Injury of the spine in old age: causes, symptoms, diagnosis, treatment

The elderly age of the affected persons imposes their own peculiarities on the mechanism of origin, clinical forms and clinical manifestations, the course and treatment of spine trauma.

In connection with socio-economic changes in our country, the contingent of the elderly has increased significantly.

Anatomical and physiological features of the body of older people require a special, unique approach to the treatment of their injuries, including trauma to the spine. Along with the changes taking place in all systems and organs of an elderly person, bone tissue and joints undergo considerable changes. It should be borne in mind that involute processes in the body. Including in the system of the musculoskeletal system, come gradually. Far from always in people of the same age, these changes are equivalent: in some, older age they are less expressed, in others, less elderly, more. This allows us to talk about premature or late aging, and why it is not necessary to associate senile involutive processes only with the age of a person.

[1], [2]

Age changes in the spine

Age changes in the spine are characterized by senile osteoporosis in the bone elements of the spine and age-related degenerative changes in the intervertebral discs.

Senile, or senile osteoporosis is a mandatory symptom of aging of bones and occurs in all people older than 60-70 years. Its essence is the quantitative and qualitative violation of the protein matrix of the bone in the absence of pronounced violations from the calcium-phosphorus metabolism. With the help of electron microscopy, Little and Kelly showed that the essence of bone matrix changes in osteoporosis is reduced to a more dense collision of collagen bundles to each other, to the disappearance of tubules, to the transformation of the matrix into an unstructured mass. Consequently, the primary cause of osteoporosis is not calcium deficiency in bone tissue, but a protein deficiency that occurs.

Clinically, osteoporosis in the spine is manifested in the form of various deformations in the spine. In women, it is expressed in the form of an increase in the thoracic kyphosis, in men - in the form of straightening of the lumbar lordosis, which in its essence is also a tendency to the development of kyphotic deformation.

The anatomical basis of senile osteoporosis is the progressive transformation of the dense bone substance into spongy bone due to a disturbance of the balance between osteoblastic and osteoclastic processes in favor of the latter. There is a thinning and quantitative reduction of bone beams in the spongy bone. A complex system of bone beams - the architectonics of the bone - is simplified due to the disappearance of a portion of the bone beams. The degree of thinning of the cortical bone and the quantitative decrease of bone beams reach such limits that contribute to the appearance of entire territories lacking bone elements, dilution and increase of spongy cells and weakening of bone lines of force. AV Kaplan, in studying the spongy bone microscope, showed that the walls of cells of the spongy substance become much thinner by the time they are old.

All these changes lead to increased brittleness of the senile, as evidenced by the frequency of fractures in the elderly with the impact of violence, which in children, adolescents and middle-aged people never causes a bone fracture.

Significantly earlier and subtle changes occur in intervertebral discs. As mentioned earlier, the intervertebral disc consists of a fibrous ring, a pulpous core and hyaline plates. Histological studies have shown that the fibrous ring consists of dense collagen fibers, which in the outer sections of the fibrous ring are concentrically arranged plates. The pulpous core consists of an amorphous substance in which collagen fibers and cellular elements are located. Closing plates are hyaline cartilage.

Most researchers believe that all the tissue components of the intervertebral disc form during the period of prenatal life. Fibrous structures of the disc appear in children of the first months of life under the influence of a load on the spine. With age, the disk dries up, especially its pulpous core. "Drying" of the disc with age occurs because the pulpous nucleus changes its structure and approaches the structure of the fibrous ring, and in the elderly - to the structure of the hyaline cartilage. With age, the number of cartilaginous cells increases in the discs and that they tend to settle in the form of nests. There is a hyalinization of the fibrous ring, in the hyaline plates there are cracks and crevices.

Based on the biochemical study of the intervertebral disk tissue, it was shown that in the pulp nucleus there are mucopolysaccharides mainly of the chondroitin sulfate type. With age, the content of mucopolysaccharides decreases, and the concentration of chondroitin sulfates falls faster than keratosulfate.

Histochemical study of polysaccharides in intervertebral discs is represented by single studies and conducted without sufficient histochemical analysis and a small number of techniques.

As is known, the pulpous nucleus of the intervertebral disc contains a large amount of liquid, which can be explained histochemically by the high content of acid mucopolysaccharides in its tissue and their high ability to retain water. A significant decrease in the content of acidic mucopolysaccharides, and possibly also a change in their composition towards an increase in keratosulfate, leads to a decrease in the hydrophilic properties of the basic substance and a decrease in the water component in the pulpous nucleus. These phenomena in turn lead to a slowing down and deterioration of the diffusion processes, which are the main factor in trophic avascular tissue of the disc. Probably, the compaction of the disc tissues due to the increase in collagen fibers also influences the slowing of diffusion and the decrease in the intake of nutrients. It should be assumed that a deterioration in nutrition affects the state of thin molecular and submicroscopic structures. Apparently, the protein-mucopolysaccharide complex is separated from the collagen and the latter is disintegrated. Collagen fibers devoid of a cementing substance are disorganized and break down into separate fibrils, which are essentially collastromin with or without precollagenic residues. Probably, this is associated with a change in the color of picrofuxin and an increase in argyrophilia in the foci of dystrophy.

It is possible that the depolymerization of mucopolysaccharides plays a certain role in the development of dystrophy, since the longer and more polymerized the macromolecules, the more vigorously the water formed by the gel restrains them. Probably only an integral structure of the protein-mucopolysaccharide complex determines the characteristic physicochemical and mechanical properties of the intervertebral disc tissue. An important role in the integrity of the protein-mucopolysaccharide complex is given to enzyme systems.

Due to the biochemical and biophysical changes described above, the elasticity and elasticity of the disc decrease, its damping properties weaken.

In the process of studying the intervertebral discs of man, attention was drawn to certain features in the structure of the outer plates of the fibrous ring and the cartilaginous hyaline plate. Both those and others almost do not perceive fuchsin when painting according to van Gieson; in them, acid mucopolysaccharides are very weakly compared to other zones of the disk and neutral mucopolysaccharides are represented in large quantities.

Possible causes of structural changes in the "old" disks is a change in the nature of the connection between acidic and neutral mucopolysaccharides with proteins, redeployment and some changes in the composition of acidic mucopolposaccharides. These causes can cause a violation of tissue nutrition processes, collagen formation, elasticity and mechanical strength of the disc, which in turn will inevitably affect the changes in the fibrous structures of the intervertebral disc.

The histochemical changes described above correspond schematically to the dynamics of morphological changes.

The pulpous nucleus of the intervertebral disc of the newborn and the child of the first years of life is extremely rich in substance, which under the microscope has a homogeneous, amorphous appearance. This substance is dyed pale and hardly noticeable on preparations. Against the background of this structureless mass, thin collagen fibers are found. Cellular elements of the pulpous core are represented by fibroblasts, cartilage cells, groups of cartilaginous cells. Some cartilaginous cells have an eosinophilic capsule. In the pulpous nucleus of the first years of life there are still many chordal cells that disappear by the age of 12 years.

As the child grows and, consequently, the intervertebral disk, the collagen fibers become denser, the fiber formation in the pulpous nucleus increases. In the third decade of a person's life in the intervertebral disc, the laminae and fiber bundles of the fibrous ring become denser and partially hyaline. The pulpous core almost entirely consists of a fine-fibrous, felt-like network of collagen fibers with a large number of cartilaginous cells and isogenic groups. In adulthood, especially to old age, increases gpalinizatsiya and coarsening of bundles and plates of the fibrous ring, in the pulpous nucleus, the number of cartilaginous elements increases. In the pulpous nucleus and the fibrous ring, foci of granular and lumpy decomposition of the basic substance and its ossification appear. In the thickness of the hyaline plates, there is a tissue of the pulpous nucleus in the form of cartilaginous nodules described by Schmorl. All the described phenomena begin to be observed from the end, and sometimes even the beginning of the third decade of human life, progress with age and reach extreme degrees in old age.

The described age changes in the bodies of the vertebrae and in intervertebral discs lead to the fact that the spine of the elderly person undergoes significant age changes. In addition to the above-mentioned clinically sensed deformations of the spine, it becomes rigid, inelastic, slow-moving, less resistant to the usual vertical loads. This is manifested by a feeling of fatigue, the inability to hold the trunk in an upright position for a long time. Older osteoporosis and involute changes in the intervertebral discs lead to the fact that the length of the spine decreases with age and, as a result, the growth of the person as a whole. All these phenomena are aggravated by age-related changes: in the muscular apparatus.

In X-ray examination, age-related changes in vertebral bodies are manifested in the form of "transparency" of vertebral bodies, a significant decrease in the intensity of their X-ray shadow. Lumbar vertebrae often take the form of a fish vertebra, between which are visible seemingly significantly increased in height intervertebral spaces resembling tight motor tires.

The thoracic vertebrae can acquire a wedge shape due to a significant decrease in the height of their ventral divisions. Then the intervertebral spaces in the thoracic region are considerably narrowed and sometimes difficult to differentiate. As in the lumbar and in the thoracic, as well as in the cervical spine, a significant number of osteophytes appears, especially in the area of the ventral parts of the vertebral bodies. Often osteophytes also appear on the posterior edges of the body. In the cervical spine, these osteophytes are facing the intervertebral foramen. The age peculiarity of the cervical spine is the development of unco-vertebral arthrosis. In the intervertebral synovial articulations a degenerative process develops in the form of spondyloarthrosis radiographically manifested in the form of uneven articular slits, intensifying the intensity of the X-ray shadow in the region of the subchondral zones, emphasizing and sharpening the ends of the articular processes.

Rough changes are detected from the intervertebral disc. As a rule, their height is reduced. Straightening of the lumbar lordosis, coming with age, leads to the fact that on the anterior spondylograms the intervertebral fissures are clearly traced and located parallel to each other. In the thoracic region, as a result of an increase in the thoracic kyphosis on the anterior spondylogram, these gaps, on the contrary, are poorly differentiated, and a false idea of their absence is created. In the cervical region of old people, complete disappearance of the intervertebral spaces can be observed, which gives the impression of having a block of the body of adjacent vertebrae. In the cervical region and somewhat less frequently in the upper thoracic region, calcification of the anterior longitudinal ligament can be observed up to its complete ossification. The cervical spine also loses its lordosis with age, it acquires a strictly vertical form, and sometimes also angular kyphotic deformation.

In addition to osteophytes located perpendicular to the long spine of the spine and resulting from degenerative age changes in the intervertebral discs, bone growths located within the anterior longitudinal ligament and going strictly parallel to the long axis of the spine can be observed. These manifestations of spondylosis are a reflection of local degeneration of the outer sections of the fibrous ring of the intervertebral disc, in contrast to osteochondrosis, in which degenerative processes occur primarily in the pulpous nucleus.

In the subchondral zones of the vertebral bodies against the background of osteoporosis, zones of pronounced subchondral sclerosis of the bone tissue are clearly defined.

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

Symptoms of spine injury in old age

Symptoms of spine trauma in the elderly and senile age are very scarce, which sometimes gives rise to considerable difficulties in establishing the correct diagnosis.

The most common and persistent complaints are local pain in the spine. Pain can irradiate over the intercostal spaces, but with a fracture of the body of the thoracic vertebra and in the limb. The intensity of pain is different. Usually these pains are insignificant. The great constancy of these pains and their locality give reason to suspect the presence of a fracture. The study of the mobility of the spine may add little to the rationale for the clinical diagnosis. The backbone of an elderly, old man is already inactive, rigid and all kinds of movements in it are considerably limited. The detection of local soreness by palpation also does not allow obtaining clear data, since in older and older people the palpation of the posterior parts of the spine is often painful and without a fracture. Only pronounced local soreness can help in justifying the diagnosis. Little information gives an axial load on the spine and effleurage over the region of spinous processes.

Consequently, with the most common compression wedge fractures of vertebral bodies in elderly and old people, the clinical manifestations and symptoms of these lesions are very scarce and do not have a vivid clinic. This requires the doctor to pay special attention to the complaints of the victim and the most detailed objective examination.

Clinical forms of spine injury in old age

People of elderly and senile age do not meet all the diverse clinical forms of spine trauma, characteristic of people of flowering and middle age. This is explained by the peculiarity of the rhythm of life and behavior of the elderly and old man. Heavy spinal injuries occur in the elderly and senile years, mainly during road and rail accidents.

Consequently, the first circumstance that limits the possibility of the emergence of a variety of clinical forms of spine trauma in the elderly and old people is the conditions in which they are found, their behavior and way of life. The second circumstance, no less important, are those age changes that occur in the elements of the spine of an elderly person and which are described above.

A typical spinal cord injury that occurs in the elderly and senile age is compression wedge-shaped, usually uncomplicated, vertebral body fractures. One of the features of these injuries is a relatively small degree of decrease in the height of the broken body - compression of the vertebrae and inadequacy of the violence causing damage, the nature of the fracture. A peculiarity of these injuries in the elderly is that they often go unnoticed and are detected in the subsequent or in case of random radiographic examination, or in the late after the trauma periods due to pain.

The most common localization of spine injuries in the elderly is the middle, lower thoracic and upper lumbar vertebrae. Especially often damaged are the vertebral bodies located in the transitional chest-lumbar region.

[8],

Diagnosis of spine injury in old age

X-ray examination is especially important in diagnosing vertebral fractures in elderly and old people. However, this method of examination does not always solve the difficulties of diagnosis. Due to pronounced senile osteoporosis, it is difficult to obtain a qualitative picture, especially in elderly obese patients and especially women. Difficulties are aggravated by the presence of age-related changes in the spine. On the profile spondylogram, it is not easy to differentiate the senile wedge-shaped vertebra from the wedge shape that arose due to a fracture of the vertebral body. Only significant compression ratios of the vertebral body allow the assumed diagnosis to be considered reliable. With minor and light degrees of compression, this presents certain difficulties. Therefore, reliable spondylography confirms the diagnosis of a vertebral fracture; negative data with the relevant clinical symptoms do not reject it.

The osteophyte of the most diverse localization is characteristic of the old spine. These osteophytes can sometimes reach considerable sizes.

A careful analysis of spondylograms often allows you to clarify the clinical diagnosis. In some cases, tomography may be useful.

[9], [10], [11]

Treatment of spinal injury in old age

In the treatment of vertebral fractures, elderly and old people usually do not have the task of restoring the anatomical shape of the fractured vertebra and the full function of the spine. The organism of the elderly and especially the old man undergoes well-known involutive processes characterized by inferiority of the cardiovascular and pulmonary systems, disorders of the hormonal function, gastrointestinal function, changes in the excretory system, central and peripheral systems, abnormalities of the psyche and the above changes in the locomotor system apparatus. These changes, a significant decrease in reactivity, inferiority of reparative processes, changes in blood and blood-forming organs, a tendency to thrombus formation and other occlusive processes in the vessels, vitamin deficiency, metabolic processes, a tendency to stagnant processes in the lungs, etc. Make the body of the elderly and old man easily vulnerable. All this makes the doctor first of all to direct his efforts to prevent possible complications and struggle with them in order to save the life of the patient. Understanding should be given to the treatment of senile osteoporosis. This can be achieved to some extent with a high-grade protein diet, the introduction of a large dose of vitamin C into the body and hormone therapy.

A major role in the prevention of complications is played by the early motor activity of the elderly.

For these reasons, all methods and methods of treatment of vertebral fractures associated with the long stay of the injured person in bed in a forced posture, the methods of treatment associated with wearing gypsum corsets are completely unacceptable. They are burdensome for these patients, are poorly tolerated by them and can cause complications.

Methods of treatment of vertebral fracture in elderly and senile people

The treatment of compression wedge fractures of the lumbar and thoracic vertebral bodies in elderly and senile people has the following features. Local anesthesia of the region of the fractured vertebra, as a rule, does not produce. The pain is removed or significantly reduced by the administration of analgesics per os or subcutaneous administration of promedol. If it is necessary to anesthetize a good effect is given by intradermal or paravertebral neocaine blockades. The victim is placed on a bed with a dense mattress. Laying it on a hard board is not always possible due to age-related deformations of the spine. Compliance with this, it would seem, mandatory situation leads to the fact that the victim significantly increased pain. It is not always possible to unload the spine by stretching behind the armpits and, especially, the Glisson loop. Therefore, patients with wedge-shaped compression fractures of the bodies of the lumbar and thoracic vertebrae are prescribed a relatively free regimen. They are allowed to lie down to change position on the back, on the side and turn on the stomach. Only in some cases, unloading is carried out by stretching or gradual light reclamation on a soft hammock, provided that these procedures are well tolerated and do not aggravate the pain. Early appoint massage and therapeutic gymnastics.

The purpose of the early medical gymnastics, we pursue somewhat different goals than the young victims. It is not necessary to count on the creation of a muscular corset in elderly and old people for obvious reasons. The therapeutic gymnastics basically activates these patients, improves breathing and increases their vitality. Such treatment, supplemented by appropriate symptomatic medication, is carried out for 6-8 weeks. After this period, the victim is lifted to his feet in a lightweight skeletonized removable orthopedic corset or in a soft corset such as "graces". For 3-4 weeks he is not allowed to sit. Individually, depending on the conditions and conditions of the victim, he spends the last 3-4 weeks in a hospital or at home.

At home, after discharge from the hospital, treatment should be conducted aimed at combating senile osteoporosis, as prevention of possible repeated fractures of the spine. With pronounced pains it is useful to wear "grace" for a long time, especially to fat old and old women.

Anatomical results with this method of treatment are not always good, but functional ones are quite satisfactory. In severe spinal injuries apply all the methods of treatment described in the previous chapters.