy, the staff performs passive movements in the joints through the full range of physiological motion with muscle stretching without the patient's participation (hands, wrists, elbows, shoulders, knees, ankles, hips). It can be performed every 3 hours (at least 6 times) with 5-7 movements in each joint at a slow pace. Passive kinesitherapy can also be performed using mechanical exercise devices (including robotic ones) that provide cyclic training for individual joints and have sensors to determine the patient's contribution during the active-assisted mode. Active kinesitherapy is a series of exercises with the active participation of the patient to maintain and increase the motor activity required for verticalization. The implementation of this recommendation will be influenced by the organization of rehabilitation/mobilization measures in intensive care units.

LRE 1, GR A

LRE 1, GR A

LE 4 GSR C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Comments. Adequate bladder drainage using one of the methods: (1) permanent catheterization with a Foley catheter replaced every 5-7 days, with monitoring of adequate catheter function; (2) permanent catheterization with a silver-impregnated Foley catheter replaced once every 3-4 weeks, with function monitoring; (3) intermittent sterile catheterization with a lubricated catheter. The catheterization regimen is selected individually; the recommended frequency is every 3-4 hours to ensure adequate bladder drainage; cystostomy in the presence of complications.

The mechanism of urinary dysfunction in post-traumatic myelopathy is based on impaired communication between spinal and supraspinal levels of micturition regulation as a result of damage to pathways or spinal micturition centers. In the acute period of spinal cord injury, spinal shock develops with depression of spinal reflex activity and detrusor paresis, while preserving residual tone of the urethral sphincters and, consequently, urinary retention. Life-threatening complications of neurogenic urinary dysfunction in the acute and early periods of spinal cord injury are urosepsis and uremia. [It should] be applied in the early stages following spinal cord injury; in practice, applying the method during the spinal shock period is hindered by the intensity of rehabilitation measures, significant diuresis, and the need for its precise monitoring.

The method of periodic bladder emptying using a urethral catheter is symptomatic therapy aimed at compensating for the lost evacuation function of the organ and preventing associated urinary system complications.

Number of catheterizations

In the early period of spinal cord injury, preference should be given to sterile intermittent catheterization; subsequently, the patient can be switched to aseptic or clean catheterization. In European countries, 95% of patients with post-traumatic myelopathy use lubricated catheters (RZN 2021/16059) and perform aseptic catheterization during intermittent catheterization. At the same time, self-catheterization is used by 85% of patients with paraplegia and 46% of patients with cervical myelopathy and decreased manual capabilities of the upper extremities. The level of spinal cord injury is not necessarily a limiting factor for intermittent self-catheterization. In cervical myelopathy with motor impairment below the C5 segment, patients are able to master self-catheterization.

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Comments: normal bowel function results from the activation of the bowel reflex with a peristaltic wave and relaxation of both sphincters (S2-S4). Fecal incontinence is prevented by the tonic contraction of the internal (smooth muscle fibers) and external anal sphincters (skeletal muscle fibers). With an upper motor neuron lesion above S2, the defecation reflex remains intact, but automatic defecations occur due to a hypertonic or spastic external sphincter. With a lower motor neuron lesion, the defecation reflex is impaired and the external sphincter is hypotonic, but some intrinsic contraction remains in the intestine. Peristalsis "returns" when ileus subsides as spinal shock resolves. The bowel retraining technique is identical for central and peripheral nervous system lesions and includes several rules

- Bowel evacuation should take place every two days.

- Prescribe a laxative at bedtime (senna) and daily stool softeners (liquid paraffin) to the patient.

- The defecation reflex is triggered by anal stimulation using suppositories (glycerin) or other methods.

- A stool-forming diet is also important.

- It is important to avoid factors that lead to the disruption of functional bowel habits.

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Comments: patients with acute spinal cord injury have the highest risk of venous thromboembolic complications throughout their hospital stay. The incidence of deep vein thrombosis (DVT) in patients with spinal cord injuries who did not receive prophylaxis ranges from 39% to 100%, compared to 9% to 32% in medically and surgically untreated ICU patients. Among patients with spinal cord injury, the risk of DVT is higher with complete injury than with incomplete, with thoracic than with cervical, and during the first three months after injury. The incidence of pulmonary embolism following spinal cord injury in the absence of prophylaxis is estimated at 4% to 10%. Pulmonary embolism is one of the three most common causes of death after spinal cord injury

Level of Evidence (LoE) 2, Grade of Recommendation (GoR) B

LE 4 GSR C

Comments: to date, there are no evidence-based methods for pharmacological and combined prevention of delirium in the ICU, as no single strategy has led to a reduction in delirium incidence. Nevertheless, there is a consensus that multicomponent interventions carried out by an ICU multidisciplinary team can minimize the risks of cognitive impairment and delirium.

The prevention of delirium and other emotional and cognitive impairments is based on fulfilling the core requirements of analgosedation guideline protocols as a primary priority in PICS prevention. Current FAR guidelines mandate regular screening of the patient's pain status, regardless of their level of consciousness, and its balanced pharmacological control.

Combined physical exercise and cognitive training positively affect neuronal proliferation and improve the inflammatory environment [reduction of tumor necrosis factor (TNF)-α, interleukin (IL)-1, 6, 8, and C-reactive protein (CRP)]. These changes, in turn, contribute to improved brain structure (increased frontal and temporal gray matter density) and neural activation, as well as reduced astrocytic and microglial activity [reduction of S-100β and glial fibrillary acidic protein (GFAP)], which clinically manifests as a reduced risk of delirium and minimizes long-term emotional and cognitive impairments.

A multicomponent rehabilitation program aimed at preventing cognitive impairment includes simple limb movement exercises, spontaneous breathing cycles, maintaining the patient's current level of orientation in place and time (which is significantly facilitated by allowing the use of hearing aids and glasses), measures to ensure nighttime sleep, and performing basic self-care activities.

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Comments: pain severity at rest is influenced by both psychological (e.g., anxiety, depression) and demographic factors (e.g., young age), as well as comorbidities and a history of surgery. Pain severity during procedures is influenced by pre-procedural pain intensity, type of procedure, primary surgical or traumatic diagnoses, and demographic factors (younger age, female sex). Pain self-assessment scales: patient self-report is the gold standard for pain assessment in patients who can communicate adequately. Among critically ill adults who can self-report pain, a numeric rating scale from 0 to 10, administered verbally or visually, is a valid and feasible pain scale. The Behavioral Pain Scale (BPS) (Appendix 4) is the most reliable scale for monitoring pain in postoperative, general, and trauma ICUs for poorly responsive patients with controlled behavioral responses and motor functions who are unable to self-report pain.

Physiological parameters: vital signs (i.e., heart rate, blood pressure, respiratory rate, oxygen saturation, and EtCO2) are not reliable indicators of pain in critically ill adults and should be used only as cues to initiate further assessment using appropriate and validated methods. When appropriate and when the patient is unable to self-report, family members may be involved in the loved one's pain assessment process.

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Comments: occupational therapy is a distinct section of emotional and cognitive rehabilitation. In the ICU setting, an occupational therapist teaches the patient simple daily living activities necessary for body care (personal hygiene, dressing, eating, using a bedpan, etc.). The importance of occupational therapy in the structure of ICU rehabilitation is that it helps accelerate the restoration of the patient's premorbid performance patterns, i.e., returning to their habits, lifestyle, and social status.

The inclusion of occupational therapy in the rehabilitation complex can reduce the length of ICU stay and, in mechanically ventilated patients, the time required to adapt to spontaneous breathing. In ICU practice, occupational therapy elements are included in the duties of nursing and support staff, but future development of ICU rehabilitation will require a qualified specialist for this area of work.

LNC 4 LeC C

Comments: criteria for transfer to a specialized rehabilitation center with an intensive care unit for phase II medical rehabilitation in patients with PICS and/or chronic critical illness:

• end of the acute phase of the disease (stable clinical and radiological picture in the lungs, but with ongoing replacement of vital functions)

• stay in the intensive care unit for more than 20 days;

• low level of consciousness or functional and personality changes;

• hypermetabolic-hypercatabolic state (BMI less than 19; weight loss of more than 10% per month);

• presence of persistent bacterial infectious complications (respiratory tract infection, urogenital system infection, pressure ulcers), the most probable cause of which is the presence of invasive devices (tracheostomy tube, gastrostomy tube, urinary catheter);

• consequences of prolonged immobilization: spasticity syndrome, joint degenerative changes, teno-myogenic contractures.

If there is no regional rehabilitation center, to organize a teleconsultation, you should submit an application for a teleconsultation on the website of the National V.A. Negovsky Research Institute of General Reanimatology of the Russian Ministry of Health (or the All-Russian Center for Disaster Medicine "Zashchita" of the Russian Ministry of Health) following the established format. When requesting the consultation type, you should indicate "chronic disorder of consciousness. RSM 6." On the scheduled day, after a tele-consilium with specialists from one of the accredited rehabilitation centers, a conclusion must be issued on referring the patient to stage 2 of rehabilitation or to a palliative care department at their place of residence

4.3. Medical Rehabilitation in an Inpatient Medical Rehabilitation Department (Stage 2)

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

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Level of Evidence (LE) 3, Grade of Recommendation (GR) B

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Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

LNC 5 LeC C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

LE 4 GSR C

LVE 3 GCR A

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

LE 4 GSR C

LNC 5 LeC C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

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Level of Evidence 2, Grade of Recommendation B

• For patients over 18 years of age, for the purpose of rehabilitation (restoration) of motor functions, it is recommended to perform transcranial magnetic stimulation procedures (A17.23.004.001) in all patients with spinal cord injury [107].

Level of Evidence (LE) 2, Grade of Recommendation (GR) A

Level of Evidence (LE) 2, Grade of Recommendation (GR) A

Level of Evidence (LE) 2, Grade of Recommendation (GR) C

LNC 5 LeC C

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

LNC 4 LeC C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

LNC 4 LeC C

LE 4 GSR C

LNC 5 LeC C

4.4. Medical rehabilitation in day care medical rehabilitation departments or outpatient medical rehabilitation departments in outpatient settings (Stage 3)

LNC 5 LeC C

Level of Evidence (LE) 3, Grade of Recommendation (GR) C

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

LNC 5 LeC C

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

LNC 5 LeC C

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

LNC 5 LeC C

LNC 5 LeC C

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

LNC 5 LeC C

LNC 5 LeC C

• To prevent orthostatic hypotension, it is recommended to engage in moderate-to-vigorous aerobic exercise at least 2 times a week for at least 20 minutes, and to perform strength exercises (A19.03.001) targeting major muscle groups with moderate-to-vigorous intensity for 3 sets [87].

LNC 5 LeC C

Comment: Orthostatic hypotension is extremely common in individuals with spinal cord injury: according to one study, it was detected during orthostatic tests during physical therapy and mobilization in 74% of patients.

LE 4 GSR C

LE 4 GSR C

LNC 5 LeC C

LE 4 GSR C

LE 4 GSR C

LNC 5 LeC C

LNC 4 LeC C

4.5. Evaluation of rehabilitation efficacy

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

Examples of such tests include

-Rehabilitation Routing Scale (RRS) (APPENDIX G6),

-Rankin Scale, assessing both the degree of functional impairment and the severity of activity limitations (APPENDIX G7),

-Rivermead Mobility Index, assessing the primary criterion of activity limitation — mobility (APPENDIX G9),

-Ashworth Scale — an indicator of muscle spasticity.

-Functional Independence Measure (FIM) — a measure of independence scale (APPENDIX G5),

-Spinal Cord Independence Measure (SCIM) — a measure of independence scale in spinal cord injury (APPENDIX G8).

1. Initiation of medical rehabilitation measures no later than 48 hours after surgical treatment. [53, 54, 57, 58]

LOD 3, LEVEL OF EVIDENCE B

2. Formation of an individual medical rehabilitation program based on the diagnosis of impairments in body structures, functions, activity, and participation, as well as environmental factors influencing the outcome of the patient's disease/condition, taking into account the course of the main and concomitant diseases. [53, 54, 57, 58]

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

3. Implementation of medical rehabilitation measures by a multidisciplinary rehabilitation team. [53, 54, 57, 58]

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

4. Dynamic assessment of the patient's functions and vital activity based on the Rehabilitation Routing Scale (RRS) at all stages of medical rehabilitation. [53, 54, 57, 58]

Leveled Research Evidence (LE) 2 Grade of Recommendation (GR) B

5. Prevention and Dispensary Observation

LNC 5 LeC C

LNC 5 LeC C

• When choosing a conservative treatment strategy for a patient with thoracic and/or lumbar spine injury, it is recommended to perform follow-up CT/MRI (spiral computed tomography of the spine / magnetic resonance imaging of the spine (one segment)) at 3, 6, and 12 months to rule out the progression of kyphotic deformity and late spinal cord compression [10, 44, 47].

Level of Evidence (LE) 5, Grade of Recommendation (GR) C

6. Organization of Medical Care

6.1 Provision of first aid to patients with suspected thoracic and/or lumbar spine injury at the prehospital stage

LNC 5 LeC C

Comment: The combination of a rigid cervical collar and a rigid spinal board with patient straps is considered the most effective. A combination of a rigid cervical collar and vacuum immobilization stretchers is also possible.

LNC 5 LeC C

Comment: A patient is considered to have a spinal injury until proven otherwise.

LNC 5 LeC C

LNC 5 LeC C

Comment: To assess the severity of pain syndrome and objectify its dynamics during treatment, it is advisable to use standard methods, the simplest and most convenient of which are the visual analogue scale (VAS) and the numerical rating scale (NRS). A good "response" to treatment is considered to be a pain reduction of 50% or more, and the minimum clinically important difference is a pain reduction of 20% or more from the baseline level.

6.2 Indications for hospitalization in a medical organization for patients with thoracic and/or lumbar spine injury

In uncomplicated trauma:

· Type A0 – multiple fractures of the spinous and transverse processes, articular process fracture accompanied by severe pain syndrome;

· Type A1, A2 – in the presence of severe pain syndrome;

· Types A3, A4, B1, B2, B3, C;

In complicated trauma – any type of fracture.

6.3 Provision of specialized medical care to patients with thoracic and/or lumbar spine injury

For the treatment of patients with thoracic and/or lumbar spine injuries, the hospital must be equipped with the following: an operating room with a multifunctional radiolucent table (radiolucent operating table), a mobile digital X-ray C-arm system, a set of microsurgical instruments, high-speed drills, a set of bone rongeurs and conchotomes, a microscope or binocular loupes, sets for cervical spine fixation, halo devices, transpedicular fixators, and anterior fixation plates.

7. Additional Information

• It is recommended to assess functional outcomes in patients with acute spinal cord and vertebral trauma using the FIM scale (APPENDIX G5). To predict trauma outcomes in patients with spinal cord injury without instrumental evidence of bony damage, follow-up MRI of the injured spinal cord segment is recommended [44, 51].

LNC 5 LeC C

1. Severity of polytrauma with an ISS > 50 points.

2. Cervical spinal cord injury according to the ASIA scale type A.

3. Age over 51 years.

4. Unstable fractures of 3 or more vertebrae.

5. Unstable fractures at two or more levels.

6. Time from injury to surgery less than 31 hours (for ISS > 37 points).

Level of Evidence (LE) 3, Grade of Recommendation (GR) B

LNC 5 LeC C

Comment: Complications arising during the treatment of patients with spinal cord and vertebral trauma aggravate the course of the disease, increase hospital stay duration, and can lead to a fatal outcome. Various types of complications occur in 54%–82% of patients with spinal cord and vertebral trauma. Knowledge of these complications and applied preventive and therapeutic measures can reduce their incidence by 2–3 times. Complications occurring in operated patients can be divided into three groups: implant-related complications; non-implant-related surgical complications; and infectious complications. The most frequently anticipated ones include [ 1, 44, 51 ]:

Urinary tract infection.

1. Adequate bladder drainage.

2. Strict adherence to asepsis rules during urinary catheter insertion.

3. Administration of systemic antibacterial drugs based on urine culture results and susceptibility testing of the identified microorganisms to antibacterial agents.

4. Electrical stimulation of the urinary bladder.

5. Electrophoresis to the urinary bladder area (A17.30.024 Pulsed current electrophoresis).

6. Ensuring adequate diuresis: regulation of fluid intake and infusion therapy.

Pneumonia.

1. Antibacterial therapy.

2. Respiratory exercises: active and passive.

3. Therapeutic bronchoscopies.

4. Physiotherapy for spinal injuries and massage for spinal disorders starting from the second postoperative day.

5. Early mobilization of the patient.

6. Inhalation administration of medications, including via a nebulizer, and oxygen therapy.

7. Multifunctional muscle electrical stimulation, short-wave diathermy (UHF electric field application), microwave electromagnetic field therapy, electrical stimulation,

8. short-wave ultraviolet radiation therapy, long-wave ultraviolet radiation therapy, broadband ultraviolet radiation therapy

Intestinal paresis.

1. Early feeding with coarse-fiber foods with the addition of vegetable oils, adequate fluid intake.

2. Pharmacological and non-pharmacological stimulation of bowel motility.

3. Enemas at least once every 3 days.

Pressure ulcers.

1. Use of anti-decubitus mattresses and positioning devices.

2. Turning the patient in bed every 1.5 hours.

3. Rubbing the sacral region, greater trochanters, heels, and scapulae with camphor alcohol or a 1:1 mixture of shampoo and vodka.

4. Early mobilization.

5. Physiotherapy for spinal injuries, medical neck massage, massage for spinal disorders.

6. Active methods of pressure ulcer treatment (necrectomy, reconstruction with transferred or free flaps, etc.).

7. Monitoring nutritional adequacy, especially protein intake.

8. Skin care and maintenance of hydration (use of creams, etc.).

9. Phototherapy (laser therapy, UV therapy, polarized light).

PE and deep vein thrombosis of the lower extremities.

1. Administration of low molecular weight heparins (LMWH) (ATC Heparin group) in patients with severe motor deficit during the first two weeks post-surgery. For bedridden patients, followed by a switch to oral anticoagulants (ATC Platelet aggregation inhibitors excluding heparin) for up to 3 months. Coagulogram monitoring is required (exploratory assessment of the hemostatic system).

2. Use of LMWH in combination with functional beds, intermittent pneumatic compression devices (pneumatic boots/stockings), or lower limb muscle electrical stimulation.

3. Use of duplex ultrasonography (Duplex scanning of lower extremity vessels [arteries and veins]) every 5 days to diagnose deep vein thrombosis.

4. Addressing the surgical method for PE prophylaxis in patients who are tolerant to anticoagulants (ATC Platelet aggregation inhibitors excluding heparin) or have contraindications to anticoagulant therapy.

5. Early mobilization of the patient.

7. Exercise therapy for spinal injuries and limb massage (Massage for spinal disorders) starting from the first day after hospitalization.

6. Elastic compression of the lower extremities.

7. Pneumatic compression massage of the extremities every 4–6 hours for prophylactic purposes.

Sepsis.

1. Prevention of urinary tract infection, pneumonia, pressure ulcers, and wound suppuration.

2. Prevention and treatment of intestinal paresis.

3. Transcutaneous or intravenous laser therapy.

4. Monitoring of immunological status in high-risk patients (those with verified antibodies to hepatitis, HIV infection, and syphilis, as well as debilitated individuals and patients with polytrauma).

Gastrointestinal bleeding.

1. Gastroprotective therapy for up to 3 weeks.

2. Coagulogram monitoring (exploratory assessment of the hemostatic system).

3. Monitoring of the patient's nutritional status.

Postoperative wound suppuration.

1. Administration of antibacterial drugs (J01 Antibacterials for systemic use) 30 minutes before surgery, with additional doses of antibacterial drugs (J01 Antibacterials for systemic use) administered every 6 hours of surgery or for each 1 liter of blood loss.

2. Careful layered (5–6 rows of sutures) tension-free wound closure.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belkin, Andrey Avgustovich – Dr. med. sci., Professor of the Departments of Nervous Diseases and Anesthesiology and Reanimatology, Ural State Medical Academy; Chairman of the Supervisory Board of the Clinical Institute of the Brain, ANO.

2. Belova, Anna Naumovna – Dr. med. sci., Professor, Head of the Department of Medical Rehabilitation, Privolzhsky Research Medical University of the Russian Ministry of Health, Chief freelance specialist in neurology of the Ministry of Health of the Nizhny Novgorod Region.

3. Bodrova Rezeda Ahmetovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Rehabilitology and Sports Medicine at the Kazan State Medical Academy - branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation, Chairman of the Tatarstan Regional Branch of the All-Russian Public Organization for the Promotion of the Development of Medical Rehabilitology "Union of Rehabilitologists of Russia".

4. Buylova Tatyana Valentinovna - Doctor of Medical Sciences, Associate Professor, Director of the Institute of Rehabilitation and Human Health at the National Research Lobachevsky State University of Nizhny Novgorod, Chief Freelance Specialist in Medical Rehabilitation for the Volga Federal District of the Russian Federation, Chairman of the Nizhny Novgorod Regional Branch of the All-Russian Public Organization for the Promotion of the Development of Medical Rehabilitology "Union of Rehabilitologists of Russia".

5. Vissarionov Sergey Valentinovich – Doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Sciences, Director of the Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health.

6. Grin Andrey Anatolyevich - Doctor of Medical Sciences, Head of the Department of Emergency Neurosurgery at the Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department, Professor at the Department of Fundamental Neurosurgery of the Pirogov Russian National Research Medical University of the Russian Ministry of Health (Moscow, Russia).

7. Gubin Alexander Vadimovich - Doctor of Medical Sciences, Professor, Director of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation (Moscow, Russia).

8. Gumarova Lyaysyan Shamilovna - Candidate of Medical Sciences, Assistant Professor at the Department of Rehabilitology and Sports Medicine, Kazan State Medical Academy - branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation.

9. Daminov Vadim Damirovich - Doctor of Medical Sciences, Chief Specialist in Medical Rehabilitation at the Pirogov National Medical and Surgical Center of the Ministry of Health of the Russian Federation.

10. Dulaev Alexander Kaysinovich - Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Head of the Department of Traumatology, Orthopedics and Vertebrology at the Dzhanelidze Research Institute of Emergency Medicine, Head of the Department of Traumatology and Orthopedics at the Pavlov First Saint Petersburg State Medical University (Saint Petersburg, Russia).

11. Zakamyrdina Aigul Damirovna - Assistant Professor at the Department of Rehabilitology and Sports Medicine, Kazan State Medical Academy - branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation.

12. Ivanova Galina Evgenyevna - Doctor of Medical Sciences, Professor, Head of the Department of Medical Rehabilitation at the Faculty of Continuing Professional Education of the Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Head of the Department of Medical Rehabilitation at the Federal Center of Brain Research and Neurotechnologies of the Federal Medical-Biological Agency, Chief Freelance Specialist in Medical Rehabilitation of the Ministry of Health of the Russian Federation, Chairman of the All-Russian Public Organization for the Promotion of the Development of Medical Rehabilitology "Union of Rehabilitologists of Russia".

13. Ivanova Nataliya Evgenyevna – Doctor of Medical Sciences, Professor, Head of the Scientific Department at the Polenov Russian Neurosurgical Institute, Professor at the Department of Neurology and Psychiatry of the Institute of Medical Education at the Almazov Centre, Honored Doctor of the Russian Federation.

14. Kokushin Dmitry Nikolaevich – Candidate of Medical Sciences, Leading Researcher at the Department of Spinal Pathology and Neurosurgery at the Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health.

15. Komarov Alexander Nikolaevich - Candidate of Medical Sciences, Head of the "Doverie" National Center for the Development of Social Support and Medical Rehabilitation Technologies, Associate Professor at the Department of Adaptive Physical Culture and Recreation of the Russian State Social University.

16. Konovalov Nikolay Alexandrovich - Corresponding Member of the RAS, Doctor of Medical Sciences, Professor at the Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Head of the Department of Spinal Neurosurgery at the Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation (Moscow, Russia).

17. Kordonsky Anton Yuryevich – Candidate of Medical Sciences, Senior Researcher at the Department of Emergency Neurosurgery at the Sklifosovsky Research Institute for Emergency Medicine (Moscow, Russia).

18. Kostenko Elena Vladimirovna – Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Deputy Director for Scientific Work at the Spasokukotsky Moscow Scientific and Practical Center of Medical Rehabilitation, Restorative and Sports Medicine of the Moscow Healthcare Department (Moscow, Russia).

19. Krylov Vladimir Viktorovich - Academician of the RAS, Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Head of the Department of Fundamental Neurosurgery at the Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation; Chief Researcher at the Department of Emergency Neurosurgery at the Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department (Moscow, Russia).

20. Kulikov Alexander Gennadievich - Doctor of Medical Sciences, Professor, Chief Researcher at the Department of Medical Rehabilitation at the Spasokukotsky Moscow Scientific and Practical Center of Medical Rehabilitation, Restorative and Sports Medicine of the Moscow Healthcare Department (Moscow, Russia).

21. Lutokhin Gleb Mikhailovich – Candidate of Medical Sciences, Senior Researcher at the Department of Medical Rehabilitation at the Spasokukotsky Moscow Scientific and Practical Center of Medical Rehabilitation, Restorative and Sports Medicine of the Moscow Healthcare Department (Moscow, Russia).

22. Makarova Marina Rostislavovna - Candidate of Medical Sciences, Associate Professor, Leading Researcher at the Department of Medical Rehabilitation at the Spasokukotsky Moscow Scientific and Practical Center of Medical Rehabilitation, Restorative and Sports Medicine of the Moscow Healthcare Department (Moscow, Russia).

23. Manukovsky Vadim Anatolyevich - Doctor of Medical Sciences, Professor at the Department of Military Field Surgery of the Kirov Military Medical Academy of the Ministry of Defense of Russia, Professor at the Department of Neurosurgery of the Pavlov First Saint Petersburg State Medical University of the Ministry of Health of Russia, Deputy Director for Clinical Work at the Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine (Saint Petersburg, Russia).

24. Mlyavykh Sergey Gennadievich – Candidate of Medical Sciences, Trauma Surgeon, Neurosurgeon, Head of the Institute of Traumatology and Orthopedics at the Privolzhsky Research Medical University of the Ministry of Health of Russia (Nizhny Novgorod, Russia).

25. Morozov Ivan Nikolaevich - Doctor of Medical Sciences, Head of the Center for Neurorehabilitation of Patients with Spinal Cord Pathology at the University Clinic of the Privolzhsky Research Medical University of the Ministry of Health of the Russian Federation.

26. Meshcheryakov Semyon Vladimirovich - Candidate of Medical Sciences, Neurosurgeon, Leading Researcher at the Department of Neurosurgery and Neurotrauma at the Research Institute of Emergency Pediatric Surgery and Traumatology of the Moscow Healthcare Department (Moscow, Russia).

27. Nazarenko A.G., MD, Professor of the RAS, Director of the Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, Vice President of ATOR.

28. Parfenov Valery Evgenyevich - Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Director of the Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine (Saint Petersburg, Russia).

29. Pogonchenkova Irena Vladimirovna - Doctor of Medical Sciences, Associate Professor, Director of the Spasokukotsky Moscow Scientific and Practical Center of Medical Rehabilitation, Restorative and Sports Medicine of the Moscow Healthcare Department, Chief Freelance Specialist in Medical Rehabilitation and Sanatorium-Resort Treatment of the Moscow Healthcare Department (Moscow, Russia).

30. Prokopenko Semyon Vladimirovich - Doctor of Medical Sciences, Professor, Head of the Department of Nervous Diseases at KrasSMU, Chief Neurorehabilitator of the Siberian Federal District, Scientific Director of the Neurology and Neurorehabilitation Service at the Federal Siberian Research and Clinical Center of the Federal Medical-Biological Agency.

31. Rerikh Viktor Viktorovich - Doctor of Medical Sciences, Head of the Research Department of Spinal Pathology at the Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation (Novosibirsk, Russia).

32. Semenova Zhanna Borisovna - Doctor of Medical Sciences, Chief Freelance Pediatric Neurosurgeon, Head of the Department of Neurosurgery and Neurotrauma at the Research Institute of Emergency Pediatric Surgery and Traumatology of the Moscow Healthcare Department (Moscow, Russia).

33. Tsykunov Mikhail Borisovich - Doctor of Medical Sciences, Professor, Head of the Department of Medical Rehabilitation at the Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Professor at the Department of Medical Rehabilitation of the Faculty of Continuing Professional Education at the Pirogov Russian National Research Medical University, Deputy Chairman of the All-Russian Public Organization for the Promotion of the Development of Medical Rehabilitology "Union of Rehabilitologists of Russia".

34. Nikita O. Khusainov - Ph.D. in Medical Sciences, Researcher at the Department of Spinal Pathology and Neurosurgery, National Medical Research Center for Children's Traumatology and Orthopedics named after G.I. Turner, Russian Ministry of Health.

35. Irina P. Yastabtseva – D.Sc. in Medical Sciences, Professor at the Department of Neurology and Neurosurgery, Ivanovo State Medical Academy, Russian Ministry of Health.

Members of the working group are affiliated with the Association of Neurosurgeons of Russia, Association of Vertebral Surgeons, Association of Traumatologists and Orthopedists of Russia, and Russian Union of Rehabilitologists.

Conflict of interest.

The working group responsible for drafting the clinical guidelines for the treatment of humeral shaft fractures has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

1. Neurosurgeons;

2. Medical students, residents, and postgraduate students.

In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.

Scale for assessing levels of reliability of evidence (LRE) for diagnostic methods (diagnostic interventions)

Rating scale for levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Grading system for the levels of evidentiary certainty (LEC) of recommendations for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

The methods used to formulate the recommendations were expert consensus. Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Procedure for updating clinical guidelines every 5 years.

Appendix A3. Reference Materials

1. "Order of the Ministry of Health of the Russian Federation No. 931n dated November 15, 2012, 'On Approval of the Procedure for Providing Medical Care to the Adult Population Profile "Neurosurgery"'."

2. "Order No. 927n dated November 15, 2012, 'On Approval of the Procedure for Providing Medical Care to Victims with Associated, Multiple, and Isolated Traumas Accompanied by Shock'."

3. "Order No. 388n dated June 20, 2013, 'On Approval of the Procedure for Providing Emergency, Including Specialized Emergency, Medical Care'."

4. "Standard of Specialized Medical Care for the Consequences of Spinal Cord Injury at the Cervical, Thoracic, and Lumbar Levels dated December 20, 2012, No. 1264n."

5. Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of the Criteria for Assessing the Quality of Medical Care".

Centrally acting agents:

Opioid (narcotic) analgesics. Trimeperidine**. Available in ampoules (1 ml of 1% and 2% solution). Its analgesic potency is 2–4 times lower than that of morphine. Duration of action is 2–4 hours. It less frequently causes nausea and vomiting and has a milder respiratory-depressant effect. It is still used in outpatient practice for managing chronic cancer pain, although evidence supporting its efficacy is lacking.

Opioid receptor agonists-antagonists (N02AF Morphinan derivatives). Butorphanol. Available in ampoules (1 ml — 2 mg) and as a nasal spray (2.5 ml of butorphanol solution, 1 ml contains 10 mg). The analgesic potency of butorphanol is 3–5 times higher than that of morphine. It causes less respiratory depression than morphine and is less likely to cause drug dependence. It has a hemodynamic effect similar to pentazocine—it increases preload and is therefore not recommended in patients with acute myocardial infarction. The duration of effect is shorter than that of morphine upon intravenous administration and lasts 4–5 hours upon intranasal administration. Given that butorphanol is an opioid receptor agonist-antagonist, its use against the background of the residual action of other classes of analgesics may temporarily intensify pain. In outpatient practice, it is used to treat chronic pain in oncology.

Partial opioid receptor agonists (N02AE Orypain derivatives). Buprenorphine** is registered in the Russian Federation only as a transdermal patch containing 0.2 mg of the drug. Side effects are less pronounced than those of morphine and fentanyl**, but elderly and debilitated patients may develop respiratory depression up to complete respiratory arrest, and the administration of naloxone** only partially reverses respiratory depression. If well tolerated, it can be used for months in patients with chronic pain due to oncological diseases.

Narcotic analgesics with a mixed mechanism of action (N02A Opioids). Tramadol** is a centrally acting analgesic (opioid receptor agonist, serotonin reuptake inhibitor). Tramadol** is available in various formulations: 50 mg capsules, drops (20 drops = 50 mg), 100 and 150 mg sustained-release (retard) tablets, solution for injection in ampoules (1 ml — 50 mg and 2 ml — 100 mg), and 100 mg rectal suppositories. Sustained-release tablets provide an analgesic effect for up to 12 hours after a single dose. Tramadol** has minimal abuse potential, does not depress respiration at usual doses, and does not alter the motility of the gastrointestinal tract, urinary, or biliary tracts. Its analgesic efficacy is comparable to that of trimeperidine**.

Tricyclic antidepressants (N06AA Non-selective monoamine reuptake inhibitors). Amitriptyline**. Used as an analgesic for chronic pain. Available as 0.025 g tablets and in ampoules (2 ml of 1% solution). It is recommended to start amitriptyline** at a low dose (10 mg/day) and gradually increase it. The analgesic effect develops within 1–2 weeks. The use of amitriptyline is accompanied by a number of side effects, including tachycardia, constipation, urinary retention, confusion, and memory impairment. Therefore, it is not recommended in patients older than 65 years.

Serotonin-norepinephrine reuptake inhibitor antidepressants. Venlafaxine is available as 37.5 and 75 mg tablets. The starting dose is 75 mg daily. Duloxetine is available in 60 mg tablets. It is prescribed once daily. It is the first antidepressant whose indications include neuropathic pain. In addition, it is recommended for the treatment of fibromyalgia.

Anticonvulsants (N03AF Carboxamide derivatives). Carbamazepine** was one of the first anticonvulsants used to treat neuropathy. Available in 0.1–0.2 g tablets. The initial dose is 0.1 g, gradually increased up to 0.8 g daily. The drug has a number of side effects—somnolence, ataxia, dizziness. Leukopenia may develop with prolonged use. Gabapentin. Belongs to the new generation of anticonvulsants. Available in capsules in doses ranging from 100 to 800 mg. For analgesia, it is prescribed at a dose of 300 mg daily, with a gradual increase to a daily dose of 1800 mg. If necessary, the daily dose can be increased up to 3600 mg daily. Gabapentin is effective in diabetic neuropathy. Pregabalin**. Possesses anticonvulsant activity. Available in 50, 75, and 150 mg capsules. Prescribed at 75 mg twice daily; the dose may be subsequently increased. It provides analgesia in neuropathy and fibromyalgia, reduces anxiety, and improves sleep.

Analgesics (ATC Analgesics and antipyretics) Paracetamol**. Available in 0.2, 0.325, and 0.5 g tablets. Its mechanism of action involves the inhibition of cyclooxygenase (COX) in the central nervous apparatus, which reduces prostaglandin synthesis. Acetaminophen lacks a peripheral effect and therefore does not exhibit pronounced anti-inflammatory activity. It provides analgesic and antipyretic effects. Unlike acetylsalicylic acid, it does not damage the gastric mucosa and does not affect platelet aggregation, as it does not inhibit COX-1. The main disadvantage of the drug is its narrow therapeutic index. Toxic doses exceed therapeutic doses by a factor of 2–3. Biotransformation of acetaminophen produces a hepatotoxic and nephrotoxic metabolite, so prescribing this drug is not recommended for patients with hepatic or renal impairment. Acetaminophen should be used with caution in patients with alcohol dependence, considering potential liver damage. It is relatively safe for children, as the biotransformation pathway of acetaminophen differs in children under 12 years of age, preventing the formation of toxic metabolites.

Peripherally acting agents:

Nonsteroidal anti-inflammatory drugs (NSAIDs) (M01A Anti-inflammatory and antirheumatic products, non-steroids) are widely used for pain management at all stages of care. Even short-term NSAID use can cause side effects, occurring in 25% of cases. In 5% of elderly and senile patients, these can pose a serious life-threatening risk. Therefore, when choosing a pain relief method, it is essential to ascertain whether the patient is taking medications from this group, for how long, and in what doses. Indometacin (indoleacetic acid derivative). Available in 0.025 mg capsules and dragees. Has a strong anti-inflammatory effect. It is not recommended to prescribe this drug as an analgesic, since it causes gastrointestinal side effects in approximately 30–50% of patients. Ketorolac** available as a solution for intramuscular injection at a dose of 30 mg. It has high analgesic activity, comparable to narcotic analgesics. Given the high incidence of gastrointestinal side effects, it can be used for acute pain management. Not recommended in elderly and senile patients due to side effects. Ketoprofen** available in various dosage forms: forte tablets 100 mg, capsules 50 mg, retard tablets 150 mg, suppositories 100 mg, solution for intramuscular injection (100 mg in 1 ml), ointment for external use. For chronic pain management, retard tablets taken at 12-hour intervals are most convenient. The maximum daily dose is 300 mg. Gastrointestinal side effects are possible. Diclofenac**. Available in 0.015 and 0.025 mg tablets, and as a 2.5% solution in 3-ml ampoules. It has a pronounced analgesic effect and a significant therapeutic window, but can cause dyspeptic and allergic reactions, and gastrointestinal bleeding. The maximum daily dose is 150 mg. Intravenous administration is possible for acute pain syndromes. Ibuprofen**. Available in 0.2, 0.4, and 0.6 mg tablets. It has an analgesic effect, while its anti-inflammatory effect is less pronounced. It causes fewer side effects compared to other non-selective COX inhibitors. Naproxen. Available in 0.25, 0.375, and 0.5 mg tablets. It is inferior to diclofenac in its anti-inflammatory effect, but superior in its analgesic effect. The pain-relieving effect is more prolonged, so twice-daily administration is sufficient. It is characterized by a longer duration of action and is well tolerated by patients. NimesulideAvailable as 100 mg tablets and as a 1% gel for external use. Belongs to the group of preferential COX-2 inhibitors. In European Union countries, it is not recommended for long-term use due to reported cases of liver failure. Consequently, its indications are restricted to acute pain. MeloxicamAvailable as 7.5 and 15 mg tablets and as a solution for intramuscular injection at a dose of 15 mg. Belongs to COX-2 inhibitors. Prescribed once daily with meals.

Local anesthetics. Lidocaine**. For infiltration anesthesia, lidocaine is used as a 2% solution; for regional nerve block, as a 1% solution. The maximum allowable dose in adults is 200 mg. In elderly patients, the dose should be reduced by one third. In case of overdose, the first symptom of lidocaine toxicity is seizures. The drug should be used with caution in patients with epilepsy, hepatic impairment, and renal failure.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Complications arising in the management of patients with spinal cord injury aggravate the course of the disease, prolong hospital stay, and can lead to death. Various complications occur in 54%–82% of patients with spinal trauma. Knowledge of these complications and the application of preventive and therapeutic measures improve the prognosis of treatment. Below are the prophylactic measures for the most frequent complications.

Urinary tract infection:

1. Adequate bladder drainage using one of the following methods:

- continuous catheterization with a Foley catheter, replacing it every 5–7 days, with monitoring of adequate catheter function;

- continuous catheterization with a silver-impregnated Foley catheter, replacing it every 3–4 weeks, with monitoring of function;

2. Strict adherence to asepsis rules when inserting the urinary catheter.

3. Administration of urinary antiseptics (ATC Fluoroquinolones) — medications are prescribed by the attending physician.

Pneumonia:

1. Antibacterial therapy — medications are prescribed by the attending physician.

2. Breathing exercises: active and passive.

3. Massage for spinal disorders, thermovibrational massage of the paraspinal muscles.

4. Physical therapy and massage for spinal disorders starting from the second postoperative day

Intestinal paresis:

1. Early feeding with coarse-fiber foods supplemented with vegetable oils, adequate fluid intake.

2. Drug-based stimulation of intestinal motility — medications are prescribed by the attending physician.

3. Cleansing enemas at least once every 3 days.

Pressure ulcers:

1. Use of anti-decubitus mattresses and positioning devices.

2. Turning the patient in bed every 1.5 hours.

3. Rubbing the sacral region, greater trochanters, heels, and shoulder blades with camphor spirit, or a 3:1 shampoo-and-alcohol mixture.

4. Early mobilization.

5. Physical therapy and massage for spinal conditions.

6. Hyperbaric oxygen therapy (HBOT).

7. Active methods of pressure ulcer treatment — performed by the attending physician.

8. Monitoring nutritional adequacy, especially protein intake.

9. Skin care and maintenance of moisture balance (use of creams).

Deep vein thrombosis of the lower extremities:

1. Administration of anticoagulants (ATC heparin group) — medications are prescribed by the attending physician.

2. Elastic compression of the lower extremities.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Russian title: International Standards for Neurological and Functional Classification of Spinal Cord Injury (ASIA Scale)

Original title: American Spinal Injury Association and International Standards for Neurological and Functional Classification of Spinal Cord Injury

Source: Guidelines for the management of acute cervical spine and spinal cord injuries // Neurosurgery. - 2002. - Vol. 50, N. 3. - Suppl. - S1-S199

Type:

- rating scale

- index

- questionnaire

Purpose: assessment of the severity of neurological impairment

Content: classification form is presented in Fig. 1

Key:

Based on the severity of spinal cord injury, all patients are divided into 5 categories:

Grade A — complete: no motor or sensory function is preserved in the segments below the neurological level. No sensory function is present in the S4-S5 segments.

Grade B — incomplete: sensory but not motor function is preserved below the neurological level and includes the S4-S5 segments.

Grade C — incomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.

Grade D — incomplete: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.

Grade E — normal: motor and sensory functions are normal.

Notes:

The criteria for spinal cord status used are muscle strength, tactile and pain sensation, and reflex activity in the anogenital zone. Motor functions are assessed by testing the strength of key muscle groups corresponding to spinal cord segments. Five segments for the upper (C5–T1) and 5 segments for the lower (L2–S1) extremities were selected. Muscle strength is graded as follows: 0 - plegia, 1 - palpable or visible contraction of individual muscle groups, 2 - active movement with gravity eliminated, 3 - active movement against gravity, 4 - active movement against some resistance, 5 - active movement against full resistance. Muscle strength is assessed bilaterally, and the scores obtained in each segment are summed up. The results are recorded on the examination chart. If muscle strength cannot be tested for any reason (e.g., the limb is in a cast), the NT (not tested) designation is entered. The maximum score for the 10 segments on each side is 50. The examination chart notes the presence or absence of voluntary contraction of the external anal sphincter, which is checked by digital rectal examination. Even in the absence of active limb movements, if voluntary sphincter contraction is present, the spinal cord injury is considered incomplete. Sensation is tested in 28 segments bilaterally. To determine sensation in an entire segment, it is sufficient to test it at a single key point anchored to a clear anatomical landmark. C2 - occipital protuberance, C3 - supraclavicular fossa, C4 - apex of the acromioclavicular joint, C5 - lateral side of the antecubital fossa, C6 - thumb, C7 - middle finger, C8 - little finger, T1 - medial side of the antecubital fossa, T2 - apex of the axilla, T3 - third intercostal space, T4 - nipple level, T6–T9 - corresponding intercostal spaces, T10 - umbilicus level, T11 - eleventh intercostal space, T12 - inguinal crease, L1 - halfway between T12 and L2, L2 - middle of the anterior thigh, L3 - medial femoral condyle, L4 - medial malleolus, L5 - dorsum of the foot at the third metatarsophalangeal joint, S1 - lateral heel, S2 - popliteal fossa in the midline, S3 - ischial tuberosity, S4-5 - perianal area. Sensation is scored on the following scale: 0 - absent sensation, 1 - altered sensation, 2 - normal sensation. If sensation was not tested, NT is entered in the corresponding cell of the examination chart. Inability to distinguish between sharp and dull pinprick is scored as absent pain sensation. Tactile sensation is determined by cotton wisp touch. The examination results are entered into the chart. When testing sensation in 28 segments bilaterally, the maximum score is 56. Additionally, anal sensation is determined to establish the extent of injury - complete or incomplete. Sensation assessment involves determining limb position and deep pressure sense, which are scored as absent, altered, or normal. To assess joint position and kinesthetic sense, it is proposed to test passive movements in the index fingers and big toes. These data are not entered into the chart, but provide additional information on the extent of injury..

Appendix G2. Rating scales, questionnaires, and other patient assessment tools presented in clinical guidelines

Russian title: Classification of vertebral injuries

Original title: AOSpine thoracolumbar spine injury classification system

Source: Vaccaro A.R., Oner C., Kepler C.K. et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status and key modifiers. Spine 2013;38(23):2028–2037.

Type: - rating scale

Purpose: description of vertebral injury

Contents:

Compression injuries (Type A) are characterized by varying degrees of injury localized to the vertebral bodies.

Distraction fractures (Type B) are characterized by failure of the anterior or secondary posterior structures due to excessive flexion or extension.

Displacement/translation (Type C) implies complete separation of one vertebra from another with dislocation in any direction or angular deformity.

Facet injuries (Type F) are assessed for isolated facet joint injuries or in combination with types A, B, and C.

Compression injuries (Type A) are characterized by varying degrees of injury localized to the vertebral bodies. There are 5 subtypes (Fig. 2):

- A0 - no fracture or minor bone injuries (lamina, spinous process). This category is also used to designate spinal cord contusion without bony injury;

- A1 - wedge-compression fracture involving a single endplate without involvement of the posterior ligamentous complex;

- A2 - split fracture passing through both endplates without fragments and without posterior ligamentous complex injury, also includes coronal split ("pincer") fractures of the vertebra;

- A3 - incomplete burst fracture involving a single endplate with retropulsion into the spinal canal and potential posterior ligamentous complex injury;

- A4 - complete burst fracture of the vertebral body involving both endplates. Also includes sagittal split fractures with involvement of the posterior ligamentous complex.

Figure 2 - Compression injuries according to the AOSpine classification (2013): A - type A0; B - type A1; C - type A2; D - type A3; E, F - type A4.

Distraction fractures (Type B) are characterized by failure of the anterior or posterior structures due to excessive flexion or extension (Fig. 3):

- B1 - a bony failure of the posterior element in the axial plane due to hyperflexion, extending through the pedicles and vertebral body;

- B2 - failure predominantly of the posterior ligamentous complex due to hyperflexion with potential involvement of the articular processes and intervertebral disc;

- B3 - hyperextension failure of the anterior column involving the anterior and posterior longitudinal ligaments and the disc. A vertebral body fracture (teardrop or horizontal through the entire body) may occur.

Figure 3 - Distraction injuries according to the AOSpine classification (2013): A - type B1; B - type B2; C - type B3.

Vertebral translation (Type C) implies complete separation of one vertebra from another with dislocation in any direction or angular deformity (Fig. 4).

Figure 4 - Examples of translation injuries according to the AOSpine classification (2013).

The authors also introduced additional modifiers to reflect neurological deficits. Thus, spinal cord injury (N) is graded into 6 categories:

- N0 - no neurological deficit;

- N1 - transient neurological deficit that completely resolved within 24 hours;

- N2 - radiculopathy;

- N3 - incomplete spinal cord injury;

- N4 - complete spinal cord injury (functional transection);

- NX - unspecified injury. Used for patients who are unconscious.

Specific modifiers that may influence surgical management are included in a separate group (M):

-M1 - partial injury of the posterior ligamentous complex.

-M2 - systemic connective tissue diseases that increase the "stiffness" of the spinal column (diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, etc.).

Also, the injury assessment algorithm was modified: from more severe (type C) to simple (type A), rather than in order of increasing complexity of structural injuries (from A to C) (Fig. 5).

Appendix G3. Assessment scales, questionnaires, and other patient condition assessment tools provided in the clinical guidelines

Russian title: TLICS scale

Original title (if any): Thoracolumbar Injury Classification and Severity Score

Source: Vaccaro A.R., Lehman R.A., Hurlbert R.J. et al. A new classification of thoracolumbar injuries: The importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976) 2005;30(2):2325-33. PMID: 16227897 DOI: 10.1097/01.brs.0000182986.43345.cb

Type:

- rating scale

- index

- questionnaire

Purpose: scoring of injury severity for clinical decision-making

Content: criteria included in the SLIC scale are presented in Table 2.

Table 2.

Point distribution according to the type of injury, integrity of the disc-ligamentous complex, and degree of neurological deficit according to the TLICS (Thoracolumbar Injury Classification and Severity Score) scale.

Key: If the sum of points for the three items is 5 or more, surgical treatment is indicated. With a sum of 3 or less, conservative therapy is preferred. At a value of 4, the choice is based on the surgeon's experience and takes into account the patient's condition and individual characteristics.

Appendix G4. Assessment scales, questionnaires, and other patient condition assessment tools provided in the clinical guidelines

Russian title: TL AOSIS scale

Original title: Thoracolumbar AOSpine injury score

Source: Vaccaro A.R., Schroeder G.D., Kepler C.K. et al. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system. Eur Spine J 2016; 25(4):1087–1094. PMID: 25953527 DOI: 10.1007/s00586-015-3982-2

Type:

- rating scale

- index

- questionnaire

Purpose: scoring of injury severity for clinical decision-making.

Content:

In 2015, A.R. Vaccaro et al. attempted a numerical interpretation of the AOSpine classification [15]. The study involved 100 expert spinal surgeons worldwide. Each respondent was asked to numerically rate the severity of each variable in the AOSpine thoracolumbar spine injury classification system. Using the obtained results, a numerical scoring system for this classification was developed (Table 3).

Table 3

Correspondence table of spinal injuries according to the AOSpine scale and the TL AOSIS scale

Key: with a total score of less than 4, experts recommend conservative therapy; with a total score of more than 5, surgical treatment is indicated. Treatment of patients with a score of 4 or 5 should be based on the surgeon's experience and the technical equipment of the hospital and operating room.

Appendix G5. Patient condition assessment scales, questionnaires, and other evaluation tools cited in clinical guidelines

Russian title: Functional Independence Measure.

Original title (if applicable): Functional Independence Measure (FIM)

Source: Cook L, Smith DS, Truman G. Using Functional Independence Measure profiles as an index of outcome in the rehabilitation of brain-injured patients. Arch Phys Med Rehabil. 1994 Apr;75(4):390-3. PMID: 8172496, DOI: 10.1016/0003-9993(94)90160-0

Type (underline):

- rating scale

- index

- questionnaire

Purpose: determination of the patient's functional independence for objective dynamic monitoring

Content: the questionnaire form is presented in Table 4.

Table 4.

FIM questionnaire form.

Explanations: the table is filled out based on a 7-point rating scale:

7 — complete independence in performing the respective function (all actions are performed independently, in a standard manner, and within a reasonable amount of time)

6 — modified independence (the patient performs all actions independently, slower than usual, or requires advice)

5 — supervision / setup (requires staff observation or assistance with putting on prostheses/orthoses)

4 — minimal assistance (requires assistance with actions, but performs more than 75% of the task independently)

3 — moderate assistance (independently performs 50–75% of the actions required for the task)

2 — maximal assistance (independently performs 25–50% of the actions)

1 — total assistance (can independently perform less than 25% of the required actions)

Appendix G6. Patient condition assessment scales, questionnaires, and other evaluation tools cited in clinical guidelines

Russian title: Rehabilitation Routing Scale.

Type (underline):

- rating scale

- index

- questionnaire

Purpose: determination of rehabilitation routing.

Content: the questionnaire form is presented in Table 5.

Table 5. Rehabilitation Routing Scale.

Appendix G7. Assessment scales, questionnaires, and other patient status evaluation tools provided in clinical guidelines

Russian title: Rankin Scale.

Original title (if applicable): Rankin scale

Source:

John Rankin. Cerebral Vascular Accidents in Patients over the Age of 60: II. Prognosis. Scott Med J 1957 2: 200. DOI: 10.1177/003693305700200504

van Swieten, J. C.; Koudstaal, P. J.; Visser, M. C.; Schouten, H. J.; van Gijn, J. (1988). Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 19(5), 604–607. doi:10.1161/01.str.19.5.604 

Type (underline):

- rating scale

- index

- questionnaire

Purpose: The Rankin Scale is a universal tool for assessing disability, independence, and rehabilitation outcomes. The scale is scored regardless of the cause of disability and health impairment. Capabilities:

• assessment of pre-morbid disability based on medical history and patient interview,

• assessment of rehabilitation outcomes at each stage,

• telephone interview on day 90,

• tool for transition between rehabilitation stages,

• tool for determining "rehabilitation potential",

• assessment of the efficacy of medications and rehabilitation interventions.

Contents:

1 point

• There may be certain symptoms (physical or cognitive):

• Mood,

• Speech, reading, and writing disorders,

• Movement or sensory problems;

• Can return to previous work, maintain previous level of activity and social life;

• Spends the same amount of time on tasks as before the illness.

2 points

• Has symptoms of the disease,

• Cannot perform the activities that were possible before the illness (driving a car, reading, writing, dancing, working, etc.),

• Can care for themselves independently (dresses and undresses independently, goes shopping, prepares simple meals, can take short trips and travel, moves around independently),

• Does not require supervision,

• Can live alone at home for a week or more without assistance.

3 points

• Has symptoms of the disease,

• Can move independently and without outside help,

• Independently dresses, undresses, uses the toilet, eats, and performs other types of daily activity,

• Requires assistance with complex activities: cooking, housework, shopping,

• Requires assistants for managing financial affairs.

• Can live alone at home without assistance from 24 hours to 1 week.

4 points

• Has symptoms of the disease,

• Cannot move independently and without outside help,

• Requires assistance with daily tasks: dressing, undressing, using the toilet, eating, etc.,

• In everyday life, requires a caregiver or someone to be nearby,

• Can live alone at home without assistance for up to 24 hours.

5 points

• Has symptoms of the disease,

• Cannot move independently and without outside help,

• Requires assistance with all daily tasks: dressing, undressing, using the toilet, eating, etc.,

• Requires constant care (both day and night),

• Cannot be left home alone without outside help.

6 points – death of the patient

Key: questions for differentiating between borderline scores on the Rankin scale:

Key concepts for assessing on the Rankin scale

Appendix G8. Assessment scales, questionnaires, and other patient condition assessment tools provided in clinical guidelines

Russian title: Functional Assessment Scale for Spinal Cord Injury Patients.

Source: Tsykunov M.B. et al. Examination in the process of rehabilitation of patients with spinal cord injury // Rehabilitation of patients with traumatic spinal cord disease / Edited by G.E. Ivanova et al. - M., 2010. P. 339-340.

Type (underline):

- rating scale

- index

- questionnaire

Purpose: determination of the patient's functional independence for objective dynamic monitoring.

Content: the questionnaire form is presented in Table 6.

Assess the patient's performance of the tasks listed below using a 5-point rating scale based on direct observation of the patient.

5 — performs the task without difficulty, modifications, at a normal pace, requires no assistance

4 — minor difficulties;

3 — moderate difficulties, performs 75% or more of the task independently;

2 — marked difficulties, performs about 25% of the task independently;

1 — the patient is unable to perform the task and is completely dependent on others.

Table 6. Questionnaire form.

Key: Calculation of total scores for the subscales (8) of the questionnaire (61 items), but not the total score for the entire questionnaire.

Appendix G9. Rating scales, questionnaires and other tools to assess the patient's condition given in the clinical guidelines

Russian title: Rivermead Mobility Index.

Original title (if any): The Rivermead Mobility Index

Source: Collen, F. M.; Wade, D. T.; Robb, G. F.; Bradshaw, C. M. (1991). The Rivermead Mobility Index: A further development of the Rivermead Motor Assessment. Disability & Rehabilitation, 13(2), 50–54. doi:10.3109/03790799109166684

Type:

- rating scale

- index

- questionnaire

Purpose: scoring the severity of mobility impairment.

Content: the criteria included in the mobility index are presented in Table 7.

Table 7. Rivermead Mobility Index rating scale.

Appendix G10. Rating scales, questionnaires and other tools to assess the patient's condition given in the clinical guidelines

Russian title: Glasgow Coma Scale

Original title (if any): Coma and impaired consciousness practical scale

Source:

Assessment of coma and impaired consciousness. A practical scale / Teasdale G., Jennett B. // The Lancet : —1974. — Vol. 2, no. 7872. — P. 81—4. doi:10.1016/S0140-6736(74)91639-0. PMID 4136544

Type:

- rating scale

- index

- questionnaire

Purpose: scoring the level of impaired consciousness

Content: the criteria included in the GCS are presented in Table 8.

Table 8. Glasgow Coma Scale.

Appendix G11. Assessment scales, questionnaires, and other patient condition evaluation tools given in clinical guidelines

Monitoring, contraindications, or STOP signals for mobilization at stage 1 of rehabilitation in the ICU

PLR (passive leg raising) test – passive leg raising test to assess volume status: with the patient lying supine in a horizontal position, the investigator raises the straightened legs to an angle of at least 60⁰. Hemodynamic parameters (BP, HR, central venous pressure – if a central venous catheter is present) are recorded before the start of the elevation and at the highest point. The test is positive if there is an increase in BP and/or HR by 10%, and CVP by 2 mm Hg from the baseline level. A positive test is a contraindication to starting rehabilitation

Appendix G12. Assessment scales, questionnaires, and other patient condition assessment tools cited in clinical guidelines

Medical Research Council (MRC) Scale

The scale has several names. In Russia, the scale is better known as the neurological muscle strength scale.

Who performs the scale assessment: critical care physician, physical therapist (physical rehabilitation specialist), physical and rehabilitation medicine physician, neurologist, trauma surgeon / orthopedist.

Conditions for performing the scale assessment. If the patient is unconscious, objective assessment using the scale is not possible. If the patient has severe cognitive impairment or speech disorders, it is necessary to observe how the patient moves their limbs and perform the assessment based on that. Alternative sources of communication can also be used.

This scale can be used to assess the strength of any muscle. The basis of testing all muscles is the principles of manual muscle testing. The specialist should know the position of the body part being tested and which movement allows for maximum loading of the tested muscle. The specialist ensures that agonist muscles are, as far as possible, "excluded" from the movement, and the tested muscle is maximally "engaged" in the work.

Instructions for specialists on scale assessment

Sources: Medical Research, 1981; van der Ploeg et al., 1984; Paternostro-Sluga, Grim-Stieger, Posch et al., 2008

Appendix G13. Assessment scales, questionnaires, and other patient condition assessment tools cited in clinical guidelines

Behavioral Pain Scale (BPS)

Gélinas C, Puntillo KA, Levin P, et al: The Behavior Pain Assessment Tool for critically ill adults: A validation study in 28 countries. Pain 2017; 158:811–821

Appendix G14. Assessment scales, questionnaires, and other patient condition assessment tools cited in clinical guidelines

Borg scale for patient self-assessment of exercise tolerance

This version of the scale is modified. Scoring on a 10-point scale is more convenient than the older version. ESPRM uses this version.

Who performs the scale assessment: physical rehabilitation specialist or physical and rehabilitation medicine physician.

Time required for scale assessment: 3–5 min.

Conditions for performing the scale assessment. The patient is conscious and able to maintain verbal contact.

Sources: Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377-81.

Instructions for specialists. The physician makes an assessment based on the patient's existing complaints following a load test. The patient must choose a number that reflects the degree of shortness of breath they experience during the rehabilitation maneuver