Compression splinter fractures of cervical vertebral bodies: causes, symptoms, diagnosis, treatment

Comminuted compression fractures of the cervical vertebrae occur with a compression mechanism of violence, when the traumatic force acts vertically along the axis of the straightened cervical spine.

Since the normal position of the cervical spine is lordosis, such injuries occur when the head and neck are in the position of anterior flexion - in this position, lordosis disappears and the vertebral bodies are installed vertically. Preservation of the integrity of the posterior supporting structures in such injuries allows them to be classified as stable. Despite this, a posteriorly displaced posterior fragment of the body of a broken vertebra or the mass of a ruptured disc can cause compression of the anterior sections of the spinal cord.

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Symptoms of comminuted compression fractures of the cervical vertebrae

Symptoms of comminuted compression fractures of the cervical vertebrae vary from a picture of a spinal contusion to a spinal injury complicated by tetraplegia. Such injuries, occurring with minor, seemingly harmless symptoms, are especially insidious. Relatively minor, additional violence can lead to a catastrophe. Victims with minor complaints and a poor clinical picture, with an appropriate mechanism of violence, should definitely be subjected to an X-ray examination. Most often, with uncomplicated injuries, victims complain of pain in the neck, which increases with movement. They hold their heads with their hands. All types of movement are limited and painful. Abrasions and hemorrhages in the occipital and parietal regions may be detected. Difficulty and painful swallowing is sometimes noted. Neurological symptoms may be absent or detected during a special examination. Finally, they: can be expressed roughly, up to the presence of tetraparesis or tetraplegia.

Diagnosis of comminuted compression fractures of the cervical vertebrae

The radiographic picture is characterized by varying degrees of fragmentation of the vertebral body with damage to the endplates and rupture of adjacent disks. More often, one anterior, larger fragment is more clearly visible, which usually protrudes beyond the anterior marginal line of the vertebral bodies. The height of the body is reduced. It may be somewhat expanded in the lateral or anteroposterior projection. Adjacent intervertebral spaces are narrowed. On a profile spondylogram at the level of damage, the spinal canal may be narrowed due to the posterior protrusion of the posterior fragment of the broken vertebral body.

Correct assessment of the anamnesis and clinical and radiological data usually allows for a correct diagnosis of the injury.

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Treatment of comminuted compression fractures of the cervical vertebrae

The most common and generally accepted method of treating comminuted compression fractures of the cervical vertebrae is long-term immobilization with a plaster cast in the hope of achieving spontaneous anterior bone block.

In case of minor compression of the fractured vertebral body, a plaster cast is applied immediately. In case of significant reduction in the height of the fractured vertebral body, an attempt can be made to restore the anatomical shape and height of the fractured vertebra by traction along the long axis of the spine with moderate hyperextension of the cervical spine. For this purpose, skeletal traction is applied to the bones of the cranial vault and a load of 6-8-10-12 kg is used. In case of fresh injuries, as a rule, it is possible to achieve straightening of the fractured vertebral body and restoration of its anatomical shape. A control spondylography is performed. The most conclusive is a profile spondylogram, which allows determining a decrease or disappearance of flattening of the vertebral body, straightening of the marginal line of the posterior section of the vertebral bodies that form the anterior wall of the spinal canal. Preservation of the anterior and posterior longitudinal ligaments makes this manipulation relatively safe. For the same reasons, a fragment of a broken vertebral body that has shifted backwards, towards the spinal canal, can be reset.

Once the reduction is achieved, a craniothoracic plaster cast is applied for 4-6 months. After the cast is removed, an anterior bone block along the calcified anterior longitudinal ligament is usually determined radiographically. There is some limitation of movement in the cervical spine, and varying degrees of pain. All these phenomena soon disappear under the influence of massage and physiotherapy procedures. Therapeutic gymnastics must be carried out carefully, under the supervision of an experienced specialist.

A craniothoracic plaster cast provides the best immobilization of the injured cervical spine. However, a plaster collar-type bandage with well-modeled "peaks" in the area of the back of the head, chin and upper chest can be used instead.

The injured person's ability to work is quickly restored after the plaster cast is removed. People who perform mental work can often return to work before the plaster cast is removed.

Not all patients experience clinical recovery even with the onset of spontaneous anterior bone block. This is due to the anatomical changes that occur with this type of injury. Quite often, with these injuries, there is an interposition of the masses of the torn disc between the fragments of the body of the broken vertebra. The resulting bone block covers only the anterior fragment of the body. The masses of the torn intervertebral discs prevent the formation of a solid bone monolith. This leads to the fact that the most important parts of the broken vertebra - the posterior fragment of the body - remain mobile, which predetermines subsequent pathological changes and late complications. These late changes and complications include the possibility of secondary compression of the body of the broken vertebra, leading to axial deformation of the spine, the occurrence of intervertebral osteochondrosis with all the bright and diverse range of their clinical manifestations, progressive compression of the anterior and anterolateral parts of the spinal cord and spinal roots. In later cases, chronic progressive lateral myelopathy can also be observed.

Conservative treatment of these late complications is usually ineffective, and surgical treatment is associated with certain difficulties.

Therefore, in case of compression comminuted fractures of the cervical vertebral bodies, in appropriate cases, primary early surgical treatment is advisable, consisting of removing fragments of the broken vertebral body, damaged adjacent intervertebral discs, restoring the normal height of the anterior sections of the damaged segment of the spine, correcting the axial deformation of the spine and creating conditions for the onset of a total anterior bone block. This method of treatment is the anterior spondylodesis by partial replacement of the broken vertebral body, proposed and developed by Ya. L. Tsivyan in 1961. Given the necessary conditions and the qualifications of the doctor, we consider this method to be the method of choice in the treatment of comminuted compression fractures of the cervical vertebral bodies.

If appropriate indications are present, this intervention can be expanded to complete removal of the fractured vertebral body and anterior decompression followed by complete replacement of the fractured vertebral body.

Anterior spondylodesis

Indications for surgery: crushed comminuted compression fractures of the cervical vertebrae. In the absence of special indications for immediate intervention, the operation is performed on the 3rd-1st day after the injury. Preoperative preparation consists of the following. Skeletal traction is performed for the cranial vault bones. The victim is placed on a hard bed with a shield. Since these injuries usually involve axial deformation of the spine at an angle open to the front, traction for the skull is performed in the horizontal plane. Symptomatic drug treatment is performed. Intestinal and bladder care and prevention of bedsores are necessary.

Pain relief - endotracheal anesthesia with controlled breathing. The victim is placed on the operating table in a supine position. Skeletal traction for the cranial vault bones. A hard oilcloth flat pillow 10-12 cm high is placed under the victim's lower arms. Traction for the cranial vault bones is carried out along an axis passing slightly downwards from the horizontal plane, as a result of which the victim's head is slightly thrown back, and the neck is in an extension position. In addition, the head is turned slightly to the right so that the chin is turned to the right at an angle of 15-20°.

Surgical access. Transverse access is used along one of the cervical folds or along the anterior-inner edge of the sternocleidomastoid muscle. Preference should be given to the left-sided access, but the right-sided one can also be used.

Manipulations on the spine. After exposing the area of damage, before proceeding with manipulations on the vertebral bodies, it is necessary to ensure the exact localization of the damage.

With some skill, the body of the damaged vertebra is determined by the presence of hemorrhages in the surrounding paravertebral structures, the color and nature of the anterior longitudinal ligament, which is usually duller at the site of injury. Sometimes small longitudinal ruptures and fiber delaminations are found in it, it is somewhat thickened, covered with a thin layer of fibrin. It is possible to detect a protrusion of the anterior part of the broken body forward, a decrease in the height of its anterior sections, a narrowing or complete disappearance of adjacent intervertebral discs covered by the ventral plates of the broken body and the bodies of adjacent vertebrae. The most convincing data are found with detachment of the anterior longitudinal ligament: a fracture of the ventral endplate of the body, its cyanotic coloration, lower density, loss of masses of pulpous nuclei of damaged adjacent discs. At first, it is better, even with complete, it would seem, confidence and accuracy of the localization of the damaged vertebra, to resort to control spondylography with preliminary marking with thick metal spokes. For this, after exposing the anterior sections of the spine, one metal spoke is inserted into the intervertebral discs located above and below the supposed broken vertebra and a control lateral spondylogram is performed, on the basis of which the correct localization of the damage site is determined.

The anterior longitudinal ligament is dissected in the shape of the letter H lying on its side. Its parallel lines pass through the bodies of the overlying and underlying vertebral bodies, and the transverse line is closer to the left side of the vertebral body. We pay attention to this seemingly insignificant technical detail because the detachment of the left edge of the dissected anterior longitudinal ligament presents certain technical difficulties. The dissected anterior longitudinal ligament is peeled off with a thin sharp chisel from the anterior surface of the fractured body, adjacent intervertebral discs, the caudal part of the overlying and cranial part of the underlying vertebral bodies. In fresh injuries, as mentioned above, the anterior longitudinal ligament is covered with blood-soaked blood. Blood clots can be found under the ligament. Dark venous blood is released from the fractured body. It can be soft and crumple under the chisel. Using bone spoons and chisels, fragments of the broken vertebral body, fibrin clots, bone detritus, and masses of torn discs are removed. Bone fragments are usually easily removed even with tweezers. Removal of the remains of damaged discs, especially their fibrous rings, presents known difficulties. Damaged discs are removed as completely as possible, excluding the posterolateral sections of their fibrous rings. When removing bone fragments, the lateral compact plates of the vertebral bodies should be preserved. Using a sharp thin chisel, the endplates on the adjacent bodies of adjacent vertebrae are removed and removed by approximately 1/2 or 3/4 of their anterior-posterior diameter. When removing the endplates, it is necessary to preserve their limbus, which hangs over the bodies like a small visor. Preserving the limbus will help hold the bone graft inserted into the vertebral defect in place, preventing it from slipping forward.

As a result of the manipulations performed, a rectangular defect is formed at the site of the damaged body and adjacent intervertebral discs. Its upper wall is the body of the overlying vertebra, in which the spongy bone is exposed as a result of the removal of the endplate, the lower wall is the exposed spongy layer of the underlying vertebra, and the posterior wall is the spongy layer of the posterior part of the broken vertebra. Thus, with partial removal of the body of the broken vertebra, a bed is formed, the walls of which are exposed bleeding spongy bone.

To fill the resulting bone defect, either autoplastic or homoplastic bone graft can be used.

A compact-spongy autograft taken in the form of a rectangle from the crest of the iliac wing is inserted into the formed defect of the vertebral body. The vertical size of the graft should be 1.5-2 mm larger than the same size of the vertebral defect. The posterior, upper and lower walls of the graft should be spongy bone. At the moment of insertion of the graft into the defect, the cervical spine is given a slightly greater extension, due to which the vertical size of the defect slightly increases. After installation of the graft, the cervical spine is returned to its previous position. The graft is firmly held in the defect by the bodies of adjacent vertebrae. A flap of the exfoliated anterior longitudinal ligament is placed in its place and fixed with thin nylon sutures. Careful hemostasis is performed during the operation. Usually, as a rule, minor blood loss occurs only during manipulations on the vertebral bodies; all other stages of the surgical intervention are not accompanied by blood loss. Antibiotics are administered. The edges of the wound are sutured layer by layer. An aseptic bandage is applied. During the operation, timely and complete replenishment of blood loss is performed.

All manipulations on the spine should be soft and smooth. Otherwise, ascending edema of the spinal cord may occur in the postoperative period. Every 8-10 minutes, the hooks stretching the edges of the wound (especially the outer one) should be loosened to restore blood flow in the carotid artery and the outflow of venous blood from the brain through the internal jugular vein system. Care should be taken with the ascending sympathetic fibers. If they are compressed, persistent Horner's symptom may occur. Careful and gentle treatment should be given to the recurrent nerve to prevent paralysis of the vocal cord,

After spontaneous breathing is restored, extubation is performed. The victim is transferred to the postoperative ward and placed on a hard bed. A soft elastic bolster is placed under the neck area. Skeletal traction is performed for the cranial vault bones in the horizontal plane with a load of 4-6 kg. Symptomatic drug treatment is performed, antibiotics are administered. Dehydration therapy is used as indicated. In the postoperative ward, everything must be prepared for emergency intubation and tracheostomy in the event of respiratory distress.

On the 7th-8th day, the stitches are removed and skeletal traction is stopped. A craniothoracic plaster cast is applied for a period of 3 months. In the absence of concomitant neurological disorders or residual effects of damage to the spinal cord or its elements, working capacity is restored 2-3 weeks after the plaster cast is removed.

Control spondylograms show the correct axis of the cervical spine and restoration of the anatomical shape of its anterior sections. Anterior bone block of the IV-VI cervical vertebrae.

In the presence of gross petrological symptoms of compression of the anterior sections of the spinal cord caused by the posterior fragment of the broken vertebral body displaced to the side of the spinal canal or other symptoms indicating progressive compression of the spinal cord, and in the process of the surgical intervention described above, anterior decompression of the spinal canal can be performed with subsequent complete replacement of the vertebral body. To summarize, the operation of partial resection and partial replacement is supplemented by the fact that, in addition to the anterior sections of the broken vertebra, its posterior sections are additionally removed. If there is a multi-comminuted fracture of the body, then removal of its posterior sections does not present any difficulties. If the posterior fragment of the broken body is a single fragment, then its removal should be performed with a certain amount of caution so as not to damage the dural sac located behind the posterior longitudinal ligament. The most important and difficult operation is removal of the posterior compact plate of the vertebral body. With a certain amount of skill and caution, this manipulation is feasible, since the posterior surface of the vertebral body has weak connections with the posterior longitudinal ligament.

It is known that the anterior longitudinal ligament is firmly fixed to the anterior surface of the vertebral bodies and is thrown over the intervertebral discs in the form of a bridge. In contrast, the posterior longitudinal ligament is firmly fixed to the posterior surface of the fibrous rings of the intervertebral discs and is rather loosely connected to the posterior surface of the vertebral bodies.

Significant bleeding from the venous sinuses of the vertebral body, as a rule, does not occur, since the latter are damaged at the time of injury and thrombosed.

To restore the support and stability of the spine, the operation is completed with a complete replacement of the vertebral body. Technically, a complete replacement of the vertebral body is performed in the same way as a partial replacement of the body. It should be noted that the anterior-posterior diameter of the transplant is 2-3 mm smaller than the anterior-posterior diameter of the removed vertebral body. Under this condition, there will be a free reserve space between the posterior surface of the transplant and the anterior surface of the dural sac.

As with partial vertebral body replacement, both auto- and homo-bone can be used for total cervical vertebral body replacement. However, preference should be given to autograft.

The postoperative period is carried out in the same way as the postoperative period after partial replacement of the cervical vertebral body.

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