Subluxations, dislocations and fracture-dislocations of the thoracic and lumbar spine: causes, symptoms, diagnosis, treatment

Subluxations of lumbar vertebrae are rare. Clinically, they often take the form of "bruises" of the spine or "stretching" of its ligament apparatus. They are easily corrected in the position of moderate spinal extensionality and, as a rule, do not determine radiographically at the time of the patient's admission to the hospital.

Unlike the cervical spine, the clean dislocations of the lumbar and lower thoracic vertebrae are also extremely rare in clinical practice. Their clinical manifestations, symptomatology, diagnosis and treatment have much in common with the fracture-dislocations of this localization, why it is advisable to treat them together. Differentiation of pure dislocation from fracture-dislocation is possible only on the basis of X-ray data.

The lumbar and lower thoracic spine are the most frequent localization for fracture-dislocations. Fractures in the thoracic spine are very rare due to anatomical and functional features of the thoracic spine.

Fractures-dislocations are the most severe injuries of the lumbar and lower thoracic spine. They arise under the influence of massive violence, accompanied by concomitant injuries, severe shock and almost always combine with the damage of the contents of the spinal canal.

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

What causes fracture-dislocation of the thoracic and lumbar spine?

Mechanism. Fracture dislocations arise from the flexor-rotational mechanism of violence, but can also occur with flexion violence, when violence, breaking the strength of the anterior parts of the vertebra, causes a fracture of the body and, continuing to act, disrupts the integrity of the posterior support complex. In more rare cases, the emergence of fracture-dislocations is possible with the extensor mechanism of violence. However, the most typical is the flexion-rotational mechanism. Often fracture-dislocations occur in the fall, road and rail accidents.

Symptoms of fractures and dislocations of the thoracic and lumbar spine

Anamnestic data, which allows us to specify the circumstances of the damage, the immediate material causes that caused the damage, and the mechanism of the violence, suggest a fracture-dislocation.

Complaints of the victim depend on his general condition, the severity of traumatic shock, the presence or absence of complications from the spinal cord and its elements, the presence or absence of concomitant damage to other organs. A brain concussion or bruise can lead to retrograde amnesia and make it difficult to find out an anamnesis. The victim may be unconscious, which makes it even more difficult to identify complaints and circumstances of damage.

The most typical complaints are pain pains in the area of damage, amplified when trying to reproduce certain movements, complaints of abdominal pain, varying degrees of intensity of sensitivity disorder and restriction or loss of active movements below the injury site. In many respects, complaints depend on the period that has elapsed since the injury occurred. In a later period, the victim complains of the impossibility of independent urination (with complicated fracture dislocations with a disorder of pelvic organs), pain in the kidneys, general weakness, etc. With pronounced degrees of traumatic shock, the victim may not make any complaints, he is apathetic, does not react to the environment.

Objective data largely depends on the nature of the damage. As a rule, the victim takes a forced position. Skin and mucous membranes are pale. In the area of the shoulder or shoulder blade there may be traces of contusion in the form of abrasions, bruising, swelling. The detection of these data allows us to confirm the flexural-rotational mechanism of violence and to suspect the presence of unstable damage. Traces of injury in typical places may not be, if the damage arose from a fall, road or railway accident. In these cases bruising and abrasions are localized in the most diverse areas of the victim's body. With complicated injuries, which are almost the rule in fracture-dislocations, symptoms of damage to the spinal cord or its roots are observed. The nature of the disorder of sensitivity and disturbance of active movements, the degree of their severity and extent, the presence or absence of pelvic disorders, the prevalence of paresis or paralysis depend on the level of damage to the spinal cord or horse tail, the nature and extent of their damage. Neurological manifestations should be identified on the basis of a detailed and qualified neurological examination. The most typical local symptom of fracture-dislocation is the disruption of the length of the line, which runs through the tips of the spinous processes. If there is a lateral displacement of the cranial segment of the spine, the line traversed through the apex of the spinous processes becomes bayonet - from the fracture level it deviates at a right angle to the side into which the cranial segment of the spine has shifted. When the anterior processes of the vertebrae, located directly above the site of injury, are displaced anteriorly, they fall forward and are probed less distinctly than the underlying ones. More often the displacement is combined - to the side and forward, which is reflected in the change in the line of spinous processes. In this place, usually local soreness and swelling, extending to the lumbar and perineal region, are noted. The victim's torso can be deformed due to displacement of the vertebrae and local swelling of soft tissues due to hemorrhage.

From the front abdominal wall, as a rule, the symptoms of peritoneism are revealed, which is due to the presence of retroperitoneal hematoma and damage to the roots of the spinal cord, which can simulate the clinical picture of the "acute abdomen."

To clarify the nature of damage to the contents of the spinal canal, a spinal puncture is performed with appropriate indications, followed by examination of the cerebrospinal fluid (presence of blood, cytosis, protein). In the process of performing spinal puncture, the liquorodynamic tests of Quakenstedt and Stukkei are made for the presence or absence of a sub-abdominal space block. A partial or especially complete block of the subarachnoid space indicates the compression of the spinal cord and is an indication for an urgent audit of the contents of the spinal canal. The absence of violation of patency of the subarachnoid space is not a guarantee of well-being in the vertebral canal.

Diagnosis of fracture-dislocation of thoracic and lumbar spine

Produce a spondylography in two typical projections. Since fracture-dislocation refers to the number of unstable injuries, an X-ray examination should be performed in compliance with all precautions that preclude additional displacement of the vertebrae or damage to the contents of the vertebral canal. Direct and profile spondylograms should be done without changing the position of the victim, in view of the possibility of secondary trauma.

Possible variants of vertebral lesions and their displacements are described by us in the above classification.

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

Conservative treatment of dislocations and fracture-dislocations of the thoracic and lumbar spine

Conservative treatment of dislocations and fracture-dislocation of the lumbar, lower thoracic and thoracic spine, according to our data, is ineffective. The basis for this statement is the following:

• conservative treatment does not provide much-needed in these cases reliable early stabilization of the damaged spine segment;
• Closed direction of the occurring in this area of clasped single or bilateral dislocations or fracture-dislocations, as a rule, is untenable;
• often associated with these injuries, concomitant damage to the spinal cord or its elements is often an indication for the audit of the contents of the spinal canal, which can only be performed operatively;
• often occurring in these lesions, the complex dislocation plane (dislocation, fracture) of the vertebral elements makes it impossible to adapt the displaced fragments.

The forced one-moment correction for these injuries is contraindicated.

From the existing methods of conservative treatment, one can apply traction along the inclined plane or with the help of axillary traction or skeletal traction according to ZV Bazilevskaya. However, by these methods, as a rule, it is not possible to achieve the elimination of the existing displacement of fragments. In our opinion, these methods can be used in those cases when fracture-dislocation or dislocation for some reason can not be corrected and stabilized in an operative way, i.e., when there are absolute contraindications to surgical intervention and when this operative intervention more dangerous than the existing damage.

With fractures like "traumatic spondylolisthesis" in the lower lumbar region, in the absence of absolute indications to audit the contents of the vertebral canal, an attempt may be made to fix the displaced body of the lumbar vertebra by Johnson's method. The victim is laid on his back. They give anesthesia. The head, the forelegs and the thoracic section of the trunk rest on the table, and the lumbar region of the trunk and pelvis freely sag. The legs are bent at right angles to the knee and hip joints and in this position, together with the pelvis, are pulled upward and fixed in this position on a higher table. The sagging of the lumbar spine and the simultaneous pulling of the pelvis together with the sacrum to the top contribute to correcting the body of the vertebra that has moved forward. In the position of the achieved correction, a gypsum corset with a hip lock is applied. We have never succeeded in achieving this in this way.

You can make an attempt to correct "traumatic spondlolisthesis" and gradual skeletal traction. For this, the victim is placed on a bed with a rigid shield in the supine position on the back. Both his legs are placed on standard Belera-type tires. For epicondyle or tuberosity of the lumbar bones, skeletal traction is imposed by means of spokes. Extension is carried out by large loads along the hip axis. This method rarely leads to success.

[9], [10],

Operative treatment of dislocations and fracture-dislocations of the thoracic and lumbar spine

Due to the fact that dislocations and fracture-sprains of the spine are the most unstable of all known spine injuries, it is especially important as soon as possible and more reliably to translate them into stable ones. This applies equally to uncomplicated fracture-dislocations and to fracture-dislocations, complicated by damage to the elements of the spinal cord. In the first case, this is important, since considerable mobility of the vertebrae in the area of damage can lead to secondary damage to the elements of the spinal cord. The slightest careless movement, a more abrupt turn in bed, an inadvertent movement when laying a ship or changing bed linens can lead to disaster. In the second case, it is important not to exacerbate the existing damage to the spinal cord elements and create conditions for the treatment of trophic disorders and pressure sores. Reliability and good stability are achieved by internal fixation with metal plates bolted together by bolts.

Indication for the operation of internal fixation of the spine by metal plates with bolts are fracture-dislocations of the lumbar, lumbosacral and thoracic localization.

The task of surgical intervention is stabilization of the damaged spine segment. In the presence of complicated fracture-dislocation, it is also necessary to evaluate the state of the elements of the spinal cord.

The optimal timing for intervention is early, unless there are absolute life contraindications to it. If the patient's condition is serious, follow-up tactics should be applied for a while.

Preoperative preparation consists in the most careful transfer of the patient to the operating table, symptomatic medication, shaving the operating field.

Apply endotracheal anesthesia. The introduction of muscle relaxants greatly facilitates the correction of fracture-dislocation.

On the operating table, the victim is placed in the position on the abdomen.

The metal fiketor used to stabilize the fracture-dislocation of the lumbar and thoracic spine consists of two metal plates with holes for bolts made of stainless steel of the brand name. The plates have a rectangular shape with rounded edges. There is a set of plates of three sizes: 140, 160 and 180 mm. The width of each plate is 12 mm, thickness - 3 mm. Every 7 mm in the plates there are holes with a diameter of 3.6 mm. The bolts have a length of 30 mm, a diameter of 3.6 mm.

Online access. Line cut through the line of spinous processes dissect the skin, subcutaneous tissue and fascia. Cutaneous incision is performed with calculation of exposure of the damaged vertebra - two overlying and two underlying vertebrae. The damaged vertebra should be located in the middle section. The tops of spinous processes are exposed, covered with an adnate bundle. The location of the lesion can be easily determined by the broken intermittent and interstitial ligaments, by the displacement of the overlying spinous process, depending on the nature of the displacement - sideways, upwards or downwards. Since more often antero-lateral dislocations are observed, the spinous process is displaced upwards, to the side and forward. The interstitial gap is increased. If a little time has passed since the injury, the paravertebral tissues are imbibed with blood. On either side of the spinous processes, the lumbosacral fascia is dissected. With the help of vertebral ropas and scissors, the muscles are separated from the spinous processes and arches. Separated muscles are diverted to the sides. In the wound are nude spinous processes, arches and articular processes of the vertebrae. After the muscles are diluted, the torn yellow ligaments, the broken articular processes and the displaced arms become clearly visible. Through the torn yellow ligaments, the dura mater is visible. It can be viewed through the interstitial space. By the presence or absence of cerebrospinal fluid, one can judge whether or not the spinal cord membranes are damaged. With the indications, the necessary intervention is made on the membranes of the spinal cord and the brain.

Technique of fixing and fixing the spine

The direction is controlled by the eyesight. With the help of helical elastic rods, fixed with leather cuffs on the ankles, head and axillary hollows, sprain is stretched along the length. Stretching is done carefully, dosed slowly, slowly. Often this stretching is quite enough to eliminate the lateral and antero-posterior displacement of the vertebrae. The correction can be supplemented by a surgeon, in the wound with bone forceps for spinous processes or arches of displaced vertebrae. In rare cases, there is a need to resort to side-screw propellers. Usually the correction in fresh cases is achieved quite easily. With grafting dislocations, one sometimes has to resort to resection of articular processes. After repositioning, the metal plates of the fixator are laid on the lateral surfaces of the bases of the spinous processes so that the middle of the length of the fixator falls to the site of the lesion. Depending on the degree of displacement, the size of the spinous processes, the musculature of the affected person fix 3 or 5 vertebrae. In addition to the displaced vertebra, 1-2 overlying and 1 - 2 underlying vertebrae are ligated. Fixation is carried out by bolts drawn through the holes in the plates and the base of the corresponding spinous process. The minimum displacement of the plates at the time of the bolt leads to a mismatch between the corresponding holes and makes it difficult to hold the bolts. To prevent this, through the holes in the plates and the bases of the spinous processes, bayonet-shaped awls are made, which make holes and do not allow the plates to move. Successively remove the awl, insert and fasten the bolt, remove the next awl, fasten the bolt, etc. Bolts are fastened with two wrenches. It is better to first fix the bolts passing through the extreme spinous processes. Produce a thorough hemostasis. Enter antibiotics. Apply layered seams to the edges of the wound.

Postoperative management for fractures and dislocations of the thoracic and lumbar spine

With the restoration of spontaneous breathing, extubation is performed. The victim is laid on his back in bed, equipped with two Balkan frames and a wooden shield. To relax the musculature and hold the spine in the position of a small extension under the damaged spine section, a cloth hamock is brought to the ends of which 3-5 kg are suspended. The legs are given a position of moderate flexion in the knee and hip joints.

Conduct symptomatic drug treatment, inject antibiotics. On the 7th-8th day, sutures are removed. From the first days, the active movement of the lower extremities is allowed to the affected person, massage. Breathing exercises, hand movements are mandatory from the first hours after the intervention. In bed, the victim spends 3-4 weeks. In some cases, a gypsum corset is applied through this period for l, 5 g for 2 months.

As a rule, by the end of the 5th-6th week the victim is discharged for outpatient treatment. Remove the latch should be no earlier than 1 year from the time of surgery.

Internal fixation with a metal retainer in fracture-dislocations and dislocations in the lumbar, lumbar-thoracic and thoracic spine can be combined with osteoplastic fixation according to the type of posterior spinal fusion. For this purpose, from the arch and posterior surfaces of the articular processes, a compact bone is removed before exposing the bleeding spongy bone. Bone grafts are placed in the prepared bed (auto- or homochondria). In connection with the severe condition of the victim, autoplasty is undesirable.

Fixation can be performed only with bone grafts used instead of metal plates and fixed, as well as metal plates, with bolts to the bases of spinous processes. When performing osteoplastic fixation, the cortical bone should be removed from the spinous processes and the adjacent sections of the arch.

Negative aspects of this method are long duration and traumatic intervention, some weakening of the strength of spinous processes and mandatory additional, longer external immobilization by the corset. When using only bone grafts with bolts, the fixation strength is very relative.

Early internal fixation with fracture-dislocations of the thoracic, thoraco-lumbar and lumbar spine allows instantly correcting the displaced vertebrae, transferring the damage from unstable to stable and reliably preventing the possibility of secondary damage to the contents of the spinal canal. Care for the victim is greatly facilitated.

Operative intervention on the contents of the spinal canal with closed complicated fractures of the spine

Our task does not include a detailed description of all the subtleties of the interventions on the contents of the spinal canal with complicated closed spinal injuries. Surgeon-traumatologist, who helps the injured with spinal cord injury, should have an idea of the technique of surgical intervention on the spinal cord, its roots and membranes, the need for which may arise during the intervention.

Violation of the active function of the spinal cord in complicated closed spinal injuries can depend on concussion and injury of the spinal cord, extra- and subdural hemorrhage, hemorrhage into the brain substance (hematoma), various degrees of damage to the spinal cord substance up to its complete anatomical break, spinal cord compression by fragments damaged vertebrae, damaged intervertebral disc and deformed vertebral canal.

In the first hours and days after the injury, it is not only possible to clarify the cause that caused the disturbance of the active function of the spinal cord. A detailed neurological examination of the patient affected by the dynamics, a qualitative X-ray examination, the use of special samples to determine the permeability of the subarachnoid space (liquorodynamic assays of Pussep, Stukkei, Queckenstedt, Ugryumov-Dobrotvorsky respiratory test), contrast X-ray methods of investigation facilitate this task and help to clarify the cause of conduction disturbance of the dorsal the brain. Naturally, liquorodynamic tests and simple spinal puncture should be performed only in the position of the victim lying down. It is necessary to resort to contrast methods of X-ray examination with caution and when absolutely necessary.

The optimal period of intervention should be considered 6-7th day from the moment of injury. If the cervical spine is damaged, these terms are significantly reduced.

Indications

Most authors give the following indications for revision of the contents of the spinal canal with complicated closed spinal injuries:

• the growth of phenomena from the side of the spinal cord in the form of paresis, paralysis, loss of sensitivity and pelvic disorders;
• violation of patency of subarachnoid spaces, determined by means of lkvorodynamic samples; VM Ugryumov emphasizes that maintaining the patency of the subarachnoid space is not an absolute sign of lack of interest in the spinal cord and its elements;
• finding of bone fragments in the spinal canal during X-ray examination;
• syndrome of acute damage to the anterior parts of the spinal cord.

In addition to the usual preoperative preparation (easily assimilated food, general hygiene measures, cleansing enema, bladder emptying, restorative and sedative treatment, etc.), serious attention should be paid to immobilization of the spine when transferring and rearranging the victim. It should be remembered that the slightest careless movement of the injured or the slightest carelessness when shifting it to a gurney or an operating table, especially with unstable damages, will cause additional damage to the spinal cord. With cervical localization of damage, this can cost the affected life.

The victim's position on the operating table depends on the level and nature of the damage. The victim should take such a position that, first of all, will not aggravate the displacement of fragments of the damaged spine and will be convenient for the intervention.

Preference should be given to endotracheal anesthesia, which facilitates not only intervention, but also subsequent correction and stabilization of the damaged spine segment. Laminectomy is feasible under local infiltration anesthesia.

The technique of interfering with the spine and the contents of the spinal canal

Use the back medial access. A linear incision is made along the line of spinous processes. Its length should be such that it starts at one vertebra above and ends at one vertebra below the expected level of laminectomy. A semi-oval cutaneous incision on the lateral base can also be used. Split the skin, subcutaneous fat, surface fascia. The edges of the cutaneous-fascial wound are spread out with sharp hooks. They expose the bony bundle covering the tips of the spinous processes. The bundle is dissected to the bone strictly along the midline. The lateral surfaces of the spinous processes, the arch, the region of the articular processes, are suburasthenic. Particular care and caution should be observed when separating soft tissues at the site of damaged vertebrae, as moving fragments of a broken arch with careless manipulations can cause additional damage to the spinal cord. Bleeding from the muscle wound is stopped with a tight tamponade gauze compresses moistened with hot saline. With the help of the retractor, the wounds are sliced apart. In one of the interstitial spaces intersect the interstitial and interstitial ligaments. At the bases, Diston's nippers are spiked with spinous processes during the planned laminectomy. Truncated spinous processes are removed along with the ligaments. In the area of one of the interstitial spaces, using a laminectomy, resection of the arches begins. The bite is produced from the middle to the articular processes. If more extensive resection is needed, including the removed part and articular processes, one should remember about possible bleeding from the veins. Resection of the arch of the cervical vertebrae lateral to the articular processes is fraught with the possibility of injuring the vertebral artery. When skewing the handles, care must be taken to ensure that the laminect does not injure the underlying casings and contents of the dural bag. The number of removable handles depends on the nature and extent of the damage. After removing the spinous processes and arches in the wound, epidural fiber is shown naked, in which the internal venous vertebral plexus is located. The veins of this plexus are devoid of valves, do not tend to collapse, since their walls are fixed to the cellulose. When they are damaged, significant bleeding occurs. Possible and air embolism. To prevent the occurrence of air embolism in case of damage to these veins, a tamponade should be performed immediately with moist gauze strips.

The arches are removed upward and downward until the unmodified epidural cell is exposed. Epidural fiber with the help of moist gauze balls is shifted to the sides. They expose the dura mater. Normal, unchanged dura mater is grayish, slightly shiny, pulsing synchronously with the pulse. In addition, the swelling of the dural sac is discarded, respiratory movements. Damaged dura mater has a darker coloration up to cherry bluish, loses its characteristic shine and transparency. If there is compression, the ripple disappears. A dural bag can be stretched, strained. Remove clots of fibrin, blood, loose bone fragments, scraps of ligaments. The presence of cerebrospinal fluid indicates damage to the dura mater. Small linear ruptures of the dura mater can be detected by increasing the cerebrospinal pressure of the compressed jugular veins.

With intervention under local anesthesia, this can be detected by coughing or straining. If there is a rupture of the dura mater, the latter is expanded. If it is kept intact along the middle line, a test cut is made 1.5-2 cm long. The presence or absence of subdural hematoma is determined through this incision.

The edges of the dissected dura are stitched with provigory ligatures and diluted to the sides. When expanding the section of the dura mater, it should not reach the edges of the bone wound (unremoved arch) by 0.5 cm. If a hemorrhage is detected, the spilled blood is carefully removed. If the arachnoid membrane is not changed, it is transparent and in the form of a light vesicle protrudes into the incision of the dura mater. It is subject to autopsy in the presence of subarachnoid accumulation of blood and damage to brain material. Absence of cerebrospinal fluid intake into the wound after opening the arachnoid membrane and carrying out liquorodynamic tests indicates a violation of the permeability of the subarachnoid space. Inspect the posterior and lateral surfaces of the spinal cord. According to the indications, the anterior surface of the spinal cord can also be inspected by carefully moving the spinal cord with a narrow medulla trowel. Brain detritus is removed. With cautious feeling, bone fragments can be found in the brain. The latter are subject to removal. Inspect the front wall of the dural sac. The fallen substance of the damaged intervertebral disc is removed. If there is deformation of the vertebral capal, it is corrected by the displacement of the displaced vertebrae. The dura mater is sutured with a continuous hermetic suture. In the presence of a significant swelling and swelling of the spinal cord, it is not necessary to cover the dura mater, according to some authors (Schneider et al.). If necessary, plasty of the dura mater can be performed.

It is mandatory to correct the fracture and stabilize it in one of the ways described above, depending on the nature and level of damage.

Reliable stabilization of the damaged spine should be the final stage of intervention in the complex treatment of complicated spinal injuries. Stabilization eliminates mobility in the area of damage, creates conditions for fracture fusion in anatomically correct position, prevents the occurrence of early and late complications, greatly facilitates post-operative care for the victim.

The wound is sewn layer by layer. Enter antibiotics. During the operation, carefully and pedantically make up for blood loss.

Postoperative management of the victim is dictated by the level and nature of damage and the technique of operative stabilization of the damaged spine. Details of it are set out above in the relevant sections on the surgical treatment of various spine injuries.

In patients with complicated spinal injuries, it is necessary to use other special measures in the postoperative period.

Careful attention is required cardiovascular and respiratory systems in the first hours and days after surgery. Intravenous administration of blood and blood substitutes is discontinued only after consistent alignment of blood pressure values. It is extremely important to systematically monitor blood pressure. In the ward, everything should be ready for an immediate infusion of blood, and, if necessary, also to the arterial administration of blood and other resuscitation measures. With respiratory disorders, intravenous lobulations or cytiton are administered. Subcutaneous administration of them is ineffective. In the case of increasing respiratory disorders, one should resort to the imposition of a tracheostomy and be ready to switch to artificial respiration.

In view of the fact that patients with complicated spinal injuries are prone to various infectious complications, massive and extended courses of treatment with broad-spectrum antibiotics should be carried out. It is necessary to determine the sensitivity of microflora to antibiotics and apply those to which the microflora of the patient is sensitive.

The closest attention should be paid to the prevention of pressure sores. Clean clothes, smooth sheets without the slightest folds, careful turning of the patient, careful skin care prevents the development of pressure sores. Under the area of the sacrum, a rubber circle is placed, under the heels - cotton-gauze "kalachki". It is very cautious to use a warmer, remembering that these patients may have a sensitivity disorder.

Serious attention should be paid to emptying the bladder and intestines. In cases of urinary retention, 1-2 times a day, urine should be excreted by the catheter. At the same time, strict observance of the rules of aseptic and antiseptic is essential. With a persistent delay in urination, the imposition of the Monroe system is shown and only in extreme cases of the suprapubic fistula. It is recommended to impose a tubular fistula, not a guboid, but when the mucous membrane of the bladder is not attached to the skin. The tubular fistula, after passing through the need for it, is closed independently. Indications for the closure of the suprapubic fistula are signs of restoration of urination. In these cases, the drainage tube is removed from the fistula and a permanent catheter is inserted for 6-10 days.

Systematic washing of the bladder with antiseptic solutions is mandatory, and the type of antiseptic is recommended to be periodically changed. Obligatory restorative treatment, vitamin therapy, rational nutrition. In later terms, it is necessary to apply massage, therapeutic gymnastics and physiotherapy.