Injuries of the cervical spine: causes, symptoms, diagnosis, treatment

Injuries to the cervical spine account for approximately 19% of all spine injuries. But compared with injuries of the thoracic vertebrae, they are found in a ratio of 1: 2, and lumbar - 1: 4. Disability and mortality with injuries to the cervical spine are still high. The mortality rate for these injuries is 44.3-35.5%.

The most common are injuries to V and VI cervical vertebrae. This level accounts for 27-28% of all injuries to the cervical vertebrae.

Among spinal injuries, dislocations, fracture-dislocations and fractures of the cervical spine take a special place. This is because the damage to the cervical spine is often combined with damage to the proximal part of the spinal cord, directly passing into the stem part of the brain.

Often, those who suffered this category, who safely spent an acute period of trauma, subsequently there are secondary displacements or an increase in the primary, previously not eliminated deformation. Observations show that many of the victims even with timely adjustment of a dislocation or fracture-dislocation, timely and correct treatment of a penetrating fracture in the subsequent quite often there are complications, which are explained by the interest of intervertebral discs and posterior-external intervertebral synovial joints. Even simple head injuries without visible damage to the cervical spine very often entail the occurrence of severe degenerative changes in cervical intervertebral discs.

[1], [2], [3], [4]

Causes of injuries to the cervical spine

Most often, injuries to the cervical spine arise from the effects of indirect violence.

The main mechanisms of violence that cause damage to the front of the spine are extensor, flexion, flexion-rotational and compression.

The significance and role of extensor violence in the origin of trauma in the cervical spine has been underestimated until recently.

Flexion and flexion-rotational mechanisms of violence entail the emergence of dislocations, subluxations, fracture dislocations and fracture. Compression type of violence causes the emergence of fragmented comminuted compression fractures of vertebral bodies with damage to adjacent intervertebral discs.

Dislocations and fractures of the dislocation, as it was, are accompanied by rupture of the ligamentous apparatus and are among the unstable ones.

Fragmented comminuted compression fractures, although they are classified as stable lesions, often cause paresis and paralysis of the posterior fragment of the injured vertebral body, which has shifted towards the vertebral canal.

It is known that with injuries of the cervical spine, sometimes one awkward turn of the neck and head is enough to cause a sudden death. These features of the trauma of the cervical spine cause as soon as possible to remove the existing displacements and reliably immobilize the damaged segment of the spine. Apparently, these considerations are guided by those who are in favor of early internal operative fixation of the damaged cervical vertebrae.

The provision of assistance to victims with injuries to the cervical spine requires some special conditions. It is highly desirable that this assistance is urgent. It is necessary that it turns out to be a team of specialists, consisting of a surgeon-traumatologist, who owns the technique of surgical interventions on the spine and its contents, an anesthesiologist, neuropathologist and neurosurgeon.

If surgical intervention is necessary for injuries to the cervical spine, endotracheal anesthesia should be considered the best method of anesthesia. Fear of spinal cord injury during intubation is exaggerated and unreasonable. With careful and reliable fixation of the head, intubation is easily feasible and safe for the injured.

Turning off the consciousness of the victim, relaxation of the muscles and freedom of manipulation for the surgeon can fully implement the necessary intervention, and controlled breathing to cope with possible in these cases, breathing disorders.

In treating the trauma of the cervical spine, both non-operative and surgical methods of treatment are used. Passion only conservative or, conversely, only an operative way of treatment is wrong. The art of a surgeon-traumatologist is the ability to choose the only correct method of treatment from existing ones that will be useful to the victim.

Anatomical and functional features of the cervical spine

The severity of the trauma of the cervical spine is due to the anatomical and functional features of this area. On an insignificant length of the neck are concentrated extremely important anatomical formations, the violation of the normal function of which makes human life impossible.

Due to the fact that the complex of the largest and most important vascular and nerve formation, as well as the middle formations of the neck, are located in front and outside of the spine, it does not surprise that the operative accesses to it until recently were limited to the back. To no lesser extent did this contribute to the complexity of the structure of the fascia of the neck. The vertebral bodies and deep neck muscles are covered with a prevertebral (staircase) fascia. In addition to these formations, this fascia surrounds the stair muscles and the diaphragmatic nerve.

[5], [6], [7], [8], [9], [10]

Throat and ligament rupture

Isolated tears and ligament ruptures are more often the result of indirect violence. They can occur with sudden, uncoordinated movements without control from the cervical musculature. They are manifested with local pains, with limited mobility. Sometimes pain can irradiate along the spine of the spine. If suspicion of tearing or rupturing of ligaments, the diagnosis becomes reliable only after the most pedantic and thorough analysis of the radiographs and exclusion of heavier spine injuries. This circumstance should be especially insisted, as often under the guise of damage to ligaments, more severe spinal injuries are seen.

Treatment is reduced to a temporary rest and relative immobilization, carrying out novocain blockades (0.25-0.5% novocaine solution), physiotherapy, cautious medical gymnastics. Depending on the profession and the age of the victim, work capacity is restored after 1.5-6 weeks. More massive damage to the ligamentous apparatus usually does not occur in isolation and is combined with more severe injuries to the skeleton of the spine. In these cases, the treatment tactics are dictated by the resulting damage to the skeleton of the spine.

Intervertebral disc ruptures

More often ruptures of intervertebral discs occur in middle-aged people, whose intervertebral discs have undergone partial age-related degenerative changes. However, we observed acute ruptures of cervical intervertebral discs and in people aged 15-27 years. The main mechanism of violence is an indirect trauma. In our observations, sharp discontinuities of the cervical intervertebral discs arose when relatively small weights were lifted and forced movements in the neck region were observed.

Symptoms of acute ruptures of cervical intervertebral discs are very diverse. Depending on the level of rupture, localization of the rupture of the fibrous ring and the degree of prolapse of the pulpous nucleus, clinical manifestations are expressed in the range of local pain during movements, coughing, sneezing, more severe painful "lumbago" with forced position of the head and neck, significant restriction of their mobility to heavy radicular and spinal lesions up to tetraplegia.

In the diagnosis of acute ruptures of the cervical intervertebral discs, a comprehensive clinico-radiological examination with the participation of an orthopedist traumatologist and a neurologist should be used. Clarification of the detailed anamnesis with. The treatment of special attention to the condition of the neck is absolutely necessary. In addition to the most pedantic orthopedic examination, in the presence of indications, a spinal puncture is necessary with the study of the patency of the subarachnoid spaces and the composition of the cerebrospinal fluid. Often, simple survey spondylograms are inadequate. Additionally, in these cases, functional and contrast spondplograms should be used.

As far as the symptoms of acute ruptures of cervical intervertebral discs are variable, the methods and methods of their treatment are so diverse and diverse. Depending on the nature of the symptoms, various treatment complexes are used - from the simplest short-term immobilization to surgical interventions on the disk and vertebral bodies. Since the primary cause of the manifestation of clinical symptoms is the rupture of the intervertebral disc, the main in any complex are orthopedic manipulations. Only a combination of orthopedic manipulation with physiotherapy and medication, allows you to count on a favorable therapeutic effect.

Treatment of injuries of the cervical spine

To the simplest orthopedic manipulations include unloading and stretching of the spine.

Unloading of the spine is carried out by immobilization of the cervical spine with the simplest gypsum (such as the collar of Shantz) or with removable orthopedic corsets. When applying the corset, you should slightly extend the cervical spine and give the head a position that is convenient for the patient. Do not try to eliminate the anterior flexion, if it is familiar and convenient for the patient. Sometimes it is advisable to impose a corset with support on the forelegs and an emphasis in the back of the neck and chin area.

A number of patients may have a good effect on the use of a semi-rigid corset, such as the Shanz collar, which combines the elements of unloading and the effects of heat. To make such a collar, take a tight elastic cardboard and cut out the shape of the neck. At the front, its edges are rounded and have a slightly smaller height than the rear. The card is wrapped with a layer of white cotton wool and gauze. Gauze ties are sewn to the front edges of the collar. The patient's collar wears constantly during the day and removes it only for the duration of the toilet. If at first the patients feel some inconvenience, then after a few days, getting used to the collar and getting relief, they willingly use mm. After 3-6 weeks of pain usually pass.

Extension of the cervical spine is carried out with the aid of the Glisson loop or in the prone position on an inclined plane or in the sitting position. It is better to produce intermittent stretching by loads of 4-6 kg for 3-6-12 minutes. The time of extension and the magnitude of the load are determined by the sensations of the patient. The intensification of pain or the appearance of other unpleasant sensations is a signal to reduce the magnitude of the load or to stop the stretching. You should gradually increase the time of extension and increase the value of the load. Such stretching sessions are repeated daily and last depending on the effect achieved 3 to 5-15 days.

Medical treatment of trauma of the cervical spine is to give large doses of antirheumatic drugs and vitamins of group B and C: vitamin B1 - in the form of 5% solution but 1 ml, vitamin B12 - 200-500 mg intramuscularly 1-2 times a day, vitamin B2 - 0.012 g 3-4 times a day, vitamin C - 0.05-0.3 g 3 times per day per os. Useful is nicotinic acid to 0.025 g 3 times a day.

Various kinds of thermal physiotherapy in the absence of general contraindications have an undoubted effect. A good analgesic effect is observed with Novocaine electrophoresis.

Effective intradermal and paravertebral novocaine (5-15 ml of 0.5% solution of novocaine) blockade.

To remove acute pain in individual patients, intra-disc blockades with the introduction of 0.5-1 ml of a 0.5% solution of novocaine and 25 mg of hydrocortisone are very useful. This manipulation is more responsible and requires a certain skill. Produce it as follows: the antero-lateral surface of the neck on the side of the lesion is treated twice with 5% tincture of the hearth. The projection of the level of the damaged intervertebral disc is applied to the skin. With the index finger of the left hand, at the appropriate level, the sternocleidomus muscle and the carotides are forced outwards, simultaneously penetrating into the depths and somewhat anteriorly. Injection needle of medium diameter with a shallow slant length of 10-12 cm along the finger is injected in the direction from the outside to the inside and from the front to the back to the stop in the body or intervertebral disc. As a rule, you can not enter the right disk immediately. The position of the needle is controlled by a spondylogram. With a certain skill and patience it is possible to get into the right disk. Prior to the introduction of the solution, re-position the needle's coccyx in the disc. With a syringe, 0.5-1 ml of a 0.5% solution of novocaine and 25 mg of hydrocortisone are injected into the damaged disc. The introduction of these drugs even paravertebrally near the damaged disc gives an analgesic effect.

After passing through acute trauma phenomena and eliminating muscle spasm, a massage course is very useful. Therapeutic gymnastics should be conducted with extreme caution under the supervision of an experienced specialist. Unskilled medical gymnastics can bring harm to the patient.

The listed orthopedic, medicamental and physiotherapeutic methods of treatment should not be used in isolation. Correct individual selection of the treatment complexes necessary for the patient in most cases allows to achieve a positive effect.

With ineffectiveness of conservative methods of treatment, there is a need for surgical treatment.

The main objective of the current operative treatment is to eliminate the consequences of rupture of the disc and prevent subsequent complications, i.e. Decompression of the spinal cord elements, to prevent the development or progression of degenerative phenomena in the damaged disc and to create stability at the level of damage. Since often a sharp rupture of the intervertebral disc occurs against the background of already existing degenerative disc changes, the operative treatment is developed into the treatment of cervical intervertebral osteochondrosis, complicated by an acute rupture of the intervertebral disc. Since the indications and operational tactics for acute ruptures of intervertebral discs and cervical intervertebral osteochondrosis with the deposition of the substance of the disc or protrusion of it are completely identical.

Among surgical methods of cervical intervertebral osteochondrosis treatment, the most widespread and recognized were interventions aimed only at eliminating one of the complications of intervertebral osteochondrosis - the compression of spinal cord elements. The main element of the intervention is the removal of a part of the fallen pulpous core of the ruptured disc and the elimination of the compression caused by it.

Intervention is performed under local anesthesia or anesthesia. Some authors consider endotracheal anesthesia to be dangerous due to the possibility of acute spinal cord compression during the re-dissection of the cervical spine and further loss of pulp core mass. Our experience of surgical interventions on the cervical spine with its injuries and diseases allows us to make a judgment that the fear of using endotracheal anesthesia is exaggerated. Technically correctly produced intubation with appropriate immobilization of the cervical spine is fraught with dangers for the patient.

The essence of palliative surgery is that the posterior middle operative access reveals the spinous processes and arches of the cervical vertebrae at the desired level. They produce a laminectomy. Allan and Rogers (1961) recommend the removal of the arches of all vertebrae, while others limit the laminectomy to 2-3 arches. Dissect the dura mater. After dissecting the tooth-like ligaments, the spinal cord becomes relatively mobile. With a spatula, the spinal cord is pushed aside. A revision of the anterior wall of the spinal canal, covered by the anterior sheet of the dural sac, is performed. With enough lead of the spinal cord, one can see with an eye the fallen part of the disc. More often it is carried out by a thin buttoned probe, held between the roots. Upon detection of the fallen pulpous core of the ruptured disc, a front sheet of dural sac is dissected over it and the dropped out masses are removed with a small bone spoon or curette. Some authors recommend the production of a posterior radiocaetomy for better access to the posterior sections of the intervertebral disc.

In addition to the transural, there is also an extradural pathway when the fallen part of the ruptured disc is removed without opening the dural sac.

The positive side of the back operative access with a laminectomy is the possibility of a wide revision of the contents of the spinal canal located in the dorsal half of the contents of the dural sac, the possibility of changing the operation plan with an unconfirmed diagnosis. However, this method has a number of serious drawbacks. They include: a) palliative intervention; b) direct contact with the spinal cord and manipulation near the spinal cord; c) insufficient room for manipulation; d) the inability to examine the anterior wall of the vertebral capal; e) the need for a laminectomy.

A very serious drawback is the need for a laminectomy. With laminectomy, the posterior support structures of the vertebrae are removed in the region of the damaged intervertebral disc. Due to the inferiority of the intervertebral disc, its function is lost as an organ that stabilizes the cervical vertebrae with respect to the other. From an orthopedic view, this is completely unacceptable. Laminectomy leads to a complete loss of stability of the spine, fraught with very serious complications. Therefore, we believe that the described palliative intervention as not meeting the orthopedic requirements should be used for forced indications. In the same cases, when the surgeon has to resort to palliative surgical intervention and is forced to produce a laminectomy, he must take care of reliable stabilization of the lamepectomized spine. The doctor must remember about orthopedic prophylaxis of possible complications in the future.

Undoubted advantages are operative interventions, implemented through front-line access. Such operative interventions include total discectomy with corporeodesis.

Total discectomy with corporeodes. Total discectomy with subsequent corporodesis has all the advantages of radical surgery. It responds to all orthopedic and neurosurgical settings for the treatment of the damaged intervertebral disc, as it provides a radical removal of the entire damaged disc, restoration of the height of the intervertebral space and reliable stabilization of the damaged spine, as well as decompression of the spine when it is compressed. The most important advantage of this surgical intervention is the preservation of the posterior supporting structures of the vertebrae and the prevention of all possible complications caused by laminectomy.

The main condition for the possibility of implementing this surgical intervention is the precise definition of the level of lesion.

The level of lesion is determined on the basis of clinical data, review and functional spondylograms, and in the presence of indications - pneumomyelography.

In some cases, it is advisable to resort to contrast discography, when it becomes necessary to detail the condition of the damaged disk. Contrast discography is produced in a manner similar to the cervical intradisk blockade described above.

In most cases, it is possible to localize the damaged disc on the basis of clinical-roentgenological data.

Preoperative preparation includes usual general hygiene measures. Carry out appropriate medication. Immediately before the start of the operation, you should monitor the emptying of the bladder and intestines. Carefully shave your head.

Anesthesia is endotracheal anesthesia.

The patient is placed on his back. Under the area of the shoulder blades, an oilcloth dense pillow 10-12 cm high is placed; The pillow is located along the spine between the scapulae. The head of the patient is slightly thrown backwards, the chin is turned to the right at an angle of 15-20 ° and somewhat anteriorly.

The first stage of intervention is the imposition of skeletal traction over the bones of the cranial vault. The predetermined position of the head is held by stretching. The cervical spine is given the position of some hyperextension.

Skeletal traction beyond the bones of the cranial vault is carried out by special terminals. Terminal ends, immersed in the thickness of the parietal bones, represent a cylinder 4 mm in diameter with a height of 3 mm. To ensure that the end of the terminal does not penetrate into the cranial cavity and does not damage the internal vitreous plate at the outer edge of the cylinder immersed in the bone, there is a limiter. The technique of applying the terminal is as follows. On the lower slope of the stump of the parietal bone, an incision to the bone is made with a sharp scalpel. The direction of the incision should correspond to the long axis of the spine - the direction of thrust. The incision in the transverse direction may subsequently cause necrosis of the soft tissues by the pressure of the terminal limiter. Sharp two-pronged hooks edge wound wounds to the sides. Carry out hemostasis. An electric drill with a diameter of 4 mm with a limiter that allows penetration of the drill into the thickness of the bone by only 3 mm, make a hole in the outer compact plate of the parietal tubercle and the adjacent spongy bone. The same manipulation is repeated on the opposite side as well. In the formed holes in the parietal bone introduces the cylindrical ends of the terminal. The position of the terminal ends in the thickness of the bone is fixed with a lock on opposite ends of the terminal. On the skin wounds are stitched. A cable from the terminal throws a block attached to the head end of the operating table. Toward the end of the cable, a cargo of 4-6 kg is suspended. Only after this, the helper can release the victim's head.

The second stage of the intervention is the exposure and removal of the damaged disk. Two types of skin incisions can be used to expose a damaged disc. If it is necessary to expose only one disc, a transverse cutaneous incision can be applied along one of the cervical folds to the level of the damaged disc. This incision is more cosmetic. More convenient is the cutaneous incision along the antero-inner edge of the sternocleidomusus muscle; it provides better access to the front sections of the cervical vertebrae. Preference should be given to left-hand access.

Slightly oblique vertical incision along the anterior edge of the left sternoclavicular-nipple muscle (can be used and a cross-section) cut the skin and subcutaneous tissue layer by layer. They bandage and cross the subcutaneous venous trunks. Dissect the subcutaneous muscle of the neck. The thoracic-clavicular-nipple and the scapula-hyoid muscle are bred in the sides. The pretraheal fascia, which covers the entrance to the space between the carotid artery and the medial neck formations, is becoming visible and accessible. Retreating somewhat to the inside of the carotid artery, determined by a palpable pulsation, strictly in parallel to the carotid artery, the pre-tracheal fascia is dissected. In the space bounded above by the upper thyroid artery, and from below - by the lower thyroid artery, through the pre-tracheal tissue it is easy to penetrate to the front surface of the vertebral bodies covered with the prevertebral fascia. This gap is free of nerve trunks and blood vessels. If necessary, without any damage, the upper and lower thyroid arteries, or any of them, may be bandaged and dissected. The prevertebral fascia is a furnace, transparent, shiny plate. It is dissected lengthwise along the spine; when dissection should be remembered about the closely located wall of the esophagus and do not damage it. After dissection of the prevertebral fascia, the median neck formations easily shift to the right, and the anterior surface of the cervical vertebrae and intervertebral discs is exposed. This operative access easily reveals anterior sections of the cervical vertebrae from the caudal section of the 2nd cervical vertebra to the first thoracic vertebra.

It must be remembered that in the groove between the esophagus and the trachea, a recurrent nerve lies on their lateral surface. The loop formed by the recurrent nerve is somewhat longer on the left than on the right. Therefore, the left-hand operative access should be preferred, but if necessary, it can be done right-sided. With wide, deep hooks, the edges of the brine are bred to the sides. The anterior longitudinal ligament, intervertebral disks and the bodies of the cervical vertebrae become available for manipulation. During the intervention, when stretching the edges of the wound with hooks, the carotid artery and the ascending sympathetic fibers are squeezed, therefore, after every 8-10 minutes, the hooks should be loosened for 1 to 2 minutes to restore blood flow to the carotid artery. In contrast to the bodies of the lumbar and thoracic vertebrae, the bodies of the cervical vertebrae do not stand anteriorly, but lie in a hollow formed by the muscles covering the anterior surface of the transverse processes and the anterior-lateral surface of the cervical vertebral bodies. Under these muscles are the ascending sympathetic fibers, the damage of which is fraught with complications (Gorner's symptom).

If it is necessary to expand the access, the thoracic-clavicular-nipple muscle can be dissected in the transverse direction. Practical need for this we have never met.

Be sure to make sure that the front surface of the cervical vertebrae is exposed. A damaged disc is easily detected by the narrowed intervertebral space, the possible presence of osteophytes (in comparison with spondylograms). At the slightest doubt in the correct localization of the desired level should resort to control spondylography with marking, for which a putative damaged disk is injected with an injection needle and a profile spondylogram is produced.

At the desired level, the front longitudinal ligament is dissected H-shaped and peeled off to the sides. Dissect the anterior section of the fibrous ring. The extension of the cervical spine increases somewhat: the intervertebral space expands and yawns. Using a small acute bone curette, remove the damaged disc. To create conditions for the subsequent formation of the bone block between the bodies of adjacent vertebrae, it is necessary to expose the spongy bone of the adjacent vertebral bodies. Usually, the closure plates of the vertebral bodies are rather dense because of the existing sciroidal sclerosis. Even a sharp bone spoon can not be removed. For this purpose we use narrow chisels. They should be worked very carefully. Hammer blows should be soft and gentle. When removing the closure plates, one should strive to leave the bony limbs of the bodies intact. Their preservation ensures reliable retention of the graft, laid between the bodies of adjacent vertebrae in the intervertebral space. The closing plates are removed in an area of about 1 cm ². When removing the disc in the end plates, you must adhere to the middle line and do not deviate to the sides. Do not go back more than 10 mm. After removal of the damaged disc and closing plates from adjacent surfaces of the vertebral bodies, an intervertebral defect is formed up to 6 mm. If the front osteophytes are significant in size and interfere with the entrance to the intervertebral space, they should be cut with a resection knife or bored with bone nippers. This completes the second stage of the intervention.

The third stage of the intervention is to take a spongy autograft and place it in a prepared bed between the vertebrae instead of the removed damaged disc. The graft is taken from the crest of the wing of the ilium.

A small linear incision length of 4-5 cm along the crest of the ileal wing splits the skin, subcutaneous tissue, superficial fascia layer by layer. The periosteum is dissected. The periosteum is separated from both sides by a thin chisel along with the adjacent compact bone. From a spongy bone, take a graft of a cubic shape with a face size of 10-15 mm. Produce a hemostasis. Seize the periosteum, fascia, skin.

The neck extension is slightly increased. The transplant is placed in the intervertebral defect so that the bone limb of adjacent vertebrae hangs slightly over it. After eliminating excess extensities, the graft is well retained between the vertebral bodies. Sew the front longitudinal ligament. Enter antibiotics. Layer wound the wound. Apply an aseptic bandage.

The patient is laid in bed with a hard shield. Under the area of the shoulder blades, a rigid oilcloth pillow is put. The head is slightly thrown backwards. The skeletal traction continues beyond the bones of the cranial vault with a load of 4-6 kg. Extubation is performed after restoration of spontaneous breathing. Carry out a symptomatic medical treatment. If appropriate indications are available, then dehydration therapy should be started. Everything should be prepared for urgent intubation in case of a breathing disorder. The state of the patient is carefully monitored. The anesthetist should pay special attention to the patient's breathing.

On the 6th-8th day, seams are removed. Stop the skeletal traction. Apply a thoracocadial bandage. To remove the skeletal tract and apply a bandage should be treated as a responsible and serious procedure. The doctor must do this. The period of immobilization by the thoracocranal bandage is 2.5-4 months.