Injury of the cervical spine

Injury of the cervical spine, especially in adults, refers to the most severe variants of injuries. For such injuries are typical:

• high risk of developing severe neurological complications, up to tetraplegia;
• a high incidence of lethal injuries, with death often occurring at the prehospital stage;
• a diverse nature of bone damage, due to the peculiar anatomical structure of the cervical spine.

The severity of the trauma of the cervical spine is often aggravated by the provision of insufficiently qualified medical care. This is due to several factors that are both objective and subjective:

• doctors, including traumatologists and neurosurgeons, are practically unaware of the features of cervical spine injuries and methods of their management;
• to date, the "market" of cervical orthoses is insufficiently filled, the role of which at the stages of treatment of injuries of the cervical spine can not be overestimated;
• there is clearly a deficit of modern domestic tools for low-traumatic operations in the cervical department, including tools for its internal instrumental fixation. This does not allow to carry out in sufficient volume a full-fledged surgical intervention on all parts of the cervical vertebrae and in the craniovertebral zone.

All of the above necessitated the need to acquaint the reader with the most frequent variants of traumas of atlantoaxial articulation and cervical vertebrae, some typical mechanisms of their origin, and also with the basic principles of their management.

Anterior Q dislocation, accompanied by a rupture of the transverse ligament and a sharp narrowing of the retrodental distance (SAC, see abbr.), Is in most cases a lethal trauma due to compression of the C2 distal medulla oblongata and the cranial region of the spinal cord. With this type of damage, it is necessary to fix the cervical spine and head in the position of extension of the head. Conservative methods, as a rule, can not achieve adequate stability of the Q-C2 segment, which leads to the development of chronic atlantoaxial instability, which in this case is potentially lethal and requires early or delayed surgical fixation.

Anterior C1 subluxation with a fracture of the base of the C2 tooth as compared to anterior dislocation C1 is more favorable for neurological complications by trauma. In children, the analogue of the fracture of the tooth C2 is the rupture of the corporeal-dental synchondrosis or epiphysiolysis of the tooth Cs. Treatment of this injury consists in carrying out traction on the Glisson loop or in the Halo apparatus in the position of extension of the head. After the elimination of subluxation confirmed by radiological examination, gypsum or orthosis fixation is performed for 12-16 weeks in adults or 6-8 for children in a rigid craniocervical dressing of Minerva type or a hardware fixation for Halo-cast. In the absence of fracture fusion in the long term, confirmed by functional radiographs in the flexion / extension position, surgical stabilization of the craniovertebral zone is recommended.

Posterior transcendental dislocation C1 is typical for trauma, accompanied by a sharp extension of the head, often noted when striking the submandibular zone (in adults). In newborns, this damage occurs when the head is excessively unbent during delivery, especially when using various obstetric obstetrics. Reduction (correction) of the dislocation is achieved by moderate axial traction behind the head followed by an extensor-flexural movement of the head. The transverse ligament is not damaged in this type of injury, so immobilization in a Minerva corset or Halo-cast apparatus for 6-8 weeks is usually sufficient. Surgical stabilization is undertaken in the presence of long-term pathological mobility segment or with persistent pain syndrome.

Rotational subluxation of Q is the most frequent variant of damage to the atlantoaxial junction, the typical clinical manifestation of which is the restriction of the mobility of the CVD, accompanied by a pain syndrome. The mechanism of its appearance is different, more often associated with a sharp turn of the head. With the concomitant Kimerli anomaly (see terms), trauma can be accompanied by an acute violation of cerebral circulation. Treatment consists in the elimination of subluxation with functional stretching on the Glisson loop and subsequent immobilization in the collar of Shantz for 7-10 days.

It should be noted that any deviation of the head from the frontal plane is accompanied on the anteroposterior radiographs of the atlantoaxial zone by the projection asymmetry of the paradental gaps, the lateral atlantoaxial joints, the lateral masses of the atlant. This allows us to assume that for radial confirmation of the diagnosis of the rotational subluxation of vertebra C1, CT is more objective than the traditional X-ray examination of this zone through the open mouth, which is accompanied by hyperdiagnosis of this pathology.

The peculiarity of the anatomical structure of the C2 vertebra requires attention to such a peculiar trauma as the fracture of its dentate process. There are three typical variants of such damage: a transverse or oblique fracture of the tip of the tooth at the level of the pterygoid ligament (type I fracture), transverse fracture of the base of the tooth (type II fracture), and a fracture passing through one or both of the upper articular processes (type III fracture). These variants of damage are characterized by varying degrees of disruption in the stability of the atlantoaxial segment. The severed fracture of the tip of the C2 tooth is rarely accompanied by fragment bias and instability of the d-C2 segment, while for other types of fracture mechanical atlantoaxial instability and neurologic complications are typical.

Earlier, we mentioned the features of the formation of the corporeal-dental synostosis, which can be mistaken for traumatic injury. We add that in children after a fracture of the C2 tooth, the vertebra may be mistaken for an anatomical development variant, designated as a tooth-bone (see terms), as well as the apophysial growth zone of its ossification nucleus.

Subluxations and dislocations of the cervical vertebrae can be observed both in the form of independent injuries, and in combination with fractures of the cervical vertebrae, complicated by rupture of the ligamentous apparatus of the vertebral-motor segments. Depending on the degree of dislocation in the intervertebral joints of the cervical vertebrae, simple and subluxation of the vertebrae, as well as a linked dislocation of the vertebrae, are isolated.

X-ray signs of dislocation (subluxation) of cervical vertebrae, revealed on the roentgenogram in the anteroposterior projection, are:

• step-like deviation of the line of spinous processes, while:
• with a one-sided forward bias in the articular joints, the spinous process deviates to the sore side;
• with a one-sided posterior displacement, the spinous process deviates into a healthy side (it should be remembered that the absence of deformation of spinous processes does not exclude the possibility of violation of the ratio in the joints, which, in the opinion of VP Selivanov and MN Nikitin (1971), may be explained by variability of development of spinous processes;
• the heterogeneity of the transverse processes in the sprained vertebra on the right and left: the transverse process extends more on the side rotated posteriorly, and less on the side rotated anteriorly;
• Increase by more than 1.5 times the distance between the tips of the spinous processes at the level of the damaged segment;

Signs of dislocations and subluxations of cervical vertebrae, revealed in the lateral projection, is the magnitude of the angle formed by the lines drawn along the lower edges of adjacent vertebrae, more than 1 G and local narrowing of the spinal canal.

According to the nature of the dislocation of the vertebrae, "overturning" displacements of cervical vertebrae at an angle and "slipping" displacements in the horizontal plane are distinguished. Slipping dislocations are often accompanied by spinal disorders, which is associated with the narrowing of the vertebral canal that occurs with this trauma.

Some variants of the trauma of the cervical spine, namely the fractures of the cervical vertebrae, received special names, under which they are denoted in the vertebrological literature.

The Jefferson fracture is a fracture of the arcs and / or lateral masses of the Atlantean C1. A typical mechanism of injury is the axial vertical load on the head. Characteristic are the presence of extensive pre- and paravertebral hematomas, pain in the neck. Allocate the following damage options:

• a typical fracture of Jefferson - a multi-lobed explosive ("bursting") fracture or a "true" Jefferson fracture, with damage to the anterior and posterior half-angle of the atlant. Characteristic of the presence of paired fractures (two in front and behind). The anterior and posterior longitudinal ligaments usually remain intact, the spinal cord is not damaged. Damage can occur without rupture of the transverse ligaments (damage is stable) and with rupture of the transverse ligaments (potentially unstable injury);
• atypical fracture Jefferson - a fracture of the lateral masses of the atlas, more often bilateral, but it can be one-sided. Fracture stable.

Fracture executioner (trauma of the "gallows", Hangman-fracture) - traumatic spondylolisthesis C2. A typical mechanism of injury is a
sharp extension of the head with axial load. Historically, the term "gallows injury" is due to the fact that this damage to the cervical vertebrae is characteristic of those executed by hanging.

Injury of the cervical spine can also be observed in car injuries (direct head-on against the windshield). Depending on the degree of leafose, there are 3 types of damage:

• I - forward displacement less than 3 mm, without rupture of anterior and posterior longitudinal ligaments; damage is stable;
• II - anterior displacement of more than 3 mm without anterior and posterior longitudinal ligament rupture, conditionally stable lesion;
• III - damage with a rupture of the anterior and posterior longitudinal ligaments and the intervertebral disc: it is accompanied by a true instability of the vertebral-motor segment and is complicated by the spinal cord injury, up to its rupture.

Fracture of excavator - a detachable fracture of spinous processes C7, C6, T, (the vertebrae are distributed according to the frequency of injury in this trauma). A typical mechanism of injury is a sharp bending of the head and upper cervical vertebrae with strained neck muscles. The name refers to the trauma that a person who is in a pit ("excavator") receives, on the head of which is inclined to the front of which falls cargo (crumbling land). Damage is clinically accompanied by local soreness associated with only the trauma of the posterior column of the spine. Damage is stable mechanically and neurologically.

Injury of the plunger - an explosive fracture of the cervical vertebrae bodies below C2, accompanied by rupture of the anterior and posterior longitudinal ligament, posterior interocular ligaments and intervertebral disc. A typical mechanism of injury - axial load, with a sharp bend of the head and neck. Damage is mechanically and neurologically unstable.

Injury of the cervical spine of the C3-C7 vertebrae, accompanied by stretching of the anterior and posterior support complexes, is classified as "C" (the heaviest) in the AS / ASIF classification because of the worst prognosis and the need for more active surgical treatment.

Instability of the cervical spine. With regard to the cervical spine, the term instability has become particularly widespread in recent years, due to the increasing attention to its pathology. The diagnosis is most often made on the basis of X-ray data, and not only the age features of the cervical spine are not taken into account (the physiological mobility of the cervical vertebral-motor segments in children is much higher than in adults), but also the constitutional features characteristic of some systemic dysplasias all such as the hypermobility of the PDS.

Classification of cervical vertebra lesions noAO / ASIF

Damage level	Type of fracture
	A	AT	FROM
Fracture of the Atlantean (C1)	Fracture of only one arc	Explosive fracture (Jefferson fracture)	Dislocation of the atlanto-axial joint
Fracture C2	Cranial fracture (vertebral arch fracture or hip fracture)	Fracture of the tooth-shaped process	Crural fracture in combination with a fracture of the tooth
Fractures	Compression fractures	Damage to the front and rear support complexes with or without rotation	Any damage to the front and rear support complexes with stretching

To assess the severity of clinical manifestations of cervical myelopathy of various etiologies (caused by congenital malformations of the cervical spinal canal, traumatic injuries, spondylosis and other degenerative diseases), the Japanese Orthopedic Association (JOA, 1994) proposed a 17-point scoring scale. The scale looks somewhat exotic (due to some national characteristics), but this does not reduce its significance and, with appropriate modification, it can be used in any other country. The principles laid down in the JOA scale were used to create our own scale for assessing the adaptive status of patients with spine pathology.

If it is impossible to accurately determine the estimated parameter ("intermediate value"), it is assigned the smallest score. With the asymmetry of the scores evaluated on the right and left sides, the sign is also assigned the smallest value.

The jOA scale for assessing the severity of clinical manifestations of cervical myelopathy

Estimated indicators	Criteria for evaluation	Points
Motor functions of the upper limbs	A patient...
	Can not independently eat with the use of tableware (spoons, forks, table sticks) and / or can not button up buttons of any size;	0
	Is able to eat with a spoon and fork, but can not use table sticks;	1
	Can, but practically does not use chopsticks, can write with a pen or can fasten buttons on cuffs;	2
	Can and uses for food with chopsticks, writes with a pen, fastens buttons on cuffs;	3
	Has no limitations on the functions of the upper limbs.	4
Motor function of the lower limbs	A patient...
	He can neither stand nor walk;	0
	Can not stand and walk without a cane or other external support on the ground;	1
	Can independently walk on a horizontal surface, but to climb the ladder you need help;	2
	Can go quickly, but clumsily.	3
	Has no limitations on the functions of the upper limbs.	4
Sensitivity
A. Upper extremities	Obvious disorders of sensitivity	0
	Minimal sensitivity disorders	1
	Norm	2
B. Lower limbs	Obvious disorders of sensitivity	0
	Minimal sensitivity disorders	1
	Norm	2
S. Body	Obvious disorders of sensitivity	0
	Minimal sensitivity disorders	1
	Norm	2
Urination	Urinary retention and / or incontinence	0
	Delay and / or more frequent and / or incomplete emptying and / or thinning of the jet	1
	Violation of frequency of urination	2
	Norm	3
Maximum score		17th

Increased in recent years, the level of radiation diagnosis of various pathological conditions of the cervical spine has led to a situation where the detected changes are a priori taken for the cause of complaints, most often having a general cerebral character. In consideration neither the clinical features of the symptoms nor the absence of pathological signs revealed by other objective methods of research - i.e. All that allows you to question the vertebrogenic nature of the complaints. The diagnosis of "cervical spine trauma" should be established only on the basis of a combination of clinical symptoms, radiation diagnostic methods (primarily radiographic and / or MRI), and functional examination of the blood flow of the main vessels of the head in the neck region. 

[1], [2], [3], [4], [5], [6], [7]