Uncomplicated fractures of thoracic and lumbar vertebrae

Compression wedge-shaped uncomplicated fractures of the bodies of the lumbar and thoracic vertebrae are perhaps the most common type of spine injury and are localized in the upper lumbar and lower thoracic spine.

What causes compression wedge-shaped uncomplicated fractures of the thoracic and lumbar vertebrae?

These injuries to vertebral bodies are the result of the action of the flexor mechanism of violence. By their nature, they refer to stable damage.

The opinion of some authors that a slight wedge-shaped compression of vertebral bodies is completely harmless and easily compensated by a change in the position of the upper and lower parts of the spine is incorrect.

Often, even a very small compression of the vertebral bodies in the transitional lumbar and thoracic region, in which these lesions occur most often, leads to severe complications in the long term in the form of pain syndrome and compression of the anterior-lateral parts of the spinal cord. The cause of these complications are progressive degenerative changes in adjacent intervertebral discs, aggravated by a former trauma and a seemingly insignificant deformation of the vertebral body.

These seemingly harmless, "small" fractures of vertebral bodies require the most serious attention.

Symptoms of compression fractures of vertebral bodies

The most common and typical complaint is the presence of pain. Usually the  pains  are strictly localized at the level of damage, amplified by movement. Sometimes the pains are spilled and spread to the lumbar and thoracic areas. Pain syndrome is most pronounced in the first hours and days after injury, and in later periods significantly smoothed out and even disappears.

The most distinct and bright pains are expressed in the vertical position of the victim when walking. Their intensity increases when walking on uneven ground, when driving in a motor vehicle, etc. Often these feelings are joined by a feeling of uncertainty about the "strength of the spine", the phenomenon of discomfort.

Diagnosis of compression fractures of vertebral bodies

Detailed clarification of the anamnestic data, the circumstances of the trauma and the place of application of violence allows one to suspect the presence of a wedge-shaped compression fracture of vertebral bodies and its probable localization.

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Inspection

Often, the victims are sufficiently active. The degree of deformation of the spine is sometimes so little that it can only be caught by the experienced eye. In the lumbar department, this deformation can only be manifested by smoothing out the physiological lordosis, against which you can see a spinous process standing in the form of a button in thin individuals. Often this distance of the spinous process is determined only by palpation. In the thoracic spine, a certain strengthening of the physiological kyphosis is determined, against which background the pugular outgrowth of the spinous process is more clearly visible. In addition to the deformation of the spine in the sagittal plane, there may be a lateral curvature of the line of spinous processes, indicating the presence of lateral compression of the vertebral body.

Slight deformity of the spine can be masked by the existing swelling of the soft tissues at the fracture level. This swelling is absent in the first hours after the injury and appears later.

When examining the victim, it is almost always possible to detect the tension of the long back muscles, determined by eye, limited to the area of damage, or extending to the entire lumbar and thoracic spine. Sometimes the topical tension of the muscles is determined only palpation, especially in subjects with pronounced subcutaneous tissue.

With palpation, local soreness is determined at the level of the spinous process of the fractured vertebra. In a later period after the trauma, in the presence of kyphotic deformation, local soreness is determined at the level of the spinous process of the vertebra, located above the broken vertebra. Palpation revealed an increase in the interstitial gap, which is expressed all the more, the greater the compression of the body of the fractured vertebra. With the help of palpation, a deformity of the spine can be detected, which was not detected during the examination.

The pain symptom with an axial load on the spine usually does not appear in the prone position. It is not so valuable as to give the victim a vertical position for its detection, since this situation is not always safe for the victim.

Mobility of the spine

Many authors note the limitation of the volume of active movements in spine injuries. There is no doubt that, as with any damage to the musculoskeletal system, there is a restriction of the mobility of the spine when it is damaged. However, this method of examining the victim in the presence of acute spinal injury should be excluded from clinical use as unjustified and risky for the victim.

Of particular interest is an examination of active movements in the legs. As is known, with uncomplicated injuries of the spine, active movements in the legs remain. If you offer the patient with a compression wedge fracture of the body of the vertebrae in the position on the back to bend in the hip joints and somewhat dilute the legs straightened at the knee joints in the legs, there is always pain in the fracture region. This pain symptom persists significantly longer than others.

In the diagnosis of an uncomplicated compression wedge fracture, Thompson's symptom may help, that pains in the spine at the level of damage in the sitting position disappear when the spine is unloaded by focusing the hands of the injured person in the chair seat.

Of the other clinical symptoms observed with uncomplicated compressive wedge-shaped fractures of the body, there may be reflex urinary retention, pain in the posterior abdominal wall, with deep palpation, resulting from the presence of retroperitoneal hematoma.

Sometimes, for the same reason, there is a tension in the anterior abdominal wall, sometimes so pronounced that it simulates a picture of the "acute abdomen", but about which laparotomy is produced.

Spondylography

X-ray examination method is one of the most important and in many cases a decisive addition to the clinical examination for compression wedge fractures of vertebral bodies. Spondylography is produced in two typical projections - posterior and lateral. Decisive in the diagnosis is a lateral spondylogram.

Compression wedge fractures of vertebral bodies are characterized by typical radiologic symptoms, which allow not only to confirm or reject the alleged clinical diagnosis, but also to clarify and detail the existing damage.

The most typical radiologic symptom is the wedge shape of the vertebra with the vertex of the wedge facing inverted. The degree of this wedge-shapedness is very variable - from controversial, subtle, to utterly undeniable, well-expressed and conspicuous. The crush, some thickening and especially the rupture of the ventral closure plate make the diagnosis of the fracture indisputable. These data are determined on the profile spondylogram: the change and irregularity of the bone structure of the vertebral body, displayed on the spondylograms (direct and lateral) by thickening the bony beams of vertebral bodies along the compression line; rupture of the closure, more often cranial plate of the vertebral body. In the thoracic region, the damage to the cranial closure plate often has a step-like character; with the rupture of the closure plate, more often cranial, on the lateral spondylogram there is an impression of it and a discontinuity (Schmorl's acute hernia); the detachment of the cranioventral angle of the vertebral body, revealed on the profile spondylogram; narrowing of the intervertebral space and the area of adjacent intervertebral discs, more often in the ventral areas; an increase in the interstitial space, defined on the anterior and lateral spondylograms; axial deformation of the spine more often in the sagittal, rarely in the frontal plane. With lateral compression of the vertebral body on the profile spondylogram, it is not possible to detect a wedge-shaped deformation of the body, but a condensation of the bone structure of the body can be detected in the cranial closure plate. The anterior spondylogram in these cases allows determining the lateral compression of the body. In compression fractures of the thoracic vertebra due to significant bleeding, an invertebral hematoma forms, which forms a spindle-shaped paravertebral shadow on the anterior spondylogram that resembles a stitch.

In some cases spongeography in oblique projections is useful. With an insignificant degree of compression and the absence of distinct radiologic symptoms, the vertebral body fracture does not always succeed in radiologically confirming the clinical diagnosis of the existing lesion. In these cases, it is recommended to repeat the X-ray examination after 6-10 days. By this time, due to the resorption of bone tissue along the fracture line, its display on the X-ray film becomes more distinct.

On the basis of clinical and radiological data, in typical cases it is not difficult to recognize and diagnose the compression wedge fracture of the body of the lumbar and thoracic vertebra. Spondylography allows you to refine and detail the nature of the damage, its features and shades. Serious difficulties can occur when recognizing light, minor degrees of compression of vertebral bodies, especially in the thoracic department. Additional spondylograms, including sighting, and sometimes tomography, analysis of clinical and radiological data in dynamics in the vast majority of cases allow us to approach the truth.

In the presence of appropriate clinical and anamnestic data pointing to fracture of the vertebral body, in the absence of convincing roentgenologic symptoms, one should incline towards the diagnosis of fracture and treat the injured person as having a fractured vertebral body. Only with the appearance in the future of convincing and indisputable evidence of the absence of damage can we abandon the alleged diagnosis. Such tactics will protect the victim from unwanted and sometimes severe late complications arising in the event of undiagnosed damage.

Treatment of compression wedge-shaped uncomplicated fractures of the thoracic and lumbar vertebral bodies

In the treatment of compression wedge-shaped uncomplicated fractures of the thoracic and lumbar vertebral bodies, as in the treatment of fractures in general, the ultimate goal is to restore the anatomical shape of the damaged segment and restore its function. There is no doubt that the restoration of the anatomical shape of the damaged bone segment with proper treatment more often contributes to a more complete restoration of function. Unfortunately, this seemingly quite obvious situation is most often disturbed in the treatment of compression wedge-shaped uncomplicated vertebral fractures. Many traumatologists have firmly established the idea that the loss of the correct anatomical shape of the body of one vertebra does not conceal any trouble for the injured and is easily compensated for by changing the position of other segments of the spinal column. It is this concept that is one of the main causes of unsatisfactory nondes, not so rarely observed in the treatment of these injuries.

The ideal method of treatment of uncomplicated compression wedge fractures of the lumbar and thoracic vertebral bodies is one that would restore the anatomical shape of the damaged vertebral body, eliminate the vertical load on it, reliably hold the position of the achieved reclination and create a prolonged immobilization of the damaged vertebral segment for a period necessary for healing the fracture , not limiting the function above and underlying the spine. Conventional existing methods of treatment of compression wedge fractures of vertebral bodies do not meet all these requirements. The method we proposed is not ideal in the full sense of the word with the use of a "screed" fixator.

Among the existing methods of treatment of uncomplicated compression wedge fractures of the lumbar and thoracic vertebrae bodies are the following:

• method of one-stage repositioning followed by immobilization with a gypsum corset;
• method of gradual step-by-step repositioning;
• functional method;
• surgical methods of treatment;
• complex functional method with the use of a fixator-"screed".

The method of one-stage repositioning followed by immobilization with a gypsum corset. Feasibility and the possibility of restoring the anatomical shape of the fractured vertebra by extension and re-opening of the spine was expressed by Henle at the end of the 19th century. Implementation of this idea in practice was restrained by fear of the possibility of damage to the spinal cord during reposition. In 1927, Dunlop and Parker proved that the anatomical shape of the fractured vertebra could be restored by stretching and extending the spine. Wagner and Stopler (1928) managed to reach the body of a broken vertebra of the body in a number of victims, but could not keep it in the corrected position. Only after 1929, when the works of Davis were published, and subsequently Boliler, Watson Jones, BA Petrova, II. E. Kazakevich, A. Velikoretsky, and others, the detailed and justified method of one-stage repositioning became part of everyday practice. In our country this method has not received a significant spread.

Simultaneous correction is performed under local anesthesia by the Shnek method. The victim is laid on his side. Palpation, focusing on local soreness, compared with the data of spondylography determine the spinous process of the damaged vertebra. If the lumbar vertebra is damaged, retreating 6 cm from the line of spinous processes to the side on which the injured person lies, mark the point of injection of the needle. Injection needle 16 cm long through the wetted point is injected from the bottom upwards at an angle of 35 °. As the needle moves, the tissue is anesthetized with a 0.25% solution of novocaine. Depending on the severity of the subcutaneous fat and musculature at about 6-8 cm, the tip of the needle rests against the posterior surface of the transverse process. The injection needle is somewhat pulled backward, the angle of its inclination is not changed in any way so that when it moves to the depth it slides along the upper edge of the transverse process. At a depth of 8-10-12 cm the tip of the needle rests against the posterior-lateral surface of the broken vertebra's body. A 5 ml 1% solution of novocaine is injected with a syringe. A syringe is taken from the pavilion of the needle. If a blood-stained liquid is allocated from the pavilion of the needle, this means that the needle is inserted into the hematoma in the area of injury. Otherwise, the needle is removed and re-introduced as described above to one vertebra above or below. In the region of the fractured vertebra, no more than 10 ml of 1% solution of novocaine should be administered, so that complications do not arise in the case of puncture of the dura mater or the penetration of novocaine through a possible rupture of it into the subarachnoid space.

When anesthetizing the body of the thoracic vertebra, the injection needle is inserted at the level of the spinous process of the overlying vertebra, since the spinous processes of the thoracic vertebrae are located more vertically and their apexes are below the corresponding body.

Anesthesia of the body of a fractured vertebra can be achieved by administering 40 ml of 0.25% solution of novocaine to the interstitial gap between the injured and adjacent vertebra. Once in the hematoma, the anesthetic solution reaches the fracture region. Anesthesia of a fractured vertebra can be achieved by intraosseous anesthesia - by injecting 10-50 ml of 0.25% solution of novocaine into the spinous process of the damaged vertebra. In this latter case, anesthesia is achieved for a very short time, since the solution of novocaine is quickly carried away by the flow of venous blood.

With technically correct anesthesia, beats in the region of the broken vertebra disappear rather quickly or decrease significantly.

Method of one-time correction

One-time control can be achieved in various ways. Bohler produces one-step forced forwarding using two tables of different heights; they are installed along one line so that there is a gap between them that allows one to freely approach the body of the victim during the lumbar and most of the thoracic spine. The injured person is laid in the position on the abdomen so that his legs and lower body are placed on the lower table approximately to the level of the anterior upper limbs of the iliac crest. And on a higher table it rests with axillary areas and arms bent at the elbow joints anteriorly. In this position, the spine of the injured person, as it were, sags between the tables and "overstrains".

In this position, the victim is 15-20 minutes, after which they impose a plaster corset, which preserves the position of the spine achieved during the process of reclamation.

Watson Jones produces one-step forced forwarding by means of traction through a block fixed to the ceiling. For this, the victim is laid on the table in the position on the stomach. In case of damage to the lumbar vertebrae, the traction is carried out by special straps for the lower parts of the legs of the straightened legs, with damage to the upper lumbar vertebrae or lower thoracic vertebrae - by special straps by the thorax. In the position of the achieved "overextension" also impose a plaster corset.

The degree of achieved expansion of the body of the fractured vertebra in the process of forced one-moment correction is controlled by profile spondylograms.

Very important is the question of the duration of wearing a corset after a one-stage forced reposition. BA Petrov, Bohler consider the period of immobilization with plaster corset to be sufficient for 2-3 months, IE Kazakevich, Watson Jones - for 4-6 months, and Kazmirowicz (1959) - 8-9 months. It is well known that the process of healing the body of a broken vertebra is quite long and takes 10-12 months. For this reason, external immobilization with gypsum, and then removable corset should be long - at least 1 year, otherwise the secondary compression of the broken vertebra may occur. Wearing gypsum and a removable orthopedic corset should be accompanied by a therapeutic massage and gymnastics aimed at preventing the development of atrophy and weakness of the musculature.

The method is not fraught with danger if it is used for correct indications only with compression wedge-shaped uncomplicated fractures of the bodies of the thoracic and lumbar vertebrae.

The main disadvantage of this method of treatment of compression wedge-shaped fractures of vertebral bodies is the need for prolonged wearing of gypsum, and then removable orthopedic corset. Negative moments of corset immobilization are well known. These include unhygienic, the need to immobilize intact spine sections, which puts the spine in conditions of passive relaxation, restriction of the function of the thorax and its organs, atrophy and weakness of the musculature. The most significant drawback of this method of treatment is the inability to quite often prevent the secondary deformation of the body of a fractured vertebra.

The method of the step-by-step repositioning of the body of a broken vertebra is not a one-stage, but a gradual, stage-by-stage expansion of the vertebra. Various authors proposed various devices in the form of pads, special frames, stands, etc.

The simplest and most effective method is the stage-by-stage repositioning of AV Kaplan. It boils down to the following. Immediately upon admission to the hospital, the victim is placed on a hard bed in the position on the back. A small, thick roller is placed under the waist. After a day, this roller is replaced with a higher one, and after 1 or 2 days a large roller of width 15-20 cm and height of 7-10 cm is fed under the waist. Due to the "over-bending" on the roller, the broken vertebra is gradually expanded and its anatomical integrity is restored. According to the author of the method, this method is more easily tolerated by the victims - they gradually get used to the dosed "overdisplay", with no paresis, or more rarely, intestinal paresis, delay in urination and other possible complications. In some cases, the author advises to combine stepwise expansion with one-stage stretching along an inclined plane. In the process of gradual spreading of the toll of the fractured vertebra, spondylography is monitored.

On the 8th-15th day, a gypsum corset is applied with "small displacements" for a period of 2-3 months, and for "large" - for 4 months. The ability to work is restored in 4-6 months. Patients engaged in heavy physical labor, for a year from the end of treatment transferred to light work.

AV Kaplan (1967) notes that in recent years, after the stage reposition, he fixes the broken vertebrae behind the spinous processes with metal plates. This suggests that, apparently, not always a stepwise repositioning followed by a prolonged wearing of the corset leads to favorable outcomes.

The functional method of treatment of uncomplicated wedge-shaped fractures of the bodies of the lumbar and thoracic vertebrae has become particularly widespread in our country. Until now, it is a method of choice in the treatment of compression fractures in vertebrae in many trauma hospitals.

The functional method is based on the concept of Magnus (1929, 1931) and Haumann (1930) that the compression wedge-shaped fracture of the body of the lumbar or thoracic vertebrae is punctured, which in itself favors the fastest healing of the fracture and excludes the possibility of secondary displacement, is impractical and unlikely (Klapp). In the opinion of V. V. Gornnevskaya and E. F. Dreving, the plaster corset, delaying the regeneration of the broken vertebra and causing atrophy of the musculature, causes more harm than good.

Proceeding from the above, the authors of the method believe that the expansion of the body of the fractured vertebra is harmful and that restoration of the anatomical shape of the fractured vertebra in the course of treatment does not follow. The main thing in the treatment of this type of damage, in their opinion, is to create a good "muscle corset", which is achieved by therapeutic gymnastics; The authors believe that therapeutic gymnastics speeds up the regeneration processes in the broken vertebra, that under the influence of systematic "thrust and dosed load", an appropriate reconstruction of the spongy substance of the broken vertebra body occurs and the bone trabeculae are located in statically advantageous directions during the process of restructuring.

To create a "muscular corset" EF Dreving developed a harmonious system of therapeutic gymnastics, which includes four periods.

The essence of the method is reduced to the fact that the victim is placed on a hard bed with an inclined plane on the traction with the help of the Glisson loop and the rings for the axillary areas. From the first hours and days begin to conduct therapeutic gymnastics aimed at strengthening and developing the muscles of the spine, back and stomach .. After 2 months. By the time when the victim rises to his feet, a well-pronounced "muscular corset" is formed, holding the spine in a state of some hyperextension.

Functional focus of the method, its simplicity and accessibility. The lack of need for active manipulation and wearing of a corset led to the fact that this method quickly gained considerable distribution. The experience of applying it in practice for 35 years has made it possible to identify a number of significant shortcomings. These include the inability to comply with the correct treatment regimen. Thus, according to AV Timofeevich (1954), 50% of the victims who were treated with a functional method failed to sustain the necessary regimen and were discharged from the hospital ahead of schedule. Only 10% of the victims did the recommended outpatient treatment. This is explained by the fact that, after passing through acute trauma phenomena, the victims feel healthy, forget about the fracture of the spine and do not want to burden themselves with treatment. In many cases, it is not possible to form a "muscular corset" (especially in elderly and obese people, in weakened patients with concomitant diseases. The disadvantage of the method is the need for prolonged stay in bed, etc. However, the most serious drawback of this method is the refusal to restore anatomical shape of the fractured vertebra, which, in our deep conviction, is the main cause of subsequent complications.

Operative methods of treatment

The surgical methods for treating spine injuries described in the literature refer to the treatment of various other clinical forms of its damage and are not directly related to the treatment of compression wedge-shaped uncomplicated fractures of the bodies of the lumbar and thoracic vertebrae. Only in recent years some authors have proposed methods of surgical treatment of uncomplicated compression wedge fractures of the bodies of the lumbar and thoracic vertebrae.

Complex functional method with the use of a fixer-"screed"

Close to the ideal method of treatment of uncomplicated compression wedge fractures of the bodies of the lumbar and lower thoracic vertebrae is one that would allow a reliable immobilization of the damaged segment of the spine after restoration of the anatomical shape of the fractured vertebra for the period necessary for healing the fracture and at the same time would not interfere with the creation of a "muscular corset ", Would relieve the victim from having to stay in bed and wearing a corset.

Proposed by us and developed with the participation of E. A. Ramich and A. I. Koroleva, a complex functional method of treatment with temporary internal fixation of the damaged spine segment with a "screed" fixer meets some of the tasks mentioned. The basis of this method is a temporary internal fixation of the damaged segment of the spine with a special metal fixer-"screed".

The use of metal to fix broken vertebrae is not new. Wilkins (1886) first wired broken arms of the vertebrae. Novak (1952) for the first time applied a wire seam in the treatment of uncomplicated compression wedge fractures of vertebral bodies in a group of victims. Havlin (1961) modified the technique of laying a wire seam. Ladio (1959) uses the final screw metal retainer to stabilize the fracture-dislocation of the thoracic and lumbar localization.

Indications: closed uncomplicated compression wedge fractures of the lower thoracic and lumbar vertebral bodies.

In the process of treatment, three periods are conventionally distinguished. The first period covers the length of time from the moment of receipt of the victim to the hospital until the operational internal fixation.

The task of the first period is elimination of acute phenomena of the former damage, improvement of the general condition of the victim, correction of axial deformation of the spine, restoration of the anatomical shape of the fractured vertebra.

The same period is preparatory for the subsequent internal fixation. Its average duration is 7-10 days.

Immediately upon admission of the victim to the hospital, the diagnosis and the specification of the localization of the lesion, an anesthetic of the injury site is performed.

Anesthesia of the body of a broken vertebra is performed according to Shnek. The technique of anesthesia is described above. The victim is laid on a hard bed. Under the damaged section of the spine a cloth hammock is attached, at the ends of which are fixed metal cables that are tossed through blocks fixed on two Balkan frames on the bed. To the cables hang a load of 3-5 kg. During the first 3-5 days, the cargo is increased to 12-18 kg, depending on the weight of the victim. With this gradual reclination, it is possible not only to correct the axial deformation of the spine, but also to restore the anatomical shape of the broken vertebra body. The use of a hammock for reclining is more convenient for the patient and for the staff than using sandbags or other hard recliners.

Co of the second day, the victim begins to engage in therapeutic gymnastics in the complexes developed by AI Korolyova and E. A. Ramikh. These gymnastic complexes are based on the technique of EF Dreving, which is modified taking into account the short period of the patient's stay in bed and the subsequent early gymnastics in the standing position. The first complex, designed for the first 2-3 days, basically involves exercises of a general hygienic nature. Much attention is paid to breathing exercises. At the same time, gradually include exercises designed to strengthen the extensors of the back. At the end of the first period, exercises are introduced for a more active training of the muscles of the back and abdominals, some power exercises for the upper limbs, "half-knives", and walking in place, etc., are introduced.

The second period of complex functional treatment covers "a short period of time necessary for the internal fixation of the damaged spine segment in an operative way by a metal fixer" screed ".

Clamping device "screed" consists of a coupling and two hooks. The coupling is a cylindrical tube 50 mm in length. Its internal diameter is 4.5 mm, the outer diameter is 6 mm.

Anesthesia, as a rule, is performed as a local layer-by-layer infiltration with 0.25% solution of novocaine and supplemented with the introduction of 1% novocaine solution to the body of the broken vertebra. It is quite permissible, and for especially reactive patients, endotracheal anesthesia is preferable. In these cases, at certain times of intervention, muscle relaxation occurs. For this period the patient is transferred to controlled breathing.

Use a universal surgical operating table, on which the victim is placed in the position on the stomach.

Guided by anatomical landmarks, compared with the available anteroposterior spondylogram, the spinous process of the fractured vertebra is localized and labeled with a metal injection needle inserted into its apex. It should be borne in mind that it is not always easy to determine the spinous process of a fractured vertebra, as usually the axial deformation of the spine is eliminated and the pain reaction to pressure disappears by the time of surgery.

The technique of internal fixation of a damaged spine segment is as follows. A median linear incision along the line connecting the tips of spinous shoots cuts the skin, subcutaneous tissue, superficial fascia layer by layer. The tops of spinous processes are exposed, covered with an adnate bundle. On the right or left, depending on the nature of the deformation of the spine in the injury bridge, a lumbosacral fascia is dissected at the lateral surface of the spinous processes 0.5 cm from the midline. The choice of the side of the dissection of the fascia, and ultimately the side of the fixation of the "screed" depends on whether there is an angular deformation of the spine to the side. If there is one, then it is more advantageous to install the retainer on the convex side of the deformation; If the angular deformation is absent, it does not matter which side to install the clamp.

The size of the cutaneous incision approximates the extent of 4-5 vertebrae. With the help of a scalpel, scissors and a vertebral raspator, a long, partially blunt path from the lateral surface of the spinous processes and arches separates the long back muscles along the broken higher and lower vertebrae. Inevitable bleeding stops rather quickly with tamponade with gauze napkins moistened with hot physiological solution. In the wound, the bases of three spinous processes and interstitial spaces, made by interstitial ligaments, become visible.

One of the hooks of the clamp-"screed" is unscrewed from the coupling. Hooks of the scaffold-"ties", one of which is left in connection with the coupling, a sharp curved end is introduced into the interstitial space, they cover the upper surface of the spinous process of the vertebra, located above the broken vertebra. The coupler lies at the base of the spinous processes along their lateral surface. The previously unscrewed second hook is inserted into the interstitial space with an edge, it covers the lower surface of the spinous process of the vertebra located under the broken vertebra, its end bearing thread is in contact with the coupling. Fixation is usually subject to three vertebrae: injured, above and below. Accordingly, and set hooks fnksatora-"ties". A control radiography in an anteroposterior projection is made, by means of which the surgeon is convinced that the fixator is inserted correctly.

Having ascertained the exact location of the fixation clamp, the surgeon makes anesthesia of the region of the broken body by administering 10 ml of a 1% solution of novocaine. Naturally, this manipulation is carried out only if the intervention is performed under local anesthesia!

The patient is given an extension position. If the lumbar vertebra is broken, then a large hyperextension is attached to the scabrous end of the trunk; if the lower thoracic vertebra is damaged, then overdistension is given to the head end of the trunk. This position is given to the patient using a cable fixed with a leather cuff or on the shins of the victim or on the chest and the position of the operating table.

In the retuning position, the clamping device "screed" is twisted and stabilizes the damaged spine in the position of correction achieved. When the compression of the vertebra is not fully extended, additional extension of its body occurs when the latch is pulled. In the position of hyperexstensin, the main load of the overlying spine is in the posterior, unaffected part of the spine, which contributes to the faster healing of the fracture.

It should be noted that when an operative intervention is performed under local anesthesia, the hyperextension given to the affected person is rather unpleasant for him. Therefore, in this position, it must be a minimum time.

During the operation, a thorough hemostasis is produced. The wound is sutured layer by layer. Subcutaneous fat is injected with a rubber strip for 24 hours. Apply an aseptic bandage.

After acquiring some skill with careful, consistent and pedantic implementation of the operation, it is not difficult to implement and takes minimal time.

The third period of complex functional treatment is the longest. It begins practically from the moment of the end of the operative intervention, and ends at the recovery of the patient.

The task of the third period is the earliest possible rehabilitation of the victim and his return to useful work.

The presence of a strong and reliable fixation of the damaged segment of the spine, achieved with the help of the "screed" fixer, creates optimal conditions for performing active functional therapy, which contributes to the fastest healing of the fracture and the creation of a "muscle corset".

Due to reliable internal fixation of the damaged spine after 14-16 days after surgery, it is possible to put the injured to the feet and conduct active curative gymnastics in a standing position. The effectiveness of early exercise therapy in standing position in the absence of restriction of function in undamaged parts of the spine is quite obvious.

The patient is placed on the bed with a shield in the position on the back. Under the back, at the level of the damaged spine, a hammock is introduced with weights of 3-5 kg on each side at its ends. During the first postoperative days, the victim usually receives anesthetics and antibiotics. If necessary, conduct appropriate symptomatic treatment.

From the first day after surgery, the victim begins to engage in therapeutic gymnastics. The complex of gymnastic exercises in the 1st - 3rd day is designed for 10-15 minutes and is built from general hygienic to general restorative exercises. These are predominantly static and dynamic breathing exercises (complete breathing, abdominal breathing according to IM Sarkizov-Sirazini). Exercises are selected strictly individually taking into account the patient's condition.

On the 2nd day after surgery, the victim is allowed to turn gently on his side. Change the dressing, remove the rubber graduate, inspect the wound. Apply an aseptic bandage.

On the 4th day after the operation, a set of exercises is introduced, designed to strengthen the muscles of the lower extremities and extensors of the back. Continue breathing exercises. With these gymnastic exercises the victim is gradually prepared for the transition from horizontal to vertical position. The complex of exercises is designed for 15-20 minutes and is repeated 5-6 times during the day.

Starting from the 7th day, the third set of gymnastic exercises is introduced. This complex provides for an even more intense training of the muscles of the back and lower limbs. Additionally include exercises in the position on the abdomen. On the 8th-9th day, sutures are removed. On the 4-16th day, the victim is allowed to stand up. Gymnastic exercises of this period are combined into the fourth complex. It usually begins with a series of exercises of previous complexes, after which the victim is transferred to a vertical position. On the first day, the sufferer usually gets accustomed to the vertical position, stands by the bed, tries to walk in the ward. Gymnastics ends with a series of dynamic breathing exercises in prone position.

3-4 days after the transfer of the victim to the vertical position, gymnastic exercises are carried out mainly from the standing position. In addition to the power exercises of the previous complexes include exercises for the lower limbs and pelvis, for the extensor back. A rest between exercise is free walking and breathing exercises. This fifth complex is designed for 35-40 minutes.

Usually, by the end of the 3rd - the beginning of the 4th week after the operation of internal fixation of the victim in good condition, they are prescribed for outpatient treatment. At home, he continues to practice therapeutic gymnastics mainly from the fifth complex. Duration of gymnastics for 30-40 minutes 3-4 times a day.

Approximately by the end of the 2nd month after the operation, work is allowed that is not associated with significant physical stress. In the future, it is highly desirable to have a systematic permanent exercise with therapeutic gymnastics.

This is the general scheme of complex functional treatment of uncomplicated wedge-shaped compression fractures of the vertebral bodies of the lumbar and lower thoracic localization. Naturally, depending on the individual characteristics of the victim, the nature and localization of damage, age, etc., this scheme may vary.

The described complex functional method of treatment with the use of a scaffold-scraper method of choice in the treatment of various kinds of uncomplicated compression wedge fractures of the lumbar and thoracic spine, in particular compression wedge-shaped uncomplicated fractures of the lumbar and thoracic vertebral bodies with varying degrees of reduction in their height, uncomplicated compression wedge fractures of the bodies of the lumbar and thoracic vertebrae with detachment of the cranioventral angle, compression fractures of the lumbar vertebra with a break in zamykatslyyuy plate - the so-called penetrating fractures.

SS Tkachenko (1970) modified the fixator-"screed", called it "special", and modified the technique of its superposition. The modification of the "screed" consists in a certain change in the angle of inclination of the hooks. In our opinion, it somewhat reduces the possibility of its "work" on twisting. More serious objections are available on the technique of intervention recommended by SS Tkachenko. Hooks-"ties" are fastened behind the spinous processes, and in half, for which the yellow ligaments are previously exfoliated, they produce "partial resection of the part of the arch" near its root. In defects formed at partial resection of the bow, hooks are introduced-"ties". Thus, foreign metal bodies are introduced into the lumen of the vertebral dripping, the interruption of which epidural fiber will certainly react. It is difficult to say what effect these moments will have on the relationship between the spinal cord and the walls of the spinal canal.

Recommendations of the author with a fracture of the body of one vertebra to fix not 3, but 4 vertebrae are hardly justified.

[3], [4]

Anterior spondylodesis in the treatment of closed uncomplicated, "penetrating" fractures of the thoracic vertebral bodies

Closed compression wedge-shaped fractures of the bodies of the thoracic vertebrae occur with the flexion mechanism of violence. In cases of damage to the cranial or, more rarely, caudal closure plate, the intervertebral disc is damaged - this fracture should be referred to a group of heavier "penetrating" ones.

The compression fractures of the lumbar vertebrae with detachment of the cranio-ventral angle are also essentially "penetrating". However, with these lesions, the powerful lumbar intervertebral disc either does not suffer, or its damage is subsequently compensated to a certain extent by cicatricial healing of the disc. In the thoracic region intervertebral disks are of low power and, as a rule, their damage entails the subsequent occurrence of intervertebral osteochondrosis.

It is known that every pathological process in the anterior parts of the spine entails the development of kyphotic deformation. This is especially true of the thoracic spine, the anatomical norm of which is a moderate physiological kyphosis. As a rule, this kyphosis increases and takes the character of the pathological after compression fractures of the thoracic vertebral bodies. This is due to the almost inevitable secondary decrease in the height of the broken vertebra's body. Some surgeons believe that the wedge-shaped compression of one vertebra and even the axial deformation of the spine do not affect its function and do not cause pathological phenomena. Our numerous observations confirm this. Relatively small wedge deformation of the body of only one vertebra, without a rough axial deformation of the spine, can lead to pain, functional backbone inconsistency, and in some cases, disability.

The existing methods of treating these spine injuries are not always able to prevent the occurrence of these pathological phenomena. Experience shows that even an early posterior spinal fusion in these cases can be untenable,

Indications for anterior spondylodesis of the thoracic vertebrae are "penetrating" compression fractures of the thoracic vertebral bodies in young patients.

The main task of anterior spondylodesis is to maintain the normal height of the anterior part of the injured spine segment, to prevent secondary compression of the injured vertebrae and axial deformation of the spine, to prevent the development of intervertebral osteochondrosis in damaged discs. The most favorable time for intervention in the absence of contraindications is 5-7 days after the injury. Anesthesia is endotracheal anesthesia with controlled breathing.

The victim is placed on the operating table on the left side and slightly deployed on the back. The right arm is extended upward. The left leg is bent at the knee and hip joints.

Online access. Preference should be given to right-sided Crespleural access, however, left-sided access may be used if necessary. Depending on the level of damage, the level of access is also chosen: for the lower thoracic - the level of the IX rib, for the middle chest - the level of the VI rib.

Cutaneous incision is performed along the corresponding rib from the paravertebral to the anterior axillary line. Split the skin, subcutaneous fat, surface fascia. Dissect the superficial sheet of the periosteum along the rib, planned for resection. The rib is secreted subperiosteally and resected from the cervix to the anterior axillary line. Dissect a deep leaf of the periosteum and parietal pleura. They open the pleural cavity and perform its examination.

In the presence of intrapleural fusion, they are separated by a blunt or acute route, depending on their nature. With the help of a screw retractor dilute the edges of the wound of the chest. The lung is displaced to the root - the anterior-lateral surface of the thoracic vertebra becomes visible and accessible for manipulation. Through the translucent mediastinal pleura are visible intercostal vessels that run along the front surface of the bodies of the thoracic vertebrae, twigs of the large internal nerve and the intervertebral discs that stand in the form of ridges. Along the left axial surface of the spine is clearly visible pulsating thoracic aorta. On the right, closer to the posterior lateral surface of the bodies of the thoracic vertebrae, an unpaired vein is visible. The damaged vertebra is easily detected by decreasing the height of its ventral wall, along the narrowed, disc-shaped disc or disk that has lost its characteristic shape. Often helps in the orientation of subpleural hemorrhage.

At the slightest difficulty in localizing the area of damage, it is necessary to resort to control radiography with a preliminary marking of the intended site of damage with injection needles.

Linear sections of the long axis of the spine, slightly to the right of the akin line, dissect the mediastinal pleura.

The mediastinal pleura should be cut to the right of the middle line in order not to enter into a conflict with the thoracic duct. The mediastinal pleura is exfoliated. If necessary, right-sided access can be approached to the aorta, the left lateral surface of the vertebral bodies and the left paravertebral area. After dissecting the mediastinal pleura, the anterior longitudinal ligament and the underlying structures are exposed. Isolate, bandage and dissect intercostal arteries and veins passing along the front surface of the vertebral bodies. Isolate and divert aside the lateral surfaces of the branch of the large internal nerve. The anterolateral surface of vertebral bodies, anterior longitudinal ligament and intervertebral discs are exposed. The length of exposure of the anterior surface of the spine depends on the number of damaged vertebrae.

[5], [6]