Compression hairs fractures of the cervical vertebral bodies: causes, symptoms, diagnosis, treatment

Splinter compression fractures of the cervical vertebral bodies occur with the compression mechanism of violence, when the traumatic force acts vertically along the axis of the straightened cervical spine.

Since the normal position of the cervical spine is lordosis, such damage occurs when the head and neck are in the forward flection position - in this position lordosis disappears and the vertebral bodies are set vertically. The preservation of the integrity of the rear support structures with such damages makes it possible to classify them as stable. Despite this, the posterior fragment of the body of a fractured vertebra or the mass of a ruptured disc may move posterior parts of the spinal cord.

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Symptoms of comminuted compression fractures of the cervical vertebral bodies

Symptoms of comminuted compression fractures of the cervical vertebral bodies vary from the picture of the spinal contusion to spinal injury, complicated by tetraplegia. These kinds of injuries, which occur with insignificant, seemingly harmless symptoms, are especially insidious. Relatively small, additional violence can lead to disaster. Victims with minor complaints and poor clinical picture, with the appropriate mechanism of violence should be subjected to X-ray examination. Most often, with uncomplicated injuries, the victims complain of pain in the neck, which increase with movement. They rest their heads with their hands. All kinds of movements are limited and painful. There can be abrasions and hemorrhages in the occiput and the crown. Sometimes there is a difficult and painful swallowing. Neurological symptoms may be absent or be detected by a special examination. Finally, they: can be expressed roughly, up to the presence of tetraparesis or tetraplegia.

Diagnosis of comminuted compression fractures of cervical vertebral bodies

X-ray picture, characterized by varying degrees of fragmentation of the vertebral body with damage to the closure plates and rupture of adjacent discs. More often distinctly distinguish one front, larger fragment, which usually protrudes from the anterior marginal line of the vertebral bodies. The height of the body is reduced, It can be slightly widened in the lateral or anteroposterior projection. Adjacent intervertebral spaces are narrowed. In the profile spondylogram at the level of damage, the vertebral canal may be narrowed due to the distal position posterior to the posterior fragment of the fractured vertebral body.

Correct evaluation of anamnesis and clinical radiology data, as a rule, allows you to put the correct diagnosis of damage.

[2], [3], [4]

Treatment of comminuted compression fractures of the cervical vertebral bodies

The most common and universally accepted method of treating comminuted compression fractures of the cervical vertebral bodies is a prolonged immobilization with a plaster bandage with the expectation of an offensive spontaneous anterior bone block.

With a slight compression of the body of the broken vertebra, a plaster bandage is applied immediately. With a pronounced reduction in the height of the fractured vertebra, an attempt can be made to restore the anatomical shape and height of the fractured vertebra by stretching along the long axis of the spine with moderate hyperextension of the cervical spine. For this, skeletal traction is applied over the bones of the cranial vault and a weight of 6-8-10-12 kg is applied. With fresh injuries, as a rule, it is possible to reach the body of the fractured vertebra and restore its anatomical shape. Do control spondplography. The most evident is the profile spondylogram on which it is possible to determine the decrease or disappearance of the flattening of the vertebral body, the straightening of the marginal line of the posterior part of the vertebral bodies that form the anterior wall of the vertebral canal. The safety of the anterior and posterior longitudinal ligaments makes this manipulation relatively safe. For the same reasons, the fragment of the fractured vertebral body that has shifted to the back, towards the vertebral dripping, can recover.

When the correction is achieved, a craniotoracic gypsum dressing is applied for a period of 4-6 months. By removal of the bandage, the anterior bone block is usually determined radiographically along the course of the calcified anterior longitudinal ligament. There is some restriction of movement in the cervical spine, a different degree of pronounced soreness. All these phenomena soon disappear under the influence of massage and physiotherapy procedures. Therapeutic gymnastics must be conducted carefully, under the supervision of an experienced specialist.

Craniotoracic cast plaster best ensures immobilization of the damaged cervical spine. However, instead of it, a dressing of the type of gypsum collar of Shantz can be used with well-modeled "visors" in the nape of the neck, chin and upper chest.

The work ability of the victim is quickly restored after the removal of the plaster bandage. People of mental labor can often start working before the cast is removed.

Not all patients even after the onset of the spontaneous anterior bone block come to clinical recovery. This is due to anatomical changes that occur with this type of damage. Quite often in these injuries, there is an ipterposition of the masses of a ruptured disc between fragments of the broken vertebra's body. The formed bone block covers only the front part of the body. The masses of ruptured intervertebral discs prevent the formation of a solid bone monolith. This leads to the fact that the most important parts of the broken vertebra - the posterior fragment of the body - remain mobile, which predetermines subsequent pathological changes and the resulting late complications. These later changes and complications include the possibility of secondary compression of the body of a fractured vertebra leading to axial deformation of the spine, the appearance of intervertebral osteochondrosis with the entire bright and diverse gamut of their clinical manifestations, the progressive compression of the anterior and anterior-lateral divisions of the spinal cord and spinal roots. In later cases, chronic progressive myelopathy can also be observed.

Conservative treatment of these late complications, as a rule, is inefficient, and operative - is associated with certain difficulties.

Therefore, in case of compression fractured fractures of the cervical vertebral bodies, in appropriate cases, it is expedient to perform a primary early surgical treatment consisting in removing fragments of the fractured vertebra's body, damaged adjacent intervertebral discs, restoring the normal height of the anterior sections of the injured spine, correcting the axial deformation of the spine and creating conditions for the onset of total anterior bone block. This method of treatment is proposed and developed by Ya. L. Tsivyan in 1961, anterior spondylodesis by the type of partial replacement of the body of a fractured vertebra. Given the necessary conditions and the qualification of a doctor, we consider this method a method of choice in the treatment of comminuted compression fractures of the cervical vertebral bodies.

If there are appropriate indications, this intervention can be extended to the complete removal of the body of the fractured vertebra and the implementation of anterior decompression, followed by the complete replacement of the body of the fractured vertebra.

Anterior spondylodesis

Indications for surgery: fragmented comminuted compression fractures of the cervical vertebral bodies. In the absence of special indications for immediate intervention, surgery is performed 3-1 days after the injury. Preoperative preparation is as follows. Produce a skeletal traction beyond the bones of the cranial vault. The victim is laid on a hard bed with a shield. Since these lesions usually have axial deformation of the spine at an angle open anteriorly, traction beyond the skull is carried out in a horizontal plane. Conduct symptomatic medication. Care is necessary for the intestine and bladder, prevention of pressure sores.

Anesthesia is endotracheal anesthesia with controlled breathing. The injured person is placed on the operating table in the position on the back. Skeletal traction beyond the bones of the cranial vault. Under the padplechya injured lay a hard oilcloth flat cushion 10-12 cm in height. Thrust beyond the bones of the cranial vault is carried along the axis, passing somewhat downward from the horizontal plane, so that the head of the victim is somewhat tucked back, and the neck - in the position of extensionality. In addition, the head turns slightly to the right so that the chin turns to the right at an angle of 15-20 °.

Online access. Apply a transverse one of the cervical folds or along the antero-inner edge of the sternocleidine-nipple muscle. Advantage should be given to left-side access, but right-sided can be used.

Manipulation on the spine. After exposing the area of damage, before proceeding to manipulation on the vertebral bodies, you should ensure that the lesion is located accurately.

With the known skill, the body of the damaged vertebra is determined by the presence of hemorrhages in the surrounding paravertebral formations, the color and nature of the anterior longitudinal ligament, which is usually more dim at the site of injury. Sometimes it shows small longitudinal tears and fiber bundles, it is somewhat thickened, covered with a thin layer of fibrin. It may be found that the anterior part of the fractured body is anterior to the front, the height of its anterior sections decreases, the intervertebral disks are narrowed or completely disappear, covered by the ventral plates of the broken body and the bodies of adjacent vertebrae. The most convincing data are found when the anterior longitudinal ligament is detached: the fracture of the ventral closure plate of the body, the cyanotic coloring, the lower density, the mass loss of the pulpous cores of damaged adjacent discs. At first, it is still better, even with full, it would seem, confidence and accuracy of localization of the damaged vertebra to resort to a control spondylography with a preliminary marking with thick metal spokes. For this, after exposing the anterior sections of the spine to the intervertebral discs located above and below the alleged fractured vertebra. Introduce one metal spokes and produce a control lateral spondylogram, on the basis of which the correct location of the lesion is determined.

The anterior longitudinal ligament is dissected in the form of the letter H lying on its side. Its parallel lines pass through the bodies of the higher and lower body of the vertebrae, and the transverse line is closer to the left side of the vertebral body. We pay attention to this seemingly insignificant technical detail because the detachment of the left edge of the dissected anterior longitudinal ligament presents known technical difficulties. The dissected anterior longitudinal ligament is exfoliated with a thin sharp chisel from the anterior surface of the broken body, adjacent intervertebral discs, caudal section of the overlying and cranial section of the underlying vertebral bodies. With fresh lesions, as mentioned above, the anterior longitudinal ligament is impregnated with blood soaked. Under the ligament you can find blood clots. From a broken body, dark venous blood is secreted. It can be soft and crumples under the chisel. With the help of bone spoons and bits, fragments of the broken vertebral body, fibrin clots, bone detritus and masses of ruptured discs are removed. Bone fragments are usually easily removed even by tweezers. Known difficulties are the removal of the remains of damaged discs, especially their fibrous rings. Damaged discs can be removed completely, except for the posterior-lateral parts of their fibrous rings. When removing bone fragments, it is necessary to preserve lateral compact, vertebral body plates. With the aid of an acute thin bit, the closure plates are removed and removed from the adjoining bodies of adjacent vertebrae by approximately 1/2 or 3/4 of their anterior-posterior diameter. When removing the end plates, it is necessary to preserve their limb, which hangs over the bodies in the form of a small visor. Preservation of the limb will help to hold in place the bone graft inserted into the defect of the vertebra, not allowing it to slip anteriorly.

As a result of the manipulations in the place of the injured body and adjacent intervertebral discs, a rectangular defect is formed. Its upper wall is the body of the overlying vertebra, in which the spongy bone is exposed as a result of the removal of the terminal plate, the underside of the spongiosum layer of the underlying vertebra is exposed by the lower wall and the spongiform layer of the posterior part of the fractured vertebra is posterior. Thus, with the partial removal of the broken vertebra's body, a bed is formed, the walls of which are the naked bleeding spongy bone.

To fill the formed bone defect, both auto- and homoplastic bone grafts can be used.

In the formed defect of the vertebral body insert a compact-spongy autograft, taken in the form of a rectangle from the crest of the wing of the ilium. The vertical size of the transplant should be 1.5-2 mm larger than the same size of the vertebral defect. The posterior, upper and lower walls of the transplant should be a spongy bone. At the time of the introduction of the transplant into the defect, the cervical spine is given a somewhat greater extension, thanks to which the vertical dimension of the defect slightly increases. After the transplant is installed, the cervical spine is given the same position. The transplant is firmly retained in the defect by the bodies of adjacent vertebrae. The flap of the detached front longitudinal ligament is placed in its place and fixed with thin nylon seams. During the operation, a thorough hemostasis is performed. Usually, as a rule, minor blood loss occurs only when manipulating the bodies of the vertebrae; nevertheless, the remaining stages of surgical intervention are not accompanied by blood loss. Enter antibiotics. Wrap the wound edges layer by layer. Apply an aseptic bandage. In the course of the operation, a timely and complete replenishment of blood loss is performed.

All manipulations on the spine should be soft and smooth. Otherwise, in the postoperative period, there may be an ascending spinal cord edema. Every 8-10 minutes, weaken the hooks, stretching the edges of the wound (especially the outer), to restore blood flow in the carotid artery and the outflow of venous blood from the brain through the system of the internal jugular vein. Care should be taken for ascending sympathetic fibers. When they are compressed, a persistent Horner symptom may occur. Carefully and carefully should be taken to the recurrent nerve to prevent paralysis of the vocal cords,

After restoration of spontaneous breathing, extubation is performed. The victim is transferred to a postoperative ward and placed on a hard bed. Under the neck area, put a soft-elastic roller. Skeletal traction is carried out for the bones of the cranial vault in the horizontal plane with a load of 4-6 kg. Conduct symptomatic drug treatment, inject antibiotics. According to the indications, dehydration therapy is used. In the postoperative ward, everything should be ready for emergency intubation and tracheostomy in the event of respiratory distress.

On the 7th-8th day, the sutures are removed and the skeletal traction is stopped. Apply craniotoracic plaster bandage for a period of 3 months. In the absence of concomitant neurological disorders or residual phenomena of damage to the spinal cord or its elements, the capacity to work is restored 2-3 weeks after the removal of the plaster bandage.

On the control spondylograms, the right axis of the cervical spine is marked and the anatomical shape of its anterior regions is restored. Anterior bone block of IV-VI cervical vertebrae.

In the presence of crude petrologic symptoms of compression of the anterior parts of the spinal cord caused by the displaced side of the vertebral drip of the posterior fragment of the fractured vertebral body or by the presence of other symptoms indicative of the progressive compressed non-spinal cord, and the process of the above surgical intervention, anterior decompression of the spinal canal followed complete replacement of the vertebral body. For the whole, the operation of partial resection and partial replacement is complemented by the fact that, in addition to the anterior parts of the fractured vertebra, its posterior sections are additionally removed. If there is a multi-lobed fracture of the body, the removal of its posterior parts is not difficult. If the posterior fragment of the fractured body is a single fragment, it should be removed with caution, so as not to damage the dural sac located behind the posterior longitudinal ligament. The most important and difficult is the removal of the posterior compact plate of the vertebral body. With known skill and caution, this manipulation is feasible, since the posterior surface of the vertebral body has weak connections with the posterior longitudinal ligament.

It is known that the anterior longitudinal ligament is firmly fixed to the anterior surface of the vertebral bodies and is transferred through the intervertebral disks in the form of a bridge. In contrast, the posterior longitudinal ligament is firmly fixed to the posterior surface of the fibrous rings of intervertebral discs and rather loosely associated with the posterior surface of the vertebral bodies.

Significant bleeding from the venous sinuses of the vertebral body, as a rule, does not occur, as the latter are damaged at the time of injury and are thrombosed.

To restore the support and stability of the spine, the operation is completed by complete replacement of the vertebral body. Technically, complete substitution of the vertebral body is performed in the same way as partial replacement of the body. It should be noted that the anterior-posterior diameter of the graft is 2-3 mm less than the anterior-posterior diameter of the distant vertebral body. Under this condition, a free reserve space will remain between the posterior surface of the graft and the anterior surface of the dural sac.

As for partial replacement of the vertebral body, you can use both auto- and homogeneity to completely replace the cervical vertebral body. However, preference should be given to the autograft.

The postoperative period is carried out in the same way as the postoperative period after the partial replacement of the cervical vertebral body.

[5], [6], [7], [8],