Subluxations, dislocations and fracture-dislocations of III-VII cervical vertebrae: causes, symptoms, diagnosis, treatment

Subluxations, dislocations and fracture-dislocations of the III - VII cervical vertebrae are the most common injuries of this section of the spine. These injuries occur with a flexion or flexion-rotation mechanism of violence. If in the lumbar and lower thoracic spine with a purely flexion mechanism of violence, compression wedge-shaped fractures of the vertebral bodies most often occur, then, in contrast to this, in the cervical section, due to the anatomical and functional features of this area, subluxations and dislocations most often occur, often accompanied by fractures of various elements of the vertebra or vertebrae.

With purely flexion force, bilateral subluxations or dislocations occur; with flexion-rotation force, unilateral subluxations or dislocations occur.

The occurrence of subluxation or dislocation is regulated by the amount of violence in action, the state of the ligamentous apparatus, the degree of development of the muscles and their tone. With a moderate amount of flexion violence in combination with other factors indicated above, subluxation occurs. With more severe violence, dislocation occurs.

Subluxation or dislocation is understood as a violation of the normal relationships of the articulating articular surfaces in the postero-external synovial joints of the cervical vertebrae, in other words, a violation of the normal relationships between the articular processes of two adjacent vertebrae. It is possible that a subluxation can occur without disruption of the integrity of the ligamentous apparatus. Displacement in it can occur due to weakness of the capsular-ligamentous apparatus or a decrease in muscle tone. A complete dislocation or some types of subluxations are usually accompanied by damage to the ligamentous apparatus.

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Types of subluxations and dislocations of the III-VII cervical vertebrae

Along the III-VII cervical vertebrae, the following are distinguished (Henle): subluxations of varying degrees, superior subluxation, complete dislocation and interlocking dislocation. All of the above injuries can be either unilateral or bilateral.

Subluxation is understood as the displacement of one articular process relative to another without the loss of full contact between the articulating surfaces. Depending on the purely quantitative degree of displacement - the magnitude of the displacement - a distinction is made between subluxation by 1/2, subluxation by 1/3, subluxation by 3/4.

If the displacement of the articular processes occurs along the entire articulating surface and the apex of the lower articular process of the overlying vertebra stands on the apex of the upper articular process of the underlying vertebra, then such a displacement is called a superior subluxation (Gelahrter).

Complete loss of contact between the articular surfaces of the articular processes leads to complete dislocation.

If, as a result of force acting on the vertebra, the inferior articular process of the overlying vertebra is displaced anteriorly from the apex of the superior articular process of the vertebra below, slides downwards and becomes located anterior to this articular process, then a locked dislocation occurs. Locking of the articular processes occurs when excessive flexion force causes the inferior articular process of the overlying vertebra, under the influence of this force, to be displaced anteriorly over the apex of the superior articular process of the vertebra below. Bilateral locking occurs with excessive flexion, unilateral - with simultaneous flexion and rotation.

Bilateral complete dislocations and interlocked dislocations are always accompanied by a rupture of the ligamentous apparatus, capsule of the synovial joints and muscles. Consequently, these injuries are classified as unstable. In bilateral special dislocations, there is always a rupture of the fibrous ring of the intervertebral disc, quite often there is a detachment of the anterior longitudinal ligament from the cranioventral angle of the body of the underlying vertebra, crushing and partial rupture of the bone tissue of the upper-anterior part of the body of the underlying vertebra. Apparently, in these cases we should talk about a bilateral interlocked fracture-dislocation.

Unilateral interlocking dislocations most often occur in the lower cervical region. In unilateral interlocking dislocations, damage to the ligamentous apparatus and intervertebral discs is usually less severe. The difference in anatomical changes in unilateral and bilateral interlocking dislocations was described by Malgaigne in 1955. Beatson (1963) demonstrated with his experimental studies that the joint capsule of the synovial joint on the side of the injury and the interspinous ligaments in a unilateral interlocking dislocation may be torn, while the posterior longitudinal ligament and fibrous ring are slightly damaged. On the side opposite to the interlocking, the joint capsule and ligaments of the synovial joint are usually torn, a fracture of the superior articular process and a compression fracture of the body located below are often observed. In these cases, it is also more correct to speak of a fracture-dislocation.

The concept of sliding and overturning dislocation is extremely important. These concepts are determined by the position of the body of the dislocated vertebra in relation to the body of the underlying vertebra.

If on the lateral spondylogram the caudal endplate of the anteriorly dislocated vertebral body is located parallel to the cranial endplate of the body of the underlying vertebra, or, in other words, the caudal endplate of the body of the dislocated vertebra is located at a right angle or close to it to the ventral surface of the body of the underlying vertebra, or, what is the same, the ventral surface of the dislocated vertebra is parallel to the ventral surface of the body of the underlying vertebra, then such a dislocation is called sliding. If on the lateral spondylogram the caudal endplate of the anteriorly dislocated vertebra is located at an acute angle to the cranial endplate of the underlying vertebra or, correspondingly, the caudal endplate of the anteriorly dislocated vertebra is located at an acute angle to the ventral surface of the underlying vertebra or, in other words, the body of the dislocated vertebra hangs at an acute angle over the body of the underlying vertebra, then such a dislocation is called a tipping dislocation. The difference in understanding sliding and tipping dislocations (subluxations) is not a terminological casuistry, but has great fundamental practical significance. In clinical practice, sliding dislocations often cause more severe neurological disorders than tipping dislocations occurring at the same level. This is explained by the fact that with these two different forms of dislocation, there is a different degree of deformation of the spinal canal at the level of injury. In sliding dislocations, due to the forward shift of the dislocated vertebra strictly in the horizontal plane, a more significant decrease in the value of the anteroposterior diameter of the spinal canal occurs than in overturning dislocations. In these latter forms of dislocation, due to the lowering (pavnaniye) of the anterior section (body) of the dislocated vertebra, its posterior section, i.e. the arches that form the posterolateral sections of the spinal canal, rise upward. In this case, there is no significant decrease in the anteroposterior diameter of the spinal canal and its contents suffer significantly less.

Barnes (1948) proved that flexion injuries (dislocations, fracture-dislocations) with anterior displacement usually do not lead to significant deformation of the spinal canal, and therefore, to severe neurological disorders, provided that a fracture of the articular processes does not occur simultaneously.

With a flexion mechanism of violence, as a rule, the displacement of the dislocated vertebra occurs forward, therefore, as a rule, anterior dislocations occur. With a flexion-rotation mechanism of violence, unilateral or rotational dislocations may occur.

All the above types of displacement may be combined with fractures of various elements of the vertebrae. Most often, the articular processes and bodies of the underlying vertebrae are fractured, much less often - the arches. With a direct mechanism of violence or a combination of indirect and direct mechanisms of violence, a fracture of the spinous process may occur. If there is a displacement in the area of the synovial intervertebral articulation with an accompanying fracture of the vertebra at the same level, then, in our opinion, it is more correct to talk about a fracture-dislocation.

A fracture-dislocation is a more serious injury - it is more difficult to reset the bony vertebrae than with a simple dislocation.

Symptoms of subluxations of the III-VII cervical vertebrae

Clinical manifestations of subluxations in the region of the III-VII cervical vertebrae usually include complaints of pain and limited mobility in the neck. They may intensify with movement. Often the victim notes that he heard a click. Often such subluxations, especially unilateral ones, spontaneously correct themselves. Then the control spondylogram does not reveal any displacements. An objective examination may reveal a forced position of the head, local pain and swelling at the level of injury. Muscle spasm may occur. Radicular and spinal disorders with subluxations are relatively rare. The interspinous space is usually not enlarged.

In case of superior subluxations, clinical manifestations are more pronounced. In addition to the symptoms mentioned above, in case of bilateral superior subluxation, the protrusion of the spinous process of the displaced vertebra, the increase of the interspinous space between the displaced and underlying vertebra, and the axial deformation of the spine are clearly defined. The head takes a forced position - the chin is close to the chest, movements are significantly limited and painful. In case of superior subluxations, symptoms of irritation or compression of the spinal roots are observed much more often both at the level of displacement and below. Spinal symptoms may also be observed.

Symptoms of dislocations of III-VII cervical vertebrae

Complete dislocations of the cervical vertebrae are more severe injuries than subluxations. As mentioned above, dislocations cause more severe damage to the articular and ligamentous apparatus. Usually, dislocations involve a complete divergence of the articular surfaces of the articular processes in the intervertebral joints.

If during a dislocation the posteroinferior articular process of the overlying vertebra moves forward from the superior-anterior articular process of the underlying vertebra, then such a displacement is called coupling, and such dislocations are called interlocked. Interlocked dislocations can be unilateral or bilateral. The overlap of one articular process behind the other can be partial, incomplete. It can be complete when the apex of the posteroinferior articular process of the overlying vertebra reaches the upper surface of the root of the arch of the underlying vertebra and rests against it. Some authors consider only this last, extreme degree of displacement of the articular processes to be coupling, and only such dislocations are called interlocked. Unilateral interlocked dislocations are more common.

The clinical picture of unilateral interlocking dislocations does not have any specific features. Based on clinical data, it is usually difficult to differentiate dislocation from subluxation. In some cases, the position of the head can help. In unilateral interlocking or complete dislocations, unlike subluxation, the head is tilted toward the side of the injury, not the opposite. The chin is turned toward the healthy side. The position of the head resembles true torticollis. Neck pain is common, but it can be quite moderate. Tension of the neck muscles may be observed. In bilateral dislocations, flexion is more pronounced, and extension of the neck is limited.

In recent cases, localized pain and swelling in the area of displacement may be detected. Radicular symptoms are very common. Symptoms indicating spinal cord compression may also occur. Symptoms of spinal cord compression occur when, as a result of vertebral displacement, the spinal canal is deformed and its sagittal diameter is narrowed. Spinal cord compression may also occur as a result of a decrease in the anterior-posterior diameter of the spinal canal due to the masses of a torn intervertebral disc or effusion of blood that have displaced into the canal. In bilateral interlocking dislocations, the decrease in the anterior-posterior diameter of the spinal canal is more pronounced than in unilateral ones. Therefore, spinal disorders in bilateral interlocking dislocations may be expressed more intensely and be more persistent and severe, especially in cases where the spinal cord reserve spaces are insufficiently expressed. In unilateral interlocking dislocations, spinal disorders are asymmetrical and more pronounced on the interlocking side. Radicular phenomena occur due to deformation of the intervertebral openings. They often occur in both unilateral and bilateral dislocations.

It should be remembered that in the case of unilateral interlocking dislocations, the clinical symptoms may be so weakly expressed that the patient does not focus the doctor's attention on them and they should be actively identified.

X-ray diagnostics of cervical vertebrae dislocations is of great and often decisive importance. Usually, spondylography in the posterior and lateral projections allows establishing the correct diagnosis. In some cases, it is useful to resort to spondylography in the oblique projection in 3/4. The produced spondylograms allow not only to confirm the suspected diagnosis, but also to clarify the degree of adhesion of the articular processes, the presence or absence of concomitant fractures and to clarify a number of other details of the existing injury.

In case of a unilateral interlocking dislocation, the spinous process of the dislocated vertebra is usually displaced toward the interlocking side on the posterior spondylogram. The body of the dislocated vertebra may be in a position of lateral flexion and slight rotation relative to the body of the underlying vertebra. The lateral spondylogram reveals a displacement in the area of one synovial joint, which consists in the fact that the posteroinferior articular process of the dislocated vertebra is not located posteriorly from the anterior-superior articular process of the underlying vertebra, as is usually the case in the norm, but is displaced anteriorly from it and its posterior surface contacts the anterior articular surface of this articular process.

In case of bilateral interlocking dislocation, on the posterior spondylogram it can be noted that the intervertebral X-ray gap formed by the intervertebral disc is narrowed or completely blocked by the displaced anterior-inferior edge of the dislocated vertebra. On the lateral spondylogram the described changes in the synovial joints are observed on both sides.

Treatment of subluxations of III-VII cervical vertebrae

Treatment of fresh subluxations of the III-VII cervical vertebrae usually does not present any difficulties. In the case of a small degree of subluxation, reduction is achieved easily and relatively simply either by manual reduction by giving the cervical spine an extension position, or by traction using a Glisson loop with traction directed backwards. To do this, the victim is placed on his back, a flat oilcloth pillow 10-12 cm high is placed under the area of the shoulder blades. The cable from the Glisson loop is thrown over a block secured at the head end of the bed so that it forms an angle open downwards.

In case of unilateral subluxations, the existing rotation of the displaced vertebra should be taken into account and, in the process of reduction, derotation should be added to extension.

Derotation in the reduction of unilateral subluxations and dislocations was proposed by Kocher in 1882. It is achieved by shortening the strap of the Glisson loop on the side of the subluxation or dislocation compared to the strap of the opposite, healthy side.

In cases of uncomplicated subluxations and mild pain syndrome, patients easily tolerate reduction without anesthesia.

Reduction of superior subluxations is performed in a similar manner. When reducing this type of subluxation, one should be especially careful and pedantic, so as not to transform the superior subluxation into a complete dislocation during the reduction process.

The immobilization period depends on the type of subluxation and is 1-3 months. Immobilization is performed with a plaster Shantz collar, in some cases - a craniothoracic bandage. Subsequently, a removable orthopedic corset is prescribed for 1-2 months, massage, physiotherapy, and exercise therapy. Working capacity is restored depending on the victim's profession. Given the possible subsequent complications from the intervertebral discs, these injuries should not be considered insignificant and light.

In case of spontaneously reduced subluxations, anesthesia should be administered in the area of pain points and swelling (10-30 ml of 0.25% novocaine solution) and a cotton-gauze Shantz collar should be applied for 7-10 days. In the presence of severe pain and muscle spasm, traction with a Glisson loop with small weights (2-4 kg) for 7-10 days is advisable.

Treatment of complete dislocations of the cervical vertebrae

Treatment of these dislocations is a more difficult and complex task compared to treatment of subluxations. A trauma surgeon who begins treatment of these victims must have a good knowledge of the normal and X-ray anatomy of the cervical spine, be able to freely understand and navigate the changes that were reflected on spondylograms as a result of dislocation. He must clearly imagine the abnormal relationships that have arisen between individual elements of the vertebrae, have a good understanding of the mechanism of displacement, as well as the volumetric relationships between the spine, the spinal cord and its roots, and the vertebral artery. This will allow him to consciously and confidently perform the necessary manipulations to eliminate the existing displacement.

Treatment of cervical vertebrae dislocations consists of reduction and subsequent immobilization. The reduction process not only normalizes the displaced vertebrae, but also eliminates radicular and spinal cord compression. In certain situations, decompression of the roots and spinal cord becomes a priority, but under no circumstances should it push orthopedic aspects of dislocation treatment into the background.

The greatest difficulty is the reduction of a linked dislocation. In these cases, the reduction of the dislocated vertebra can be achieved only if the anteriorly dislocated posteroinferior articular process of the overlying vertebra (the dislocated vertebra) can be displaced over the apex of the anterior-superior articular process of the underlying vertebra to the rear and displaced downwards.

Reduction of a dislocated cervical vertebra can be achieved in three ways: immediate reduction, continuous traction, and surgery.

Manual one-stage reduction of cervical vertebrae dislocations was performed by Hippocrates. Referring to cervical vertebrae dislocations as a type of traumatic kyphosis, Hippocrates tried to treat them by eliminating the existing kyphosis. For this purpose, the assistant pulled the head, and the doctor, applying pressure to the apex of the kyphosis with the foot, tried to eliminate the existing deformation. During this "therapeutic" manipulation, the patient was in a prone position. According to Albert, in the Middle Ages, traction during reduction of cervical vertebrae dislocations was performed by one-stage traction on the hair and ears of the victim. In later times, to reduce neck dislocations, traction was performed behind the head of a patient sitting on a chair. Hoffa considered this method of reduction "a frivolous method and a dangerous game with the patient's life."

In the 1930s, manual one-stage reduction became quite widespread. In particular, it was widely used by Brookes (1933). Somewhat later, this reduction method lost its popularity due to reports of severe neurological disorders occurring with it. But this method was periodically returned to. Thus, in 1959, Burkel de la Sacher noted that, in his opinion, manual one-stage reduction was the method of choice in the treatment of cervical vertebrae dislocations, and Evans (1961) recommended it again. In 1966, V. P. Selivanov reported the successful use of manual reduction in the treatment of closed cervical vertebrae dislocations.

There are several methods of manual reduction of dislocated cervical vertebrae. The most noteworthy is the Huther method, proposed by him more than 100 years ago.

Guter's method is based on three main points:

• traction behind the head along the long axis of the spine;
• lateral flexion to the side opposite to the one on which the dislocation occurs, creating a support point at the level of displacement;
• rotation of the head and neck towards the dislocation.

Thus, reduction is performed in cases of unilateral subluxations and dislocations.

In case of bilateral subluxations and dislocations, such manipulation is repeated alternately - one of the sides is initially conventionally taken as "healthy". Since the reduction of displacement is based on the principle of a lever, the method is also called "lever".

Manual one-stage reduction according to Güther is used for rotational subluxations of the atlas, unilateral and bilateral subluxations and dislocations of the C3-C4 vertebrae.

The victim is positioned on his back. The head and neck are extended beyond the edge of the table on which the reduction is performed and are supported by the assistant's hands. The height of the table on which the reduction is performed should be 80-85 cm. In cases of mild pain and in children, anesthesia is not administered. In cases of severe pain in adults, local anesthesia is administered by injecting 5-10 ml of 0.25-0.5% novocaine solution paravertebrally from behind at the level of displacement into the paravertebral tissues. The use of anesthesia poses a known risk due to the loss of control by the patient. Braakman and Vinken recommend using anesthesia with relaxation for dynamic reduction of cervical vertebrae displacements."

The first stage of reduction. The victim lies on the table in a supine position. His body is fixed to the table with belts or flannel straps. The table is positioned so that the patient lying on it can be accessed from all sides. The surgeon performing the reduction stands at the head end of the table facing the victim, the assistant stands to the side, on the "healthy" side. A Glisson loop is secured to the victim's head. Its extended straps are secured at the back of the lower back of the surgeon performing the reduction. The surgeon grasps the lateral surfaces of the victim's head with his palms. By tilting his body backwards, the surgeon tightens the straps of the Glisson loop, thereby traction of the victim's head and neck along the long axis of the spine. The amount of traction is gradually increased over 3-5 minutes.

The second stage of reduction. The assistant grasps the lateral surface of the victim's neck on the healthy side so that the upper edge of the palm corresponds to the level of damage. The upper edge of the assistant's palm is the point through which the lever action is performed. Without stopping traction along the long axis of the spine, the surgeon performs a lateral tilt of the patient's head and the section of the neck located above the upper edge of the assistant's palm, towards the healthy side. The upper edge of the assistant's palm is the support point through which the lateral tilt of the section of the neck located above the damage is performed.

The third stage of reduction. Without stopping the traction along the long axis of the spine and without eliminating the tilt of the head and neck to the healthy side, the surgeon, with his hands, located on the lateral surfaces of the victim's head, turns the head and the section of the neck located above the site of injury to the side of the dislocation.

The victim's head is returned to its normal position. A control spondylography is performed. If the control spondylograms confirm the elimination of the existing displacement, then the reduction is completed. If there is no reduction, all manipulations in the above sequence are repeated.

In case of bilateral dislocations, reduction is performed sequentially - first on one side, then on the other.

After the achieved reduction, immobilization is performed with a craniothoracic plaster cast. In case of rotational subluxations of the atlas, immobilization is limited to a plaster or soft Shantz collar. The immobilization period varies, depending on the nature of the injury, its location and the age of the victim, within 1.5-4 months.

During the three stages of reduction, the posteroinferior articular process of the dislocated vertebra undergoes the following evolution. During the first stage of reduction - stretching the spine along the long axis - a diastasis is created between the tops of the displaced articular processes. During the second stage of reduction - lateral tilt to the healthy side - the diastasis created by stretching increases somewhat and, most importantly, the posteroinferior articular process of the dislocated vertebra is brought to the side lateral to the anterior-superior articular process of the underlying vertebra. During the third stage of reduction - rotation towards the dislocation - the posteroinferior articular process of the dislocated vertebra, having described a semicircle, takes its place behind the anterior-superior articular process of the underlying vertebra.

Traction as a method of reduction of cervical vertebrae dislocations is the most widespread. Practical experience allows us to state that this method is often used without a clear idea of the nature of the injury, the type and degree of vertebral displacement, new abnormal relationships between the displaced vertebrae that have developed as a result of the injury. This probably explains the significant number of unsatisfactory treatment outcomes reported in the literature. At the same time, with the correct use of this method of reduction for certain types of cervical vertebrae displacement, it is possible to achieve quite satisfactory results. Traction can be carried out both by the Glisson loop and by skeletal traction by the bones of the cranial vault. Traction using the Glisson loop is extremely inconvenient for the patient, it is poorly tolerated by the patient and, most importantly, does not create sufficient, necessary stretching of the spine, since it does not allow for the long-term use of loads of the required size. Despite all of the above, traction with the Glisson loop is most often used in the practice of medical institutions. The significantly more effective skeletal traction of the cranial vault bones is used much less frequently in the practice of traumatological institutions of the medical network either due to the lack of necessary equipment, or due to the inability to apply it in practice, or due to unjustified fear of using this method.

Reduction by traction can be accomplished over several days (constant traction) using relatively small loads, or over several hours (forced traction) using larger loads (Bohler, 1953). Braakman and Vinken (1967) reported that using loads less than 10 kg in skeletal traction on the cranial vault, they were never able to achieve reduction in unilateral interlocking dislocations of the cervical vertebrae, while continuous skeletal traction over several days using loads greater than 10 kg achieved reduction in 2 of 5 victims. In 1957, Rogers reported that in his 5 cases of unilateral interlocking dislocations, continuous skeletal traction was ineffective. When using skeletal traction with 10 kg weights to treat uni- and bilateral interlocking dislocations in 15 patients, Ramadier and Bombart (1964) achieved reduction in only 8 of 15 patients. According to L. G. Shkolnikov, V. P. Selivanov and M. N. Nikitin (1967), none of the 10 victims with uni- and bilateral complete dislocations of the cervical vertebrae were able to achieve reduction using Glisson's loop traction, and out of 113 victims with subluxations, a positive result was achieved in 85 people. A. V. Kaplan (1956, 1967) emphasizes the difficulties and ineffectiveness of reducing cervical vertebral dislocations using Glisson's loop or skeletal traction.

Continuous traction with a Glisson loop can be used to reduce recent subluxations of the cervical vertebrae. It is effective if it is possible to achieve rapid reduction. If the traction continues for a longer period of time, patients, as a rule, cannot tolerate it and stop it voluntarily. The Glisson loop does not allow the use of loads of the required size due to compression of the soft tissues of the neck and compression of the vessels. It does not allow the patient to eat, talk, etc. Glisson loop traction is probably more suitable for immobilization rather than reduction. Skeletal traction by the cranial vault bones is more effective.

The method of applying skeletal traction to the cranial vault bones and its technique are described above. In case of bilateral anterior dislocations, traction is performed with large loads up to 20 kg. Since anterior dislocations are usually flexion dislocations, traction is performed at an angle open to the back. To do this, a dense pillow 10-12 cm high is placed under the victim's shoulder blades, the head is thrown back a little, the block, over which the cable with the load is thrown, is fixed at the head end of the bed a little below the frontal plane drawn through the victim's torso. In case of unilateral dislocations, derotation is performed by shortening the strap of the Glisson loop on the side of the displacement. After the control spondylogram confirms the achievement of some diastasis between the displaced articular processes, achieved during traction, the plane and direction of traction are slightly changed and transferred to a more horizontal one, and the size of the load is slightly reduced. After control spondylograms have proven the presence of reduction, a craniothoracic bandage or a Schantz collar type bandage is applied.

Formed traction is not fundamentally different from continuous traction. It is performed in shorter periods of time using more massive loads. Over a short period of time, the load is increased. Under the control of spondylography, the stages of reduction described for continuous traction are carried out sequentially. Control spondylograms allow monitoring the position of the displaced vertebrae during each individual moment of reduction and making adjustments during the reduction by increasing or decreasing the load and changing the position of the traction.

Immobilization after closed reduction of complete dislocations of III-VII cervical vertebrae is carried out for 3-4 months with a craniothoracic plaster cast. Subsequent treatment consists of physiotherapy, massage, and careful therapeutic exercises under the supervision of an experienced specialist.

Surgical reduction of dislocations and fracture-dislocations of the III - VII cervical vertebrae

This method, as a rule, does not have to be resorted to in case of fresh subluxations of vertebrae. Complete dislocations, especially interlocking ones, as well as fracture-dislocations are often a reason for open reduction.

The question of the legitimacy of using open or closed reduction in complicated injuries of the cervical spine is especially controversial. One extreme opinion is that any type of injury with displacement of the cervical vertebrae is subject to closed reduction, the other - that all complicated injuries of the cervical vertebrae should be accompanied by a wide opening of the spinal canal and its revision. Both methods have their advantages and disadvantages. Wide opening of the spinal canal is not always indifferent to the subsequent fate of the patient, and closed reduction in complicated injuries sometimes carries a serious risk to the health and life of the victim. Apparently, the art of a trauma surgeon lies in finding the right method of treatment for each victim, and for this he must master both open and closed methods of reduction.

There is no doubt that the open surgical method of reduction in certain situations is more gentle and less dangerous for the victim.

The operative method of reduction goes beyond the reduction of displaced vertebrae, since it is possible and necessary to perform reliable internal immobilization of the damaged section of the spine, which is extremely important and is a serious advantage in the treatment of unstable injuries. In addition, the operative method, with appropriate indications and the need, allows for revision of the spinal canal and the necessary manipulations on its contents in complicated injuries. These two circumstances - the ability to perform reliable internal immobilization and revision of the contents of the spinal canal - are an undeniable advantage of the operative method of treatment. Consequently, the possibilities of operative treatment of dislocations and fracture-dislocations of the III - VII cervical vertebrae go beyond the simple reduction of displaced vertebrae, and with appropriate indications allow for simultaneous revision of the spinal canal and its contents, reduction and internal fixation.

Attempts to use surgical treatment for cervical vertebrae injuries were made by individual doctors already at the beginning of the 20th century. In 1916, Mixter and Osgood tied the arches of the first and second cervical vertebrae with a silk ligature. However, this method has been used more widely in the last 15-20 years.

We draw the reader's attention to the technique of operative reduction and internal fixation of the damaged segment of the cervical spine. Internal fixation can be performed using a wire suture, posterior spondylodesis, and a combined use of a wire suture and posterior spondylodesis.

Indications: all types of injuries accompanied by pronounced instability, one of the signs of which is very easy reduction of displaced vertebrae; failure of closed reduction in case of uncomplicated injuries or injuries with mild radicular and spinal symptoms; injury of two or more elements of the same vertebra (dislocation in combination with fracture of the arch, etc.); multiple injuries of the vertebrae; complicated injuries; injuries with progressive neurological disorders and symptoms.

Preoperative preparation, the position of the victim on the operating table, and pain relief are similar to what was said about occipitospondylodesis.

The intervention is also performed with preliminary skeletal traction applied to the bones of the cranial vault.

Technique of operative reduction and posterior fixation

The skin, subcutaneous tissue, and superficial fascia are dissected layer by layer by a linear incision along the spinous processes strictly along the midline. The level and length of the incision depend on the location of the injury. Careful hemostasis is performed. The nuchal ligament, which goes to the tops of the spinous processes, is exposed in the wound. The nuchal ligament is dissected strictly along the midline. Using a raspatory and scissors, the tops of the spinous processes are carefully isolated, the lateral surfaces of the spinous processes and the arches are skeletonized. This manipulation should be carried out with utmost caution, especially in places where the ligaments are torn or there is a fracture of the arches. It should be remembered that in case of fracture-dislocations and dislocations, there may be a significant increase in the interanterior space, sometimes reaching 3 cm. In these cases, the dura mater, partially covered by torn yellow ligaments, is exposed under the muscles, which is easily damaged during the skeletonization of the posterior elements of the vertebrae. It should be remembered that the cervical vertebrae are very delicate and tender structures that cannot withstand significant force. Particular care and caution should be taken when manipulating the injury site. Careful hemostasis is performed by tamponade of the wound with gauze compresses soaked in hot physiological solution of table salt. After separating the muscles and moving them apart, the entire area of injury becomes clearly visible. Usually, the overlying spinous process is displaced upward and forward. In unilateral dislocations, the spinous process is also deviated to the side, and the interspinal fissure may have a wedge-shaped form. The yellow and interspinous ligaments are torn. In the interspinal defect, a gray-blue hard callus membrane is visible under the torn yellow ligaments, easily determined by the presence of pulsation. It may be covered with blood-soaked epidural tissue and, as a result, is colored dark cherry. But it may turn out that the pulsation is weak or absent. In this case, the dura mater, surrounded by blood clots and blood-immobilized epidural tissue, may not be recognized. In the case of a bilateral fracture of the arch, accompanying the dislocation, the arch together with the spinous process may be in place or even slightly displaced posteriorly.

Depending on the nature of the damage detected during the intervention, clinical data and the presence of appropriate indications, one or another intervention is performed on the contents of the spinal canal. In indicated cases, a laminectomy is performed first.

The length of the laminectomy should not be increased without sufficient grounds. Removal of extradural hematoma and blood clots is also possible through the intervertebral space between the displaced vertebrae.

Under visual control, the displaced vertebrae are repositioned. This is accomplished by stretching the spine along its long axis, followed by tilting it toward the healthy side, extending it, and rotating it toward the dislocation. The traction is performed by an assistant using the skeletal traction clamp. At the same time, the surgeon performs the repositioning using instruments in the wound. Particular difficulties with repositioning arise with interlocked dislocations, when the articular processes are in such intimate contact with each other that a false impression may be created about the absence of damage and disruption of normal anatomical relationships. Repositioning requires from the surgeon, first of all, a clear orientation in the anatomical changes that have occurred, patience, sufficient persistence, and, of course, caution. To eliminate the adhesion of the articular processes, one can resort to leverage using a thin chisel.

A. V. Kaplan is absolutely right to emphasize the difficulties of closed reduction of such a dislocation, since even open reduction is often associated with significant difficulties.

Sometimes, especially in the case of old interlocking dislocations, it is not possible to reduce the articular processes and it is necessary to resort to their resection. Resection of articular processes in case of irreducible interlocking dislocations was first performed by V. L. Pokatilo in 1905. After the achieved reduction of the displaced vertebrae, it is necessary to fix the damaged section of the spine. Fixation can be performed with a wire suture or a wire suture in combination with bone grafting of the posterior sections of the spine.

Posterior spondylodesis in its classical sense (using only bone grafts), in our opinion, is inappropriate for unstable injuries. We believe it is inappropriate because its stabilizing effect begins to exert its effect only after the onset of the posterior bone block, i.e. 4-6-8 months after the operation. In the most critical first months and weeks after the injury, when the fusion of the posterior sections of the spine has not yet occurred, classical posterior spondylodesis does not exert a stabilizing effect on the spine. Therefore, we believe that primary early "rigid" stabilization using a wire suture or a wire suture in combination with bone grafting of the posterior sections of the spine is absolutely necessary. The wire suture is performed in various versions. The most reliable is the figure-of-eight wire suture, which captures the spinous processes of the fractured and two adjacent vertebrae.

To apply such a wire suture, a channel with a diameter of 0.5-1 mm is drilled in the frontal plane at the base of the spinous process of the dislocated vertebra, the vertebrae above and below it, using a thin awl or electric drill. A stainless steel wire in the form of a figure eight is passed through the made channels. The suture can also be applied behind the arches. In posterior combined spondylodesis, along with applying a wire suture, osteoplastic fixation of the damaged section of the spine is also performed. To do this, compact bone is removed from the bases of the spinous processes and adjacent sections of the semi-arches until the spongy bleeding bone is exposed. This prepares the bed for placing bone grafts. A compact-spongy bone graft taken from the crest of the iliac wing is placed in the formed parent bed.

The transplant should be placed so that it covers the arch of the displaced vertebra and 1-2 vertebrae above and below. The best material for bone grafting is autograft bone. If for some reason taking an autograft is undesirable, one can use homobone preserved at low temperatures. In no case can one agree with the opinion of E. G. Lubensky that the best material for these purposes is lyophilized bone.

After fixing the bone graft or grafts on both sides of the spinous processes, a wire suture is applied and careful hemostasis is performed. Then layered sutures are applied to the wound, antibiotics are administered. An aseptic bandage is applied.

Spondylodesis of the laminectomy segment of the spine has some peculiarities. In case of removal of 1-2 arches, provided that the articular processes are preserved, its technique is no different from that described above. In case of a more extensive laminectomy, posterior spondylodesis appears to be technically difficult and often proves to be ineffective, since the lack of contact of the grafts with the bone tissue often leads to their resorption. The bed for placing the grafts is formed at the roots of the arches in the area of the articular processes, where the grafts are placed. In these cases, it is necessary to closely contact the base of the transverse processes. It is necessary to remember the proximity of the vertebral arteries and not to damage them.

If the failure of the posterior spondylodesis is subsequently detected and the spine does not stabilize, then anterior spondylodesis is performed in the second stage. During the operation, blood loss is compensated promptly and fully.

In the days immediately following the operation, the patient's care is not much different from the postoperative care described for occipitospondylodesis.

In case of intervention for dislocation, cranial traction can be stopped on the 3rd-4th day after the operation. After intervention for fracture-dislocation and dislocation without significant damage to the vertebral body and if there is confidence in the reliability of the fixation performed, it is possible not to apply a plaster cast. In doubtful cases, the most reliable additional method of external fixation is a craniothoracic plaster cast for a period of 1.5-4 months.

The time of discharge of the victim for outpatient treatment depends on the presence of concomitant injuries to the spinal cord and brain. In the absence of these injuries, the victim can be discharged for outpatient treatment by the 12th-14th day.

Skeletal traction of the cranial vault bones quite easily corrects the existing displacement, but it is not possible to maintain it in the desired position. Therefore, it was decided to perform a posterior combined spondylodesis, which was performed on the 8th day.