Cervical Vertebral Dislocation: Clinical Guidelines

List of Abbreviations

AB – systemic 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 – nonsteroidal anti-inflammatory drugs (ATC non-steroidal anti-inflammatory and antirheumatic products),

FMS — functional spinal unit,

PNF – proprioceptive neuromuscular facilitation

Spinal cord injury (SCI),

VBR — vertebral body replacement,

ACSF — anterior cervical spine fusion,

CT – spine computed tomography with multiplanar and three-dimensional reconstruction

EMS — emergency medical services,

Dura — dura mater,

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 for peripheral nervous system disorders,

EMS – electrical muscle stimulation,

image intensifier.

SCIWORA – spinal cord injury without radiographic abnormality.

Terms and Definitions

Instability is a pathological condition characterized by a reduced ability of the vertebral 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 the influence of 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 manifested by impaired motor functions, pain and temperature sensation with preserved proprioceptive sensation;

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

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 opposite side.

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.

Spinal shock is the absence of spinal cord function below the level of the injury for 3–30 days resulting from 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.

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

Spinal cord injury without spinal damage is damage to the spinal cord occurring due to a disruption of spinal cord structure or function under the influence of external force.

Spinal cord contusion – injury to the spinal cord occurring at the time of trauma and accompanied by complete or partial anatomical destruction of its substance with hemorrhages, areas of ischemia, necrosis, and regional edema. It manifests as neurological disorders lasting more than 7 days.

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.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Vertebral dislocation is a type of spinal injury that represents the displacement of a vertebra relative to the underlying vertebrae, during which the joint connection between the dislocated and the lower vertebra is disrupted.

Vertebral subluxation is a type of spinal injury that represents partial displacement and/or rotation of one vertebra relative to another, disrupting the joint connection between the dislocated and the lower vertebra in a single joint.

Spontaneous reduction of a vertebral dislocation is a type of spinal injury that represents the displacement of a vertebra relative to 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 cord and vertebral injury in adults are: catatrauma (approximately 50% of victims), motor vehicle accidents (approximately 30% of victims), and diving into shallow water (approximately 10% of victims).

The mechanism of spinal injury is typically flexion-distraction, accompanied by rupture of the intervertebral disc, stretching or rupture of the ligamentous apparatus of the vertebral motion segment, and fractures of the vertebral body or intervertebral joints.

Mechanisms of neuronal damage in spinal cord injury:

1) primary: acute compression, progressive compression, impact, stretching, rupture, gunshot wound, movements in an unstable spinal segment.

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

1.3 Epidemiology of the Disease or Condition

Spinal injuries account for 5.5%–17.8% of all musculoskeletal system injuries. Patients with acute spinal cord injuries account for 2%–3% of all patients admitted to neurosurgery departments.

Associated injuries are detected in 28%–50% of patients with spinal cord injuries. Cervical spine injuries are diagnosed in 28%–38% of patients. Dislocation of the cervical vertebrae accounts for 22% of all spinal cord injuries.

1.4 Features of Coding the Disease or Condition

S10.8 – Superficial injury of other parts of neck

S12.1 – Fracture of second cervical vertebra

S12.0 – Fracture of first cervical vertebra

S12.2 – Fracture of other specified cervical vertebrae

S12.7 – Multiple fractures of cervical vertebrae

S13.0 – Traumatic rupture of cervical intervertebral disc

S13.1 – Dislocation of cervical vertebra

S13.3 – Multiple dislocations of cervical spine

S13.4 – Sprain and strain of cervical spine

S14.0 – Concussion and oedema of cervical spinal cord

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 based on the presence of damage to the neurovascular structures of the spinal canal:

1. Uncomplicated (ASIA grade E);

2. Complicated (ASIA grades A, B, C, and D).

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

1. Spinal cord concussion;

2. Contusion of the spinal cord and/or spinal nerve roots;

3. Compression of the spinal cord and/or spinal nerve roots;

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

5. Complete anatomical transection of the 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.

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 one level may be combined with multiple injuries at another level. Such injuries are referred to as multiple multilevel spinal column injuries.

1.6 Clinical presentation of the disease or condition

Cervical vertebral dislocation is characterized by neck pain, paraspinal muscle tension, decreased range of motion in the neck and extremities, and often impaired motor function and sensory disturbances.

The clinical presentation of a cervical vertebral dislocation typically manifests as one of the following syndromes or their combination: radicular syndrome, central cord syndrome, anterior cord syndrome, Brown-Séquard syndrome, or spinal shock.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the disease or condition:

1. An anamnesis that does not rule out the presence of a spinal cord injury.

2. The appearance of characteristic complaints after the moment of injury, with the onset of neurological deficit (if present).

3. Identification of relevant traumatic spinal injuries at the cervical level using instrumental diagnostic methods.

2.1 Complaints and Anamnesis

• When taking the anamnesis, it is recommended to determine the mechanism and time of the injury, the 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. It is recommended to establish whether the patient lost consciousness at the time of the injury, whether there was vomiting, and whether they remember the circumstances of the injury [1].

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Comment: Any patient admitted to the intensive care unit with trauma should be evaluated and treated as a victim of spinal injury until the absence of spinal injury at all levels is proven.

2.2 Physical Examination

• Spinal palpation is recommended to be performed with extreme caution [2].

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Comment: performing forced palpation may cause additional injury to the victim. Upon examination, pay attention to the pattern and type of respiration, as well as hemodynamic parameters—pulse and blood pressure. The combination of arterial hypotension and bradycardia may indicate the severity of spinal cord injury.

• When assessing neurological status in patients with spinal cord injury, it is recommended to use the ASIA/ISCSCI scale (International Standards for Neurological and Functional Classification of Spinal Cord Injury) (APPENDIX G1) [1–3, 6].

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2.3 Laboratory Diagnostics

• All admitted patients with a cervical vertebra dislocation are recommended to undergo a complete (clinical) blood count with leukocyte differential, a complete (clinical) urinalysis, a general clinical biochemical blood test (including total blood protein, albumin, blood urea, creatinine, sodium, potassium, chlorides, aspartate aminotransferase activity, alanine aminotransferase activity), blood typing (ABO system) and Rh factor (Rh antigen D) determination, a coagulogram (exploratory hemostasis screening), and a complete (clinical) urinalysis for the purpose of assessing the general functional state of the body [1–4].

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2.4 Instrumental Diagnostics

• Patients with suspected cervical vertebra dislocation are recommended to undergo spiral computed tomography (SCT) of the neck to assess the degree of osteotragic vertebral damage and changes in the anatomical relationships within the motion segment [1–6].

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• Patients with polytrauma are recommended to undergo computed tomography of the spine with multiplanar and three-dimensional reconstruction in order to determine the full extent of associated injuries [4, 8, 9].

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• In cases where there is doubt regarding the interpretation of the studies performed, or the clinical picture does not match the radiological and/or CT findings, and when visualization of the spinal cord is necessary, magnetic resonance imaging (MRI) of the spinal cord (one region) is recommended [1, 6, 10, 11].

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Comment: Spinal MRI allows for the evaluation of soft tissue structures of the spine: ligaments, intervertebral discs, spinal meninges, and the spinal cord itself with its underlying changes (ischemia, edema, hemorrhage, cyst, extra- and intradural hemorrhages), as well as changes in the vertebral bodies. MRI holds a leading role in the diagnosis of post-traumatic disc herniations. In patients presenting with compressive radicular or myeloradicular symptoms in the absence of bone pathology on radiographs, MRI may reveal a traumatic disc herniation.

• When describing a cervical spine injury, it is recommended to use the AOSpine classification (APPENDIX G2) [1, 2, 9].

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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 pattern or allow for the selection of optimal treatment tactics. Therefore, in all cases of suspected spinal injury, computed tomography of the spine with multiplanar and three-dimensional reconstruction is recommended.

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Comment: To determine the lower boundary of the subarachnoid space block, ascending myelography is recommended (contrast medium is injected in 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 is recommended (contrast medium injection into the lateral cistern).

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• In patients with suspected cervical spine injury where SCT and MRI are not feasible, radiography of the spine with functional tests in the early and intermediate periods of spinal trauma is recommended to detect instability [4, 6].

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

3.1. Conservative management

• To provide qualified pre-hospital care to victims with suspected spinal injury, it is recommended to use a rigid cervical collar [3, 6].

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• Cervical spine immobilization is not recommended for patients who are fully conscious, non-intoxicated, have no neck pain, no paraspinal muscle spasm, no neurological deficits, no polytrauma, and have a full range of motion in the neck and limbs [6].

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• Cervical spine immobilization in conscious patients with neck pain or muscle spasm, given normal findings on three-view cervical spine radiography and CT, is recommended to be discontinued [3, 6]:

a) upon resolution of complaints;

b) in the absence of pathology on early functional radiographs;

c) in the absence of injuries on an MRI performed within 48 hours of the injury;

d) by decision of the attending physician.

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• In victims presenting with neurological symptoms in the absence of pathology on cervical spine SCT, it is recommended to [6]:

a) continue cervical spine immobilization until symptoms resolve;

b) discontinue cervical spine immobilization in the absence of pathology on functional radiographs;

c) discontinue cervical spine immobilization in the absence of injuries on an MRI performed within 48 hours after the injury;

d) discontinue immobilization by decision of the attending physician.

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Comment: Baseline therapy includes: regulation of respiratory and cardiovascular function, correction of biochemical homeostasis parameters, management of brain edema, prevention of infectious complications, pressure ulcers, hypovolemia, hypoproteinemia; regulation of pelvic organ function via intermittent urinary bladder catheterization; correction of microcirculatory disorders; normalization of blood rheological parameters; administration of angio- and cytoprotective drugs, hyperbaric oxygen therapy sessions, etc.

• The use of methylprednisolone is not recommended [6].

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• Patients presenting with neurological deficits are recommended to receive antithrombotic therapy [1, 6].

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3.2. Surgical treatment;

• Patients diagnosed with a cervical vertebra dislocation are recommended to undergo emergency neurosurgical intervention [1, 12, 14, 15].

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• In the presence of the following factor(s), surgical treatment for patients with a cervical vertebra dislocation is not recommended [1, 4]:

1. Traumatic or hemorrhagic shock with hemodynamic instability.

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

3. Severe traumatic brain injury with an Glasgow Coma Scale score of less than 10, when intracranial hematoma is suspected (Appendix G6).

4. Severe comorbid conditions 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 segments with the clinical picture of a complete functional transection of the spinal cord.

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• To assess injury severity in the spinal motion segment and determine management tactics, it is recommended to use the SLIC scale. The CSISS scale is not recommended for use due to its low sensitivity in determining treatment tactics and low inter-rater agreement (APPENDIX G3, APPENDIX G4) [6, 16, 17].

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• For a C1 vertebra dislocation, it is recommended to perform open (surgical) reduction. Following reduction of the atlas dislocation, either atlantoaxial arthrodesis is performed, or external fixation with a Halo apparatus or an orthopedic brace for 10–12 months. In cases of spinal cord compression, the compression must be relieved and arthrodesis performed; laminectomy and external fixation for 3–6 months are permissible if necessary [1].

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• Patients with distraction injuries (AOSpine type B) are recommended to undergo anterior or posterior decompression and stabilization intervention. For type B1 injuries, posterior fixation using a certified spinal stabilization system is indicated, with posterior decompression performed if necessary. Type B2 injuries involve complete disruption of both the posterior ligamentous structures of the spine and the anterior disc-ligamentous complex; therefore, the method of choice is excision of the ruptured disc, anterior arthrodesis using an auto- (allo-) graft and a plate, followed by posterior fixation of the vertebrae using a certified spinal stabilization system. For type B3 injuries, the ruptured disc is excised and anterior arthrodesis is performed using an auto- (allo-) graft and a titanium plate [3, 12, 14, 18].

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• For translation injuries (AOSpine type C), it is recommended to first perform anterior decompression with excision of ruptured intervertebral disc fragments and/or, if necessary, corpectomy of the fractured adjacent vertebra, followed by open dislocation reduction and anterior arthrodesis using an auto- (allo-) graft and a titanium plate. Due to the instability of the posterior tension band in such injuries, at the operating surgeon's discretion, a second-stage posterior spinal stabilization may be performed [3, 12, 14, 18].

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• For unilateral vertebral subluxation (AOSpine type F4), it is recommended to perform the earliest possible reduction of the vertebrae and stabilization: excision of the ruptured disc, open reduction of the dislocated vertebra, and arthrodesis with bone autograft (cage with bone chips, allo- or xenograft) and a titanium cervical plate [3, 12, 14, 18].

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• In the absence of a disc herniation at the dislocation level according to MRI data, closed reduction is recommended as early as possible [6].

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• Skeletal traction treatment is recommended when other treatment methods are unavailable or in severely ill patients provided there is no traumatic herniation within the spinal canal lumen. Following the application of skeletal traction via the parietal eminences, subsequent head position correction, traction weight adjustment, and radiological control are required. After reduction of the dislocation and stabilization of the patient's condition, it is recommended to perform excision of the ruptured disc, anterior arthrodesis with bone autograft (cage with bone chips, allograft) and a titanium cervical plate [1].

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• Following surgical treatment of any scope, a follow-up imaging study (cervical spine radiography, CT, or spine MRI) is required [1].

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4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients following cervical vertebra dislocation are recommended to undergo early rehabilitation starting from the first postoperative day. The scope of rehabilitation measures (muscle electrical stimulation – A17.02.001; spinal cord electrical neurostimulation – A17.23.003; multifunctional muscle stimulation – A17.24.010;24; therapeutic exercise for spinal trauma – A19.03.001; mechanotherapy for spinal trauma – A19.03.001.002; robotic mechanotherapy for spinal trauma – A19.03.001.003; A19.03, 04, 23, 24; A17.02, 03, 04, 23, 24; A20.03, 23, 24; massage of the cervicothoracic spine – A21.03.002.005; A21.03, 04, 23, 24; A22.02, 03, 04, 23, 24; A23.30.005, 006, 008, 009; A25.23, 24) is determined for each patient by MDRT specialists jointly with the attending physician [19].

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

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

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

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

LoE 3 GoR A

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Level of Evidence C, Quality of Evidence 5

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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 trauma segments, patients with SCI during the period of primary conservative and neurosurgical care undergo the 1st stage of treatment in an intensive care unit (ICU) or specialized emergency care wards of a traumatology or neurosurgery department with round-the-clock condition monitoring. The need for medical rehabilitation at the 1st stage of specialized care is determined by the necessity of treating primary SCI complications and preventing the secondary post-intensive care syndrome (PICS), the risk of which is directly related to the duration of the ICU stay. Diagnosing neurological disorders in SCI is extremely challenging and largely depends on the phase of the disease. On the one hand, during the "spinal shock" period of 4–12 weeks, it presents a picture of lower motor neuron lesion, gradually evolving into a true topographically determined symptom complex of upper and/or lower motor neuron lesion. On the other hand, the presence of para- and/or tetraparesis combined with clinically justified use of sedation, mechanical ventilation, and other intensive care methods contributes to the development of critical illness polymyoneuropathy with a corresponding clinical presentation, which complicates differential diagnosis and makes it difficult to predict rehabilitation outcomes. This explains the inevitability of a predominantly symptomatic approach to early rehabilitation. The goals of rehabilitation at the 1st stage should focus on preventing secondary conditions and preparing the patient for the maximum possible participation in rehabilitation.

The volume of rehabilitation measures is determined by the severity and level of SCI as well as other associated injuries, the degree of "spinal shock", general clinical severity, and the patient's perioperative status. Prior to neurosurgical stabilization of the damaged spinal cord segment and compensation of vital functions (respiration, circulation), an immobilization regimen is maintained, which gradually transforms into an active-passive mobilization regimen. The faster surgical treatment is performed, the sooner the patient can be involved in the active rehabilitation process, and the lower the risk of developing PICS. PICS (Post-Intensive Care Syndrome) is a constellation of somatic, neurological, and socio-psychological consequences of an ICU stay that limit a patient's daily life, lead to a decrease in their quality of life, and require rehabilitation. Although the intensity of rehabilitation at stage 1 may be limited, all patients with SCI should be given the opportunity to participate in it. An individualized program should include (but not be limited to) out-of-bed activities, acquiring tolerance to the vertical position, range of motion (ROM) exercises, early strengthening exercises, 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 dysreflexia;

• prevention of the development and progression of acute respiratory failure in patients with cervical-thoracic SCI

• prevention and treatment of pain syndrome;

• prevention of dysphagia and nutritional deficiency, including bowel dysfunction and water-electrolyte imbalance;

• positioning and mobilization taking into account:

  - early spasticity syndrome

  - high risk of critical illness polymyoneuropathy combined with lower motor neuron lesion resulting in muscle wasting/atrophy and contracture formation

• verticalization taking into account orthostatic intolerance;

• prevention of pressure ulcers, urinary tract infections, and deep vein thrombosis of the lower leg, including specialized 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 and 80% of mechanically ventilated patients demonstrate the development of PICS. Its main component is immobilization syndrome:

- critical illness polymyoneuropathy (CIP): diffuse reduction of limb strength;

- prolonged respiratory support due to weakness of the respiratory muscles and diaphragm;

- reduced exercise tolerance (weakness) and dyspnea during minimal physical activity due to post-pneumonic fibrosis;

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

- orthostatic intolerance in the vertical position;

- impaired urine passage and predisposition to urolithiasis

- constipation

- complications of learned non-use: dysphagia due to tracheoesophageal dissociation (nasogastric tube + endotracheal or tracheostomy tube);

- delirium;

- chronic pain syndrome (musculoskeletal, neuropathic);

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

- dyssomnia

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Comments: Complications occurring in the hyperacute and acute periods of SCI aggravate the course of the disease, increase the length of hospital stay, and can lead to a fatal outcome. Various complications occur in up to 80% of patients with SCI. Knowledge of these complications and the applied preventive and therapeutic measures can reduce their incidence by 2–3 times. Early rehabilitation of a patient with SCI begins with prevention. Of individuals living with SCI, 70% will have at least one primary or secondary (non-neurological) condition during their hospital stay; individuals with high-level injury (C1–4) have a 2.2 times higher probability of having at least one complication. Preventing secondary conditions accelerates the transition to the rehabilitation phase and increases the level of patient socialization].

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

Comment: The list of STOP signs includes criteria with the highest level of reproducibility, obtained through a rigorous review of literature and clinical experience from ICU departments. If any single one of these symptoms appears, RehabIT should either not be initiated or must be terminated. If STOP signs develop during verticalization, the procedure should be stopped and the patient returned to the previous position (declined by 20^°) or lowered to 0^°.

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

Autonomic dysreflexia is a phenomenon of massive neurosympathetic response occurring in response to spinal cord irritation when the lesion is localized 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 the disruption of intersynaptic connections leads 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 can 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 arteriolar vasoconstriction, increased peripheral vascular resistance, and elevated blood pressure due to the stimulation of baroreceptors 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, resulting in a sharp increase in blood pressure combined with bradycardia. In addition, the AD symptom complex includes: throbbing headache, anxiety, 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 the involvement of the parasympathetic system. 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. In patients with cervical spinal cord injuries, PSH occurs in cases of concomitant traumatic brain injury within the first hours of ICU admission. At the same time, somatic manifestations of PSH may include: gastrointestinal stress ulcers, cerebrocardiac syndrome (ECG changes characteristic of subendocardial ischemia, acute cardiac arrhythmias, etc.), and neurogenic pulmonary edema. Subsequently, such conditions may be a manifestation of somatic complications, primarily venous thromboembolism and nosocomial infections, which requires the attention of multidisciplinary team members.

4.2.2. Prevention of development and progression of acute respiratory failure

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Comments: Respiratory dysfunction and pulmonary complications are a major problem for patients with spinal cord injuries. Cervical spinal cord injury is associated with significant impairment of ventilatory regulation, respiratory cycle, respiratory mechanics, and bronchial reactivity. Respiratory muscle weakness plays a leading role in alveolar hypoventilation and hypercapnic/hypoxemic respiratory failure. The average duration of mechanical ventilation in patients with C1–C4 injuries is 65 days, and 22 days for C5–C8 injuries. Complete injury above the C3 level leads to apnea and death if immediate respiratory support is not provided. In the acute phase, there is a decrease in lung capacity requiring ventilatory support, but a significant proportion of patients no longer require mechanical ventilation after one week to one month from the time of injury. Respiratory dysfunction is characterized from days 2 to 5, after which it progressively improves, although it never returns to baseline. Functional recovery reflects the functional regression of neurological damage with the subsiding of spinal cord edema and the recruitment of accessory respiratory muscles. Injuries below C5 are less associated with ventilatory impairment, but the risk of pulmonary complications remains present in these patients, especially with tetraplegia. Effective coughing and expectoration are also ensured by the action of expiratory muscles. Effective coughing and the ability to clear secretions are limited by paralysis of the expiratory muscles, increasing the risk of atelectasis and pneumonia. In this group of patients, as well as in those with thoracic spinal cord and vertebral injuries, respiratory disorders are usually the result of direct chest trauma (pneumothorax, hemothorax, rib fractures, and pulmonary contusion).

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Comments: electrical muscle stimulation (EMS) has been investigated as a treatment for the prevention of critical illness polymyoneuropathy. It involves placing electrodes on the skin to induce isometric muscle contraction. Treatment involves minimal joint movement and does not require patient interaction. EMS treatment administered during studies lasted from 30 to 60 minutes daily for at least 4 days. Three systematic reviews (including eight randomized trials) showed that EMS can be a useful intervention for critically ill patients and may help maintain muscle mass and strength in an intensive care setting, especially in patients with a prolonged ICU stay under mechanical ventilation. A more recent meta-analysis analyzed the results of 6 randomized clinical trials representing 718 patients.

4.2.3. Positioning and mobilization

Currently, there is no reliable evidence regarding the necessity and benefit of using cervical collars to stabilize the injured segment in patients with post-traumatic spinal cord injury (PSCI) [40]. Patient positioning to achieve sufficient spinal traction must be performed with careful attention to complications, which include exacerbation of neurological damage; increased intra-abdominal pressure and an increased risk of bleeding; corresponding thoracic injury, ischemic optic neuropathy, and peripheral nerve injury. In patients with spinal injuries, position changes can lead to significant hemodynamic alterations; sudden head elevation can result in severe hypotension due to impaired cerebral venous drainage, whereas the 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 wall excursion in more than 70% of patients; in addition, neck immobilization increases the risk of respiratory disorders, intubation difficulties, gastric aspiration, and elevated intracranial pressure.

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4.2.4. Prevention of dysphagia and nutritional deficit

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

4.2.5. Prevention of immobilization complications in patients with SCI

Level of Evidence (LE): 4 | Grade of Recommendation (GR): C

Level of Evidence (LE): 4 | Grade of Recommendation (GR): C

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

Comments: Adequate bladder drainage using one of the following methods: (1) indwelling Foley catheterization with replacement every 5–7 days, monitoring adequate catheter function; (2) silver-impregnated indwelling Foley catheterization with replacement every 3–4 weeks, monitoring function; (3) intermittent sterile catheterization using 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 the disruption of communication between spinal and supraspinal levels of micturition regulation as a result of damage to neural pathways or spinal cord 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; although intermittent catheterization should ideally be applied in the early stages following spinal cord injury, in practice, its application 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 may be switched to aseptic or clean catheterization. In European countries, 95% of patients with post-traumatic myelopathy use lubricated catheters during intermittent catheterization and perform aseptic catheterization. Furthermore, self-catheterization is used by 85% of patients with paraplegia and 46% of patients with cervical myelopathy and reduced upper extremity manual dexterity. 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 a central motor neuron lesion above S2, the defecation reflex remains intact, but automatic defecations will occur due to a hypertonic or spastic external sphincter. With a peripheral motor neuron lesion, the defecation reflex is impaired, the external sphincter is hypotonic, but some endogenous contraction remains in the bowel. Peristalsis "returns" when ileus subsides as spinal shock resolves. The bowel training technique is identical for central and nervous system lesions and includes several rules:

- Bowel evacuation should occur every two days.

- Prescribe laxatives at night and daily stool softeners (liquid paraffin) to the patient.

- The defecation reflex is initiated by stimulating the anus using suppositories (glycerol, approved from 2 years of age) 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 events throughout their hospital stay. The incidence of deep vein thrombosis (DVT) in patients with spinal injuries who do not receive prophylaxis ranges from 39% to 100%, compared to 9–32% in medically and surgically untreated ICU patients. Among patients with spinal cord injury, the risk of DVT is higher with complete than incomplete injury, and with thoracic than cervical injury, as well as during the first three months post-injury. The incidence of pulmonary embolism following spinal cord injury in the absence of prophylaxis is estimated at 4% to 10%. PE is one of the three most common causes of death after spinal cord injury.

Level of Evidence 2, Grade of Recommendation B

4.2.6. Prevention of Emotional, Cognitive Impairments, and Delirium

LE 3 GSR C

Comments: to date, there are no evidence-based methods for pharmacological and combined prevention.

4.2.8 "Patient routing" to rehabilitation stages

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:

• termination of the acute period of the disease (stable clinical and radiological picture in the lungs, but ongoing replacement of vital functions);

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

• duration of mechanical ventilation for more than 14 days;

• low level of consciousness or functional-personality changes;

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

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

• consequences of prolonged immobilization: spasticity syndrome, degenerative joint changes, tenogenic and 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

LNC 4 LeC C

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

LNC 5 LeC 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

LNC 5 LeC C

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

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

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

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

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

LVE 3 GCR A

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

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

LE 4 GSR 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

LNC 4 LeC C

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

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

LNC 5 LeC C

LNC 4 LeC C

LE 3 GSR 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

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

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

LNC 5 LeC C

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

LNC 5 LeC C

LNC 5 LeC C

LNC 5 LeC C

LNC 5 LeC C

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

LNC 4 LeC C

LNC 4 LeC C

• To prevent orthostatic hypotension, it is recommended to engage in moderate-to-high-intensity aerobic exercise at least 2 times a week for at least 20 minutes, as well as moderate-to-high-intensity strength exercises targeting major muscle groups for 3 sets [67].

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 [75, 97].

• To prevent pressure ulcers, it is recommended for patients with spinal cord injury to undergo low-intensity laser therapy (predominantly in the infrared range), magnetotherapy, ELF/VLF therapy, and ultrasound therapy [94, 98, 99].

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

• For screening assessment of patient status and rehabilitation outcomes, it is recommended to use brief tests that provide a global evaluation of results (at least every 10 days of the course) and a final assessment upon discharge [21, 23, 24].

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

Comments: 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),

- Ashworth scale – an indicator of muscle spasticity (Appendix G10),

- Functional Independence Measure (FIM) (Appendix G5),

- Spinal Cord Independence Measure (SCIM) (Appendix G11).

1. Initiation of medical rehabilitation measures no later than 48 hours after surgical treatment.

2. Formulation of an individualized medical rehabilitation program based on the diagnostics of impairments in body structures, functions, activity and participation, and environmental factors influencing the outcome of the patient's disease/condition, taking into account the specifics of the underlying and concomitant diseases.

3. Delivery of medical rehabilitation measures by a multidisciplinary rehabilitation team.

4. Dynamic assessment of the patient's functions and daily activities based on the Rehabilitation Routing Scale (RRS) at all stages of medical rehabilitation.

5. Prevention and Dispensary Observation

Complications arising during the treatment of patients with spinal cord injury aggravate the course of the disease, increase hospital stay duration, and may lead to a fatal outcome. Various complications occur in 54%-82% of patients with spinal cord injury. Knowledge of these complications and the applied preventive and therapeutic measures can reduce their incidence by 2-3 times [1, 4, 12].

• To prevent urinary tract infections, it is recommended for all patients after surgery to perform the following interventions [1, 4, 5, 12, 107-109]:

1. Adequate bladder drainage using one of the following methods: (1) permanent Foley catheterization with replacement every 5–7 days, monitoring of adequate catheter function; (2) permanent silver-impregnated Foley catheterization with replacement every 3–4 weeks, monitoring of function. 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 (A11.28.007 Urinary bladder catheterization).

2. Strict adherence to asepsis rules during urinary catheter insertion (A11.28.007 Urinary bladder catheterization).

3. Electrical stimulation of the urinary bladder.

4. Bladder electrophoresis (A17.30.024 Pulsed-current electrophoresis).

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

LNC 5 LeC C

• To prevent pneumonia, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109, 110]:

1. Antibacterial therapy.

2. Breathing exercises: active and passive.

3. Therapeutic bronchoscopies.

4. Physical therapy for spinal injury and massage for spinal disorders starting from the second day after surgery.

5. Early mobilization of the patient.

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

7. Multifunctional muscle electrical stimulation, ultra-high-frequency (UHF) electric field therapy, microwave electromagnetic field therapy, electrical stimulation,

8. Short-wave ultraviolet therapy, long-wave ultraviolet therapy, integral ultraviolet therapy.

LNC 5 LeC C

• To prevent intestinal paresis, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109]:

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

2. Pharmacological stimulation of intestinal motility.

3. Cleansing enemas at least once every 3 days.

LNC 5 LeC C

• To prevent pressure ulcers, all patients should undergo the following interventions after surgery [1, 4, 5, 12]:

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 alcohol or a 1:1 shampoo-and-vodka mixture.

4. Early mobilization.

5. Physical therapy for spinal injury (PT), medical neck massage, and massage for spinal disorders.

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

7. Monitoring nutritional adequacy, especially protein intake.

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

9. Phototherapy (laser therapy, ultraviolet irradiation [UVI], polarized light).

LNC 5 LeC C

• To prevent VTE and deep vein thrombosis of the lower extremities, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109]:

1. Administration of low-molecular-weight heparins (LMWHs) (ATC Heparin group) in patients with severe motor deficit during the first two weeks postoperatively. For bedridden patients, subsequent transition to indirect anticoagulants (ATC Antiplatelet agents excluding heparin) for up to 3 months. Monitoring of hemostatic parameters with a coagulogram (screening hemostasis test) is required.

2. Use of LMWHs in combination with adjustable beds, intermittent pneumatic compression of the lower extremities, or electrical stimulation of the leg muscles.

3. Use of duplex ultrasound scanning (Duplex scanning of lower extremity vessels [arteries and veins]) for the diagnosis of deep vein thrombosis every 5 days.

4. Addressing the issue of surgical VTE prevention methods in patients intolerant to anticoagulants (ATC Antiplatelet agents excluding heparin) or in patients with contraindications to anticoagulant therapy.

5. Early mobilization of the patient.

7. Physical therapy for spinal injury and limb massage (Massage for spinal disorders) from the first day of hospitalization.

6. Elastic compression of the lower extremities.

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

LNC 5 LeC C

• To prevent sepsis, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109]:

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

2. Prevention and treatment of intestinal paresis.

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

LNC 5 LeC C

• To prevent gastrointestinal bleeding, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109]:

1. Gastroprotective therapy for up to 3 weeks.

2. Monitoring of hemostatic parameters with a coagulogram (screening hemostasis test).

3. Monitoring of the patient's nutrition.

LNC 5 LeC C

• To prevent postoperative wound suppuration, it is recommended that all patients undergo the following interventions after surgery [1, 4, 5, 12, 107-109]:

1. Systemic antibacterial administration 30 minutes before surgery, with additional doses administered every 6 hours of surgery or per 1 liter of blood loss (antibiotic prophylaxis).

2. Meticulous layered wound closure (5–6 rows of sutures) without tension.

LNC 5 LeC C

6. Organization of Medical Care

6.1 Providing first aid to patients with suspected cervical spine dislocation at the prehospital stage.

• To provide qualified care at the prehospital stage for victims with suspected cervical spine dislocation, it is recommended that each ambulance team be equipped with a rigid cervical collar and rigid or vacuum stretchers (vacuum immobilization devices) [1, 4].

LNC 5 LeC C

Comment: The most effective combination is considered to be a rigid cervical collar and a rigid spine board with patient strapping. A combination of a rigid cervical collar and vacuum 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

6.2 Providing specialized medical care to patients with cervical spine dislocation in a hospital setting.

• For the treatment of patients with cervical spine dislocation, the hospital must be equipped with the following: an operating room with a multifunctional radiolucent table, a C-arm, microsurgical instrument sets, high-speed drills, bone rongeurs and conchotomes, a microscope or binocular loupes, sets for cervical spine fixation, halo devices, pedicle fixators, and anterior plates [1, 12].

LNC 5 LeC C

7. Additional Information

Functional outcomes in patients with acute spinal cord and spinal injury should be evaluated using the FIM scale (APPENDIX G5). To predict injury outcomes in patients with spinal cord injury without instrumental signs of bony damage, dynamic MRI of the affected spinal cord segment is recommended [4].

Risk factors for adverse surgical outcomes in patients with concomitant spine trauma (SST):

1. Severity of concomitant trauma 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)

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. Anna N. Belova – D.Sc. in Medicine, Professor, Head of the Department of Medical Rehabilitation at the 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. Rezeda A. Bodrova – D.Sc. in Medicine, Associate Professor, Head of the Department of Rehabilitology and Sports Medicine at the Kazan State Medical Academy, a branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation, Chairperson of the All-Russian Public Organization for the Promotion of Medical Rehabilitology "Union of Rehabilitologists of Russia" in the Republic of Tatarstan.

4. Tatyana V. Buylova – D.Sc. in Medicine, 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 of the Privolzhsky Federal District of the Russian Federation, Chairperson of the Nizhny Novgorod Regional Branch of the All-Russian Public Organization for the Promotion of Medical Rehabilitology "Union of Rehabilitologists of Russia".

5. Andrey A. Grin – Corresponding Member of the RAS, D.Sc. in Medicine, Head of the Department of Emergency Neurosurgery at the Sklifosovsky Research Institute for Emergency Care of the Moscow Healthcare Department, Professor at the Department of Fundamental Neurosurgery, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Moscow, Russia).

6. Aleksandr V. Gubin – D.Sc. in Medicine, 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).

7. Lyaysan Sh. Gumarova – Ph.D. in Medicine, Assistant at the Department of Rehabilitology and Sports Medicine at the Kazan State Medical Academy, a branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation.

8. Vadim D. Daminov – D.Sc. in Medicine, Chief Specialist in Medical Rehabilitation at the Pirogov National Medical and Surgical Center of the Ministry of Health of the Russian Federation.

9. Aleksandr K. Dulaev – D.Sc. in Medicine, 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).

10. Aigul D. Zakamyrdina – Assistant at the Department of Rehabilitology and Sports Medicine at the Kazan State Medical Academy, a branch of the Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation

11. Galina E. Ivanova – D.Sc. in Medicine, Professor, Head of the Department of Medical Rehabilitation at the Faculty of Additional Professional Education, 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 of Russia, Chief freelance specialist in medical rehabilitation of the Ministry of Health of the Russian Federation, Chairperson of the All-Russian Public Organization for the Promotion of Medical Rehabilitology "Union of Rehabilitologists of Russia".

12. Nataliya E. Ivanova – D.Sc. in Medicine, Professor, Head of the Scientific Department at the Polenov Russian Neurosurgical Institute, Professor at the Department of Neurology and Psychiatry, Institute of Medical Education of the Almazov National Medical Research Centre, Honored Doctor of the Russian Federation.

13. Aleksandr N. Komarov – Ph.D. in Medicine, Head of the National Center for the Development of Social Support Technologies and Medical Rehabilitation "Doverie", Associate Professor at the Department of Adaptive Physical Culture and Recreation at the Russian State Social University (RSSU).

14. Nikolay A. Konovalov – Corresponding Member of the RAS, D.Sc. in Medicine, Professor at the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Head of the Department of Spinal Neurosurgery at the Burdenko National Medical Research Center of Neurosurgery of the Russian Ministry of Health (Moscow, Russia).

15. 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).

16. Elena V. Kostenko – D.Sc. in Medicine, Professor, Deputy Director for Research at the Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky of the Moscow Healthcare Department.

17. Vladimir V. Krylov – Academician of the RAS, D.Sc. in Medicine, Professor, Honored Scientist of the Russian Federation, Head of the Department of Fundamental Neurosurgery, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Chief Researcher at the Department of Emergency Neurosurgery, Sklifosovsky Research Institute for Emergency Care (Moscow, Russia).

18. Aleksandr G. Kulikov – D.Sc. in Medicine, Professor, Chief Researcher at the Department of Medical Rehabilitation, Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky of the Moscow Healthcare Department.

19. Gleb M. Lutokhin – Ph.D. in Medicine, Senior Researcher at the Department of Medical Rehabilitation, Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky of the Moscow Healthcare Department.

20. Ivan S. Lvov – Ph.D. in Medicine, Senior Researcher at the Department of Emergency Neurosurgery, Sklifosovsky Research Institute for Emergency Care (Moscow, Russia).

21. Marina R. Makarova – Ph.D. in Medicine, Associate Professor, Leading Researcher at the Department of Medical Rehabilitation, Moscow Scientific and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky of the Moscow Healthcare Department.

22. Vadim A. Manukovskiy – D.Sc. in Medicine, Professor at the Department of Military Field Surgery, Kirov Military Medical Academy of the Ministry of Defense of Russia, Professor at the Department of Neurosurgery, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Deputy Director for Clinical Work at the Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine (Saint Petersburg, Russia).

23. 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).

24. Morozov Ivan Nikolaevich – MD, PhD, Head of the Center for Neurorehabilitation of Patients with Spinal Cord Pathology at the University Clinic of the Privolzhsky Research Medical University of the Russian Ministry of Health.

25. Meshcheryakov Semen Vladimirovich – PhD, Neurosurgeon, Leading Researcher at the Department of Neurosurgery and Neurotrauma, Research Institute of Emergency Pediatric Surgery and Traumatology of the Moscow Healthcare Department (Moscow, Russia).

26. Parfenov Valery Evgenyevich – MD, PhD, Professor, Honored Doctor of the Russian Federation, Director of the I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Medicine (St. Petersburg, Russia).

27. Pogonchenkova Irena Vladimirovna – MD, PhD, Associate Professor, Director of the S.I. Spasokukotsky Moscow Research and Practical Center for 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.

28. Prokopenko Semen Vladimirovich – MD, PhD, Professor, Head of the Department of Nervous Diseases at KrasSMU, Chief Neurorehabilitologist of the Siberian Federal District, Scientific Director of the Neurology and Neurorehabilitation Service, Federal Siberian Research and Clinical Center of the Federal Medical-Biological Agency of Russia.

29. Rerikh Viktor Viktorovich – MD, PhD, Head of the Research Department of Spinal Pathology, Ya.L. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Russian Ministry of Health (Novosibirsk, Russia).

30. Semenova Zhanna Borisovna – MD, PhD, Chief Freelance Pediatric Neurosurgeon, Head of the Department of Neurosurgery and Neurotrauma, Research Institute of Emergency Pediatric Surgery and Traumatology of ሞscow Healthcare Department (Moscow, Russia).

31. Tsykunov Mikhail Borisovich – MD, PhD, Professor, Head of the Medical Rehabilitation Department at the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation, Professor at the Department of Medical Rehabilitation of the Faculty of Additional Professional Education at the Pirogov Russian National Research Medical University, Deputy Chairman of the All-Russian Public Organization for the Promotion of Development of Medical Rehabilitology “Union of Rehabilitologists of Russia”.

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

The working group members are part of the Association of Neurosurgeons of Russia, the Association of Spine Surgeons, the Association of Traumatologists and Orthopedics of Russia, and the Union of Rehabilitologists of Russia.

There is no conflict 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.

1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

3. Grade of Recommendation (GoR) scale 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.

Clinical guidelines update procedure: 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. “Procedure for Providing Medical Care to Victims with Associated, Multiple, and Isolated Injuries Accompanied by Shock” dated November 15, 2012, No. 927n.

3. “Procedure for Providing Ambulance, Including Specialized Emergency Medical Care” dated June 20, 2013, No. 388n.

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".

6. “Procedure for Organizing Medical Rehabilitation of Children” dated October 23, 2019, No. 878n.

7. 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".

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 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 urinary bladder drainage;

2. Compliance with all asepsis rules during urinary catheter insertion.

3. Uroseptics intake – medications are prescribed by the attending physician.

Pneumonia:

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

2. Respiratory exercises: active and passive.

3. Massage for spinal disorders, thermal vibromassage of paraspinal muscles.

4. Exercise therapy and massage for spinal disorders starting from the second day after surgery

Intestinal paresis:

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

2. Medical stimulation of intestinal motility – the drugs 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 scapulae with camphor spirit, a 3:1 mixture of shampoo and alcohol.

4. Early mobilization.

5. Exercise therapy (physiotherapy) and massage for spinal disorders.

6. Hyperbaric oxygen therapy (HBOT).

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

8. Monitoring adequate nutrition, especially protein intake.

9. Skin care, maintaining skin moisture (use of creams).

Deep vein thrombosis of the lower extremities:

1. Use of anticoagulants – the drugs are prescribed by the attending physician.

2. Elastic compression of the lower extremities.

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

Appendix G1. International Standards for Neurological and Functional Classification of Spinal Cord Injury (ASIA scale)

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

Original title: American Spine 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 lesion. No sensory or motor function is preserved 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.

Fig. 1. Neurological status assessment form ASIA/ISCSCI

Notes:

Spinal cord status criteria include muscle strength, tactile and pain sensitivity, and reflex activity in the anogenital region. Motor functions are assessed by testing the strength of key muscle groups corresponding to spinal segments. Five segments were selected for the upper extremities (C5–T1) and five for the lower extremities (L2–S1). Muscle strength is graded as follows: 0 – plegia, 1 – palpable or visible contractions of individual muscle groups, 2 – active movement with gravity eliminated, 3 – active movement against gravity, 4 – active movement against moderate resistance, 5 – active movement against full resistance. Muscle strength is assessed bilaterally, and the scores from each segment are summed up. The results are recorded on the examination chart. If muscle strength cannot be assessed for any reason (e.g., limb in a cast), the abbreviation NT (not tested) is recorded. The maximum possible score for 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 evaluated 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. Sensory function is tested in 28 segments bilaterally. To determine sensitivity throughout an entire segment, testing it at a single key point anchored to a clear anatomical landmark is sufficient. C2 – occipital protuberance, C3 – supraclavicular fossa, C4 – peak 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 line, T6–T9 – corresponding intercostal spaces, T10 – umbilicus, T11 – eleventh intercostal space, T12 – inguinal ligament, L1 – halfway between T12 and L2, L2 – midpoint 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. Sensitivity is graded on the following scale: 0 – absent, 1 – impaired, 2 – normal. If sensation was not tested, NT is entered in the corresponding examination chart cell. The inability to distinguish between sharp and dull pinprick is scored as absent pain sensation. Tactile sensation is determined using cotton wool or Semmes-Weinstein monofilaments. The test results are recorded on the chart. When testing sensation in 28 segments bilaterally, the maximum score is 56. Additionally, anal sensation is assessed to determine the completeness of the injury. Sensory assessment includes determining limb position and deep pressure sense, which are graded as absent, impaired, or normal. To assess joint position sense, passive movements of the index fingers and big toes are tested. These data are not recorded on the chart but provide additional information regarding the severity of the injury.

Appendix G2. Vertebral injury classification

Russian title: Classification of vertebral injuries

Original title: AOSpine subaxial cervical spine injury classification system

Source: AOSpine subaxial cervical spine injury classification system / A. R. Vaccaro, J. D. Koerner, K. E. Radcliff [et al.] // Eur. Spine J. - 2016. - Vol. 25, N. 7. – P. 2173-2184.

Type:

- rating scale

- index

- questionnaire

Purpose: description of vertebral injury

Contents:

Compression injuries (Type A) are characterized by localization of injury in the vertebral bodies of varying severity (Fig. 2):

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

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

Facet injuries (Type F, Fig. 5) are assessed for isolated joint injury or in combination with types A, B, and C.

Fig. 2 Compression injuries according to the AOSpine classification: a – type A0; b – type A1; c,d – type A2; e – type A3; f,g – type A4.

Fig. 3 Distraction injuries according to the AOSpine classification: a – type B1; b – type B2; c,d,e – type B3.

Fig. 4 Examples of translation injuries according to the AOSpine classification.

Fig. 5 Types of facet joint injuries according to the AOSpine classification: a – type F1; b – type F2; c – type F3; d,e – type F4.

Notes:

Compression injuries (Type A):

A0 – no fracture or minor bone injuries (lamina, spinous process). Also used for spinal cord contusion without bone trauma;

A1 – wedge-compression fracture of one endplate without involvement of the posterior ligamentous complex;

A2 – split fracture involving both endplates without fragments and without posterior ligamentous complex injury, also includes coronal split fracture of the vertebra;

A3 – incomplete burst fracture of one endplate with displacement into the canal and potential posterior ligamentous complex injury;

A4 – complete burst fracture of the vertebral body involving both endplates. Also includes sagittal split fracture involving the posterior ligamentous complex.

Distraction fractures (Type B):

B1 – transverse fracture of the posterior arch in the axial plane due to hyperflexion, extending into the pedicles and vertebral body;

B2 – injury predominantly to the ligamentous structures of the posterior ligamentous complex due to hyperflexion, with potential involvement of articular processes and intervertebral disc;

B3 – extension injury of the anterior column involving the anterior and posterior longitudinal ligaments and the disc. Vertebral body fracture is possible (teardrop or horizontal across the entire body).

Facet injuries (Type F):

F1 – nondisplaced fracture, fragment less than 1 cm in the sagittal plane or less than 40% of the lateral mass;

F2 – displaced fracture or fragment greater than 1 cm or greater than 40% of the lateral mass;

F3 – floating lateral mass – fracture extending into the pedicle, lamina, transverse process, resulting in a portion of the lateral mass being detached from the vertebra;

F4 – joint capsule rupture with instability or dislocation.

Spinal cord injury (N) is graded according to 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 functional transection of the spinal cord;

NX – unspecified injury. Used for patients in an unconscious state.

In case of ongoing compression of neural structures, a "+" sign is indicated.

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

M1 – partial injury to the ligamentous structures of the posterior ligamentous complex.

M2 – intervertebral disc herniation;

M3 – systemic connective tissue diseases increasing spinal column "stiffness" (diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, ossification of the posterior longitudinal ligament, etc.).

M4 – vertebral artery injury.

Appendix G3. SLIC scale

Russian title: SLIC scale

Original title (if available): Subaxial Injury Classification System

Source: The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex / A. R. Vaccaro, R. J. Hulbert, A. A. Patel [et al.] // Spine (Phila Pa 1976). - 2007. - Vol. 32, N. 21. - P. 2365-2374.

Type:

- rating scale

- index

- questionnaire

Purpose: scoring of injury severity for clinical decision-making

Content: the criteria taken into account in the SLIC scale are presented in Table 1.

Table 1. Distribution of points depending on the type of injury, integrity of the disc-ligamentous apparatus, and degree of neurological deficit.

Key: If the sum of points across the three items is 5 or more, surgical treatment is indicated. With a sum of 3 or less, conservative therapy is preferred. With 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. CSISS scale

Russian title: CSISS scale

Original title: cervical spine injury severity score

Source: Moore, T. Classification of lower cervical spine injuries / T. Moore, A. R. Vaccaro, P. A. Anderson // Spine. - 2006. - Vol. 31, N. 11. - Suppl. - S37–S43.

Type:

- rating scale

- index

- questionnaire

Purpose: scoring of injury severity for clinical decision-making

Contents:

4 anatomical zones are identified: (1) vertebral body, intervertebral disc, uncovertebral joint, adjacent part of the transverse process, anterior and posterior longitudinal ligaments; (2) spinous process, lamina, ligamentum flavum, interspinous and supraspinous ligaments; (3 and 4) lateral masses with articular processes and capsules, pedicles, and the adjacent part of the transverse process on the right and left (Fig. 6).

Bone injuries are assessed according to the magnitude of fragment displacement. Ligamentous injuries are assessed based on the degree of separation of the corresponding bone landmarks: 0 points – no injury. 1 point – injury without displacement. 5 points – maximum possible injury for the given level, for example, complete perched dislocation in the facet joints, or complete rupture of the ligamentous apparatus of the posterior tension band (Fig. 7).

Fig. 6 Illustration of anatomical zones whose injury is taken into account in the CSISS scale.

Fig. 7 Visual scoring scale when using the CSISS scale.

Key:

The points of all 4 columns are summed. The maximum total score is 20. With a value of 7 or more, surgical treatment is indicated, and if the sum is less than 7, conservative therapy

Notes:

The most injured level is classified. In each column, the injury to the bone and ligamentous apparatus is assessed. The final score in the column is assigned based on the most pronounced injury. That is, if the bone structure injury corresponds to 3 points, and ligament rupture to 5, then the final score for the column is 5.

Appendix G5. Functional Independence Measure

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 as Table 2.

Table 2. FIM questionnaire form.

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

7 – complete independence in performing the corresponding function (all actions are performed independently, in a standard manner, and with a reasonable expenditure of time)

6 – modified independence (the patient performs all actions independently, slower than usual, or needs outside advice)

5 – supervision / setup (performing actions requires staff observation or assistance in putting on prostheses/orthoses)

4 – minimal assistance (requires outside help when performing actions, but performs more than 75% of the task independently)

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

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

1 – total assistance / complete dependence on others (can independently perform less than 25% of the required actions)

Appendix G6. Rehabilitation routing scale

Russian title: early rehabilitation routing scale.

Source:

1. Order of the Russian Ministry of Health dated July 31, 2020, No. 788N "On Approval of the Procedure for Organizing Medical Rehabilitation of Adults". Link active as of 21-04-2021: https://www.garant.ru/products/ipo/prime/doc/74581688/

2. Belkin A.A., Rudnik E.N., Belkin V.A., Pinchuk E.A., Lipovka N.S. Optimization of staged care for patients in intensive care units based on the rehabilitation routing scale-6 grading. Physical and Rehabilitation Medicine, Medical Rehabilitation. 2021;3(1):142–148. https://doi.org/10.36425/rehab64082

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. Rankin scale

Russian name: Modified Rankin Scale.

Source:

1. J Rankin. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J.  1957 May;2(5):200-15. doi: 10.1177/003693305700200504. PMID: 13432835

2. J C van Swieten, P J Koudstaal, MC Visser, HJ Schouten, J van Gijn. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988 May;19(5):604-7.  doi: 10.1161/01.str.19.5.604. PMID: 3363593

Original title (if applicable): Rankin scale

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. It is used in neurology, cardiology, and traumatology. Time to complete: 5 minutes. Applications:

• assessment of pre-stroke/pre-illness disability based on history and patient interview,

• assessment of rehabilitation outcomes at each stage,

• 90-day telephone follow-up interview,

• tool for transitioning between rehabilitation stages,

• tool for determining "rehabilitation potential",

• assessment of the efficacy of medications and rehabilitation interventions.

Contents:

1 point

• Certain symptoms (physical or cognitive) may be present:

• Mood,

• Speech, reading, and writing disorders,

• Mobility or sensory problems;

• Can return to previous work, maintain the 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 activities that were possible before the illness (driving a car, reading, writing, dancing, working, etc.),

• Can take care of themselves independently (dresses and undresses, goes to the store, cooks simple food, can make short trips and journeys, moves around independently),

• Does not require observation,

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

3 points

• Has symptoms of the disease,

• Can ambulate independently and without outside help,

• Dresses, undresses, uses the toilet, eats, and performs other daily activities independently,

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

• Requires assistance with financial management.

• Can live alone at home without assistance for 1 day to 1 week.

4 points

• Has symptoms of the disease,

• Cannot ambulate 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 nearby,

• Can live alone at home without assistance for up to 1 day.

5 points

• Has symptoms of the disease,

• Cannot ambulate 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 – patient death

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

Key concepts for assessing on the Rankin scale

Appendix G8. Spinal Cord Injury Functional Assessment Scale

Russian name: Spinal Cord Independence Measure

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, or at a normal pace, requires no assistance

4 – slight difficulty;

3 – moderate difficulty, performs 75% or more of the task independently;

2 – marked difficulty, 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. Glasgow Coma Scale

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 G10. Ashworth Scale

Russian title: Modified Ashworth Scale for Spasticity

Original title (if any): Ashworth Scale of Muscle Spasticity

Source:

1. Bohannon R., Smith V. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys. Ther. 1987; 67:206-207.

2. Wade D.T. Measurement in neurological rehabilitation. Oxford University Press, 1992.

Type (underline):

- rating scale

- index

- questionnaire

Purpose: scoring the degree of muscle spasticity

Content: criteria used in the scale are presented in Table 9.

Table 9. Modified Ashworth Scale for Spasticity.

Appendix G11. Spinal Cord Independence Measure

Russian title: Spinal Cord Independence Measure

Original title (if any): Spinal Cord Independence Measure – SCIM

Source: 1. The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study / M. Itzkovich, I. Gelernter, F. Biering-Sørensen et al. – DOI 10.1080/09638280601046302 // Disability and Rehabilitation. – 2007. – Vol. 29, Issue 24. – P. 1926–1933.

2. Spinal Cord Independence Measure (SCIM III). Preparation of the Russian-language version / E.M. Vasilchenko, G.K. Zoloev, A.S. Kislova et al. – DOI: 10.18821/1560-9537-2016-19-2-96-102 // Medical and Social Expert Evaluation and Rehabilitation. – 2016. – Vol. 19, no. 2. – P. 96-102.

Type (underline):

- rating scale

- index

- questionnaire

Purpose: assessment of individual functional status in patients with paraplegia or tetraplegia during rehabilitation

Content: the questionnaire form is presented as a table.

In 2016, a Russian-language version of the SCIM III questionnaire was prepared, which allows assessing the degree of impairment in self-care, mobility, urination, defecation, and respiration in a patient with spinal cord injury, including during dynamic follow-up in the course of rehabilitation. The following main domains and functions are assessed: self-care (scored from 0 to 20 points), respiration and sphincter management (from 0 to 40 points), mobility in room and toilet, as well as indoor and outdoor mobility (from 0 to 40 points). Each domain is weighted according to its proportional importance in the overall activity of these patients. The final score ranges from 0 to 100 points.