Extensor injuries of III-VII cervical vertebrae: causes, symptoms, diagnosis, treatment

When treating patients with injuries of the cervical spine, we often have to meet with patients in whom severe spinal disorders up to complete physiological spinal cord break at the level of damage occur with minor, minimal dislocations of the vertebrae, often confined to a small anterior displacement of the body of the overlying vertebra.

The unusual nature of the observed clinical picture is further aggravated by the fact that many patients with cervical spine injuries who radically identify significantly coarser anterior displacements up to 1/2 or 3/4 of the anterior-posterior diameter of the body, neurological disorders are minimal or absent. For a long time, these severe spinal cord injuries with seemingly innocuous injuries with minimal radiologic changes remained a mystery and could not be explained. The symptoms of the spinal cord in these victims were explained by isolated injuries, hematomia, etc. The veil of secrets of the origin of these severe damages of the cervical spinal cord was ajar Taylor and Blackwood (1948), who described the mechanism of posterior displacement of the cervical vertebrae, and Forsyth (1964) , described in detail those changes that occur with extensor lesions of the cervical spine.

It is universally recognized that extensor injuries of the spine, including the middle and lower cervical spine, are rare.

In 1964, Forsyth reported that, in a retrospective analysis of 159 patients with cervical spine injuries observed for 12 years, the extensor mechanism of violence occurred in half of the cases. Consequently, extensor injuries of the cervical spine are often found and are often accompanied by severe spinal cord injuries.

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

Causes of extensor injuries of III-VII cervical vertebrae

Extensor injuries of the cervical vertebrae occur when the violence applied to the chin, the face or forehead of the victim, unbendingly sharply unbends the unrestrained cervical spine at any one time. The extensor mechanism of damage to the cervical vertebrae has recently been increasingly observed in motorists in sudden sudden braking at high speed, when the head is sharply thrown back. The breaking force acts on the spine in the direction of the back and down. The head and neck at the same time and sharply unbend, which leads to a rapprochement of the articular and spinous processes. The head and the overlying segment of the neck continue to rotate posteriorly around the frontal axis passing through these articular processes, which leads to rupture of the anterior longitudinal ligament. Further, either the intervertebral disc is ruptured, or a fracture of the body of the overlying vertebra occurs over its caudal closure plate. The upper segment of the spine located above the site of this rupture is displaced posteriorly, tearing the intact posterior longitudinal ligament from the posterior surface of the underlying vertebral body. At the level of damage, the spinal cord is clamped between the arches and the posterior corner of the caudal occlusal plate of the displaced posterior body of the overlying vertebra in the case of rupture of the disc or the posterior-lower body angle when the spongy bone breaks near and parallel to the caudal closure plate. To the compression and even crushing of the spinal cord, the separated posterior longitudinal ligament also contributes.

So there is an extensor "dislocation" or fracture-dislocation of the cervical vertebrae.

How to explain the front displacement of the vertebra, located above the site of damage in extensor violence? After all, usually such a shift is inherent in the violence of violence. Forsyth (1964) explains this by the direction and nature of the breaking force. Extensor violence on the spine acts not strictly behind, but behind and down. Instantaneous exposure causes the damage described above. Continuing its action, violence leads to the fact that the head and upper segment of the neck continue to move along an ellipsoidal curve that returns the head and upper spine.

This explains the position that severe damage to the spinal cord is combined with minimal radiographic findings, as spondylography is performed after the end of the violence, and damage to the spinal cord occurred at the time of its maximum impact.

At the time of maximum impact of extensor violence, with a sufficiently strong anterior longitudinal ligament, a fracture may occur in the region of the roots of the arches, articular processes, in the region of the arches and spinous processes. With the ongoing violence that overcomes the strength of the anterior longitudinal ligament, along with damage to the posterior vertebrae elements, the previously described damage and displacement occurs. In these cases, both in the anterior and posterior vertebral elements, the most severe damage occurs as a complex fracture-dislocation, the severity of which is aggravated by complete instability in the area of injury, while the extensor lesions without fracture of the posterior vertebral elements are stable in the flexion position.

Finally, if extensor violence is not able to overcome the strength of the anterior longitudinal ligament, the damage is limited to a fracture in the aforementioned posterior vertebral elements.

[5], [6], [7]

Symptoms of extensor injury of III-VII cervical vertebrae

Symptoms of extensor injuries of the cervical spine are characterized by the manifestation of varying degrees of intensity of neurological disorders. Symptoms of spinal cord injury may be minimal, but, as happens more often, can be extremely difficult up to the instant development of tetraplegia. There are extensor injuries and without neurological disorders.

Correct recognition of extensor injuries is helped to find out the circumstances of the injury, the presence of bruises, abrasions, bruises on the chin, face, in the forehead. The nature of the damage is finally refined by the profile spondylogram.

To recognize the extensor damage of the cervical spine can be based on: the presence of bruises, abrasions and other traces of contusion in the face, chin and forehead, which resulted from the fall of the victim to the head or the fall of gravity on the head of the victim; the presence of soreness in the back of the neck, local soreness and the presence of swelling in the posterior-lateral parts of the neck; limitation of mobility of the neck and head, increased pain during movement and varying degrees of instability in the cervical spine.

With injuries to the cervical spine, Kienbock distinguishes three degrees of instability: severe medium and light.

The severe degree is characterized by the presence of the symptom of "guillotining," expressed in the impossibility of restraining the head and falling it like a head falling from a guillotine. This symptom occurs with severe damage to the cervical spine with extreme instability and severe damage to the spinal cord.

The average degree of instability is expressed in the fact that the victim can hold his head only with an additional external support - he supports the head in a vertical position with his own hands.

An easy degree of instability is manifested in the fact that the victim keeps his head without additional external support only in a certain, strictly prescribed position. When trying to change the position of the head, stability is disrupted. If you want to change the position of the head, even an easy turn to look at the side, it does not turn its head in the right direction, as normal people do, but turns around with the whole body. Such a state of the victim Wagner and Stolper figuratively called the "head of the statue."

The presence of radicular and especially cerebrospinal, more often severe symptoms in combination with the above-described radiologic changes, the main of which are a slight forward, sometimes barely caught displacement and detachment of a small portion of bone tissue at the site of the anterior longitudinal ligament rupture, make the diagnosis of extensor injury of the cervical spine reliable.

Diagnosis of extensor lesions of III-VII cervical vertebrae

The changes described above, arising from extensor lesions of cervical vertebrae, explain the minimal findings that can be detected with spondylography. On the lateral spondylogram, usually a minor front displacement of the vertebral body located above the area of damage is usually noted. Sometimes this forward bias may be more significant. Very characteristic is the detachment of a small piece of bone tissue from the antero-lower angle of the vertebra that has moved to the front, which corresponds to the level of rupture of the anterior longitudinal ligament. In the posterior elements of the vertebrae, one can note a fracture of the roots of the arch or arch, the arch itself or the spinous process. The most characteristic damage of posterior vertebral elements is a dislocation or fracture-dislocation of the posterior-lower articular process of the overlying vertebra, in contrast to flexion injuries, in which fractures of the anterior-superior articular process of the underlying vertebra are more common.

[8],

Treatment of extensor injuries of III-VII cervical vertebrae

The choice of a method of treatment of extensor injuries of the cervical spine depends on the degree of clinical manifestations reflecting the anatomical and physiological changes caused by trauma. It should be emphasized that usually extensor lesions, with the exception of cases with severe damages of the posterior support structures, and this is not so common, are stable when the neck section is given flexion. This largely determines the choice of method of treatment.

With a slight forward displacement of the body of the overlying vertebra, an insignificant minimal manifestation of neurologic symptoms or their complete absence, treatment is limited to immobilization with a cranio-thoracic bandage or a gypsum-type Shantz collar for 3-6 months. The forecast in these cases, as a rule, is favorable. Usually, after 4-6 months, a spontaneous anterior bone block is radiorographically identified by calcification of the anterior longitudinal ligament.

In the presence of a more pronounced anterior displacement, correction is made either immediately or manually by giving the necessary extension, or by stretching with the aid of the Glisson loop, or by skeletal extension beyond the bones of the cranial vault. Thrust is directed along the long axis of the spine and somewhat posteriorly. Upon reaching the direction, immobilization is carried out by one of the methods mentioned above.

In the presence of severe instability, stretching is contraindicated. In these cases, external or internal immobilization should be carried out.

With severe spinal instability with the presence of neurological disorders, the revision of the contents of the spinal canal and internal immobilization are shown. This is achieved by surgical intervention. The need for reliable internal immobilization with unstable damages is obvious and understandable. With relatively stable extensor lesions of the cervical vertebrae, which require revision of the contents of the spinal canal, and consequently, of laminectomy, the need for a primary early internal immobilization is dictated by the fact that in the process of lamnectomy, the posterior supporting structures of the vertebrae that stabilize the spine are removed and the lesion becomes unstable. In these cases, we consider risky attempts of closed adjustment of displaced vertebrae. Closed direction can be hampered by the presence of free bone fragments in the region of the roots of the arches or articular processes, and most importantly it does not provide the possibility of revising the contents of the spinal canal. In the process of closed correction, the possibility of additional secondary damage to the spinal cord is not ruled out.

Preoperative preparation, anesthesia, the position of the injured on the operating table are similar to those described in the operation of occipitospondylodease. It is absolutely necessary to preliminarily apply a skeletal traction beyond the bones of the cranial vault.

The posterior middle access along the line connecting the tips of the spinous processes, on the right length, strictly along the middle line, cleaves the soft tissues layer by layer. Expose the area of damage. The spinous processes and arches are skeletonized so that at least two arches are exposed above and below the injury site. At the right length, a laminateectomy is performed.

The technique of laminectomy is well known, we only pay attention to the following points. The length of the cutaneous cut is dictated by the level of laminectomy and the degree of expression of the subcutaneous fat and the underlying musculature. Since in the cervical region the tips of articular processes are located quite deep and covered with powerful cervical musculature, the incision should be conducted strictly along the middle line through the ligamentous bundle, which is poor in blood vessels. The skeletonization of the spinous processes of the cervical vertebrae presents certain difficulties due to the bifurcation of their apexes. It is equally difficult to skeletonize the arch of the cervical vertebra because of their mobility and relatively low strength. Skeletonization should be performed subperiosteastically with minimal use of the scalpel. After dissection of the periosteum, a detachment of soft tissues from the lateral surfaces of spinous processes and arches is performed with a sufficiently wide rasporotor or, better, a chisel. I. S. Babchin recommends to make a detachment stupidly through a gauze ball. Not detached in this case, small tendons and muscles, attached to the spinous processes and arcs, pruned with scissors. The detachment of soft tissues is produced on both sides. To stop bleeding, the space between the spinous processes and the arches on one side and the detached soft tissues - on the other tightly plugged with gauze tampons moistened with hot saline. Bleeding from larger, usually venous vessels is stopped by electrocoagulation.

The spinous processes are bored at their bases with the help of curved or bayonet-shaped cutters and after removal of the ligament retaining them are removed. Using bone nippers with large rounded sponges, they also remove the bone tissue in the base of the spinous processes. In one place with the help of nippers the bone tissue is thinned and removed so that a defect in the bone is formed. Through this defect with the help of a laminectomy, a gradual skewing of the arches is produced - a laminectomy. Care should be taken when removing the lateral sections of the arch near their roots, where there are disintegrating venous trunks. Special care is required for all these manipulations in conditions of a damaged spine. Nude epidural fiber is most often imbibed with blood and does not have a normal yellowish color. Fiber is separated by a narrow cerebral spatula and exfoliated to the sides. They expose the dura mater. When it is dissected, damage to the underlying arachnoid should be avoided. The opening of the dural sac is performed if necessary to examine the spinal cord.

On the autopsy of the spinal canal, a thorough examination of the area of damage is performed. Remove loose small bone fragments and patches of ruptured ligaments. Particular attention is required to audit the anterior wall of the spinal canal and eliminate the causes that cause compression of the anterior parts of the spinal cord. If this can not be done through the rear access, then after a reliable internal immobilization of the damaged spine, resort to anterior decompression.

Preliminary carefully and carefully skeleton the lateral surfaces of spinous processes and the arches of those vertebrae, to which the transplants will be fixed. As mentioned above, two arches above and below the injury site or defect after laminectomy should be exposed. From the naked arches on their back surfaces, carefully remove the compact bone and expose the subject spongy elephant. On the sides of the spinous processes, a rather strong cortical bone grafts, taken from the crest of the tibia, is laid on the arches and fixed with a wire seam to the arches, from which, as mentioned above, the yellow ligaments are previously separated. To do this, a thin elevator, inserted between the front surface of each arch and the back surface of the dural bag, dural bag pushes anteriorly so that it is possible to conduct the wire. The seam of fine wire, covering the front surface of each arch and the posterior surface of the transplant at the appropriate level, to the right and left of the spinous process line, firmly and reliably holds and fixes the cervical vertebrae, which gives the spine the lost stability. The wound is layer-by-layer closed. Depending on the condition of the victim, the presence or absence of concomitant damage, within the next few days, skeletal traction continues beyond the bones of the cranial vault, and subsequently a well-modeled craniotoracic gypsum dressing is applied or applied immediately. In the absence of contraindications from the general condition of the victim as the neurological symptoms regress, he can be put on his feet.

In the postoperative period, symptomatic medication is administered and antibiotics are administered. According to the indications, if necessary, dehydration therapy is prescribed.

The timing of external immobilization depends on the characteristics of the former extensor lesion, the extent and prevalence of laminectomy, the degree of reliability and strength of internal fixation.

The timing of incapacity for work and the forecast of damage are largely determined by the nature of spinal cord injury and the degree of residual neurological symptoms. More often with these injuries, complicated by the interest of the spinal cord, the prognosis is not favorable.