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

Subluxations, dislocations and fracture-dislocations of III-VII cervical vertebrae are the most common injuries of this department of the spine. These injuries occur with the flexion or flexion-rotational mechanism of violence. If in the lumbar and lower thoracic parts of the spine, with a purely flexural mechanism of violence, compression wedge-shaped fractures of the vertebral bodies most often occur, then in the cervical part, as a result of anatomical and functional features of this region, subluxations and dislocations often occur, often accompanied by fractures of various elements of the vertebrae or vertebrae.

With purely bending violence, there are bilateral subluxations or dislocations, with flexion-rotational - unilateral subluxations or dislocations.

The onset of subluxation or dislocation is governed by the magnitude of the violence, the condition of the ligamentous apparatus, the degree of development of the musculature and its tone. With a moderate amount of flexion, in combination with other factors mentioned above, there is a subluxation. With coarser violence, a dislocation occurs.

By subluxation or dislocation is understood a violation of the normal relationship of articulating articular surfaces in the posterior-external synovial articulations of the cervical vertebrae, in other words, a violation of the normal relationship between the articular processes of two adjacent vertebrae. It is possible that subluxation can occur without disrupting the integrity of the ligament apparatus. Displacement with it can arise due to the weakness of the bag-ligament apparatus or a decrease in muscle tone. Full dislocation or some kinds of subluxations, as a rule, are accompanied by damage to the ligamentous apparatus.

[1], [2], [3], [4], [5]

Types of subluxations and dislocations of III-VII cervical vertebrae

Throughout III-VII cervical vertebrae distinguish (Henle): subluxations of varying degrees, subluxation, complete dislocation and mesh dislocation. All these damages can be either one-sided or two-sided.

By subluxation is understood the displacement of one articular process relative to the other without the loss of complete contact between the articulating surfaces. Depending on the purely quantitative degree of displacement - the magnitude of the displacement - distinguish subluxation by 1/2, subluxation by 1/3 ,. Subluxation by 3/4.

If the displacement of the articular processes has occurred throughout the articulating surface and the apex of the lower articular process of the overlying vertebra has risen on the apex of the upper articular process of the underlying vertebra, then this displacement is called the upper subluxation (Gelahrter).

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

If, as a result of the existing violence, the lower articular process of the overlying vertebra moves anteriorly from the apex of the upper articular process of the underlying vertebra, slides downwards and lies anterior to this articular process, then a bonded dislocation appears. The adhesion of articular processes occurs when excessive flexion violence leads to the fact that the lower articular process of the overlying vertebra, under the influence of this violence, moves forward above the apex of the upper articular process of the underlying vertebra. Two-sided grip arises with excessive flexion, one-sided - with simultaneous flexion and rotation.

Bilateral complete dislocations and bonded dislocations are always accompanied by rupture of the ligamentous apparatus, capsules of synovial joints and muscles. Consequently, these injuries are among the unstable ones. With two-sided, dislocated dislocations, the fibrous ring of the intervertebral disc always ruptures, a detachment of the anterior longitudinal ligament from the cranio-ventral angle of the underlying vertebral body is often observed, a crushing and partial detachment of the bony tissue of the upper-anterior part of the body of the underlying vertebra. Apparently, in these cases it is necessary to speak about a bilateral interlocking fracture-dislocation.

One-sided clasped dislocations appear more often in the lower scissors. With unilateral disjointed dislocations, damage to the ligamentous apparatus and intervertebral discs is usually less coarse. The difference in anatomical changes in single- and bilateral-linked dislocations was described by Malgaigne in 1955. By his experimental studies, Beatson (1963) proved that the articular capsule of the synovial joint on the side of the lesion and the interstitial ligament in a one-sided interlocking dislocation may be ruptured, while the posterior longitudinal ligament and fibrous ring are damaged slightly. On the opposite side engages N iju, articular capsule and synovial joint ligaments typically break, fracture frequently observed superior articular process and a compression fracture of the body, located below. In these cases, it is also more correct to talk about povelo-dislocation.

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

If, on the lateral spondylogram, the caudal closure plate of the vertebral body dislocated anteriorly is parallel to the cranial occlusal plate of the body of the underlying vertebra, or, in other words, the caudal closure plate of the dislocated vertebral body is located at or near the angle to the ventral surface of the underlying vertebral body, or, 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 them. If in the lateral spondylogram the caudal closure plate of the vertebral dislocated anteriorly is located at an acute angle to the cranial closure plate of the underlying vertebra or, respectively, the caudal closure plate of the vertebral dislocated anteriorly is located at an acute angle to the ventral surface of the underlying vertebra, or, in other words, the body of the dislocated vertebra, angle over the body of the underlying vertebra, then such a dislocation is called overturning. The difference in the understanding of sliding and overturning dislocations (subluxations) is not a terminological casuistry, but has a great practical significance. In clinical practice, with sliding dislocations, more severe neurological disorders are often observed than with overturning 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 damage. With sliding dislocations due to anteriorly shifting of the dislocated vertebra strictly in the horizontal plane, the size of the antero-posterior diameter of the vertebral canal decreases more than when the sprains are dislocated. With these latter forms of dislocation, due to the lowering (pausing) of the dislocated vertebra from the anterior part (body) of the dislocated vertebra, its posterior part, i.e., the arches forming the posterior-lateral parts of the vertebral canal, rise upward. At the same time, there is no significant reduction in the antero-posterior diameter of the spinal canal and its contents suffer significantly less.

Barnes (1948) proved that flexural injuries (dislocations, fractures and dislocations) with anterior displacement usually do not lead to a significant deformation of the spinal canal, and consequently to gross neurological disorders, provided that the joints do not come at the same time fracture.

With the flexion mechanism of violence, as a rule, displacement of the sprained vertebra occurs anteriorly, hence, as a rule, anterior dislocations appear. With the flexion-rotational mechanism of violence, one-sided or rotational dislocations can arise.

All these types of displacement can be combined with fractures of various elements of the vertebrae. Most often, the articular processes and the bodies of the underlying vertebrae break down, much less often - the arches. With a direct mechanism of violence or a combination of an indirect and direct mechanism of violence, a fracture of the spinous process may occur. If there is an offset in the region of the synovial intervertebral articulation with concomitant vertebral fracture at the same level, then, in our opinion, it is more correct to talk about fracture-dislocation.

Fracture-dislocation is more severe damage - it is more difficult to straighten the bones of the vertebrae with it than with a simple dislocation.

Symptoms of subluxations of III-VII cervical vertebrae

Clinical manifestations of subluxations in the region of III-VII cervical vertebrae usually fit into complaints of pain and limitation of mobility in the neck. At movements they can amplify. Often the victim notes that he heard a click. Often such subluxations, especially one-sided ones, spontaneously correct. Then on the control spondylogram does not determine any displacements. With an objective examination, the forced position of the head, local tenderness and swelling at the level of damage can be detected. There may be a muscle spasm. Radicular and spinal disorders with subluxations are relatively rare. The interstitial space is usually not enlarged.

With upper subluxations, clinical manifestations are more pronounced. In addition to the above mentioned symptoms, with a bilateral upright subluxation the distance of the spinous process of the displaced vertebra is clearly defined, the interstitial space between the displaced and underlying vertebra increases, the axial deformation of the spine. The head takes a forced position - the chin is close to the chest, the movements are significantly limited and painful. When riding subluxations, symptoms of irritation or compression of the spinal roots are much more frequent, both at the level of displacement and below. There may be spinal symptoms.

Symptoms of dislocations of III-VII cervical vertebrae

Full dislocation of the cervical vertebrae are more severe injuries than subluxations. As mentioned above, with dislocations there are more severe damage to the joint and ligament apparatus. Usually with dislocations there is a complete divergence of the articulating surfaces of the articular processes in the intervertebral articulations.

If, during a dislocation, the posterior-inferior articular process of the overlying vertebra occurs anteriorly from the upper-anterior articular process of the underlying vertebra, then this displacement is called a clutch, and such dislocations are clasped. Clasped dislocations can be one-sided and two-sided. Entering one articular process after another can be partial, incomplete. It can be complete when the apex of the posterior-lower 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 only consider this last, extreme degree of displacement of articular processes as cohesion and only such dislocations are called bonded. One-sided mating dislocations are more common.

The clinical picture of unilateral seized dislocations does not have any specifics. Based on clinical data, it is usually difficult to differentiate the dislocation from subluxation. In some cases, the position of the head may help. With unilateral joint or full dislocations, unlike a subluxation, the head is rejected in the direction of damage, and not in the opposite. The chin is facing a healthy side. The position of the head resembles a true tortoise. Pain in the neck is common, they can be very mild. There may be tension in the neck muscles. With bilateral dislocations, flexion is more pronounced, and neck extension is limited.

In recent cases, local tenderness and swelling in the area of displacement can be detected. Very often there are radicular symptoms. There may also be symptoms indicating a compression of the spinal cord. Symptoms of compression of the spinal cord occur when, due to displacement of the vertebrae, deformation of the spinal canal and narrowing of its sagittal diameter are formed. Compression of the spinal cord can also occur as a result of a decrease in the anteroposterior diameter of the spinal canal by the masses of the ruptured intervertebral disc that have shifted to the canal or the outflow of blood. When bilateral dislocated dislocations, the decrease in the size of the anterior-posterior diameter of the spinal canal is more pronounced than with unilateral ones. Therefore, spinal disorders with bilateral clasped dislocations can be expressed more intensively and be more persistent and severe, especially in those cases when the reserve spaces of the spinal cord are not sufficiently expressed. With unilateral disjointed dislocations, spinal disorders are asymmetric and more pronounced on the side of the clutch. Radicular phenomena occur due to deformation of the intervertebral foramen. They often occur in both unilateral and bilateral dislocations.

It should be remembered that with unilateral clasped dislocations, the clinical symptoms can be so weakly expressed that the patient does not focus their attention on the physician and should be actively identified.

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

In unilateral mating dislocation in the posterior spondylogram, the spinal process of the dislocated vertebra is usually displaced toward the clutch. The body of the sprained vertebra may be in the lateral flexion position and light rotation with respect to the body of the underlying vertebra. The lateral spondylogram is used to determine the displacement in the region of one synovial joint, consisting in the fact that the posterior-lower articular process of the dislocated vertebra is not located posteriorly from the anterior-superior articular process of the underlying vertebra, as is usually normal, but moved anteriorly from it and its posterior the surface comes into contact with the anterior - articular surface of this articular process.

With a bilateral interlocking dislocation in the posterior spondylogram, it can be noted that the intervertebral x-ray crack formed by the intervertebral disc is narrowed or completely blocked by the displaced antero-lower edge of the sprained vertebra. In the lateral spondylogram, the described changes in synovial joints are observed on both sides.

Treatment of subluxations of III-VII cervical vertebrae

Treatment of fresh subluxations of III-VII cervical vertebrae usually does not constitute any difficulties. With a small degree of subluxation, repositioning is achieved easily and relatively simply or manually by directing the extensional position to the cervical spine, or by pulling with a Glisson loop with a thrust directed posteriorly. For this, the injured person is laid on his back, a flat oilcloth pillow 10-12 cm high is placed under the blade area. The cable from the Gliceson loop is thrown through the block fixed at the head end of the bed so that it forms an angle open downward.

In the case of unilateral subluxations, the existing rotation of the displaced vertebra should be taken into account and, in the process of correction to the extensia, addition and de-rotation should be taken into account.

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

With uncomplicated subluxations and a poorly expressed pain syndrome, patients easily tolerate a correction without anesthesia.

The direction of the upper subluxations is similar. When adjusting this kind of subluxation, you should be especially careful and pedantic, so as not to translate in the process of correction of the subluxation in the full dislocation.

The timing of immobilization depends on the type of subluxation and is 1-3 months. Immobilization is carried out by the plaster collar of Shantz, in some cases - by craniotoracic bandage. In the subsequent appoint a removable orthopedic corset for 1-2 months, massage. Physiotherapy, physiotherapy. The ability to work is restored depending on the profession of the victim. Given the possible subsequent complications of intervertebral discs, one should not treat these lesions as insignificant and easy.

With spontaneously recovered subluxations, anesthesia should be performed in the area of pain points and swelling (10-30 ml of 0.25% solution of novocaine) and apply the cotton-gauze collar of Shantz for 7-10 days. In the presence of severe pain and muscle spasm, it is advisable to stretch the Glisson loops with small loads (2-4 kg) for 7-10 days.

Treatment of complete dislocation of cervical vertebrae

The treatment of these dislocations is a more difficult and complex task compared with the treatment of subluxations. Surgeon-traumatologist, initiating the treatment of these victims, should know the normal and X-ray anatomy of the cervical spine well, be able to understand and navigate freely in those changes that have been reflected on the spondylograms as a result of the dislocation. It should clearly represent the abnormal relationships that arise between the individual elements of the vertebrae, understand the displacement mechanism well, and also the volume relationships between the spine, the spinal cord and its roots and the vertebral artery. This will allow conscious and confident to make the necessary manipulations to eliminate the existing bias.

Treatment of dislocations of the cervical vertebrae is formed in the direction of repositioning and subsequent immobilization. In the process of correction, not only the normalization of displaced vertebrae is achieved, but also radicular and spinal compression are eliminated. In certain situations decompression of rootlets and spinal cord turns into a primary task, but under no circumstances should it overshadow the orthopedic aspects of dislocation treatment.

The greatest difficulty is the repositioning of a bonded dislocation. In these cases, the direction of the dislocated vertebra can be achieved only if the posterior-inferior articular process of the overlying vertebra (sprained vertebra) is dislocated anteriorly and can be displaced above the apex of the anterior-superior articular process of the underlying vertebrae posteriorly and displaced downward.

The direction of the dislocated cervical vertebra can be achieved in three ways: one-step repositioning, constant traction and an operative route.

A manual one-stage correction of dislocations of the cervical vertebrae was performed by Hippocrates. Referring to the dislocation of the cervical vertebrae to a variety of traumatic kyphosis, Hippocrates tried to treat them by eliminating the existing kyphosis. For this purpose the assistant produced traction for the head, and the doctor, putting pressure on the top of the kyphosis by the foot, tried to eliminate the existing deformation. In the process of this "therapeutic" manipulation, the patient was in position on the abdomen. According to Albert, in the Middle Ages the traction with the dislocation of the cervical vertebrae was stretched by one-stage traction by the hair and ears of the victim. In later times, to correct the dislocation of the neck, stretching was performed behind the head of the patient sitting on the chair. Hoffa considered this method of correction "in a frivolous way and a dangerous game of the patient's life."

In the 30-ies of the XX century manual one-stage direction has become quite widespread. In particular, they widely used Brookes (1933). Somewhat later, this method of correction lost its popularity due to reports about severe neurological disorders that occur during it. But this method was periodically returned again. So, in 1959, Burkel de la Sasr noted that, in his opinion, manual one-step reduction is a method of choice for the treatment of dislocation of cervical vertebrae, and Evans (1961) again recommended it. In 1966 VP Selivanov reported on the successful use of manual repositioning in the treatment of closed dislocations of the cervical vertebrae.

There are several ways of manually adjusting the sprained cervical vertebrae. The most attention deserves the method of Güter, proposed by him more than 100 years ago.

The Güter method is based on three main points:

• stretching behind the head along the long axis of the spine;
• lateral flexion in the opposite direction to that on which there is a dislocation, with the creation of a fulcrum at the level of displacement;
• rotation of the head and neck in the direction of dislocation.

So, the correction is made with unilateral subluxations and dislocations.

With bilateral subluxations and dislocations, this manipulation is repeated one at a time - one of the parties is initially conditionally accepted as "healthy." Since the displacement is based on the lever principle, the method is also called "lever".

Manual one-step repositioning on Gyuter is used for rotational subluxations of the atlant, unilateral and bilateral subluxations and dislocations of C3-C4 vertebrae.

Position of the victim on the back. The head and neck stand on the edge of the table, on which the correction is made, and supported by the assistant's hands. The height of the table on which the correction is made should be 80-85 cm. With a little pain syndrome, and in children, anesthesia does not occur. In severe pain in adults, local anesthesia is performed, for which paravertebrally posteriorly at the level of displacement into the cervical tissues, 5-10 ml of 0.25-0.5% solution of novocaine are administered. The use of anesthesia represents a known risk due to the disabling of the patient's control. Braakman and Vinken recommend using dynamic anterior displacement of cervical vertebrae to apply anesthesia with relaxation. "

The first stage of the correction. The victim lies on the table in the position on the back. His body is fixed to the table with straps or flannel knots. The table is set so that the patient lying on it can be accessed from all sides. The surgeon making the correction, stands at the head of the table facing the victim, the assistant stands on the side, on the "healthy" side. On the head of the victim is fastened the Glisson loop. Its elongated straps are fixed from behind on the waist of the surgeon performing the repositioning. The surgeon covers the sides of the victim's head with the palms of his hands. Rejecting his trunk to the back, the surgeon pulls the straps of the Glisson's loop, and then pulls the head and neck of the victim along the long axis of the spine. The thrust is gradually increased within 3-5 minutes.

The second stage of correction. The assistant covers the side 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 helper's palm is the point through which the lever action is effected. Without stopping traction along the long axis of the spine, the surgeon produces a lateral inclination of the head and a segment of the patient's neck located above the upper edge of the helper's palm, in a healthy direction. The upper edge of the helper's palm is the fulcrum through which the lateral slope of the neck section above the injury is carried out.

The third stage of correction. Without stopping traction along the long spine of the spine and not eliminating the inclination of the head and neck to the healthy side, the surgeon with his hands, located on the side surfaces of the victim's head, makes a turn of the head and a segment of the neck located above the site of damage in the direction of the dislocation.

The head of the victim is given a normal position. Produce a control spondylography. If the control spondylograms confirm the elimination of the existing displacement, then the correction is completed. In the absence of correction, all manipulations in the above sequence are repeated.

With bilateral dislocations, the direction is made sequentially - first on one side, then on the other.

After the achieved direction, immobilization is carried out by the cranio-thoracic gypsum dressing. With rotational subluxations of the atlant, immobilization is limited to a plaster or soft collar of Shantz. The terms of immobilization vary, depending on the nature of the damage, its location and the age of the victim, within 1.5-4 months.

In the process of three stages of repositioning, the posterior-inferior articular process of the dislocated vertebra performs the following evolution. In the process of the first stage of repositioning - spinal distension along the long axis - a diastase is created between the tips of the displaced articular processes. In the process of the second stage of repositioning-the lateral tilt to the healthy side-the diastase created by stretching increases somewhat and, most importantly, the posterolateral articular process of the dislocated vertebra is projected lateral to the anterior-superior articular process of the underlying vertebra. In the process of the third stage of repositioning - rotation towards the dislocation - the posterior-lower articular process of the dislocated vertebra, describing the semicircle, becomes in its place behind the anterior-superior articular process of the underlying vertebra.

Extension as a method of correcting the dislocation of cervical vertebrae is the most common. Practical experience suggests that this method is often used without a clear idea of the nature of the damage, the type and degree of displacement of the vertebrae, the new abnormal relationships between the displaced vertebrae that developed as a result of trauma. This probably explains a significant number of unsatisfactory outcomes of treatment, which are reported in the literature. However, with the correct application of this method of correction for certain types of displacement of the cervical vertebrae, it is possible to achieve quite satisfactory results. Extension can be carried out both by the Glisson loop and by the skeletal traction beyond the bones of the cranial vault. Extension with the help of 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 the long-term use of goods of the required magnitude. Despite all of the above, stretching with Glipson's loops is most often used in the practice of medical institutions. Much more effective skeletal traction beyond the cranial vault bones is used much less often in the practice of traumatological institutions of the treatment network or because of lack of necessary equipment, or because of inability to apply it in practice, or because of unjustified fear of using this method.

An extension can be produced for several days (constant traction) by means of relatively small loads, or several hours (forced traction) by more significant loads (Bohler, 1953). Braakman and Vinken (1967) reported that, using loads less than 10 kg with skeletal traction beyond the bones of the cranial vault, they had never been able to achieve correction with unilateral joint dislocation of the cervical vertebrae, and permanent skeletal traction for several days with loads of more than 10 kg allowed to achieve correction in 2 out of 5 victims. In 1957, Rogers reported that in his five observations of unilateral clasped dislocations, the constant skeletal traction was ineffective. With the use of skeletal traction with loads of 10 kg, 15 patients with Ramadier and Bombart (1964) achieved repositioning in only 8 of 15 patients to treat one- and two-sided dislocated dislocations. According to the data of LG Shkolnikov, VP Selivanov and MN Nikitin (1967), none of the 10 patients with cervical vertebrae with one- and two-sided dislocations succeeded in achieving extension by stretching the Glisson loops, and of 113 injured with subluxations, a positive result was achieved in 85 people. AV Kaplan (1956, 1967) emphasizes the difficulties and ineffectiveness of directing dislocations of the cervical vertebrae with the help of the Glisson loop or by skeletal traction.

Permanent extension of the Glisson loop can be used to direct fresh subluxations of the cervical vertebrae. It is effective if it is possible to achieve rapid re-direction. If the stretching continues for a longer time, the patients, as a rule, do not tolerate it and stop it on their own. Glisson's loop does not allow the use of loads of the right 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. The stretching of the Glisson loops is perhaps more suitable for immobilization, and not for repositioning. More effective is the skeletal traction beyond the bones of the cranial vault.

The technique of superimposition of skeletal traction beyond the bones of the cranial vault and its technique are described above. With bilateral forward dislocations traction is carried out by large loads up to 20 kg. Since anterior dislocations are usually flexion sprains. Then the traction is carried out at an angle open to the back. To do this, a dense pillow 10-12 cm high is placed under the shoulder blades area, the head is tilted back a few times, the block through which the cable with the cargo is thrown is fixed at the head end of the bed slightly below the frontal plane drawn through the torso of the victim. In the case of unilateral dislocations, derotation is effected by shortening the strap of the Glisson loop on the bias side. After the control spondylogram confirms the achievement of a certain diastasis between the displaced articular processes achieved during the traction, the plane and direction of the thrust are somewhat changed and converted to a more horizontal one, and the magnitude of the load is somewhat reduced. Once the control spondylograms have been proven to have a reposition, a craniotoracic bandage or a bandage of the Shantz collar type is applied.

Formed traction in principle does not differ in any way from constant traction. It is produced in shorter lengths of time using more massive loads. For a short period of time, the amount of cargo is increased. Under the control of spondylography, successive stages of reduction, described with constant extension, are carried out. Control spondylograms allow you to monitor the position of the displaced vertebrae during each individual point of correction and make adjustments along the course of repositioning by increasing or decreasing the magnitude of the goods and changing the position of the thrust.

Immobilization after closed repositioning of complete dislocations of III-VII cervical vertebrae is carried out within 3-4 months by craniotoracic gypsum dressing. The subsequent treatment consists in physiotherapy, massage, cautious medical gymnastics under the supervision of an experienced specialist.

Operative direction of dislocations and fracture-dislocations of III-VII cervical vertebrae

This method, as a rule, does not have to resort to fresh subluxations of the vertebrae. Complete dislocations, especially those that are grappled, as well as fracture-dislocations, are often an occasion for open repositioning.

Particularly debatable is the question of the legitimacy of using open or closed repositioning for complicated injuries of the cervical spine. One extreme opinion is that any type of damage with displacement of the cervical vertebrae is subject to closed repositioning, the other is that all complicated damages of the cervical vertebrae should be accompanied by a wide opening of the spinal canal and its revision. Both methods have advantages and disadvantages. It is not always indifferent for the subsequent fate of the patient to have a wide opening of the spinal canal, and closed closure for complicated injuries carries at times a serious risk to the health and life of the victim. Apparently, the art of a trauma surgeon is to find the correct method of treatment for each victim, and for this he must have both open and closed methods of correction.

There is no doubt that an open operational method of repositioning in certain situations is more sparing and less dangerous for the victim.

The operative method of correction goes beyond the direction of displaced vertebrae, since it is also possible and necessary to perform a reliable internal immobilization of the damaged spine segment, 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 arises, makes it possible to audit the spinal canal and make the necessary manipulations on its contents for complicated injuries. These two circumstances - the ability to implement reliable internal immobilization and revision of the contents of the spinal canal - are an undeniable advantage of the surgical method of treatment. Consequently, the possibilities of surgical treatment of dislocations and fracture-dislocations of III-VII cervical vertebrae go beyond the simple direction of displaced vertebrae, and with appropriate indications, one can simultaneously perform a revision of the spinal canal and its contents, directing and internal fixation.

Attempts to apply an operative method of treatment for cervical vertebrae injuries by individual physicians were made already at the beginning of the 20th century. In 1916, Mixter and Osgood were tied with the silk ligature of the arches of I and II cervical vertebrae. However more widely this method began to be applied in the last 15-20 years.

We emphasize the reader's attention to the method of surgical correction and internal fixation of the damaged segment of the cervical spine. Internal fixation can be carried out using a wire seam, a posterior fusion and the combined use of a wire seam and a posterior spondylosus.

Indication: all types of damage, accompanied by severe instability, one of the signs of which is very easy correction of displaced vertebrae; unsuccessful closed recovery in uncomplicated injuries or injuries with little expressed root and spinal symptoms; damage to two or more elements of the same vertebra (dislocation in combination with a fracture of the arch, etc.); multiple vertebral lesions; complicated injuries; damage with progressive neurological disorders and symptoms.

Preoperative preparation, the position of the injured on the operating table, anesthesia are similar to what was said about oktsipitosponilodeza.

Intervention is also performed with pre-imposed skeletal traction over the bones of the cranial vault.

Technique of rapid repositioning and rear fixation

A linear cut along the course of spinous processes along the middle line is layerwise cut through the skin, subcutaneous tissue, superficial fascia. The level and extent of the cut depends on the location of the lesion. Carried out a thorough hemostasis. In the wound, a nuchal ligament appears exposed to the tips of the spinous processes. The ligamentous ligament is dissected strictly along the midline. With the help of a rammer and scissors, the apex of the spinous processes is carefully selected, the lateral surfaces of the spinous processes and the arches are skeletonized. This manipulation should be carried out with the utmost care, especially in places where the ligaments are broken or there is a fracture of the arch. It should be remembered that with fracture-dislocations and dislocations, there may be a significant increase in the interstitial space, sometimes reaching 3 cm. In these cases, under the muscles partially covered with torn yellow ligaments, a hard dura is exposed, which can easily be damaged during skeletalization of the posterior vertebral elements. It should be remembered that the arches of the cervical vertebrae are very delicate and tender formations that can not withstand significant violence. Especially careful and careful should be when manipulating the injury site. Produce a thorough hemostasis tamponade wound gauze compresses, moistened with hot saline solution. After separating the muscles and diluting them to the sides, the entire area of damage becomes easily visible. Usually the overlying spinous process is shifted upward and anteriorly. With unilateral dislocations, the spinous process is, in addition, deflected to the side, and the intercostal gap may have a wedge shape. Yellow and intercostal ligaments are ruptured. In the intercostal defect under the torn yellow ligaments, a gray-sizaya hard brain membrane is visible, easily determined by the presence of pulsation. It can be covered with epidural-impregnated epidural fiber and, as a result, it is dyed dark-cherry. But it may be that pulsation is weak or absent. In this case, the solid medulla, surrounded by blood clots and blood-stained epidural fiber, can not be recognized. In the case of a bilateral fracture of the arch that accompanies the dislocation, the arch along with the spinous process can be in place or even slightly displaced posteriorly.

Depending on the nature of the damage detected during the intervention, the clinical data and, if there are appropriate indications, perform an intervention on the contents of the spinal canal. In the cases shown, a laminectomy is performed beforehand.

Without sufficient grounds, the length of the laminectomy should not be increased. Removal of extradural hematoma and blood clots is feasible and through the interstitial space between the displaced vertebrae.

Under the control of vision, displacement of the displaced vertebrae occurs. This is done by stretching the spine along its long axis, then tilting it to the healthy side, expanding and rotating in the direction of the dislocation. Extension is performed by an assistant at the skeletal extension bracket. At the same time, the surgeon makes adjustments with the help of tools in the wound. Special difficulties for correction arise when the dislocated dislocations occur, when the articular processes are so intimately in contact with each other that a false impression can be created about the absence of damage and the violation of normal anatomical relationships. Direction requires the surgeon first of all to clearly orientate in the anatomical changes that have occurred, patience, sufficient perseverance and, of course, caution. To eliminate the adhesion of articular processes, it is possible to resort to lever action with the help of a thin bit.

Quite rightly AV Kaplan focuses attention on the difficulties of closed reinstatement of such a dislocation, since even open direction is often associated with considerable difficulties.

Sometimes, especially with stale stuck dislocations, it is not possible to correct articular processes and it is necessary to resort to their resection. Resection of the articular processes with irreparable bonded dislocations was first carried out by VL Pokatilo in 1905. After the displacement of the displaced vertebrae has been achieved, it is necessary to fix the damaged spine segment. Fixation can be carried out by a wire seam or a wire seam in combination with bone plastic of the posterior parts of the spine.

Rear spondylodesis in its classical sense (using only bone grafts), in our opinion, is not advisable in case of unstable damage. We consider it unreasonable 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 important months after injury, the first months and weeks, when the fusion of the posterior parts of the spine has not yet occurred, the classical posterior spondylodesis does not have a stabilizing effect on the spine. Therefore, we consider it imperative that the initial early "hard" stabilization be done with a wire seam or a wire seam in combination with bone plastic in the posterior parts of the spine. Wire seam is carried out in different versions. The most reliable is the eight-shaped wire seam, capturing the spinous processes of the broken and two adjacent vertebrae.

To superimpose such a wire seam at the base of the spinous process of the dislocated vertebra, above and below the underlying vertebrae, a thin channel or electric drills are drilled with a channel 0.5-1 mm in diameter in the frontal plane. Through the made channels conduct a wire from stainless steel in the form of the figure-eight . The seam can also be applied to the arms . In the posterior combined spondylosis, along with the application of a wire seam, the osnoplasty fixation of the damaged spine segment is also performed. For this, a compact bone is removed from the bases of the spinous processes and adjacent parts of the half-bones until the spongy, bleeding bone is exposed. This prepares a bed for the laying of bone grafts. A compact-spongy bone graft, taken from the crest of the wing of the ilium, is laid in the educated maternal bed.

The transplant should be laid so that it overlaps the arch of the displaced vertebra and 1 - 2 higher and lower vertebrae. The best material for bone grafting is autostyticity. If, for some reason, the taking of an autotraper is undesirable, homogeneity can be used, preserved with low temperatures. In no case can we agree with the opinion of EG Lubensky that the best material for these purposes is the freeze-dried bone.

After fixing the bone graft or grafts, a wire seam is applied on both sides of the spinous processes and produces a thorough hemostasis. Then superimposed seams on the wound, inject antibiotics. Apply an aseptic bandage.

Spondylodesis of the laminectomized spine segment has some peculiarities. In the case of removing 1-2 arches, provided the articular processes are preserved, the technique does not differ from that described above. With a larger length of laminectomy, the posterior spinal fusion is difficult technically and often fails, since the absence of contact between grafts and bone tissue often leads to resorption. The bed for the placement of transplants is formed at the roots of the arches in the region of the articular processes, where the grafts are placed. In these cases it is necessary to closely contact the base of the transverse processes. One should remember the proximity of the vertebral arteries and not damage them.

If in the future the incidence of posterior spinal fusion and the stabilization of the spine does not occur, then anterior spondylodesis is produced in the second stage. During the operation, blood loss is timely and fully compensated.

In the days following the operation, the management of the patient differs little from the postoperative management described in the operation of the ocipitospondylodeza.

When interfering with the dislocation, the traction beyond the skull may be discontinued on the 3rd-4th day after the operation. After the intervention for fracture-dislocation and dislocation without significant damage to the vertebral body and with confidence in the reliability of the fixation made, it is possible not to impose a plaster bandage. In case of doubt, the most reliable additional method of external fixation is craniotoracic cast plaster for a period of l, 5-4 months.

The term of the patient's discharge for outpatient treatment depends on the presence of concomitant damage to the spinal cord and brain. In the absence of these injuries, by 12-14 days the victim can be discharged for outpatient treatment.

Skeletal traction beyond the bones of the cranial vault is quite easy to fix the existing displacement, but it is not possible to hold it in the desired position. Therefore, it was decided to produce a rear combined spondylodease, which was performed on the 8th day.