Compression lump fractures of the lumbar vertebral bodies: causes, symptoms, diagnosis, treatment

Compression lobular fractures of the lumbar vertebral bodies are an independent and more severe clinical form of fractures of the lumbar vertebral bodies. In contrast to compression wedge fractures, they are always accompanied by damage to adjacent intervertebral discs and fragmentation of vertebral bodies into separate fragments. In essence, these injuries are related to permanent damage.

Compression lobular fractures of the lumbar vertebral bodies account for 14.7% of all lesions of the lumbar spine and 19.9% of the compression fractional wedge fractures of the lumbar vertebral bodies.

[1], [2], [3], [4]

What causes the compression fractured fractures of the lumbar vertebral bodies?

These injuries to vertebral bodies occur with a strictly defined compression mechanism of violence, that is, in cases where the breaking force acts vertically and is located along a vertical straight body of the vertebrae. Such an arrangement. Bodies of the lumbar vertebrae are possible in those cases when the lumbar spine is in a position of moderate flexion and the lordosis, characteristic of this department of the spine, disappears. Most often compression fractured fractures are localized in region I and III of the lumbar vertebrae. Fractures occur when falling on straightened legs or buttocks with a slight flexion of the lumbar region or when significant gravity falls on the shoulder or back of the victim in a position of slight tilt. AG Karavanov (1946) described a similar damage to the first lumbar vertebra in a radio operator when the aircraft was dived. Such fractures are possible even with bailouts.

For a long time it was believed that compression fractured fractures of the lumbar vertebral bodies occur with excessive flexion of the spine and only quantitative features of violence lead to the appearance of these injuries. In 1941, Lob first put forward and substantiated the theory of the "explosive" force of the disk in the origin of these injuries. He stressed that the explosive power of the disk depends on the height of the intervertebral disc. In detail, the mechanism of the appearance of compression comminuted fractures was studied by Roaf (I960) and in our clinic EA Kovalenko (1965).

According to Roaf, with the vertical impact of violence on the spine straightened on the sheer straight lumbar spine, a significant deflection and protrusion into the body of the cranial occlusal plate and an insignificant protrusion of the fibrous ring anteriorly occur without a change in the shape of the pulpous nucleus. As a result of the increase in intra-vertebral pressure that occurs, the blood flows from the vertebral bodies into the near-vertebral space, which is accompanied by a significant decrease in arterial pressure ("shock-adsorption" mechanism). The subsequent effect of violence creates an increasingly greater pressure on the cranial closure plate and ultimately leads to a rupture. In the defect of the plate, a pulp nucleus rushes, which, according to the laws of the hydraulic effect, tears the vertebral body into separate fragments. As a rule, the degree of compression of vertebral bodies with this mechanism is insignificant, since the entire force of violence is spent on rupturing the body.

Thus, compression fractured fractures of the bodies of the lumbar vertebrae both by the mechanism of origin and by morphological changes represent a special damage to the spine. The features of this damage consist in a heavy crushing of the vertebral body into separate multiple fragments, among which there are usually two largest ones - the anterior and posterior. As a rule, there is a rupture of adjacent intervertebral discs and the interposition of the substance of damaged discs between the two main fragments. The possibility of displacement of the posterior fragment towards the vertebral canal and significant hemorrhage can cause complications from the spinal cord. The severity of the damage to the bone substance of the vertebral body adversely affects its regenerative capabilities. The healing of such a fracture lasts much longer than the healing of the usual compression wedge fracture of the body.

Symptoms of compression lumbar vertebrae fractures

Clarifying the circumstances of the trauma and clarifying the mechanism of violence allow one to suspect the presence of a compression fractured fracture of the body of the lumbar vertebra. The main clinical symptoms are similar to the clinical manifestations of compression wedge fractures of the lumbar vertebral bodies. However, the intensity and severity of these symptoms are much more pronounced.

Complaints of the victim and the data of an objective clinical examination are similar to those described in the compression wedge fractures of the lumbar vertebral bodies. The general condition of the injured is severe, it is more often possible to note the phenomenon of not pronounced shock, pallor of the skin and mucous membranes. Significantly more frequent phenomena of irritation of the peritoneum, paresis of the intestine, delay of urination. This is explained by a much larger amount of retroperitoneal hemorrhage. With these injuries, ejectorative laparotomy is sometimes produced in connection with suspected damage to the internal organs. Typical posture of the victim - on his side with bent and brought to the abdomen hips.

Neurological symptoms of compression fractured fractures of the lumbar vertebral bodies are observed in 88.2% of the victims with compression fractures. It is important to note that in patients with compression fractured fractures of the lumbar spine, treated conservatively, it is almost natural to exacerbate neurological symptoms. Some victims, who have minor neurological manifestations in the acute period or are absent, sometimes have severe radicular or spinal disorders in the long term.

Diagnosis of compression lumbar vertebrae fractures

Two typical projections usually give an exhaustive picture of the nature of the existing damage. At the same time a very typical and peculiar picture emerges.

The lumbar spine is more straight than normal. This is determined by the clarity of interdisciplinary spaces in the lower lumbar region. This emphasizes the location of spinous processes at all levels - they are more centered in relation to the shadows of vertebral bodies. The lateral marginal bodies of the fractured vertebra go beyond the lateral contours of the bodies of the adjacent lumbar vertebrae, the broken body appears wider in diameter. There is a decrease in the height of the intervertebral spaces adjacent to the broken body. Decrease in the height of the vertebral body is not observed. It only seems to be less high than adjacent bodies by increasing its transverse diameter.

On the profile spondylogram, attention is drawn to the increase in the anterior-posterior size of the fractured vertebral body. Its ventral surface extends beyond the anterior margin-forming body of the remaining vertebrae. The posterior contour of the fractured vertebra's body is displaced posteriorly towards the vertebral canal and, to a greater or lesser extent, deforms a straight line forming the anterior wall of the spinal canal. The cranial and caudal closure plates of the body are interrupted, their integrity is impaired. Between the anterior and posterior fragments of the broken body, a slit is visible, showing the plane of the fracture on the spondylogram. Sometimes such a gap is not visible because the fracture plane does not coincide with the central ray. In this case, it is detected by an irregular-shape enlightenment zone with fuzzy contours. The anterior fragment of the body of the fractured vertebra may be equal to half the body, but not so rarely it is one third of it. As a rule, smaller fragments of a fractured vertebra on a spondylogram are not determined. The lateral spondylogram clearly shows a decrease in the height of adjacent intervertebral spaces. In some cases, a decrease in the height of the anterior fragment can be observed.

This is the most typical X-ray picture of compression fractured fractures of the lumbar vertebral bodies.

[5], [6], [7], [8]

Treatment of compression fractured fractures of the lumbar spine

The preservation of the ligamentous apparatus, in particular the anterior and posterior longitudinal ligaments, with compression fractured fractures, gives the right to a number of authors to speak in favor of conservative treatment consisting of a one-step forced forwarding followed by immobilization for 3-4 months (Holdswortli) -9-12 months (A V. Kaplan).

The method of forced one-step repositioning is similar to that described by us in the treatment of compression wedge fractures.

The duration of wearing a corset is dictated by the timing of the onset of the spontaneous anterior bone block due to calcification of the anterior longitudinal ligament.

Conservative treatment with an outcome in the spontaneous anterior bone block often does not bring recovery to the injured. As shown by numerous findings in the course of surgical interventions for chronic compression fractured vertebral fractures, the cause of pain and other complications, even with the onset of anterior spontaneous bone block, is the interposition of masses of ruptured discs between fragments of the broken body. The presence of such an interposition leads to the fact that with the bodies of adjacent vertebrae only the front fragment of the fractured vertebra is soldered. The rear, the most functionally responsible fragment remains mobile. The presence of a mobile fragment, as well as the remains of damaged discs, cause pain and other late complications. Therefore, in these cases, the back fusion is also ineffective.

Partial replacement of the vertebral body

Indication for the operation of partial resection of the body of a fractured vertebra with subsequent anterior spondylodesis as a partial substitution is the presence of compression fractured vertebral fracture.

The task of the undertaken operative intervention is to create a condition for the onset of the anterior bone block between the posterior fragment of the fractured vertebral body and the bodies of adjacent vertebrae with the elimination of the available interposition of masses of intervertebral discs ruptured; removal of the remains of damaged intervertebral discs; restoration of the normal height of the damaged anterior spine and normalization of anatomical relationships in posterior vertebral elements.

The earlier the intervention is made, the technically easier and easier to implement it. The term of intervention in each individual case depends on the condition of the victim, the severity of the general phenomena of the former injury, the presence or absence of concomitant damage. In the absence of contraindications, the optimal time for surgery is the 5th-7th day after the injury occurred.

The best method of anesthesia is endotracheal anesthesia with relaxants. The muscular relaxation achieved at this type of anesthesia and the deactivation of spontaneous breathing greatly facilitate the technical performance of the operation. Mandatory timely thorough and pedantic replacement of blood loss.

The victim's location on the operating table depends on the selected operational access.

Existing operative accesses to the lumbar vertebrae can be divided into three groups: posterior and posterior-external, anteriorly peri-abdominal, anterior and antero-external extra-abdominal accesses.

Rear access is most widely used in orthopedics and traumatology. This access creates sufficient room for manipulation on the spinous, transverse and articular processes, as well as the arches of the lumbar vertebrae.

Zadnev-external access (lumbotransversectomy) is widely used by surgeons-phthisiatricians for radical intervention on the lesion in tuberculous spondylitis of lumbar localization. Our experience confirms the opinion that this operational access allows only "small" interventions on vertebral bodies, such as curettage of the focus, biopsy, since it does not create enough room for manipulation and does not allow them to exercise visual control. A number of surgeons use anterior peri-abdominal access. According to Hensell (1958), this access was not spread due to frequent complications in the form of dynamic intestinal obstruction and mesenteric vascular thrombosis. In 1932 VD Chaklin proposed a left-sided antero-external extraperitoneal access to the lower lumbar vertebrae. Later this access was modified with respect to the upper lumbar vertebrae. Hensell (1958) described anterior extraperitoneal access, carried out through the paramedial incision.

The optimal operational access is as follows.

1. To the lumbosacral spine and lumbar vertebrae, including the caudal section of the II lumbar vertebra, is anterior extraperitoneal paramedial access.

To these departments of the spine, anterior-external extraperitoneal can be used, both left and right-hand access according to VD Chaplin. Disadvantages of VD Chaklin's accession is his greater traumatic nature.

2. To the II lumbar vertebra, if necessary, manipulation and on the I lumbar intervertebral disc, including the caudal part of the body I of the lumbar vertebra, is a left-sided extraperitoneal anterior-external access with resection of one of the lower ribs.

If necessary, this operative access can easily be transformed into extraperitoneal-transthoracic access, allowing simultaneous manipulation of both the lumbar and thoracic spine.

3. To I lumbar vertebra, if it is necessary to carry out manipulations on the cranial section II of the lumbar vertebra and the body II of the lumbar vertebra, is a chespleural access with diaphragmotomy. In individual subjects, this operative approach makes it possible to intervene on the cranial section of the third lumbar vertebra.
4. To the lower thoracic, middle and upper thoracic vertebrae is the crespural both right-hand and left-side operative access.

Manipulation on the vertebrae. One of the operative approaches reveals the body of the broken vertebra and adjacent damaged intervertebral disks. For the convenience of manipulating the vertebrae, it is necessary that the body of the fractured vertebra, the intervertebral disc and the caudal half of the overlying vertebra, the intervertebral disc and the cranial half of the underlying vertebra are completely exposed. Wide curved elevators inserted between the anterior longitudinal ligament and the prevertebral fascia are crowded out and protected by large blood vessels. It is necessary to periodically relax the tension of the vessels to restore normal blood flow in them. Usually, paravertebral tissues are imbibed with blood that has been poured out at the time of injury. The anterior longitudinal ligament can be longitudinally stratified, but never torn in the transverse direction. Usually, the ruptured intervertebral discs are devoid of the intrinsic turgor and can not stand in the form of characteristic rollers. At level III of the lumbar vertebra, the fibers of the left medial stalk of the diaphragm are interlaced in the anterior longitudinal ligament. The diaphragm foot is stitched with a provigrant ligature and cut off. It should be remembered that along the medial edge there is a renal artery. Isolate, bandage and dissect two pairs of lumbar arteries and vei, passing along the front surface of the vertebral bodies. The front longitudinal ligament is dissected fart-like and on the right base it is folded to the right. The incision is made on the left lateral surface of the broken vertebra, the adjacent intervertebral disc, caudal half of the overlying and cranial half of the underlying vertebra, parallel and somewhat inside the border sympathetic trunk. It should be remembered that the anterior longitudinal ligament is intimately connected with the vertebral bodies and freely spreads through the intervertebral discs.

After the front longitudinal ligament is separated and tilted to the right, the anterior-lateral surface of the vertebral bodies is exposed. Tweezers remove fragments. Usually, there is one large fragment of the anterior part of the body of the fractured vertebra, under which are located smaller fragments, clots of fibrin, interponed masses of intervertebral discs. Bone fragments are removed quite easily, they are connected with the vertebra only by fibrous tissues. Depending on the nature of the lesion, more or less of the broken vertebra is removed. Often, from the broken vertebra, only the lateral and posterior parts remain. Obligatory full removal is subject to ripped discs. Remove the caudal plate of the overlying and cranial plate of the underlying vertebrae. After removal of all damaged tissues a rectangular defect is formed, the walls of which are the posterior and lateral parts of the fractured vertebra, the caudal and cranial surfaces, and the bodies of adjacent vertebrae. All of them are formed by a bleeding spongy bone. With appropriate indications, anterior decompression can also be performed by removing the posterior part of the fractured vertebra.

The need for anterior decompression occurs with complicated fractures. The posterior fragment of the fractured vertebra is displaced posteriorly and, deforming the vertebral canal, causes compression of the spinal cord. In these cases, under the control of vision, the posterior fragment of the broken body that is standing in the lumen of the spinal canal is removed and an operation is performed to completely replace the vertebral body.

Postoperative management

After the operation, the victim is placed in bed with a shield in the position on the back. He is given a position of moderate flexion. This is achieved by lightly bending the legs in the knee and hip joints on the roller, placed under the area of the knee joints. In this position, the victim spends the first 10-12 days. Subsequently, he is placed in a pre-made rear plaster bed, repeating the normal physiological curves of the spine. In this crib, the victim is 3-4 months old. Lumbar lordosis can also be formed with the help of previously described hammocks.

Intravenous infusion of fluids (blood, polyglucin) is discontinued after the stabilization of blood pressure. According to the indications, painkillers, cardiac, give oxygen. With the restoration of spontaneous breathing, extubation is performed. Usually all the indicators come to the norm by the time the operation ends or in the next few hours after the end of the operation. In the postoperative period, the administration of antibiotics is recommended.

After 24 hours, the rubber graduates introduced into the subcutaneous tissue are removed. There may be intestinal paresis and urinary retention.

Usually by the end of 2 - the beginning of 3 days the condition of the victim improves. After 3-4 months impose a large plaster corset. The injured person is prescribed for outpatient treatment. After 4-6 months, the corset is removed. By this time, the bone block between the broken and adjacent vertebrae is already radiological determined.

It should be borne in mind that on the roentgenogram, only the cortical part of the transplant is usually clearly visible, and its large spongy part is lost in the mass of the vertebral bodies.

Thus, early primary surgical treatment of victims with closed compression fractured penetrating fractures of the lumbar vertebral bodies, carried out according to the method proposed by us and described above, gives a good effect. With the help of the intervention, conditions are created for the fastest onset of the bone block. Removal of damaged discs excludes the possibility of late complications from the elements of the spinal cord. Partial, and if necessary, complete replacement of the body of the fractured vertebra allows maintaining the normal height of the non-vertebral injured spine to prevent the development of axial deformation of the spine. The onset of bone fusion in the region of the vertebra, which is damaged and adjacent to it, excludes the appearance of a subsequent functional inconsistency of the spine.