Symptoms of spinal ligament injuries

Symptoms of damage to the interspinous and supraspinous ligaments depend on the duration of the injury and associated spinal injuries.

At the same time, clinical diagnostics of these injuries is quite complicated: the injury is often not always detected by palpation, since the displacements in the vertebral area are insignificant, and X-rays are not always helpful in making a diagnosis. This is especially true for the fairly common sprains in the upper segment of the cervical spine. In the next order, the articular joints of the middle and lower sections of the cervical spine are subject to damage. Depending on the location of the damage, they are defined as post-traumatic suboccipital syndrome, middle and lower cervical syndrome. The clinical picture is characterized by the appearance of typical neurological pain in the occipital region with scant objective signs. The cause of occipital neuralgia (Kuhlendahl) is compression of the occipital nerves, which, being formed from the posterior roots of two cervical segments, "pierce the yellow ligament" between the arch of the atlas and the epistropheus, near the intervertebral joints. Spondylograms do not reveal any changes.

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Pain

Damage to the interspinous and supraspinous ligaments in the late stages after injury is characterized by persistent pain in the area of damage, such as cervicalgia and lumbago. Patients report rapid fatigue of the neck and back muscles. Later, radicular pain may also appear, which often depends on secondary degenerative changes in the intervertebral disc at the level of damage with the formation of posterior and posterolateral disc herniations.

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Forced situation

It is known that the lateral joints of the cervical vertebrae are located in an oblique plane, passing from back to front and from bottom to top. The deviation from the horizontal plane increases from top to bottom: it is less pronounced in the joints between the vertebrae C1 _- C2 _, more between C7 _- Th1 _. Therefore, the forward displacement of the vertebra (with hypermobility or instability) is accompanied by its lifting until the lower articular process of the vertebral body slips into the upper vertebral notch of the underlying vertebra, when the displaced vertebra again approaches the underlying one.

With various types of displacements, the head takes a characteristic position, which is considered typical. The maximum height of the displacement of the lower articular process with hypermobility (instability) - I-III st. does not exceed 0.7 cm. If there is a forced tilt of the head forward, then already upon examination, kyphosis is clearly visible, the apex of which is formed by the spinous process of the affected vertebra.

The listed so-called typical head positions are not always clearly expressed in cases of sprained ligaments in chronic cases, as they are masked by compensatory displacements in adjacent undamaged joints.

For diagnostics in unclear cases of "head tilt" it is recommended to be guided by the height of the angles of the lower jaw with the neck straightened ("unbent head"). On the convex side of the curvature, the angle of the lower jaw occupies a higher position on the side of the injury, especially if the patient makes several nodding movements beforehand.

The forced position of the head is best detected when examining the patient in the initial position - standing, which is not always possible and acceptable, especially in recent cases. Therefore, many authors emphasize the unreliability of diagnostics based on the symptoms of a typical head position. However, detection of a forced position of the head serves as a sufficient basis for an in-depth clinical and radiological examination, without which the assumption of damage to the ligamentous apparatus of the cervical spine cannot be rejected.

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Head instability

Head instability is a consequence of disorders of the spinal support due to a violation of the relationship between the vertebrae, damage to the ligamentous apparatus, displacement of the load axis and the direction of muscle pull.

The degree of instability may vary, depending on both the severity of the injury and the development of compensatory phenomena.

In severe ligamentous apparatus injuries (grade III), head instability is detected immediately after the injury and persists for a long time (weeks, months). In milder cases (grades I-II of injury), this symptom is expressed to a lesser degree and disappears more quickly due to scarring of damaged tissues and compensatory devices in the ligamentous-muscular apparatus of the neck. In some patients, head instability persists constantly in a vertical position, or it occurs when changing body position, with a more or less prolonged load (for example, when walking, sitting for a long time, especially with the head tilted forward).

A classification of degrees of "head instability" is proposed, based on clinical studies.

Classification of degrees of head instability (Epifanov V.A., Epifanov A.V., 2002)

Degree of instability	Clinical picture	Affected spinal cord PDS
Light (I)	Tension in the neck muscles that hold the head in a forced position. When moving the body and limbs, the position of the head remains unchanged (due to the tension of the neck muscles). The patient makes movements slowly and carefully. If compensation is observed, it is not stable and is easily disrupted during work, especially when it involves tilting the head forward.	One segment
Average (II)	Tension in the neck muscles that hold the head up. The patient supports the head with his hands when the body is in a vertical position, when trying to stand up or lie down, when bending the body forward (Thomsen's symptom). The patient can stand up and lie down without supporting his head with his hands, but only sideways to the horizontal plane (maintaining lateral stability)	1-2 segments
Heavy (III)	Tension of the muscles of the neck, shoulder girdle and paravertebral muscles. The patient constantly supports his head with his hands. The patient's head is not supported and falls when lifting a "lying" patient (the "guillotining" symptom)	Two or more segments

Movement disorders in the cervical spine

Movement disorders	Cervical spine injuries
	Acute trauma	Old trauma
Complete immobility	6(13%)	3 (2.9%)
Restriction of movement in all directions	8(17.5%)	55(52.3%)
Limitation of movement in the direction of damage	32 (69.5%)	47 (44.8%)

Head instability is a frequent and important symptom of damage to the ligamentous apparatus of the cervical spine, but it can also be observed in fractures of the vertebral bodies, damage to the intervertebral discs, osteochondrosis of the spine, paresis and atrophy of the neck muscles, and some developmental anomalies. Therefore, this syndrome cannot serve as an independent test in the differential diagnosis of traumatic injuries to the ligaments of the spine.

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Cervical spine movement disorder

Displacement in the lateral joints of the cervical spine at any localization is accompanied by movement disorders. These disorders are expressed more clearly, the less time has passed since the injury. Later, with the development of compensatory processes, the instability of the head decreases, the range of motion increases.

There are three possible types of movement disorders.

When studying movements, it should be borne in mind that:

• Movement impairment in the same patient is more pronounced in the vertical position than in the horizontal position.
• In the initial lying position, the limitation of tilt and rotation of the head is more accurately determined in cases where the patient's head is located along the axis of the body, since when extending the cervical spine, these movements can be limited even without damage.
• Along with the movement disorder due to damage to the ligamentous apparatus, tension in the neck muscles and crepitus during movement are observed.
• Along with the movement disorder in case of damage to the ligaments of the cervical spine, patients experience tension in the neck muscles, crunching or crepitation during movements. Muscle tension in this case may be a consequence of their reflex tension or tension when the distance of the attachment points increases.
• A crunch, clicking or crepitation during movements in the cervical spine, experienced by the patient or determined by palpation of the affected area, may be a manifestation of degenerative-dystrophic changes in the lateral joints, intervertebral discs and ligaments of the spine, not accompanied by other clinical symptoms.

Impaired movement in the cervical spine is a common symptom of damage or compensation disorders in some diseases of the spine and cannot serve as a reliable basis for differential diagnosis between damage to the ligamentous apparatus and other injuries and diseases. However, a study of movements in the cervical spine can confirm the assumption of damage to the spine, and the restoration of movement after treatment with exercise therapy is the most valuable clinical sign of recovery.

Symptoms of ligament damage revealed by palpation

• Deviation of the spinous processes to one side or another, as a result of which their arrangement in one sagittal plane is disrupted. However, detection of such a displacement is possible only in individual cases, and this depends on the unequal length of the spinous processes, the unequal form of bifurcation of their ends, the masking effect of the supraspinous ligament in the event of its detachment from the spinous processes, the large thickness of the muscles and their tension. Curvature of the line of the spinous processes is more easily detected only in the _regionof C _6-7 and C _2-3.
• When palpating the area of damage to the spinal ligament, pain is detected, and in the first hours or even days it can be detected far beyond the affected area. This depends on the more significant extent of the ligament damage, on the displacement of damaged tissues that occurs when palpating mobile formations (supraspinous ligament, muscles) and far from the site of damage.
• With anterior displacement of the vertebral bodies (hypermobility, instability), accompanied by their forward tilt, a rupture of the posterior ligaments occurs and the distance between the spinous processes of the affected and underlying vertebrae increases.

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