Damage, spinal injury and back pain

It is hardly possible to overestimate the place of spine trauma in the general structure of traumatic injuries, the number of which is steadily growing along with the growth of living standards, the development of modern transport, the increase in the number of military conflicts, etc. Etc. We give only some statistical information.

According to V.P. Bersneva et al. (1998) in St. Petersburg, combined injuries of the spine and spinal cord every year receive 300-330 people. In 5-50% of patients with spine trauma, multiple injuries of long tubular bones and skulls are noted, and 20% have trauma to the abdominal organs. 80% of patients with traumatic injuries of the spinal cord are people under the age of 40 years. Characteristically, the lethality in spine trauma in 50% of cases is not due to the initial severity of the trauma, but to its untimely diagnosis and inadequate management at the prehospital and hospital stages. Note that the information given does not concern injuries of the cervical spine, which are accompanied by the most severe complications and the details of which are given in the last chapter of this publication.

We could not find all-Russian statistics on vertebral trauma. At the same time, according to official sources in the United States, 18,000-38,000 people are injured annually in the spine, of which an average of 4,700 cases (ie, about 20%) are paraplegic.

At the heart of the classification of spine injuries, as a rule, lies one or another feature, regarded by the authors as leading in determining the nature or severity of the injury. So, the duration of the action of the damaging factor is marked by acute injuries that occur directly at the time of injury and chronic, developing with a repeated effect of the damaging factor (for example, with unstable fractures). In view of the time elapsed since the moment of injury, the consequences of trauma are also highlighted.

Depending on the involvement of tissues adjacent to the spine, especially the spinal cord, uncomplicated, complicated and combined lesions are isolated. In uncomplicated injuries, damage is limited only by bone and soft tissue structures that directly form the spine. In case of complicated trauma, the tissues and organs adjacent to the spine are damaged by bone fragments of the vertebrae. Combined trauma is characterized by simultaneous damage to the spine and other organs by the direct action of the damaging factor

Flexural, extensor, rotational, dissecting lesions and damages resulting from axial (axial) pressure are identified by the mechanism of the damaging action (Bohler L., 1956). E.A. Nicoll (1949) and FW Holdsworth (1970), the basis for dividing the injuries of the spine, was the condition of the fixing ligament apparatus and the resulting (or not occurring) disturbance of the spinal mechanical stability. Accordingly, the authors identified stable lesions (simple front compression fractures, explosive fractures and extensional injuries) and unstable, to which distractive and rotational dislocations, fractures, and dissecting vertebral fractures were attributed. The principle of determining damage stability was later used in the AO / ASIF (see abbreviation) classification of spine injuries, which is widely used at present. This classification is given below.

All of the above listed classification principles in one form or another are included in the composite classification of spinal injuries. We cite only three of them, which have now found the most widespread use in our country and abroad. The reader is given the opportunity to choose for himself the scheme most convenient for practical use.

Combined classification GP. Salduna (1983) includes eight major groups and 46 signs of vertebral segment damage, according to which injuries are subdivided as follows.

By localization of the lesion:

1. cervical department,
2. thoracic department,
3. lower thorax and lumbar spine,
4. sacrococcygeal department.

By the nature and degree of damage to the spinal cord and its elements:

1. Unheeded fractures.
2. Weighed fractures:
   1. rupture of the spinal cord (anatomical break),
   2. compression of the spinal cord,
   3. contusion of the spinal cord,
   4. compression or damage to the elements of the spinal cord (roots).

On the mechanism of damage:

1. Compression fractures.
2. Compression-flexural fractures.
3. Flexural fractures.
4. Compression-rotational fractures.
5. Rotational (rotational) damage.
6. Extensor fractures.

According to the degree of wedge deformation of the vertebra:

1. Edge fractures.
2. Deformation up to 1/4 of the normal height of the vertebral body.
3. Deformation up to 1/3 of the height.
4. Deformation up to 1/2 height.
5. The deformation is more than 1/2 of the height.

By the nature of vertebral injury:

1. Penetrating Fractures:
   1. with neurologic symptoms,
   2. without neurologic symptoms.
2. Vertical fractures.
3. Horizontal fractures
4. Splintery ("explosive") fractures,
5. Multiple vertebral fractures:
   1. adjacent,
   2. non-contiguous,
   3. Combined with damage to other areas of the musculoskeletal system;
6. Fractures of the arms:
   1. on the one hand (with displacement, without displacement),
   2. from two sides (with displacement, without displacement).
7. Fractures of articular processes:
   1. on the one hand (with displacement, without displacement),
   2. from two sides (with offset, without displacement),
   3. adjacent vertebrae.
8. Full separation of the rear support complex
9. Damage (rupture) of the ligamentous apparatus
10. Fracture dislocations:
    1. full,
    2. incomplete,
    3. weighed down,
    4. non-agglomerated
11. Fractures of spinous processes, fractures of transverse processes (single, multiple)

By the nature of sustainability.

1. Stable damage:
   1. Compression fractures of vertebral bodies are non-penetrating, with no signs of damage to the posterior support complex, with a wedge deformation of up to 1/3.
   2. Extensor fractures
2. Conditionally stable damage.
   1. Compression unbegotten fractures of vertebral bodies with wedge deformation up to 1/2 without signs of damage to the posterior support complex.
   2. Multiple fractures of vertebral bodies with total wedge-shapedness up to 1/2 of one of them. Penetrating fractures with persistent pain syndrome.
3. Unstable damage.
   1. Vertebral fractures with a wedge-shaped deformation of 1/2 and more of a burdened and non-aggravated nature.
   2. Less pronounced wedge deformation, but with signs of damage to the posterior support complex or deformation of the spinal canal.
   3. Fracture-dislocations, weighed down and not burdened.
   4. Multiple fractures of vertebrae with total wedge-shapedness more than 1/2 of one of them.
   5. Splinter, vertical and horizontal fractures.
   6. Complicated and uncomplicated fractures after laminectomy.

Vertebral fractures in the elderly.

Combined fractures (with damage to internal organs, brain, etc.).

Based on the classification of F. Denis (1983) spine injuries, the author laid down his theory of "three columns". In contrast to the theory of two columns proposed by F. Holdsworth (1970), the boundary between them being the frontal plane passing along the posterior longitudinal ligament, F. Denis singled out the middle column directly adjacent to the vertebral canal. The front column of the spine according to Denis'y consists of the anterior longitudinal ligament, anterior parts of the vertebral bodies and intervertebral discs; middle - from adjacent to the vertebral canal of the posterior halves of vertebral bodies, intervertebral discs and posterior longitudinal ligament; the posterior column is formed by arches, transverse, articular and spinous processes, as well as the posterior muscular-ligamentous capsular apparatus of the spine.

Clinical manifestations and severity of spine injury by F.Denis are determined by:

• mechanism of damage,
• a damaged area (damaged by a column) and
• stability (or instability) of the damaged segment.

The concept of "instability" has a dual interpretation and includes mechanical and neurological components.

Mechanical instability (the author uses the term "instability of the first degree" for its designation) is characterized by abnormal spinal mobility (or threat of its appearance), which occurred at the level of the damaged segment immediately at the time of injury, or by the progression of the spine deformation in long periods after trauma "Dynamic" or delayed instability).

Neurological instability (or instability of the second degree) is the damage or the presence of the theoretical possibility of damage to the spinal cord and its elements by bone fragments of the damaged vertebrae directly during the trauma or in case of its inadequate management.

The combination of mechanical and neurological instability is described by the author as "instability of the third degree".

It should be noted that to denote the theoretically possible posttraumatic instability of the spine, F. Denis uses the term "potential" instability, in the domestic literature this variant of instability is described as "threatening".

Since the concept of "spinal instability" is interpreted differently by different authors, it is advisable to cite the classical triad of clinical signs of chronic posttraumatic spinal instability, given by I. Posner et al. (1981):

1. dynamic (progressive and / or transient) neurological disorders;
2. pain;
3. progressive deformation of the spine.

According to F.Denis classification, "small" vertebral fractures, including isolated damages of the posterior vertebral column, are conventionally isolated, and "large" fractures, accompanied by mandatory damage to the anterior and / or middle columns of the spine.

To "small" fractures of the vertebrae include fractures of the joint and transverse processes, the spinous process, and fracture of the interarticular part of the arch. These fractures are often accompanied by damage to the ligamentous apparatus of the posterior column of the spine. Isolated "small" fractures are mechanically and neurologically stable in the vast majority of cases, with the exception of neurologically unstable "punctured" arched fractures. In the long-term period, isolated "small" spinal injuries can cause chronic pain syndromes, which are usually associated with the absence of bone fragments fusion, the formation of pseudoarthrosis, or the inferior healing of the injured fixing muscle-ligament apparatus with the development of segmental hypermobility.

The "large" injuries of the spine include damage to the vertebral bodies and intervertebral discs that make up the front and middle columns, including any combination with damage to the elements of the posterior column. According to the nature of bone lesions assessed radiographically, as well as from CT and / or MPT data, F.Denis identified four variants, and within each of them there are several types of vertebral lesions (we gave the letter designations of damage types according to the author's description):

[1], [2]

Compression fractures of vertebral bodies

Mechanism of damage - front and / or lateral flexion.

The area of damage is the front column of the spine. The posterior column and the part of the middle column adjacent to the vertebral canal remain intact for this damage.

Characteristic anatomical and clinical signs of trauma: the integrity of the spinal canal ring is not disrupted, the interpedicular distance is not changed, a slight widening of the interstitial space is possible. Damage is always mechanically and neurologically stable. With pronounced compression of vertebral bodies, delayed mechanical instability is possible, accompanied by pain syndrome and an increase in spinal deformity. The following types of vertebral compression fractures are distinguished:

• A - vertical fracture of the body of the vertebra, passing through the upper and lower closure plates;
• B-fracture of the upper (cranial) part of the vertebral body with damage to the upper closure plate;
• C-fracture of the lower (caudal) part of the vertebral body with damage to the lower closure plate;
• D - central ("horizontal") fracture of the body, typical for osteoporotic vertebrae.

The author notes that compression fractures of vertebral bodies can be asymmetric, i.e. Accompanied by lateral compression of the vertebral body

[3]

Explosive vertebral fractures

Mechanism of damage - a blow directed along the vertical axis of the spine, so-called. Axial trauma.

The area of damage is the middle column of the spine, possibly a combination with damage to the anterior column.

A characteristic anatomical-ray trait is an increase in the interpedicular distance and anteroposterior size of the vertebral body.

The following types of explosive vertebral fractures are distinguished:

• A - fracture passing through both closure plates (typical for lumbar vertebrae);
• B - fracture of the upper closure plate;
• C - fracture of the lower closure plate,
• D - rotational fracture (the most unstable of explosive fractures) - rotational displacement of injured fragments is noted in the presence of all typical radiographic signs of fracture-dislocation, but without damage to intervertebral joints, i.e. Without a true dislocation of the vertebrae;
• type E - an explosive fracture with lateral flexion (accompanied by a fracture of the lateral divisions and displacement of vertebral lateral fragments of the vertebra into the vertebral canal).

To diagnose explosive fractures, the most informative are CT data, incl. In combination with myelography, and transverse slices of MRI, which often reveal not only damage to the middle column of the spine and the displacement of the vertebral body fragment into the vertebral canal, but also the typical splitting of the vertebral arc along its anterior surface for this type of injury. Injury is mechanically conditionally stable, it is possible to develop delayed (dynamic) instability associated with impaired vertebral support. A characteristic feature of explosive vertebral fractures is always their neurological instability, which occurs even in the absence of signs of traumatic myelopathy. With explosive fractures of the thoracic vertebrae, the clinic of compression myelopathy is observed in almost 70% of cases, with fractures of the lumbar spines - slightly more than 20%, which is associated with anatomical features of the spinal cord.

F. Denis points to three possible causes of neurological disorders in explosive fractures:

1. compression of the spinal cord by a fragment of the vertebral body,
2. narrowing of the channels of the nerve roots with mechanical compression of the roots themselves and
3. infringement of spinal nerves in the arched vertebra of the anterior surface.

The latter variant of the lesion is typical for the lumbar spine, in which the elements of the horse tail occupy a predominantly dorsal position within the spinal canal. Understanding the various mechanisms of neurological complications of explosive fractures and their precise diagnosis is of particular importance in choosing tactics for surgical treatment: if the spinal cord is compressed with a fragment of the vertebral body, its anterior decompression is absolutely indicated, then the infringement of the nerve roots in the split arc dictates the need for revision of the posterior parts of the spinal canal.

Seat-belt damage - damage by type of "seat belts".

The mechanism of damage is a sharp flexion with axial thrust of the upper and lower fragments of the spine with its fixed "central" section (the so-called flexion-distraction mechanism). Such a mechanism is typical for car accidents: with a sudden braking of the car and fixed safety belts (which is reflected in the title), the central part of the trunk, its upper and lower halves continue to move forward by inertia.

Damage zone - the elements of the back and middle columns of the spine are always damaged, the front column may be damaged. The anterior longitudinal ligament and the anterior section of the fibrous ring of the intervertebral disc are never damaged.

Characteristic anatomical and clinical signs of trauma. In cases where the line of damage passes through the bone elements of the vertebrae, X-ray reveals fractures of the elements of the posterior column, fragments of the body fragments adjacent to the posterior sections of the intervertebral discs are possible. It is possible to expand the dimensions of inter-oestrus spaces.

The following types of seat-belt damage are identified:

• A - one-level intervertebral lesion, accompanied by rupture of the ligamentous-articular apparatus and the posterior part of the intervertebral disc;
• В - one-level intervertebral injury or Chance fracture - horizontal fracture of the posterior, middle and anterior columns;
• C - two-level damage with a fracture of the arch and damage to the fibrous section of the middle column;
• D - two-level damage with a fracture of the arch and damage to the bone part of the middle column.

Seat-belt damage is always mechanically unstable, while instability is most pronounced in case of injury to the fibrous and muscular sections of the posterior and middle column-interstitial ligaments, muscles, intervertebral discs. That is why the term "damage" is used in relation to this type of injury, and not a "fracture". In some types of injury (seat-belt damage type A) on the radiographs, there may be no signs of damage to the bone structures of the spine, which leads to an erroneous interpretation of the radiographs. Undiagnosed soft tissue injury is accompanied by inferior healing of the vertebral lock, which leads to delayed instability and chronic pain syndrome. In the acute period of trauma, the diagnosis can be more clearly established with magnetic resonance imaging: in the structures of the posterior column of the spine, the signal strength associated with local hemorrhage is always found at the level of damage.

Seat-belt lesions are not accompanied by a violation of vertebro-spinal relations, and therefore are neurologically stable. However, this kind of trauma can be accompanied by a clinic of "ascending myelopathy", the pathogenesis of which is not related to mechanical damage of nerve structures, but to traction myelo-ischemia: microcirculatory changes in the spinal cord are located above the spinal cord injury zone, which is clinically manifested by a discrepancy between the level of bone and neurological disorders.

[4], [5], [6], [7], [8], [9]

Fracture of the vertebrae

Mechanism of damage: combined action of forces - compression, stretching, rotation and bending.

Characteristic anatomical and clinical signs of trauma. All three columns of the spine are traumatized, incl. May damage the anterior longitudinal ligament. This is the most unfavorable variant of spine injuries, which are both mechanically and neurologically unstable. F. Denis identified the following types of vertebral fractures:

• A-flexion-rotational, in which it is possible to maintain normal relationships in one of the arcuate joints;
• В - "cutting" extensor fracture-dislocation;
• C - flexion-distraction fracture with bilateral dislocation.

On the basis of F. Denis classification, an algorithm for diagnosis and tactics of vertebral and vertebral-spinal cord injuries was proposed, the wide use of which, in our opinion, will allow doctors, on the one hand, to be more active in applying modern methods of treating spinal injuries, on the other - more differentiated approach to the choice of surgical intervention. Note that in some cases, with explosive fractures that are not accompanied by neurologic complications (which is more often noted in the lumbar department), it is possible to conduct conservative treatment with adequate reclining orthotics.

The classification of spine injuries AO / ASIF is compiled in accordance with the CCP - Universal Classification of Fractures, which in turn is based on the determination of the mechanical instability of the injured skeleton. According to the

According to the authors of AO / ASIF classification, punctured vertebral body fractures (type AI) are always mechanically stable and require adequate conservative treatment. Splitting and explosive damages of vertebral bodies, differing only in the number of bone fragments (types AII and AIII, respectively), are conditionally stable, as they do not fuse well, which leads to the growth of kyphosis ("dynamic" instability) or late neurologic complications.

Spinal injuries that occur with stretching (type B) are in most cases mechanically unstable, and damage with rotation (type C) is always mechanically unstable. At the modern level of development of medical technologies, these types of injuries are overwhelmingly subject to prompt treatment, including in children.

Trauma of the spine in children and adolescents has certain characteristics. Typical, but not the only possible for patients of this age group is damage to the vertebral bodies by the type of compression fracture. The type of fracture is usually determined by the degree of decrease in the height of the vertebral body, primarily the height of its ventral or central parts. Compression fractures in children are distributed according to the severity of the lesion.

Compression fractures of the spine in children.

Degree of compression	X-ray characterization (change in the height of the vertebral body)
I degree - slight compression	Decrease in ventral area by 2 mm Decrease in the height of the middle section by 1 mm
II degree - moderate compression	Decrease in the height of the ventral area by 2-5 mm, Decrease in the height of the middle section by 2 mm
III degree - significant compression	Decrease in ventral height by 4-6 mm Decrease in the height of the middle section by 2-3 mm
IV degree - pronounced compression	Decrease in the height of the ventral area by more than 5 mm Decrease in the height of the middle section by more than 3 mm

None of the degrees indicated in the table, except for some fractures with pronounced compression of the IV degree, does not go beyond the severity of the lesions corresponding to the punctured fractures of the AI group in the AO / ASIF classification. Children with such fractures never need surgical treatment. Fractures of grade IV with severe compression accompanied by detached mechanical instability leading to the formation of kyphosis can undergo surgical treatment in order to stabilize the spine and prevent the build-up of deformity. Other variants of vertebral injuries, accompanied by trauma to the middle and posterior columns, occur in childhood much less often than compression fractures. In our opinion, with such damages in children it is not only advisable to use one of the above classifications, but also to apply a more active treatment tactic - early surgical intervention aimed at eliminating mechanical and neurological instability of damage will ensure the best result of treatment of this category of patients.

Separately, we have to talk about gunshot wounds to the spine, the number of which, unfortunately, has been growing steadily in recent years due to the proliferation of firearms and numerous local military conflicts. The main classification feature of this type of damage is the ratio of the course of the wound channel to the bone structures of the vertebrae and the vertebral canal. N.S. Kosinskaya identifies the following types of injuries:

1. through wound - the wound channel crosses the vertebral canal;
2. blind penetrating wound - the wound channel terminates inside the vertebral canal;
3. tangential wound - the course of the wound channel is accompanied by an edge injury of the walls of the spinal canal;
4. blind non-penetrating wound - only bone elements of the vertebrae are damaged;
5. a paravertebral wound - the wound channel passes in soft tissues, without affecting the proper structures of the spine.