Closed spine injuries: causes, symptoms, diagnosis, treatment

In the emergence of various spine injuries, four main mechanisms of action of damaging violence should be distinguished: flexion, flexion-rotational, extensor and compression. Each of these types of violence leads to a certain form of spinal injury, each of which can be classified as either stable or unstable damage.

The concept of stable and unstable vertebral fractures in traumatology was introduced by Nicoll in 1949 for the lumbosacral spine, and in 1963 Holdsworth extended to the entire spine.

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Causes of closed spine injuries

To clarify the further presentation, it is worth remembering the basic facts about how individual vertebrae form a single organ - the spine.With exception of the first two vertebrae, the atlas and axis, the bodies of all the underlying vertebrae are connected to each other by intervertebral discs-complex anatomical structures, one of the functions of which is to hold the body of one vertebra relative to the other's body.Thus, the stability of the anterior sections of the spine is provided by intervertebral discs or, more precisely, their fibrosis bubbled rings, as well as the front n to a lesser extent the posterior longitudinal ligament.

The posterior parts of the vertebrae are held relatively to each other by posterior-external intervertebral articulations with their ligamentous and bag-like apparatus, interstitial, supraspinous and yellow ligaments.

In general, the stability of the vertebrae is provided by these four formations: posterior-external intervertebral joints, synovial joints, interstitial, annoying and yellow ligaments, called the "back support complex" ("back ligament complex" according to Holdsworth). In all cases where the elements of the "rear support complex" remain intact, the damage to the spine remains stable. In all cases where the "posterior support complex" is damaged, spine injuries are unstable.

Bending mechanism. Flexural violence affecting the spine, occurs when a sudden significant one-stage, forced bending of the human torso. Such a mechanism of violence occurs when the weight falls on the victim's shoulders, when falling from the heights on the buttocks or straightened yogas, etc. The breaking force is spent on overcoming the resistance of the extensor muscles and on the vertebral body fracture and is extinguished by this fracture. As a rule, with such a mechanism of violence, the anatomical structures of the "posterior support complex" are not damaged. A typical compression wedge shaped vertebral body appears, a fracture typical of the lumbar and lower thoracic localization. Since the structures of the "posterior support complex" are not damaged, this type of spine injury should be attributed to stable.

In some rare cases, when after a fracture of the vertebral body the damaging violence continues to function and increases its size, the ligaments of the "posterior support complex" may break. Then unstable damage can occur.

In the cervical spine, where the anatomical structures of the "posterior support complex" are less strong, as a result of flexion violence, there may be flexural dislocations or fractures, which are related to unstable injuries.

Extensor mechanism. Until recent years it was believed that extensor spine injuries are extremely rare. Indeed, this mechanism of damage is rarely the cause of damage to the thoracic and lumbar spine. However, in the cervical region, it occurs frequently. Approximately about half of the injuries of the cervical spine are due to extensor violence.

Extensor violence occurs when a sudden one-stage hyperextension of the spine. With this mechanism of violence, the anatomical structures of the "posterior support complex" remain intact. There is a fracture in the roots of the roots, or, which is more often observed in the cervical spine. The rupture of the anterior longitudinal ligament and the intervertebral disc or the spongy substance of the vertebral body near the closure plate, and an extensor dislocation arises. The damage is stable provided the bending position is maintained. If such a victim is treated with hyper-stricture, then he can cause irreparable harm. Extensor injuries of the cervical spine often occur in motorists and divers when the head at the time of impact against the bottom of the river was in the unbending position.

The flexion-rotational mechanism. Under the influence of flexion-rotational violence or purely rotational violence, as a rule, the anatomical structures of the "posterior support complex" are damaged. If only the ligaments are damaged, which is more often observed in the cervical region, there is a net dislocation: if the articular processes and the front parts of the spine break down at the same time, a fracture-dislocation occurs. Both dislocations and pore-dislocations are classified as unstable lesions. In the pure form dislocations most often occur in the cervical spine, much less often in the lumbar region and never appear in the thoracic, which has an additional rigid attachment in the form of a thorax.

The classic place for the development of fracture-dislocations are the lumbar and lumbar-thoracic spine. Not so rare they are found and the cervical department and extremely rare and thoracic. Flexibility-rotational violence occurs when gravity falls on the area of one shoulder or shoulder blade, when it acts not symmetrically and not only bends, but also rotates the spine around its vertical axis. This mechanism of violence is often the case in railway and automobile accidents. Very often such fractures are combined with damage to the contents of the spinal canal.

Compression mechanism. The compression mechanism of violence consists in the fact that the breaking force acts but a vertical vertical, applied to the bodies of the vertebrae. This mechanism of violence is peculiar only to the cervical and lumbar spine, whose bodies in a certain position can be located strictly along a vertical line. The normal position for the cervical and lumbar spine is physiological lordosis. In the position of easy bending, the cervical or lumbar spine is straightened, lordosis is eliminated, and the vertebral bodies are located along a plumb line. When at this moment vertically the vertebral bodies are acted upon by violence, then there is a compression fracture of the vertebral body. With such damage, the structures of the "rear support complex" remain intact, why this type of damage is classified as stable.

In detail, the mechanism of this fracture was studied and described by Roaf in 1960. In this case, severe damage to the spinal cord and its elements often displaced towards the vertebral canal by the posterior fragment of the body of the fractured vertebra.

These are the four main mechanisms of spine damage, which determine the nature of each given spine injury.

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Symptoms of closed spine injury

Symptoms of spine injury should reflect the degree of stability of the existing lesion, the presence or absence of complications from the spinal cord or its elements and the specific clinical form of spinal injury. A detailed clinical diagnosis can be established on the basis of detailed elucidation of the circumstances of the trauma and the material cause that caused it, clarifying the place of its application and the nature of the possible impact, the objective examination and examination data, and finally qualitative spondplograms in at least two projections, front and side.

However, when providing first aid to the victim at the scene, it is important at least to know approximately whether there is a stable or unstable damage. This is important to know because transporting a victim with unstable damage is more responsible and requires taking measures that preclude the possibility of additional or secondary damage to the contents of the spinal canal. Suspect an unstable damage the doctor can on the basis of anamnesis and examination of the victim. The presence of swelling, traces of bruising in the form of abrasions and bruising in the interblade area allows you to think about a purely flexor mechanism, the presence of bruises and abrasions in the region of one shoulder or shoulder blade - about flexion-rotational, etc. A significant increase in the interstitial gap allows you to think about the probability of rupture of bugulous and intercostal ligaments. The increase in the interstitial gap and the broken line of the spinous processes in the form of a bayonet make it possible to deem suspicion of the presence of unstable damage as reliable. Falling heaviness on a slightly bent head allows you to think about compression fractured fracture of the cervical vertebra, bruises and abrasions in the nape of the diver at the diver - about flexion damage, in the forehead and face - about the extensor.

The final clinical diagnosis is formulated after a detailed examination of the victim and is an effective beginning for choosing the most rational and appropriate method of treatment.

Treatment of closed spine injury

Operative interventions on the spinal column with its injuries and their consequences have a number of specific features. These features are generated by the originality of the spinal column as an organ and by the multifaceted and responsible role that it plays in human life, as well as its location in the human body. All this obliges the doctor, who decides to have an operative intervention on the cervical, thoracic or lumbar spine, well, perfectly, know the normal and pathological anatomy of the spine, the topographic and anatomical relationships of the spine with the surrounding structures, and be able to navigate in them. Invading the spine, the surgeon should be ready to eliminate possible complications due to damage to the paravertebral formations that have arisen or are occurring during the operation.

Located on a significant extent in the human body. The spine in intimate contact with the middle formations of the neck, posterior mediastinum and retroperitoneal space, organs of the thorax and abdominal cavity. When using the front operative accesses to the spine, the surgeon inevitably comes into contact with all the mentioned: the formations that can be damaged during surgical intervention. All this requires from a doctor operating on the spine, perfect possession of thoracic and abdominal cavity surgery, neck surgery, vascular surgery and elements of neurosurgery.

Performing many surgical interventions on the spine is possible only under endotracheal anesthesia. Well-established anesthesia service is an indispensable condition for surgical interventions on the damaged spine. No less important and mandatory condition is the opportunity to begin immediate intensive care and resuscitation in case of severe shock or blood loss. Timely and complete replenishment of blood loss during surgery requires a sufficient supply of canned blood. Finally, surgical interventions on the damaged spine require special equipment and equipment.

Indications and contraindications. The use of surgical methods of treatment is indicated in the following cases.

1. Damage to the cervical spine:
   1. ) all unstable damage (dislocation, fracture dislocation), especially if they are combined with damage to the contents of the spinal canal. With these injuries, operational methods of treatment are considered less dangerous for the injured. They allow to create a reliable internal immobilization in the place of the former damage and to transfer unstable damage to a stable one; prevent the subsequent occurrence and development of degenerative processes in the region of intervertebral discs at the level of the former damage and in this sense are not only purely curative, but also therapeutic and preventive; greatly facilitate the care of the patient and make him mobile. With them, the length of stay of the victim in bed and in the hospital is reduced;
   2. compression fractured fractures of the cervical vertebral bodies;
   3. all types of damage to the cervical spine, in which conservative methods and methods are untenable and they fail to achieve the desired effect.
2. Damage of the thoracic and lumbar spine:
   1. compression wedge-shaped uncomplicated fractures of the bodies of the lumbar and lower thoracic vertebrae;
   2. comminuted compression fractures of the lumbar vertebral bodies;
   3. fracture-dislocation of the lumbar and thoracic spine.

Contraindications: lack of necessary qualification and sufficient experience of the surgeon, necessary equipment, equipment and well-supplied anesthesia service; severe condition of the victim due to existing damage to the spine or accompanying serious injuries, excluding the possibility of surgical intervention; The presence of diseases that exclude the possibility of surgical intervention; biologically elderly age of the victim.

Anesthesia. When choosing the method of anesthesia, it is necessary to be guided by the following two main provisions - the safety of the method of anesthesia for the victim and the convenience for the operating surgeon. With regard to surgical interventions on the spine, these two requirements are best met by endotracheal anesthesia.

Conducted by a qualified, experienced anesthesiologist, modern zdotrahealnyj anesthesia seems to be the most safe for the victim. This type of anesthesia also creates maximum comfort for the surgeon. Relaxation of the muscles and switching off of spontaneous breathing create considerable convenience in the interventions performed on the lumbar spine with the use of extraperitoneal accesses. Controlled breathing nullifies the risks associated with accidental injury of the pleura with extrapleural access to the bodies of the thoracic vertebrae, with the injured mediastinal or parietal pleura of the opposite side when using the transhepral operative approach. The wide opening of the pleural cavity, the manipulation of the posterior mediastinum, near the pericardium and the roots of the lungs, the arch of the aorta and the large blood vessels leaving it inevitably lead to disturbance of external respiration and hemodynamics, in particular of central venous pressure. The thoracotomy produced in conditions of controlled respiration makes it possible to largely compensate the negative phenomena of pneumothorax. Invaluable is the role of this type of analgesia in surgical interventions on the cervical spine. The ability at any time, if necessary, to switch to long-term controlled breathing in case of injuries or surgical interventions on the cervical spine allows you to confidently carry out the necessary manipulations both in front and in the back parts of the cervical vertebrae, in the lower, middle and especially the upper segments of the cervical spine.

Resuscitation. Operative interventions on the anterior parts of the damaged spine are in inevitable contact with large main blood vessels. If these large, especially venous, vessels are injured, one-stage massive bleeding can occur, leading to severe collapse and even clinical death. The life of the victim in these cases depends on the speed and usefulness of the manipulations carried out to revitalize the victim. Therefore, surgical interventions on the spine should be arranged so that all the necessary measures for revitalization can be started instantaneously. In addition to special equipment for resuscitation (kits for intra-arterial blood transfusion, a set for tracheostomy, an apparatus for automatic breathing, a defibrillator, etc.) and a set of necessary medications. In order to help the anesthesiologist, a special doctor is allocated who has all the manipulations for revitalization and is ready to start implementing them immediately. Beforehand, before the operation begins, the venous and arterial trunks most accessible for rapid exposure should be prepared, so as not to lose valuable minutes for their search at the time of need.

The use of posterior operative accesses in a number of surgical interventions on the spine is not connected, with the need for direct contact with large arterial and venous trunks. Despite this, the blood loss for these surgical interventions is incomparably greater than when using technically correct front operative approaches. Therefore, in operative interventions in the posterior parts of the spine, the amount of blood to be lost should be monitored in the most careful manner and blood loss can be timely re-established.

As a rule, with front access, the exposure of the spine produces no blood loss and only manipulation of the vertebrae leads to it. The magnitude of blood loss in these cases is directly proportional to the amount of manipulation on the spine - the wider the spongy exposed, the more vertebral bodies lacking a compact bone, the more significant the loss of blood. Especially increases blood loss when manipulating near the roots of the arch and intervertebral foramen. Significant can be blood loss during surgical interventions for chronic spine damage. When surgical interventions on the bodies of children's vertebrae can occur significant bleeding from the basvetebral vessels.

Preparation of the victim for the operation depends on the nature of the damage, its location, the urgency of the intervention, the condition of the victim, the presence or absence of concomitant damage and illness.

Online access. The success of surgical intervention largely depends on rational access to the object of intervention. Existing operational access to vertebral elements can be basically divided into front and back. Rear operational accesses are most common in surgical interventions for various injuries of the spine. Without denying the importance and benefits of these accesses with certain interventions in the posterior parts of the spine, we emphasize that these approaches do not justify themselves in a number of surgical interventions on the damaged spine. At the same time, the anterior ones - direct access to vertebral bodies and intervertebral discs, most often subjected to damage, are far from being used insufficiently in spinal injury surgery. There is a wrong opinion that the front access to the spine is too heavy and risky for the victims, sometimes they are burdened by an already grave condition. The magnitude of blood loss and severity of the condition operated through the rear operative approaches is incomparably greater, the postoperative period is more severe and difficult and fraught with smaller but more complicated complications.

The main advantages of anterior operative accesses in the presence of appropriate indications are that they provide: wide access to the anterior sections of the damaged spine; the possibility of expanding this access in the process of intervention, if necessary; the possibility of visual control over manipulations on the spine; the possibility of one-step intervention with multiple vertebral lesions; the possibility of one-step intervention in certain types of combined injuries; minimal risk of damage to paravertebral anatomical formations and elimination of complications in case of their occurrence; absence of direct contact with the spinal cord, its membranes, spinal roots, ganglia, etc.; safety of the posterior unaffected parts of the spine.

All these advantages are extremely important.

Manipulation on the damaged spine. The nature of the manipulations performed on the damaged spinal column depends in each individual case on the clinical form of the existing lesion, the presence or absence of complications from the contents of the spinal canal, the condition of the victim and those goals and tasks to be achieved by this intervention. Some points should be emphasized.

1. In case of unstable damage, different types of bone plastic on both the front and back parts of the damaged spine do not create an early primary stability of the damaged spine segment. In these cases, the stability occurs only after the onset of the bone block, after that time, which is necessary for implantation and reconstruction of bone grafts.
2. Early primary stability of the damaged spine can be achieved only by fixing the damaged spine segment with hard metal fixatives.
3. Usually, various metal or other rigid fixatives are consistent for a certain period of time, after which they lose their useful function. This period of consistency of metal structures should be used reasonably to obtain constant stability with the help of osteoplastic fixation.
4. The most expedient is the implementation of one-stage stabilization with the help of metal structures and bone plastics, if there are corresponding indications to this. In these cases, early stabilization will be provided with metal structures, and the final one - the bone block that has arisen during this time.
5. If it is impossible to carry out a one-stage stabilization of the damaged spine segment with metal structures and osteoplastic fixation, in the presence of appropriate indications of spondylodesis with bone grafts, the second stage should be performed before the victim is elevated to the vertical position.
6. In case of stable damage, the use of metal fixators and various types of bone plastic is considered to be sustainable.
7. A more perfect and harmonious "implantation" autotransplant inserts to give preference to autostrophy. Homogeneity can only be used for forced indications.