Fractures of axial tooth and bias in the area of atlanto-axial articulation

Normal relations between the atlas and the axis in the "core" joint can be violated if:

• as a result of the violence, a fracture of the axis tooth will occur and the head, the atlas and the broken axis tooth in the form of a single block will move forward or backward;
• as a result of the violence there will be a rupture of the transverse ligament of the atlant and your head with the atlant will shift anteriorly;
• the tooth of the axis under the influence of violence will slip out from under the transverse ligament of the atlant and will shift to the back.

It is known that the boundary between the oblong and spinal cord is in the plane passing through the middle of the front arch of the atlas and the upper edge of its posterior arch. At this level, the sagittal diameter of the vertebral capal is 25-30 mm, and the anterior-posterior diameter of the bulbar neck is 10-12 mm. However, the presence of a rather massive and complex ligamentous apparatus in this area significantly reduces the spare space between the brain and the bone walls of the vertebral capal, so it appears sufficient displacement of the atlas above the axis of 10 mm to cause brain damage. These data exhaustively characterize the danger of the above injuries.

Kienbock distinguishes between transdental, transligamentary and peridental dislocations of the atlant. Transdental dislocations of the Atlantean by Kinbeku are actually fracture-dislocations, since the displacement of the head, atlant and axis tooth is due to a fracture of the tooth. The transligamentary and peridental dislocations of the Atlantean by Kinbek are true dislocations, as they result from either breaking the transverse ligament of the atlas, or slipping the axis tooth under an unbroken transverse ligament.

In the last decade there has been an increase in the number of patients with a fractured tooth-like process. It is caused by an increase in cases of severe transport trauma and an improvement in radiologic diagnosis. According to a number of authors (Nachamson, Jahna, Ramadier, Bombart, Gomez-Gonzales, Casasbuenas), fractures of the axis tooth account for 10-15% of all cervical spine injuries and 1 - 2% of all spine injuries,

[1], [2], [3], [4], [5], [6], [7]

The causes of axial tooth fracture and displacement in the area of atlanto-axial articulation

The traumatic displacement of the atlas due to a fracture of the tooth can occur both anteriorly and posteriorly. Significantly more often there are forward displacements. The severity of this damage depends on the degree of displacement of the 1st cervical vertebra and, consequently, the nature of the damage to the spinal cord. Damage occurs with the indirect mechanism of violence, most often as a result of a fall on the head. With the flexor mechanism of damage, the front offset of the atlas occurs, with the extensional one - the rear one. Fracture of the axis tooth with the displacement of the atlas may also occur with inadequate violence in cases of insufficient strength and increased brittleness of the tooth, which are observed with partial preservation of the basal cartilaginous plate of the tooth.

Symptoms of axial tooth fracture and displacement in the area of atlanto-axial articulation

Symptoms of axial tooth fracture and displacement in the area of the atlanto-axial articulation are very variable and can manifest themselves in a range of mild tenderness for neck and head movements, pain when swallowing (anterior displacement) until immediate death at the scene. This ultimately depends on the degree of displacement of the atlant over the axis. It is necessary to distinguish three degrees of displacement of the atlas anteriorly, which give rise to a different clinical course of this lesion.

First degree of displacement. Fracture of the axis tooth is not accompanied by any displacement of it, and, consequently, there is no displacement of the atlas and head over the axis. In the absence of severe concussion of the brain, the victim does not lose consciousness. Slight soreness in the movements of the head and neck, a sense of discomfort in the neck quickly pass. The victim does not understand the accident that has happened, and the doctor may underestimate the nature of the damage. This apparent prosperity is very relative. Bone fusion in the fracture region often does not occur at all or occurs extremely slowly. A subsequent minimal injury can lead to an irreparable disaster. In a figurative expression of Nguyen Quoc Anh, such a person "walks next to death."

The second degree of displacement. With an average magnitude of the traumatic force that leads to a fracture of the axis tooth, the atlas shifted anteriorly, along with the broken axis tooth, and the head is held on the lower part of the articular cusp II of the cervical vertebra, that is, a subluxation occurs. Clinically, this manifests itself as a syncope of varying duration, sometimes a loss of consciousness. When the consciousness returns, the victim complains of pain when trying to unbend the neck, the pain in the nape, in the upper cervical region. Neurological disorders are revealed in the form of pain sensations in the innervation zone of the large occipital nerve, along the course of the underlying cervical roots, monoplegia, diplegia, gemplegia, spasticity. When you try to raise your head, there is a syndrome of medullary contraction, which arises from the pressure of the back arc of the atlas on the brain stem.

The equal vertical gravity, represented by the weight of the head, decomposes into two components of the force: one of them passes through the plane of the fracture and is directed down and back, giving the cervical spine the position of the extension, the second is directed forward and downward and tends to raise the occiput, and with it the back arc of the atlant. This leads to the fact that as soon as the victim tries to raise his head, the bulb-medullary part of the brain undergoes compression, which leads to the appearance of the above-mentioned syndrome.

Third degree of displacement. With rough violence and the appearance of a fracture of the axis tooth, the head and the atlas together with the broken tooth slide along the front bevel of the articular surfaces of the 2nd cervical vertebra - a complete dislocation occurs. The posterior arch of the atlant, moving anteriorly, squeezes and damages the brain at the boundary between the oblong and spinal cord. Death comes from the instant "decapitation" of man.

If, at the second and third degree, the fracture-dislocation of I-II cervical vertebrae, which resulted from a fracture of the axis tooth, a sufficiently bright and pronounced clinical picture allows to suspect this damage, fractures of the axis tooth without displacement due to the mildness of clinical manifestations and apparent well-being may mislead the doctor and remain in time unrecognized. Insufficient or incorrect treatment of these victims is fraught with grave, sometimes irreparable consequences.

Diagnosis of axial tooth fracture and displacement in the area of atlanto-axial articulation

To clarify the nature and degree of displacement of the atlas, an inestimable benefit comes from an x-ray examination. It allows you to correctly assess the nature of damage, the features of displacement of the vertebrae, the presence or absence of concomitant rotational subluxation of the atlas, which may occur with these injuries. Of decisive importance, the X-ray method is used to diagnose an axial tooth fracture without bias. Correctly produced profile x-ray gmchmok allows you to identify all the changes that have arisen as a result of trauma, on some cases for greater detail of the available changes is useful tomography. Transoral snapshot allows you to clarify the state of the back arch of the atlas, the presence or absence of its rotational subluxation. The more pronounced the degree of displacement of the broken tooth, the more it seems more shortened on the posterior transoral radiograph.

It is not always easy and simple to confirm or reject the presence of a tooth fracture without displacement, especially in fresh cases. If it is impossible to establish the diagnosis accurately, the patient should be treated as a patient with a fracture, and after two to three weeks, repeat the X-ray examination. The appearance of a narrow line of enlightenment, especially if it is underlined by the adjacent areas of irregular sclerosis, makes the presumptive diagnosis reliable.

[8], [9]

Treatment of axial tooth fracture and displacement in the area of atlanto-axial articulation

Examination and transportation of the victim must be carried out carefully and carefully. In the process of careless examination and transportation with a fracture of the axis tooth without displacement, a secondary displacement of the atlas and the head may occur and cause compression or brain damage. According to the indications, symptomatic medication is performed. The victim is put in bed in position, on the back. In the absence of bias and accompanying severe injuries, a craniotoracic gypsum dressing is applied, which after 6-8-10 months is replaced with a removable corset. External immobilization is stopped only if there is confidence in the onset of bone fusion. Otherwise, the patient is forced or permanently using an orthopedic corset, or undergo an operation of occipisto-spondylosis (occipital cervical arthrodesis).

If there is a displacement of the broken tooth, it is necessary to eliminate the existing subluxation or dislocation (!) And compare the fragments of the broken tooth. This is achieved either manually, which is permissible only in experienced hands, or by directing by stretching (skeletal traction beyond the bones of the cranial vault, the Glisson loop). Both in the first and in the second case, a doctor needs a clear idea of the nature of damage and displacement of fragments, the ability to imagine the spatial location of the displaced vertebrae and their relation to the spinal cord.

Anesthesia is not used. Manipulation when repositioning depends on the nature of the displacement: in the case of anterior subluxations, stretching along the length and extensionality of the head is performed, with rear displacements stretching along the length and flexion. All manipulations are performed under X-ray control. Manual correction requires the doctor of known skills. When the correction is achieved manually or by stretching, a craniotoracic bandage is applied from the gypsum and the subsequent treatment is carried out in the same way as in fractures without displacement, if there are no indications to a more active intervention from the spinal cord (revision, decompression).

Oksipitosponilodez - an operation consisting in the creation of a posterior bone block between the occipital bone and the upper cervical spine with the help of bone plastic.

The first report on the operation of an occipospondylodease in the literature available to us belongs to Forster (1927), who used a bone pin from the fibula to stabilize the upper cervical spine with progressive atlanto-axial dislocation after a fracture of the 2nd cervical vertebra.

Juvara and Dimitriu (1928) attempted to perform this operation in a patient with tetraplegia; the patient died. Kahn and Iglessia (1935) first applied a graft from the crest of the iliac wing to stabilize the spine in a patient with an atlanto-axial subluxation after fracture of the axis tooth and unsuccessful conservative treatment. Rand (1944) performed this operation on a patient with a spontaneous subluxation of the atlant. Spillane, Pallisa and Jones (1957) reported 27 similar operations, performed according to various indications. About the operation, performed by the type of total cervical spondylodease, Perry and Nicel reported in 1959 that it was carried out by a patient with severe paralysis of the cervico-occipital musculature that arose as a result of the transferred poliomyelitis. We performed this operation in our own modification in the patient with a fractured root of the II cervical vertebrae (Ya. L. Tsivyan, 1963). Hamblen (1967) published 7 of his observations. IM Irgier (1968) described his method of cervical arthrodesis, performed in 3 patients.

It should be emphasized that fractures and fracture-dislocation of the axis tooth are among the dangerous for the injured and difficult for the treatment of cervical spine injuries. The danger of these injuries is due to the possibility of damage to the brainstem and upper parts of the spinal cord, severe concussions and brain contusions. Even with uncomplicated lesions, secondary brain damage can easily occur:

Regardless of whether there is a complicated or uncomplicated injury of the two upper cervical vertebrae, the result of the undertaken surgical intervention should be a reliable internal fixation of the damaged department. If, on the basis of clinical data or in the course of surgical intervention, there is no need to audit the contents of the spinal canal, the task of surgical intervention is to direct the displaced fragments and their reliable immobilization. If the need to revise the contents of the spinal canal is established on the basis of clinical data or during surgical intervention, additional needs for surgical treatment of damaged spinal cord elements and elimination of its compression are added to the above problems. A reliable internal fixation in case of damage to the two upper cervical vertebrae can be achieved with the help of an occipitospondylodease.

Indications: fresh injuries of the two upper cervical vertebrae, accompanied by instability of this part of the spine; progressive atlanto-axial subluxations after unsuccessful conservative treatment; some congenital anomalies of the upper cervical vertebrae leading to instability of the spine; the effects of laminectomy and other interventions on the upper cervical vertebrae that cause spinal instability; as a method of preventing the onset of instability in the upper cervical spine with some tumor and destructive processes in the upper cervical vertebrae; severe paralysis of the cervical musculature.

Preoperative preparation. With fresh injuries - the maximum possible rapid and careful clinical, neurological and radiological examination. With the indications - the appropriate drug treatment. Careful attitude to the damaged cervical spine is necessary, reliable immobilization of it; The exclusion of unnecessary transfer and shifting of the victim. The head of the victim should be clean-shaven.

The victim is laid on his back. Extend the head by the long axis of the spine with the help of an assistant. Fixation of the head with the help of the assistant is carried out continuously from the moment of receipt of the victim to the imposition of skeletal traction beyond the bones of the cranial vault. After intubation and the onset of anesthetic sleep with continued skeletal traction along the axis of the spine with additional immobilization of the head, the assistant turns the victim to the abdomen. Under the upper section of the chest and forehead of the injured lay flattened flat cushions.

Anesthesia is endotracheal anesthesia with controlled breathing.

Technology oktsipitosponilodeza. The median linear incision from the occiput to the spinous process of the V-VI cervical vertebrae is severely cut through the middle line by soft tissue. If the incision is not performed strictly along the median line, but deviates away from the ligamentous ligament, significant bleeding from the neck muscles is possible. The osseous bone is subacastaneously skeletonized from the occiput to the posterior edge of the large occipital foramen and to the sides of it. Strictly subperiosteal. With the utmost care skeleton the posterior arch of the atlas, the spinous processes and arches of the necessary number of underlying cervical vertebrae. When skeletonizing the posterior arch of the atlas, you should be especially careful not to damage the vertebral artery. Care is also required because there may be an inborn underdevelopment of the atlas's posterior arch or damage to it. If an intervention is made to fracture the roots of the axillas or there are accompanying injuries to the posterior sections of other vertebrae, caution should be exercised when skeletonizing the underlying vertebrae. In general, the arches of the cervical vertebrae are mobile, thin and require delicate manipulations. Orientation in the posterior paravertebral tissues can be difficult due to impregnation of their outflowing old blood. At interventions in later terms, the separation of soft tissues from the bow is hampered by scar tissue formation. Profuse bleeding is stopped with a tamponade of the wound with gauze napkins moistened with hot physiological solution. Inspect the area of damage. Depending on the presence or absence of indications, an audit of the contents of the vertebral canal with a preliminary laminectomy or removal of the broken arch is performed. In old cases, it may be necessary to resect the posterior edge of the large occipital foramen and dissect the dura mater.

Actually, the ocipitospondilodez can be carried out in two versions. The first option is limited only to the application of a wire seam and is only indicated for fresh injuries. The second option combines the application of a wire seam and bone plastic.

First option. At 1 cm to the left and right of the middle of the thickening of the occipital bone formed by the lower ear line, a 2 mm diameter drill is vertically drilled in the thickness of the occipital bone by two parallel channels 1-1.5 cm in length. These channels pass in the thickness of the spongy bone between the outer compact plate and a vitreous plate of the occipital bone. The same diameter dripping is drilled in the transverse direction through the base of the spinous process of II or III cervical vertebra. Through the canals in the occipital bone in the form of a U-shaped seam, a stainless steel wire 1.5-2 mm in diameter is used. One end of the wire is longer than the other. The long end of the wire seam is passed through the transverse canal at the base of the spinous process of II or III cervical vertebra. Under visual control, the necessary head installation is performed. The wire seam is tightened and firmly tied in the form of a figure-eight. Carry out hemostasis. On the wounds are layered sutures. Enter antibiotics. Apply an aseptic bandage. External immobilization is performed by skeletal traction for 6-8 days with subsequent application of craniotoracic bandage. The superimposed wire seam excludes the possibility of lifting the occiput and thus protects the spinal cord from the possibility of secondary compression.

This variant of the Ocipitospondylodeza allows you to quickly complete the surgical intervention. They achieve quite reliable stability in the area of the damaged spine segment. Apply it when the force of the circumstances can not be delayed surgical intervention, when it is highly undesirable to cause additional operational injury to the patient, when the nature of the damage allows us to restrict this fixation. The drawbacks of this variant of the operation include the possibility of wire rupture and failure of the weld. When the victim is withdrawn from the threatened state, if there is adequate evidence, it is possible that the second step can be supplemented with bone-plastic fixation.

The second option, in addition to the application of a wire seam, provides for immediately additional osnoplasty fixation of the occipital bone and damaged spine segment. Depending on the indications about which the intervention is made, besides the manipulations performed in the first variant, the spinous processes and arches of the underlying cervical vertebrae additionally skeletonize. From the spinous processes and half-bows, carefully remove the compact bone before exposing the underlying spongy bone. Two barely spongy bone grafts, taken from the tibia or the crest of the ileal wing, are laid on the exposed spongy bone of the half-bobs on either side of the bases of the spinous processes. The diameter of bone grafts is 0.75-1 cm, their length should correspond to the length of the spine to be fixed from the external surface of the occipital bone plus 0.75-1 cm. Both auto- and gomotransplants can be used, which should be stacked so that their spongy surface abutted to the nude spongiosis of the half-bows and spinous processes. The proximal ends of the bone grafts rest against the occipital bone near the posterior edge of the large occipital foramen. In the areas of contact of the grafts with the occipital bone with the help of a milling cutter or small semicircular bits form grooves penetrating into the thickness of the spongy layer of the occipital bone. The proximal ends of bone grafts are inserted into the nape of the occipital bone, and the rest, the more distal part of the grafts, with capron or thin wire seams, is fixed to the arches of the cervical vertebrae. A bone bridge forms, which spreads from the occipital bone to the cervical vertebrae. Bone wound is additionally performed. Bone crushed stone. If a laminectomy was performed, then bone marrow is not stacked on the area devoid of arches. The wound is layer-by-layer closed. Enter antibiotics. Apply an aseptic bandage.

The wire used for the seam should be made of sufficiently elastic stainless steel grades. As already noted, bone grafts are taken either from the tibia or from the crest of the wing of the ilium. Preference should be given to autografts, but can be applied and cold-preserved gomotransplants. Intervention is accompanied by intravenous blood transfusion. It should be timely and fully compensate for blood loss and maintain adequate breathing.

Premature extubation of the patient is dangerous. Only with complete confidence in the recovery of spontaneous breathing can you remove the tube from the trachea. In the postoperative ward should be ready for immediate use: a set of tubes for intubation, an apparatus for artificial respiration, a set of tools for tracheostomy, a system for intra-arterial blood influence.

After the operation, the victim is laid in bed with a wooden shield. Under the neck area, place a soft-elastic bead so that the head of the injured person retains a predetermined position. The cable from the staple is pulled over the bones of the cranial vault through a block fixed to the head end of the bed. Suspend the load of 4-6 kg.

Apply symptomatic drug treatment of axial tooth fracture and displacement in the area of atlanto-axial articulation. Enter antibiotics. According to the indications - a course of dehydration therapy. On the 6th-8th day, remove the stitches, remove the staple to stretch. Apply a craniotoracic bandage for 4-6 months, then remove it. On the basis of X-ray study, the question of the necessity of continuing external immobilization is solved. The issue of working capacity is decided depending on the nature of the consequences of the former trauma and the profession of the victim.

Occipital cervical arthrodesis according to IM Irger. The main difference between the method of the neck-and-neck arthrodesis according to IM Irgue lies in the technique of applying a weeding suture. Based on the calculations given, the method's author considers this method more reliable and stable. The essence of the method is as follows.

Position of the victim on his side, general anesthesia. The median incision is cut through the tissues with the help of an electron-knife and the skeleton of the occipital bone, the posterior arch of the atlant, the spinous processes and the arches of the II and III cervical vertebrae are skeletonized. With anterior subluxations of the atlas, the author advises that the posterior arch of the atlas be resected. Especially carefully the area of the posterior edge of the large occipital opening is skeletal, for which the atlanto-occipital membrane is dissected. Using a drill, two through holes are drilled, located 1.5 cm from the midline and above the posterior edge of the large occipital foramen. Through these openings a wire seam is drawn leading from front to back along the anterior surface of the scales of the occipital bone. The ends of the withdrawn suture are passed through the hole in the spinous process of II or III cervical vertebra and firmly tied. The placement and fixation of bone grafts is carried out in the same way as described by us. I. M. Irgger underlines the difficulties of conducting a wire seam.