X-ray signs of damage to the ligamentous apparatus of the spine

X-ray signs of damage to the ligamentous apparatus of the spine have been proposed, which make it possible to concentrate specialists' attention on morphological disorders and to compare them with the clinical manifestations of trauma.

• To avoid the consequences of erroneous diagnosis, extended indications for radiography and a high degree of alertness for the possibility of injury are recommended. A series of images of the cervical spine should be prescribed to all patients with localized pain, deformity, crepitus or edema in this area, with mental disorders, neurological disorders, head trauma, multiple trauma or patients with trauma, which can damage the cervical spine.
• In the case of acute injury, it is recommended that the first preliminary photograph be taken in lateroposition (LA) without stretching the head even when there is no sign of damage to the atlanto-occipital or atlanto-axial junction, since even a minimal stretch in this case can lead to neurological disorders.
• On the lateral projection, the radiographs of the cervical vertebral body are arranged in the form of a column, forming four smooth curves represented by the following structures:
  • the anterior surface of vertebral bodies;
  • anterior wall of the spinal canal;
  • posterior wall of spinal canal;
  • the tips of the spinous processes.

The first two curves correspond to the directions of the anterior and posterior longitudinal ligaments. The horizontal displacements of the adjacent vertebrae never exceed 3-5 mm. Increasing the distance by 5 mm or more is a deviation from the norm and involves damage (tearing, tearing) of the ligaments, which leads to instability of the spinal column of the spine. Similarly, the angle between the cervical vertebrae greater than 11 ° indicates a rupture of the ligaments, or at least their extension, which is manifested by a distinct interruption of the smooth lines. The line formed by the tips of the spinous processes is the most irregular of the four, since C ₂ and C ₇ are more prominent than the processes of the other vertebrae.

• The normal arrangement of all four curves emphasizes a smooth lordosis. Straightening and some variation of this bending is not necessarily pathological. Especially in the presence of trauma, when a significant muscle spasm can develop or when the patient is lying down, the disappearance of lordosis at the cervical level is of little importance. However, with hyperextension injuries, this symptom is pathological.
  

On the lateral radiographs, it is necessary to examine the intervals between the spinous processes. Their considerable expansion may indicate the extension (breakage) of interstitial or neoplastic ligaments (usually as a result of hyperflexion trauma).

The spinous processes are represented in the form of a vertical row located along the middle line with approximately equal intervals. The increase in the normal distance between the two processes is approximately 1.5 times considered pathological and may be due to sprainage as a result of hyperflexion trauma or blockage of articular surfaces.

Functional radiographs (flexion-extension) should be performed only in cases where the stability of the affected PDS is undoubted. This study is absolutely contraindicated for the instability of PDS or the presence of neurological disorders. In cases of hypermobility of the PDS, active flexion or extension of the neck should be performed gently in the patient-lying position.

The underdeveloped cervical spine in children or young people usually predisposes to physiological subluxation in the upper part. As a rule, this is due to the weakness of the transverse ligament, as a result of which the degree of mobility of the atlas relative to the axial vertebra increases. At the same time, the distance between the atlas and the tooth increases to 3-5 mm. A pseudo-subluxation between C ₃ and C ₄ is also possible , which was encountered in our observations.

Degenerative diseases of the spine are the most common cause of misinterpretation of traumatic injuries. These diseases limit the mobility of the spine at the level of the affected PDS. Increasing loads lead to stretching of ligaments, which "push" forward adjacent to them a vertebra. Such a subluxation may be misinterpreted as a consequence of hyperextension injury. Therefore, it should be differentiated by the absence of fractures and the presence of a number of other degenerative changes. However, it should be remembered that acute trauma can coexist with degenerative changes. Therefore, the chronically affected cervical spine should be carefully examined for injuries.

An acute rupture of the intervertebral disc on the radiograph will be represented by a narrowing of the intervertebral space, a vacuum disc with air accumulation in it or the disappearance of a normal lordotic curve (in the cervical or lumbar region). The latter is the least reliable confirmation of pathology; although it is proved that, depending on the patient's position, the normal arrangement of the lines can change. With different mechanisms of trauma, especially in cases of acute rupture of the disc, signs of instability and / or hypermobility with ligament damage are revealed on functional radiographs.

X-ray signs of damage to the ligamentous apparatus of the spine matter only if they correlate with the clinic. Nevertheless, important radiographic indices are:

• narrowing anteroposterior diameter of the spinal canal as a result of displacement of vertebral bodies;
• narrowing of intervertebral foramen (in oblique projection);
• violation of apophysial articulations (especially slipping of the upper articular process back);
• signs of hypermobility and / or instability of the affected PDS of the spine.

The latter appears in the case of chronic degeneration due to the spreading weakness of the fixing structures of the spine.

For the detection of "hidden" displaced vertebral bodies, the use of functional loads in the form of flexion or extension during the roentgenography of the spine is of great importance. It is extremely important at the cervical level to identify such rear displacements of the overlying vertebra. When the articular process of the underlying vertebra moves forward - a subluxation occurs. In the lateral image, especially in the position of maximum extension, the anterior processes of the articular process are not visible behind the vertebral bodies, but against the background of the overlying vertebra. The line of anterior margins of the articular processes is not continuous, but graded. Possible and lateral displacement, detected on the anteroposterior radiographs.

Classification of damage to the lumbar spine

Degree of damage	Morphological signs of damage
I (weak stretching of the ligament-muscular apparatus)	The changes in echogenicity of the sonographic image are determined: the presence of hypoechoic zones with a length of 1-3 mm
II (moderate stretching of the ligament-muscular apparatus)	In the ligament-muscle structures, the presence of hypoechoic zones with a length of 4 to 7 mm and the corresponding micro-ruptures of these structures
III (significant stretching of the ligamentous-muscular apparatus)	It is characterized by a complete rupture of the muscular or ligamentous structures. A local bulge is scanned - protrusion of the muscle tissue through a fascial defect or the appearance of muscle defects during the maximum arbitrary contraction corresponding to the rupture. With complete damage to the ligamentous structures, a hypoechoic zone with clear boundaries is visualized
IV (degenerative-dystrophic lesion)	The defeat of the ligamentous apparatus in the form of an inhomogeneous echogenic pattern with inclusions of defects of microfractures, deformations, tissue thinning

The occurrence of instability of the upper part of the spine should be evaluated depending on the specificity of the lesion. For example, atlantoaxial instability can develop only when the transverse ligament ruptures. The diagnosis is made on the basis of an X-ray in the lateral projection. Normally, the distance between the tooth and the upper arch of the atlas is within 3 mm. Its increase to 5 mm suggests a rupture of the transverse ligament, an interval of more than 5 mm definitely indicates damage to the transverse and pterygoid ligaments. Suspicion of trauma at this level is a contraindication to X-rays with flexion-extension of the neck, since these movements are the basis of the mechanism of neurological damage.

According to the results of the ultrasound investigation, a working classification of ultrasound signs of damage to the lumbar spine is developed for practical public health, which allows the most informative detection of lesions or changes in the ligamentous apparatus of the spine already on the 2nd-3rd day after trauma, as well as in the early stages of locomotor system apparatus (large joints, spine).

As for the place of ultrasonography in the diagnostic process, indications for its use and interpretation of the data obtained in the process of restorative treatment, then, based on the analysis of the work done, we formulated the following provisions:

• Indications for ultrasonography of the spine are all radicular compression syndrome in patients with dorsalgia.
• Ultrasonography is shown to all patients with reflex-pain syndromes, which do not achieve a quick positive effect from the use of traditional regimens of restorative therapy.
• In the absence of clinical manifestations during periods of remission, ultrasound examination of the spine can also be performed using the whole range of proposed techniques for predicting the course of the disease, assessing the effectiveness of the current, and also if necessary to confirm the presence of a degenerative process.
• In the process of treatment, ultrasonography is used to monitor the effectiveness of the therapy (LFK).

The choice of the whole complex of ultrasound techniques or individual components is determined depending on the clinical indications (for example, with pronounced radicular pain, it is impractical to conduct functional tests) and the technical equipment of the researcher. When obtaining ultrasound in combination with radiography and additional techniques (functional tests, dopplerography), sufficient diagnostic information coinciding with clinical data, the results obtained are used in the planning of treatment and the choice of this or that technique of exercise therapy.