Injuries of thoracic and lumbar vertebrae: causes, symptoms, diagnosis, treatment

Injuries to the thoracic and lumbar vertebrae are considered in one article, since the mechanism of their occurrence, clinical course and treatment issues have much in common.

This is especially true for the lumbar and lower thoracic vertebrae, where injuries most often occur.

Epidemiology

Injuries to the thoracic and lumbar spine are common. According to Feldini-Tiannelli, thoracic vertebrae fractures account for 33.7% of all spinal fractures, while lumbar fractures account for 41.7%. In total, thoracic and lumbar spine injuries account for 75.4%, i.e. more than 3/4 of all spinal fractures. However, mortality from thoracic and lumbar vertebrae injuries is significantly lower than from cervical vertebrae injuries. Thus, mortality from thoracic spine fractures is 8.3%, while lumbar fractures account for 6.2%. Multiple fractures of the thoracic and lumbar vertebrae occur in tetanus. In recent years, spinal fractures have been observed in pilots ejecting. Among the injuries of the lumbar and thoracic spine, the most common are isolated fractures of the vertebral bodies, which, according to M. L. Khavkin, were observed in 61.6% of all injuries of the spine. The rarest are isolated fractures of the arches, which, according to Z. V. Bazilevskaya, constitute 1.2%.

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

Causes injuries to the thoracic and lumbar vertebrae.

The most common mechanisms of violence causing damage to the lumbar and thoracic spine are flexion, flexion-rotation and compression. The extension mechanism of violence in the genesis of damage to these spine regions plays a lesser role.

Most often, fractures of the vertebral bodies are localized in the region of the XI, XII thoracic, I, II lumbar vertebrae - in the most mobile part of the spine, which Schulthes called the “critical point” (the gap between the XII thoracic and I lumbar vertebrae).

Among the injuries of the thoracic and lumbar spine, there are a variety of forms, each of which has its own characteristic clinical and radiological manifestations and is caused by a special mechanism of violence. We have summarized the clinical forms of injuries of the lumbar and thoracic spine in a special classification, which will help the trauma surgeon to correctly navigate the nature of the injury and choose the most rational method of treatment. We will dwell on this classification below.

In case of injuries to the thoracic and lumbar regions, the division of all spinal injuries into stable and unstable remains of fundamental importance.

The division of injuries to the lumbar and thoracic spine into complicated and uncomplicated also remains of fundamental importance.

In the treatment of various clinical forms of spinal injuries, both non-operative and operative methods of treatment are used, the basis of which is the restoration of the anatomical shape of the damaged section of the spine and its reliable immobilization in the position of the achieved correction until the healing of the injury. Compliance with these two fundamental conditions is a tax on improving the treatment outcomes.

The anatomical structure of the thoracic and lumbar vertebrae is identical to the structure of the middle and lower cervical vertebrae. Each thoracic and lumbar vertebra consists of a body, two semi-arches, one spinous, two transverse and four articular processes. The main anatomical differences are as follows. The bodies of the thoracic vertebrae are slightly higher than the body of the 7th cervical vertebra. Their height gradually increases, the closer they are to the lumbar region. The bodies of the lower thoracic vertebrae are similar in size and shape to the bodies of the upper lumbar vertebrae. The upper and lower semi-facets are located on the posterolateral surface of the bodies of the thoracic vertebrae. The lower semi-facet of the overlying vertebra, together with the adjacent upper semi-facet of the underlying vertebra, form a complete facet for articulation with the head of the rib. The body of the first thoracic vertebra has only one complete facet for articulation with the first rib. Consequently, the heads of the II - X ribs articulate with the bodies of two adjacent vertebrae and overlap the mouth of the intervertebral disc. Exarticulation of the head of the rib opens access to the posterolateral parts of the intervertebral disc and adjacent vertebral bodies. The bodies of the XI - XII thoracic vertebrae have one facet for articulation with the head of the rib.

The bodies of the lumbar vertebrae are more massive and bean-shaped. Unlike the thoracic vertebrae, their posterolateral surfaces lack the above-mentioned facets.

The more caudally the thoracic and lumbar vertebrae are located, the more massive are their semi-arches. The semi-arches of the lower lumbar vertebrae are the most massive and strong.

The spinous processes of the thoracic vertebrae are triangular in shape with a pointed end and are directed caudally. The spinous processes of the middle thoracic vertebrae are arranged in a tile-like manner.

The spinous processes of the lumbar vertebrae are the most massive and at the same time shorter than the thoracic ones. They are quite wide, have rounded ends and are located strictly perpendicular to the long axis of the spine.

The articular processes of the thoracic and lower lumbar vertebrae are located in the frontal plane. The articular surface of the superior articular process faces backwards, the inferior one faces forwards.

This arrangement of the articular processes does not allow the display of the articular intervertebral space on the anterior spondylogram.
In contrast, the articular processes of the upper lumbar vertebrae, starting from the semi-arch, are directed backwards and are located almost vertically. Their articular surfaces are located in the sagittal plane, which is why the articular space of the lumbar intervertebral joints is well displayed on the anterior spondylogram. At the outer-posterior edge of the upper articular process of the lumbar vertebrae there is a small mammillary process.

The transverse processes of the thoracic vertebrae are directed outward and somewhat backward and bear a facet for articulation with the tuberosity of the rib. The transverse processes of the lumbar vertebrae are located in front of the articular processes, run laterally and somewhat backward. Most of the lumbar transverse processes are represented by a rudiment of the rib - the costal process. The transverse processes of the first and fifth lumbar vertebrae are covered by the last rib and the wing of the ilium, due to which fractures of these transverse processes do not occur from direct violence.

The structure of the intervertebral discs in the thoracic and lumbar regions is similar to the structure of those in the cervical region. In the lumbar region, the intervertebral discs are especially massive and powerful.

The presence of physiological curves in the thoracic and lumbar spine leads to the fact that the nucleus pulposus of the thoracic intervertebral discs is located posteriorly, and that of the lumbar discs is located anteriorly. Consequently, the ventral sections of the thoracic discs are narrowed, and those of the lumbar discs are expanded.

The apex of the thoracic physiological kyphosis is at the level of the VI-VII thoracic vertebrae. With age, physiological kyphosis tends to increase in women. The apex of physiological lumbar lordosis is the fourth lumbar vertebra. With age, physiological lumbar lordosis in men tends to smooth out. The assertion of Ya. A. Rotenberg (1929, 1939) that lumbar lordosis increases with age is not true.

According to Allhrook (1957), the center of gravity of the human body passes anteriorly from the ventral surface of the body of the fourth lumbar vertebra. According to the same author, the fourth lumbar vertebra is the most mobile.

The degree of expression of physiological curves of the thoracic and lumbar spine is directly related to certain constitutional types of human body structure and is decisive in terms of the spine's resistance to traumatic violence.

The internal architecture of the vertebral bodies, due to its purposefulness, gives them considerable strength. The bodies of the cervical vertebrae are the least resistant to violence, the bodies of the lumbar vertebrae are the most resistant. According to Messei'er, the bodies of the cervical vertebrae break under the impact of a force equal to 150-170 kg, the thoracic - 200-400 kg, and the lumbar - 400-425 kg.

Nachemson's research has shown that with age, due to the development of degenerative processes in the spine, intradiscal pressure decreases significantly. This affects the characteristics of spinal injuries that occur in older people. In contrast, high and especially increased intradiscal pressure in conditions of a degeneratively altered fibrous ring contributes to the occurrence of acute rupture and disc prolapse.

The function of the yellow ligaments in the lumbar spine is not limited to holding the vertebral arches relative to each other. A large number of elastic fibers located in them develop quite powerful elastic forces, which, firstly, return the spine to its normal initial position after deformations that occur during the movement of the spine, and secondly, give a smooth surface to the posterior-lateral walls of the spinal canal in various positions of the spine. This last circumstance is a very powerful protective factor for the contents of the spinal canal.

Of great importance is the innervation of some structures of the lumbar spine and the degree of its participation in the perception of pain arising from injuries and other pathological conditions of the spine. Based on the data provided by Hirsch, sensitive nerve endings were found in the intervertebral discs, the capsule of the intervertebral joints, ligamentous and fascial structures. In these structures, thin free fibers, unencapsulated and encapsulated complexes of nerve endings were found.

The capsule of the synovial intervertebral joints is interpreted by a triad of nerve endings: free nerve endings, complexes of unencapsulated and encapsulated nerve endings. In contrast, only in the superficial layers of the fibrous ring immediately adjacent to the posterior longitudinal ligament were free nerve endings found. The nucleus pulposus does not contain any nerve endings.

When the capsule of the synovial intervertebral joints and the posterior sections of the fibrous ring were irritated with an 11% saline solution, a full clinical symptom complex of lumbar pain developed.

In the yellow ligament, free nerve endings have been found in the outermost layers of the dorsal surface of the ligaments and never in the deep layers of this ligament. There is no data yet on the relationship and function of these nerve sensory structures. It is assumed that free nerve endings are associated with pain perception, complex unencapsulated endings - with the position of tissues and joints, encapsulated nerve endings - with the perception of pressure.

X-ray anatomical data concerning the thoracic and lumbar spine, as well as differential diagnostic interpretation of spondylograms in norm and pathology are described in sufficient detail in special manuals and monographs of recent years. Knowledge of the X-ray anatomy of the thoracic, thoracolumbar, lumbar and lumbosacral spine will allow you to correctly assess the existing X-ray symptoms and identify those changes in the spine that have arisen as a result of damage. In practice, unfortunately, we often limit ourselves to only two typical projections, which undoubtedly greatly narrows the possibilities of the X-ray method. In the indicated cases, it is necessary to use much more widely a full-fledged X-ray examination in the form of additional special projections, functional spondylograms, contrast spondylograms, and sometimes tomography. It should be remembered that functional spondylography is completely unacceptable in case of unstable spinal injuries.

Among the relatively rare deviations from the norm that can simulate damage to individual elements of the vertebrae, the following should be mentioned. Congenital absence of the lumbar articular processes is quite rare. In the literature available to us, there are reports that Rowe in 1950 described two preparations of the lumbosacral spine in which he found congenital absence of the articular processes. These two preparations were found among 1539 normal preparations. In 1961, Forrai described 2 cases of absence of the inferior articular process of the third lumbar vertebra, observed in young people with lumbar pain that developed after a moderate injury. Finally, Keim and Keage (1967) described 3 cases of unilateral absence of the inferior articular process in the region of the fifth lumbar and first sacral vertebrae.

Typically, these anomalies were detected during spondylography performed on patients complaining of pain after injury.

The so-called persistent apophysitis, which are observed in the lumbar vertebrae, are also often mistaken for articular process fractures. The clear, uniform, rather wide gap characteristic of these anomalies allows them to be distinguished from an articular process fracture. In contrast to the existing view of persistent apophysitis as a violation of the normal ossification process of the apophysis, Reinliarat (1963) considers them to be accessory bones by analogy with the accessory bones of the foot and hand.

Baastrup syndrome, or Baastrup disease, in which in some cases a zone of enlightenment in the area of the spinous process may be observed, can also be mistaken for a fracture of the spinous process. The uniformity of this "gap" and the presence of endplates on the "fragments" of the spinous process will allow the changes found to be correctly interpreted.

[ 8 ], [ 9 ], [ 10 ]

Forms

The existing classifications of lumbar and thoracic spine injuries cover all clinical forms of injuries. At the same time, such a classification, which would cover all types of injuries occurring in the lumbar, thoracic and transitional spine, seems to us to be very important, useful and appropriate. Such a classification will help not only to promptly and correctly diagnose the existing injury, but also to choose the most rational and necessary method of treatment in a given specific case.

Modern concepts of spinal injuries and the knowledge accumulated in this area do not allow an orthopedic traumatologist to limit himself to such a general diagnosis as “spinal fracture,” or “compression fracture of the spine,” or “fracture-dislocation of the spine,” etc. Adding the concept of complicated and uncomplicated injuries to the above diagnoses does not reveal the full picture of the existing injury.

The classification is based on three principles: the principle of stability and instability, the anatomical principle of damage localization (anterior and posterior spine sections) and the principle of interest of the contents of the spinal canal. Some cumbersomeness of the proposed classification is justified by the fact that it includes all known clinical forms of spinal injuries occurring in the thoracic and lumbar spine sections.

Classification of injuries of the lumbar and thoracic spine (according to Ya. L. Tsivyan)

Stable damage.

A. Posterior spine.

1. Isolated rupture of the supraspinous ligament.
2. Isolated rupture of the interspinous ligament.
3. Rupture of the supraspinous and interspinous ligaments.
4. Isolated fracture of the spinous process(es) with displacement.
5. Isolated fracture of the spinous process(es) without displacement.
6. Isolated fracture of the transverse process(es) with displacement.
7. Isolated fracture of the articular process(es) without displacement.
8. Isolated fracture of the articular process(es) with displacement.
9. Isolated fracture of the arch(s) without displacement and without involvement of the contents of the spinal canal.
10. Isolated fracture of the arch(s) without displacement with involvement of the contents of the spinal canal.
11. Isolated fracture of the arch(s) with displacement and involvement of the contents of the spinal canal.
12. Isolated fracture of the arch(s) with displacement and without involvement of the contents of the spinal canal.

B. Anterior spine.

1. Compression wedge fracture of the vertebral body(s) with varying degrees of reduction in its height without involvement of the contents of the spinal canal.
2. Compression wedge fracture of the vertebral body(s) with varying degrees of reduction in its height with involvement of the contents of the spinal canal.
3. Compression wedge fracture of the vertebral body(s) with avulsion of the cranioventral angle without involvement of the contents of the spinal canal.
4. Compression wedge fracture of the vertebral body(s) with avulsion of the cranioventral/angle with involvement of the contents of the spinal canal.
5. Compression wedge fracture of the vertebral body(s) with damage to the endplate.
6. Compression fracture of the vertebral body without involvement of the contents of the spinal canal or roots.
7. Compression comminuted fracture of the vertebral body with involvement of the contents of the spinal canal or roots.
8. Vertical fractures of the bodies.
9. Rupture of the fibrous ring of the disc with prolapse of the nucleus pulposus anteriorly.
10. Rupture of the fibrous ring of the disc with prolapse of the nucleus pulposus to the side.
11. Rupture of the fibrous ring of the disc with prolapse of the nucleus pulposus backwards and outwards.
12. Rupture of the fibrous ring of the disc with prolapse of the nucleus pulposus posteriorly.
13. Rupture (neroloma) of the endplate with prolapse of the nucleus pulposus into the thickness of the vertebral body (acute Schmorl's node).

Unstable damage.

A. Dislocations.

1. Unilateral subluxation.
2. Bilateral subluxation.
3. Unilateral dislocation.
4. Bilateral dislocation.

B. Fractures and dislocations.

1. A fracture of the body (usually the underlying one) or bodies of the vertebrae in combination with dislocation of both articular processes.
2. Dislocation of both articular processes without displacement of the vertebral body with a fracture passing through the substance of the vertebral body.
3. Dislocation of one pair of articular processes with a fracture line passing through the root of the arch or the interarticular part of the arch or the base of the articular process with a fracture line extending in various variations to the intervertebral disc or vertebral body.
4. "Dislocation" of the vertebral body - "traumatic spondylolisthesis".

Note: There may be two options:

• the fracture line passes through the area of the roots of both semi-arches, and then forward through the intervertebral disc with or without a fracture of the body of the underlying vertebra;
• the fracture line passes through the interarticular part of both semi-arches, and then forward through the intervertebral disc with or without a fracture of the body of the underlying vertebra.

The first variant should be classified as a stable injury, but since it is often not possible to clearly distinguish between the two variants, it is appropriate to classify it as an unstable injury.

Isolated ruptures of the supraspinous ligament

According to Rissanen (1960), the supraspinous ligament, consisting of 3 layers, in 5% of cases ends at the level of the spinous process of the 5th lumbar vertebra. Much more often (in 73% of cases) it ends at the level of the spinous process of the 4th lumbar vertebra and in 22% of cases - at the level of the spinous process of the 3rd lumbar vertebra. In the lower part of the lumbar segment of the spine, the supraspinous ligament is absent and is replaced by a tendinous suture of the spinal muscles.

Mechanism. Isolated ruptures of the supraspinous ligament occur in young people with a sharp, sudden and excessive bending of the spine in the lumbar region. Much less often they occur as a result of direct violence in the form of a blow to a stretched ligament with significant bending of the spine.

Much more often, the supraspinous ligament is damaged in isolation, in unstable spinal injuries.

Complaints of victims include sudden pain in the area of the rupture, which increases with movement. Objectively, local swelling and soreness at the site of injury are noted. Palpation, and sometimes visually when bending at the level of the rupture, reveals an increase in the interspinous space due to the divergence of the spinous processes and the retraction of soft tissues. When palpating, instead of a strong, elastic, well-contoured cord characteristic of a normal ligament, the examining fingers freely penetrate into the depth. These clinical data are quite sufficient for correct diagnosis. Radiologically, on a profile spondylogram, an increase in the interspinous space at the level of injury can be detected.

Conservative treatment consists of creating rest for a period of 3-4 weeks in a position of slight extension. This rest is created either by laying the victim in bed in a supine position, or by immobilizing the lumbar spine in a position of slight extension with a plaster corset.

In recent cases, 16-20 ml of 1% novocaine solution should be injected into the site of the ligament rupture.

The healing of the ligament at the site of the rupture ends with the formation of a scar, which to a certain extent replaces the torn ligament.

Surgical treatment is used much less frequently and is more often performed in the case of old, timely undiagnosed and therefore untreated ligament ruptures. Surgical intervention has to be resorted to in the presence of pain that occurs in subjects with excessive loads on this section of the spine - in gymnasts, athletes.

The essence of the surgical intervention performed (usually under local anesthesia) consists of exposing the area of the rupture, dissecting the lumbar fascia with two parallel vertical incisions on both sides of the spinous processes and restoring the continuity of the torn ligament using either the lumbar fascia (local autoplasty), or the broad fascia of the thigh, or a Kallio skin flap (free homo- or autoplasty), or lavsan tape (alloplasty).

Postoperative management consists of immobilization for 1-6 weeks with a posterior plaster bed or plaster corset in a position of moderate extension.

After the immobilization is stopped, as with conservative treatment, massage and thermal procedures are prescribed.

Working capacity is restored soon after the immobilization is stopped.

[ 11 ], [ 12 ]

Fractures of the transverse processes

Isolated fractures of the transverse processes occur in the lumbar region and occur as a result of an indirect mechanism of violence - a sudden excessive contraction of the quadratus lumborum muscle, attached to the 12th rib and the transverse processes of the 1st - 4th lumbar vertebrae and the lumbar muscle. Much less often, these injuries occur as a result of direct violence - a blow. Direct violence does not cause damage to the transverse processes of the 1st and 5th lumbar vertebrae, since the transverse process of the 1st vertebra is protected by the 12th rib, and the 5th - by the crest of the iliac wing. The transverse process of the 3rd lumbar vertebra is most often fractured, since it is longer than the others. Both single and multiple, both unilateral and bilateral fractures of the transverse processes may occur.

Complaints

The victim complains of severe pain in the lower back, which intensifies when trying to actively reproduce forward or lateral bending. Noyr's symptom is typical - pain when bending to the healthy side. This pain intensifies sharply when the victim tries to bend his straightened legs at the doctor's suggestion. In some cases, the pain is localized in the abdominal area. There may be complaints of urinary retention.

[ 13 ], [ 14 ], [ 15 ]

Symptoms and diagnosis of transverse process fractures

External signs of the existing damage are usually not revealed. The victim is alert, avoids changes in position and movements. Palpation reveals localized pain along the paravertebral lines - 8-4 cm outward from the line of the spinous processes. In thinner subjects, pain is revealed during palpation through the abdominal wall: the examining hand rests on the body of the vertebra, and then shifts to the side along the surface of the body. The most pronounced pain is noted at the postero-outer surface of the bodies of the lumbar vertebrae. As a rule, the symptom of a "stuck heel" is expressed - the victim cannot raise the leg straightened at the knee joint, or lift the heel off the surface of the bed.

In some cases, there may be some intestinal bloating and dysuria.

The described symptoms arise as a result of retroperitoneal hemorrhage, rupture and tear of muscle and fascial formations, irritation of paravertebral nerve formations.

Anterior spondylogram clarifies the clinical diagnosis of the number of damaged transverse processes, the presence or absence of displacement. Usually the displacement occurs downward and laterally. In the absence of contraindications, the intestines should be thoroughly cleaned before the X-ray examination, since the shadows from intestinal gases, as well as the X-ray shadow from the lumbar muscles, can be mistaken for the fracture line. The fracture line can be transverse, oblique, and much less often, longitudinal.

Treatment of transverse process fractures

Treatment consists of pain relief and rest for a period of 3 weeks. Pain relief according to A. V. Kaplan consists of separate injections of 10 ml of 0.0-1% novocaine solution into the area of each damaged transverse process. In case of persistent pain, novocaine injections should be repeated. Very useful is the paranephric novocaine block according to A. V. Vishnevsky (60-80 ml of 0.25% novocaine solution). UHF therapy gives a good analgesic effect.

The victim is placed on a hard bed in a supine position. He is given the "frog" pose - the legs are bent at the knees and hip joints and slightly spread apart. A bolster is placed under the bent knees. The "frog" pose relaxes the lumbar muscles, which helps reduce pain. The victim remains in this position for 3 weeks. After the acute effects of the injury have passed, a leg massage is prescribed, active movements in the joints of the feet, ankle joints, at the end of the 2nd - beginning of the 3rd week - active movements in the knee and hip joints.

Depending on the age and profession of the victim, working capacity is restored within 4-6 weeks.

Isolated ruptures of the interspinous ligament

This type of injury occurs in the lumbar spine. Ruptures of the interspinous lumbar ligaments are one of the causes of lumbar pain.

A healthy, unchanged interspinous ligament is not subject to traumatic ruptures. Only a degeneratively changed ligament can rupture. It has been proven that from the age of 20, the interspinous ligament undergoes severe degenerative changes, consisting in the fact that cartilaginous cells appear between the collagen bundles, and by the age of 40, the deep and middle layers of the ligament consist of fibrocartilaginous tissue. The ligaments undergo fatty degeneration, fragmentation, necrosis, ruptures and cavities appear in them. These changes, in addition to degenerative processes, are caused by constant trauma to these ligaments during spine extension.

Mechanism

Ruptures of these ligaments occur with excessive flexion of the lumbar spine and, according to research by Rissanen, in 92.6% of cases they are localized caudal to the spinous process of the IV lumbar vertebra, which is caused by the weakness of the ligamentous apparatus of the posterior parts of the lumbar region due to the aforementioned absence of the supraspinous ligament in this area.

Ruptures of the interspinous ligaments occur in people aged 25 years and older. They manifest themselves as acute or gradually developing lumbar pain, the appearance of which may be preceded by forced flexion of the lumbar region. Convincing objective symptoms include localized pain during palpation of the interspinous space and pain during flexion-extension movements. The most convincing confirmation of the suspected diagnosis is a contrast "ligamentogram".

Ligamentography

The patient is placed on his stomach. The skin is treated with 5% iodine tincture. At the level of the suspected rupture of the interspinous ligament, in the interspinous space to the right or left of the line of the spinous processes (not along the line of the spinous processes!), a needle is injected through the skin, subcutaneous tissue, superficial and lumbar fascia. 15-20 ml of contrast agent is injected with a syringe. The needle is removed. A phase spondylogram is performed. Confirmation of the presence of a rupture of the interspinous ligament is the passage of the contrast agent from the side of the injection and its introduction to the opposite side behind the midline. In the most typical cases, the ligamentogram is represented as an hourglass lying on its side. The narrow part - the isthmus - displays the defect in the interspinous ligament.

Treatment of ruptures of interspinous ligaments

Treatment of ruptures of interspinous ligaments in most cases is limited to rest, massage, and thermal procedures. In persistent cases that do not respond to conservative treatment, surgical treatment can be undertaken in the form of excision of the torn ligament and plastic replacement with fascia or lavsan. Kallio uses a skin flap for these purposes.

Fractures of the spinous processes

Spinous process fractures occur in the lumbar spine. They may be caused by direct or indirect force; they are often multiple. With spinous process fractures, the broken process or processes may be displaced, but fractures without displacement may also occur.

Symptoms of spinous process fracture

The victim's complaints are limited to pain at the site of injury, which increases with bending. When questioning him about the circumstances of the injury, attention should be paid to the presence in the anamnesis of a direct blow to the area of the suspected injury or excessive hyperextension of the lumbar spine.

Objectively, a local painful swelling is noted along the line of the spinous processes at the level of damage, spreading to the sides. Palpation of the broken process causes more intense pain. Sometimes it is possible to detect the mobility of the broken process or processes.

A profile spondylogram is decisive in confirming the diagnosis and clarifying the presence or absence of displacement.

Treatment of spinous process fractures

5-7 ml of 1-2% novocaine solution is injected into the injury site. The victim must remain in bed for 7-12 days. If pain is severe, the novocaine solution is injected again.

As a rule, bone fusion of the broken process occurs.

In the absence of bone fusion and the presence of pain syndrome at a late stage after the injury, the distal fragment of the process should be removed. The intervention is performed under local anesthesia. When removing a broken spinous process, special attention should be paid to maintaining the integrity of the infraspinous ligament.

Fractures of the articular processes

Isolated fractures of the articular processes of the thoracic and lumbar vertebrae are extremely rare. They are most often localized in the lumbar region and manifest as pain syndrome during rotational movements. The diagnosis is usually made on the basis of spondylography. Among the clinical symptoms, it is worth mentioning Erden's symptom, characterized by the presence of point pain in the area of the broken articular process. In cases difficult for diagnosis, it is useful to resort to an oblique projection. It should be remembered that persistent apophysites can imitate an isolated fracture of the articular process. Waves occur due to irritation of the synovial capsule of the intervertebral joints.

Treatment consists of pain relief and rest.

Isolated fractures of the arches

Isolated fractures of the vertebral arches occur in both the lumbar and thoracic spine. They may result from direct application of force (direct mechanism) or from hyperextension of the spine (indirect mechanism). In the latter case, a bilateral fracture of the arch in the root region may occur. In such cases, anterior displacement of the lumbar vertebral body may occur, similar to traumatic spondylolisthesis in the cervical vertebrae. A fracture of the vertebral arch or arches may be accompanied by displacement of the broken arch. Displacement of the broken arch toward the spinal canal is usually caused by traumatic force or may occur secondarily during careless movements or transportation. Injuries to the vertebral arches may be accompanied by involvement of the contents of the spinal canal, but may also occur without neurological symptoms. There is no parallelism between the presence or absence of displacement of the broken arch and neurological manifestations. There may be fractures of the arches without displacement with severe neurological symptoms, and vice versa. Neurological symptoms in the absence of displacement of the broken arch towards the spinal canal are explained by concussion and contusion of the spinal cord or its roots, supra- and intrathecal hemorrhages, as well as intracerebral hemorrhages.

The victim's complaints depend on the nature of the changes. Isolated fractures of the arches without involvement of the contents of the spinal canal manifest themselves in the form of pain that intensifies with movement. The neurological picture depends on the nature of the damage to the contents of the spinal canal and manifests itself from mild radicular symptoms up to a picture of a spinal cord rupture.

Diagnostics is based on identifying the circumstances of the injury, the nature and location of the violence, and orthopedic and neurological examination data. Spondylography in at least two typical projections clarifies and details the nature of the injury to the arch or arches. In the indicated cases, a spinal puncture is performed with cerebrospinal fluid flow tests, as well as pneumomyelography.

In case of damage to the arches, the posterior subarachnoid space should be examined most thoroughly. For this purpose, pneumomyelography is performed with the victim lying on his stomach (in this position, air or gas fills the posterior subarachnoid space). The cassette with the X-ray film is placed on the side - a profile spondylogram is made.

Treatment of damage to the arches

Treatment methods for uncomplicated and complicated isolated fractures of the arch or arches of the lumbar and thoracic vertebrae differ significantly.

In cases of isolated fractures of the arches without involvement of the contents of the spinal canal, treatment consists of immobilization by applying a plaster corset in a neutral position (without giving the spine a position of flexion or extension) for a period of 3-1 months.

The presence of concomitant damage to the contents of the spinal canal significantly complicates the treatment method. If there is convincing evidence of mechanical damage to the spinal cord and its membranes, it is necessary to immediately resort to revision of the spinal canal by laminectomy. Increasing compression of the spinal cord is also an indication for decompressive laminectomy and revision of the condition of the contents of the spinal canal. In cases of rapid, distinct regression of neurological symptoms, a wait-and-see approach can be used.

[ 16 ], [ 17 ]