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

Damage to the thoracic and lumbar vertebrae is considered in one article, because in the mechanism of their occurrence, clinical course and treatment issues, there is much in common.

Especially this applies to the lumbar and lower thoracic vertebrae, where the damage most often occurs.

Epidemiology

Damage to the thoracic and lumbar spine is common. According to Feldini-Tiannelli, fractures of the thoracic vertebrae in relation to all vertebral fractures are 33.7%, and fractures of the lumbar spine are 41.7%. Totally, the damage to the thoracic and lumbar spine is 75.4%, i.e., more than 3/4 of all vertebral fractures. However, the mortality rate in lesions of the thoracic and lumbar vertebrae is much lower than with damage to the cervical vertebrae. Thus, with fractures of the thoracic spine, the mortality rate is 8.3%, and the lumbar spine - 6.2%. Multiple fractures of the bodies of the thoracic and lumbar vertebrae occur in tetanus. In recent years, fractures of the spine have been observed with the bailouts of pilots. Among the injuries of the lumbar and thoracic spine, isolated fractures of vertebral bodies are most often found, which, according to Khavkin, were noted in 61.6% of all spinal injuries. The most isolated isolated fractures of the arches, making up, according to ZV Bazilevskaya. 1.2%.

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

Causes of the damage to the thoracic and lumbar vertebrae

The most frequent mechanisms of violence, causing damage to the lumbar and thoracic spine, are flexion, flexion-rotational and compression. The extensor mechanism of violence in the genesis of lesions of these parts of the spine plays a smaller role.

Most 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 various forms, each of which has its own characteristic clinical and radiological manifestations and is conditioned by a special mechanism of violence. Clinical forms of injuries of the lumbar and thoracic spine are summarized by us in a special classification that will help the trauma surgeon correctly navigate the nature of the lesion and choose the most rational method of treatment. We will deal with this classification below.

With lesions of thoracic and lumbar localization, the division of all spinal injuries to stable and unstable remains of fundamental importance.

Of fundamental importance is also the division of injuries of the lumbar and thoracic spine into complicated and uncomplicated ones.

In the treatment of various clinical forms of spine injuries, both nonoperative and surgical methods of treatment are used, the basis of which is the restoration of the anatomical shape of the damaged spine and case immobilization in the position of the achieved correction before the healing of the lesion. Compliance with these two principal conditions is a tax to improve treatment outcomes.

The anatomical structure of the thoracic and lumbar vertebrae is identical to that of the middle and lower cervical vertebrae. Each thoracic and lumbar vertebra consists of a body, two half-bows, one spinous, two transverse and four articular processes. The main anatomical differences are as follows. The bodies of the thoracic vertebrae have a somewhat higher height than the body of the VII cervical vertebra. Their height gradually increases the more they are closer to the lumbar region. The bodies of the lower thoracic vertebrae are close in size and shape to the bodies of the upper lumbar vertebrae. On the posterior-lateral surface of the bodies of the thoracic vertebrae, the upper and lower half-fascia are located. The lower semifaceted overlying vertebra together with the upper half of the underlying vertebra adjacent to it form a full facet for articulation with the rib head. The body I of the thoracic vertebra has only one full facet for articulation with the 1st rib. Consequently, the heads of II-X ribs are joined to the bodies of two adjacent vertebrae and cover the jaw of the intervertebral disc. Exarticulation of the rib head 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 rib head.

The bodies of the lumbar vertebrae are more massive and have a bean-shaped form. In contrast to the thoracic vertebrae, there are no facets mentioned above on their posterior-lateral surfaces.

The more caudally situated the thoracic and lumbar vertebrae, the more massive are their half-bows. The most massive and strong are the half-bones of the lower lumbar vertebrae.

The spinous processes of the thoracic vertebrae have a triangular shape with a pointed end and are directed caudal. The awned, processes of the middle thoracic vertebrae are arranged in tile.

The spinous processes of the lumbar vertebrae are most massive and at the same time shorter than the thoracic vertebrae. They are wide enough, 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 posteriorly, the lower one - anteriorly.

Such an arrangement of the articular processes does not allow one to obtain a mapping of the articular intervertebral fissure on the anterior spondylogram.
In contrast, the articular processes of the upper lumbar vertebrae, starting from the half-hearth, are directed posteriorly and are almost vertical. Their articular surfaces are located in the sagittal plane, why the articular gap of the lumbar intervertebral articulations is well displayed in the anterior spondylogram. At the external-posterior margin of the upper articular process of the lumbar vertebrae there is a small mastoid process.

The transverse processes of the thoracic vertebrae are directed to the outside and somewhat posteriorly and carry a facet for articulation with the rib bugle. The transverse processes of the lumbar vertebrae are located in front of the articular processes, laterally and somewhat posteriorly. Most of the lumbar transverse processes are represented by the rudiment of the rib - the costal process .. The transverse processes of the I and V lumbar vertebrae are covered by the last rib and the wing of the ilium, and therefore there are no fractures of these transverse processes from direct violence.

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

The presence of physiological curves in the thoracic and lumbar spine leads to the fact that the pulpous nucleus of the thoracic intervertebral discs is located posteriorly, and the lumbar ones - anteriorly. Consequently, the ventral divisions of the thoracic discs are narrowed, and the lumbar regions are widened.

The apex of the thoracic physiological kyphosis is at the level of the VI - VII thoracic vertebrae. With age, physiological kyphosis in women tends to increase. The vertex of the physiological lumbar lordosis is the fourth lumbar vertebra. With age, physiological lumbar lordosis in men tends to be smoothed. The statement of Ja. A. Rotenberg (1929, 1939) that lumbar lordosis increases with age, does not correspond to reality.

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

The degree of severity of the physiological bends of the thoracic and lumbar spine is in direct connection with certain constitutional types of the structure of the human body and is determinant in terms of the stability of the spine to traumatic violence.

The internal architecture of vertebral bodies, due to their appropriateness, gives them considerable strength. The least resistant to violence is the body of the cervical vertebrae, the most stable are the bodies of the lumbar vertebrae. According to the data of Messei'er, the bodies of cervical vertebrae break down when exposed to a force equal to 150-170 kg, pectorals - strength 200-400 kg, and lumbar - 400-425 kg.

Nachemson studies have shown that with age, due to the development of degenerative processes in the spine, the intra-disk pressure is significantly reduced. This affects the features of spine injuries that occur in the elderly. In contrast, a high and especially increased internal disk pressure in the conditions of a degenerately altered fibrous ring promotes the appearance of an acute rupture and discoloration.

The function of the yellow ligaments in the lumbar spine is not limited to the retained arches of the vertebrae relative to each other. A large number of elastic fibers in them develops sufficiently powerful elastic forces, which, firstly, return the spine to its normal starting position after deformations that arise during the movements of the spine, and second, give a smooth surface to the posterior-lateral walls of the vertebral capal at different positions of the spine. This last circumstance is a very powerful protective factor for the contents of the spinal canal.

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

The capsule of synovial intervertebral articulations 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 directly adjacent to the posterior longitudinal ligament, free nerve endings were found. The pelvic nucleus does not contain any nerve endings.

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

In the yellow ligament, free nerve endings were found in the most distant layers of the dorsal surface of the ligaments and never in the deep layers of this ligament. So far, there is no data on the relationships and functions of these nervous sensory structures. It is assumed that free nerve endings are associated with painful sensations, complex unencapsulated endings - with the position of tissues and articulations, encapsulated nerve endings - with a perception of pressure.

X-ray anatomical data relating to the thoracic and lumbar spine, as well as differential-diagnostic treatment of spondylograms in norm and pathology are described in detail in special manuals and monographs of recent years. Knowledge of the radiographic anatomy of the thoracic, thoraco-lumbar, lumbar and lumbosacral spine will allow to correctly assess the available X-ray symptoms and to identify those changes in the spine that have arisen due to damage. In practice, unfortunately, we often confine ourselves to only two typical projections, which undoubtedly narrows the possibilities of the X-ray method. In the cases shown, a full-fledged X-ray examination in the form of additional special projections, functional spondylograms, contrasting spondylographies, and sometimes tomography should be used much more widely. It should be remembered that functional spondylography is completely unacceptable for unstable spinal injuries.

Among the relatively rare deviations from the norm, which can simulate damage to individual vertebral elements, it is necessary to mention the following. Rarely is there a congenital absence of lumbar articular processes. In the literature available to us there are reports that Rowe in 1950 described two drugs of the lumbosacral spine, in which he found the innate absence of articular processes. These two drugs were found among 1,539 normal drugs. In 1961, Forrai described two cases of the absence of the lower articular process of the third lumbar vertebra, observed in young people with lumbar pains that occurred after moderate trauma. Finally, Keim and Keage (1967) described three observations of a one-sided absence of the lower articular process in the region of the V lumbar and I sacral vertebrae.

Usually, these abnormalities were detected with spondylography, which is performed in patients who complain of pain after trauma.

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

Baustrup's syndrome, or Baastrup's disease, in which in some cases an enlightenment zone can be observed in the region of the spinous process, can also be mistaken for a fracture of the spinous process. The uniformity of this "gap" and the presence of closing plates on the "fragments" of the spinous process will allow us to correctly interpret the changes found.

[8], [9], [10]

Forms

Existing classification of injuries of the lumbar and thoracic spine covers all clinical forms of damage. However, such a classification, which would cover all types of damage occurring in the lumbar, thoracic and transitional parts of the spine, seems to us very important, useful and expedient. Such classification will help not only timely and correctly diagnose the existing damage, but also choose the most rational and necessary method of treatment in this particular case.

Modern ideas about spinal injuries and the knowledge accumulated in this area do not allow the orthopedic trauma specialist to confine himself to such a general diagnosis as a "spinal fracture" or "compression fracture of the spine" or "fracture-spine dislocation", etc. Does not disclose the full picture existing damage, the addition to the above diagnoses of the concept of complicated and uncomplicated damage.

The classification is based on three principles: the principle of stability and instability, the anatomical principle of the localization of damage (front and back spine) and the principle of interest in 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 that occur in the thoracic and lumbar spine.

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

Stable damage.

A. Rear departments of the spine.

1. Isolated rupture of an adnate binder.
2. Isolated rupture of the interstitial ligament.
3. The rupture of an adnate and intercostal ligament.
4. Isolated fracture of the spinous processes (processes) with displacement.
5. Isolated fracture of the spinous process (processes) without displacement.
6. Isolated fracture of the transverse process (processes) with displacement.
7. Isolated fracture of the articular process (shoots) without displacement.
8. Isolated fracture of the articular process (processes) with displacement.
9. Isolated fracture of the arch (arches) without bias and without interest in the contents of the spinal canal.
10. Isolated fracture of the arch (arches) without bias with the interest of the contents of the spinal canal.
11. Isolated fracture of the arch (arches) with displacement and interest in the contents of the spinal canal.
12. Isolated fracture of the arch (arches) with the displacement and without the interest of the contents of the spinal canal.

B. Front sections of the spine.

1. Compression wedge fracture of the body (bodies) of the vertebra with varying degrees of decrease in its height without the interest of the contents of the spinal canal.
2. Compression wedge fracture of the vertebral body (bodies) with varying degrees of decrease in its height with interest in the contents of the vertebral canal.
3. Compression wedge fracture of the vertebral body (bodies) with detachment of the cranioventral angle without interest of the contents of the spinal canal.
4. Compression wedge fracture of the vertebral body (bodies) with the detachment of the cranioventral / angle with the interest of the contents of the vertebral canal.
5. Compression wedge fracture of the body (body) of the vertebra with damage to the closure plate.
6. Compression splinter fracture of the vertebral body without interest in the contents of the spinal canal or roots.
7. Compression splinter fracture of the vertebral body with an interest in the contents of the vertebral canal or roots.
8. Vertical fractures of bodies.
9. Rupture of the fibrous ring of the disc with prolapse of the pulpous nucleus anteriorly.
10. Rupture of the fibrous ring of the disc with the prolapse of the pulpous nucleus to the side.
11. Rupture of the fibrous ring of the disc with prolapse of the pulpous nucleus posteriorly and outwards.
12. Rupture of the fibrous ring of the disc with prolapse of the pulpous nucleus posteriorly.
13. The rupture (nerol) of the closure plate with the prolapse of the pulpous nucleus into the body of the vertebral body (acute Schmorl's hernia).

Unstable damage.

A. Dislocations.

1. Unilateral subluxation.
2. Two-sided subluxation.
3. One-sided dislocation.
4. Two-sided dislocation.

B. Perelomo-dislocations.

1. Fracture of the body (often underlying) or vertebral bodies 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 interarticular part of the arch or the base of the articular process with a fracture line extending in various versions to the intervertebral disc or vertebral body.
4. The "dislocation" of the vertebral body is "traumatic spondylolisthesis."

Note. There can be two options:

• the fracture line passes in the root region of both half-bows, and then anteriorly through the intervertebral disc with fracture or without a fracture of the body of the underlying vertebra;
• the fracture line passes in the interarticular part of both half-bows, and then anteriorly through the intervertebral disc with a fracture or without a fracture of the body of the underlying vertebra.

The first option should be attributed to stable damage, but due to the fact that it is often not possible to clearly distinguish between these two options, it is appropriate to attribute it to unstable damage.

Isolated ruptures of an adnate binder

According to Rissanen (1960), the supraspinous ligament consisting of 3 layers, in 5% of cases is stuck at the level of the spinous process of the V lumbar vertebra. Significantly more often (in 73% of cases), it ends at the level of the spinous process of the IV lumbar vertebra and in 22% of cases - at the level of the spinous process of the third lumbar vertebra. In the lower part of the lumbar segment of the spine, the bony cord is absent and replaced by the tendon suture of the spinal muscles.

Mechanism. Isolated ruptures of the bony ligament are found in young people with sudden sudden and excessive flexion of the spine in the lumbar region. They are much less likely to occur due to the direct impact of violence in the form of a blow on a tight bundle. With considerable flexion of the spine.

Significantly more often, the bony unspecified ligament is damaged in isolation, with unstable injuries of the spine.

Complaints of victims consist in occurrence of sudden pains in the field of rupture, amplifying at movements. Objectively noted: local swelling and tenderness in the place of injury. Palpation, and sometimes the eye when bending at the level of rupture, there is an increase in the interstitial gap due to the divergence of the spinous processes and the occlusion of the soft tissues. When palpation, instead of a strong, resilient, well-contoured strand, inherent in a normal ligament, the investigating fingers freely penetrate into the depth. These clinical data are sufficient for proper diagnosis. Radiographically on the profile spondylogram, an increase in the interstitial gap at the level of damage can be detected.

Conservative treatment is to create a rest for 3-4 weeks in a position of easy extension. This rest is created either by placing the victim in bed in the position on the back, or by immobilization of the lumbar spine in the position of easy extension with plaster corset.

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

The healing of the ligament at the site of the rupture ends in the formation of a scar, which to some extent replaces the ruptured ligament.

Operative treatment is used much less often and more often with old, timely not diagnosed and, as a result, untreated ligament ruptures. To prompt intervention it is necessary to resort to the presence of pains that occur in subjects with excessive loads on this part of the spine - in gymnasts, athletes.

The essence of the surgical intervention (more often under local anesthesia) is to expose the rupture area, dissection of the lumbar fascia by two parallel vertical incisions on both sides of the spinous processes and restore the continuity of the ruptured ligament with the help of the lumbar fascia (local autoplasty) or the broad fascia of the thigh, or a flap of skin on Kallio (free homo- or autoplasty), or lavsan tape (alloplasty).

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

After the cessation of immobilization, as in conservative treatment, massage and thermal procedures are prescribed.

Workability is restored soon after the cessation of immobilization.

[11], [12]

Fractures of transverse processes

Isolated fractures of the transverse processes occur in the lumbar region and arise as a result of an indirect mechanism of violence - sudden excessive reduction of the square muscle of the waist, attached to the XII rib and transverse processes of lumbosacral vertebrae and lumbar muscle. Much less often, these injuries arise from the impact of direct violence - a blow. Direct violence causes damage to the transverse processes of the I and V lumbar vertebrae, since the transverse process of the 1st vertebra is protected by the XII rib, and V is the crest of the wing of the ilium. The lateral process of the third lumbar vertebra is more often fractured, since it is longer than the rest. Single as well as multiple can arise, both unilateral and bilateral fractures of transverse processes.

Complaints

The sufferer complains of severe back pain, intensifying when trying to actively reproduce anterior or lateral flexion. Characteristic is the symptom of Neur - pain when tilted to a healthy side. These pains intensify dramatically when the victim attempts to squeeze his straightened legs at the doctor's suggestion. In some cases, the pain is localized in the abdomen. There may be complaints about a delay in urination.

[13], [14], [15],

Symptoms and Diagnosis of Fractures of Transverse Processes

External signs of the existing damage, as a rule, are not detected. The victim is alert, avoids changing position and movements. When palpation, local soreness is revealed along the paravertebral lines - 8-4 cm outward from the line of spinous processes. In more lean subjects, soreness is revealed upon palpation through the abdominal wall: the investigating arm rests against the body of the vertebra, and then shifts to the side along the surface of the body. The most pronounced soreness is noted in the posterior-external surface of the bodies of the lumbar vertebrae. As a rule, the symptom of the "stitched heel" is expressed - the victim can not lift the leg straightened at the knee joint, tear the heel from the surface of the bed.

In some cases, there may be some inflations of the intestine, dysuric phenomena.

The described symptoms are caused by retroperitoneal hemorrhage. Rupture and tearing of muscular and fascial formations, irritation of paravertebral nerve formations.

The anterior spondylogram specifies the clinical diagnosis of the number of damaged transverse processes, the presence or absence of bias. Usually the displacement occurs downward and laterally. In the absence of contraindications, a thorough cleansing of the intestine should be performed before the X-ray examination, since the shadows from the intestinal gases, as well as the x-ray shadow from the lumbar muscles, can be mistaken for the fracture line. The fracture line can run transversely, oblique and much less frequently, longitudinally.

Treatment of fractures of transverse processes

Treatment consists in anesthetizing and creating rest for a period of 3 weeks. Anesthesia but AV Kaplan consists in the separate introduction into the area of each damaged transverse process of 10 ml of 0, o-1% solution of novocaine. With persistent pain, injections of novocaine should be repeated. Very useful is the paranephric neocaine blockade of AV Vishnevsky (60-80 ml of 0.25% solution of novocaine). A good analgesic effect is provided by UHF therapy.

The victim is laid on a hard bed in the position on the back. He is given a pose of a "frog" - his legs are bent at the knee and hip joints and are slightly apart. Bend the knees under the bent knees. The "frog" posture relaxes the lumbar musculature, which helps to reduce pain. In this situation, the victim is within 3 weeks. After passing through acute traumas, foot massage, active movements in the joints of the feet, ankle joints are prescribed, at the end of the 2nd and the beginning of the third week active movements in the knee and hip joints are prescribed.

The ability to work is restored, depending on the age and profession of the victim, after 4-6 weeks.

Isolated interstitial ligament ruptures

This type of damage occurs in the lumbar spine. Interrupted lumbar ligament ruptures are one of the causes of lumbar pain.

A healthy, unchanged interopercle ligament is not subject to traumatic ruptures. There may be a rupture of only a degenerately altered ligament. It has been proved that, since the age of 20, the interstitial ligament undergoes severe degenerative changes, consisting of the appearance of cartilaginous cells between the collagen bundles, and by 40 years the deep and middle layers of the ligament consist of a fibrous-cartilaginous tissue. Ligaments are subject to fatty degeneration, fragmentation, necrosis, tears and cavities appear in them. These changes, in addition to degenerative processes, are caused by the permanent traumatization of these ligaments during extension of the spine.

Mechanism

The ruptures of these ligaments occur with excessive flexion of the lumbar spine and, according to Rissanеn's research, in 92.6% the caudal is more localized than the spinous process of the IV lumbar vertebra, which is due to the weakness of the lumbar apparatus of the posterior lumbar region due to the abnormal ligament in the area mentioned above.

Intermittent ligament ruptures occur in persons aged 25 years and older. They are manifested acutely or gradually arising lumbar pains, the appearance of which can be preceded by forced flexion of the waist. Of the convincing objective symptoms, local soreness is noted during palpation of the interstitial space and pain in flexion-extensor movements. The most demonstrative confirmation of the alleged diagnosis is a contrasting "ligamentogram".

Ligamentography

The patient is placed on the stomach. The skin is treated with 5% tincture of iodine. At the level of the supposed rupture of the interstitial ligament in the interstitial space to the right or left of the line of spinous processes (not along the line of spinous processes!) Through the skin, subcutaneous tissue, superficial and lumbar fascia inject the needle. A syringe is injected with 15-20 ml of contrast medium. The needle is removed. Produce a phase spondylogram. Confirmation of the presence of rupture of the interstitial ligament is the passage of the contrast agent from the side of the injection and its introduction to the opposite side beyond the middle line. In the most typical cases, the ligamentograms are represented in the form of an hourglass lying on its side. The narrow part - the isthmus displays the defect in the interstitial bunch.

Treatment of interstitial ligament ruptures

Treatment interruptions of intercostal ligaments in most cases is limited to rest, the appointment of massage, thermal procedures. In stubborn cases that can not be treated conservatively, surgical treatment can be undertaken in the form of excision of a torn ligament and plastic replacement with its fascia or lavsan. Kallio uses a skin flap for this purpose.

Fractures of spinous processes

Fractures of spinous processes occur in the lumbar spine. They can arise under the influence of both direct and indirect violence; they are often multiple. With fractures of the spinous processes, a dislocation of the detached process or processes may occur, and fractures without displacement may also occur.

Symptoms of fracture of spinous processes

Complaints of the victim are reduced to the presence of pain in the place of damage, increasing when bending. When questioning him about the circumstances of the damage, attention should be paid to the presence in the anamnesis of a direct stroke in the area of the alleged injury or excessive over-extension of the lumbar spine.

Objectively, there is a local painful swelling along the line of spinous processes at the level of damage that spreads to the sides. When palpation of the broken process, more intense pain occurs. Sometimes it is possible to detect the mobility of a broken process or processes.

Decisive in confirming the diagnosis and clarifying the presence or absence of bias is the profile spondylogram.

Treatment of fracture of spinous processes

At the site of damage, 5-7 ml of 1-2% solution of novocaine is administered. 15 for 7-12 days, the victim must comply with bed rest. With severe pain, a solution of novocaine is re-introduced.

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

In the absence of bone adhesion and the presence of pain syndrome in the remote after the injury, the distal fragment of the appendage should be removed. Intervention is performed under local anesthesia. When removing a broken spinous process, special attention should be paid to maintaining the integrity of the underlying ligament.

Fractures of articular processes

Isolated fractures of the articular processes of the thoracic and lumbar vertebrae are extremely rare. More often they are localized in the lumbar region and manifested by pain syndrome with rotational movements. Diagnosis, as a rule, is based on spondylography. Of the clinical symptoms should be mentioned Erden's symptom, characterized by the presence of punctual pain in the region of the broken articular process. In difficult cases for diagnosis, it is useful to resort to an oblique projection. It should be remembered that persistent apophysites can mimic an isolated fracture of the articular process. Waves arise due to irritation of the synovial capsule of intervertebral articulations.

Treatment consists in anesthesia and rest.

Isolated wrench fractures

Isolated vertebrae fractures occur both in the lumbar and thoracic spine. They can arise as a result of direct application of violence (direct mechanism) or as a result of re-spinal cord (indirect mechanism). In this latter case, a bilateral fracture of the arch in the root region may occur. In such cases, the body of the lumbar vertebra may be displaced anteriorly in the type of traumatic spondylolisthesis similar to the cervical vertebrae. Fracture of the arch or arches of the vertebrae may be accompanied by a displacement of the broken arch. The displacement of the broken arch towards the vertebral canal is usually due to the action of traumatic violence or may occur again if careless movements or transportation occurs. Damage to the vertebral arches may be accompanied by an interest in the contents of the spinal canal, but may also occur without neurologic symptoms. Parallelism between the presence or absence of displacement of the broken arch and neurological manifestations is not present. There may be fractures of the arches without displacement with gross neurologic symptoms, and vice versa. Neurological symptoms in the absence of displacement of the broken arch in the direction of the spinal canal are explained by concussion and contusion of the spinal cord or its roots, supra-and adnexal hemorrhages, and intracerebral hemorrhages.

The victim's complaints depend on the nature of the changes. Isolated fractures of the arches without the interest of the contents of the spinal canal appear as pains that increase during movement. The neurological picture depends on the nature of the damage to the contents of the spinal canal and manifests itself from slight radicular symptoms right up to the pattern of the spinal cord break.

Diagnosis is based on identifying the circumstances of the damage, the nature and location of the violence, these orthopedic and neurological examinations. Specifies and specifies the nature of damage to the arch or arches of spondylography at least in two typical projections. In the cases shown, spinal puncture is performed with carrying out liquorodynamic tests, as well as pneumomyalography.

If the arch is damaged, the posterior subarachnoid space should be examined most carefully. For this, pneumomyelography is performed in the position of the victim on the abdomen (in this position air or gas fills the posterior subarachnoid space). A cassette with an X-ray film is placed on the side - make a profile spondylogram.

Damage treatment

Methods of treatment of uncomplicated and complicated isolated fractures of the arch or arches of the lumbar and thoracic vertebrae have significant differences.

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

The presence of concomitant damage to the contents of the vertebral dripping significantly complicates the treatment technique. In the presence of convincing data indicating mechanical damage to the spinal cord and its membranes, one should immediately resort to revising the vertebral canal by means of a laminectomy. Increasing compression of the spinal cord is also an indication for decompressive laminectomy and revision of the state of the contents of the spinal canal. In cases of rapid, distinct regression of neurological symptoms, expectant management may be implemented.

[16], [17]