The most appropriate in the treatment of complicated spinal fractures is the joint work of a neurologist, orthopedist and neurosurgeon. The examination of the patient is aimed at determining the degree and nature of damage to the nervous system, spinal deformity, general somatic state, the exclusion of concomitant damage to the limbs and internal organs.
The clinical picture of fractures is characterized by pain in the area of damage during palpation, deformation (for example, the formation of acute angular kyphosis – a hump during compression fracture in the thoracic region), muscle tension in the neck or back. In the case of a forward displacement of the three upper cervical vertebrae, deformation is easily established by palpation through the mouth. With severe symptoms of damage to a certain level of the spinal cord or its roots, a topical diagnosis of spinal damage can be made with a greater degree of probability, taking into account neurological symptoms. Radiography of the spine is performed under conditions that prevent an increase in the dislocation of the spine.
Therapeutic measures for fractures of the spine are as follows.
1 Transportation of the patient to a medical institution is carried out in such a way as not to increase spinal deformity and not to cause secondary damage to the spinal cord. In case of damage to the cervical spine, immediate fixation of the patient in the Stricker frame , to which the device for skeletal traction is attached, is most advisable .
2 In a medical institution, a victim with the same precautions is placed on a hard bed or on a shield, on top of which a thick or air mattress and a tightly stretched (without any folds) sheet are placed. It is most advisable to use a bed with a specially rotated Stricker double-leaf frame . It provides good immobilization, traction, facilitates the rotation of the patient, linen change and skin care, bowel movement, as well as transportation to another room.
3 Orthopedic measures should be carried out in a medical institution in order to eliminate deformation of the spine (especially the lumen of the spinal canal), to ensure its stability and to prevent secondary displacement. In most cases, the spinal cord is damaged at the time of injury, and subsequent compression of the brain by displaced vertebrae only aggravates this damage.
Naturally, compression of the spinal cord damaged at the time of injury by the displaced parts of the vertebrae, the intervertebral cartilage located within the spinal canal, edematous tissues, and sometimes the hematoma is a complicating factor that worsens the condition of the spinal cord and should be eliminated as soon as possible with orthopedic interventions or surgically.
This is achieved by the following therapeutic measures:
1 simultaneous closed reduction of spinal fractures ;
3 open (operative way) reduction of these fractures (open reposition);
4 operation of the rear or front decompression;
5 by prolonged immobilization of the spine, achieved either by surgery (surgery of the posterior or anterior spinal fusion ), or by the application of fixative dressings (gypsum, etc.).
6 Surgery should meet the following requirements:
a complete decompression of the spinal cord and its vessels;
b restoration of normal anatomical ratios of the spinal canal and spinal cord in order to create optimal conditions for the maximum possible restoration of spinal cord function;
c ensuring reliable stabilization of the damaged vertebral segment in order to prevent secondary displacements of the damaged vertebrae;
7 subsequent functional treatment to prevent muscle atrophy, providing statics of the spine while standing and walking;
8 in the late stage of the disease, when the limit of reversibility of the euro of logical symptomatology is already clear, the main task of the doctor is to create conditions for the maximum use of residual functions, therefore orthopedic measures are the main ones.
Fractures and dislocations of the two upper cervical vertebrae occupy a special place among spinal injuries, which is due to both the features of their topographic relationships and the risk of damage to the medulla oblongata and spinal cord.
In the Atlanto-axial region there are:
a traumatic anterior dislocation or subluxation of the atlas without fracture of the dentate process;
b fracture of the dentoid process without displacement;
c fractures of the atlas and dentoid process;
d Atlant fracture.
Dislocation (offset) in the atlanto-axial articulation may also be the result of acute or chronic infectious processes (mostly rheumatic arthritis or inflammation in the nasopharyngeal region), causing relaxation periarticular tissues of the joint, or congenital abnormalities atlas and epistrofeya ( epifizealnoe separation odontoid) , lack of epistrophy , malformation of Atlanta.
Treatment measures for fracture and dislocation of the two upper cervical vertebrae include prolonged skeletal traction beyond the cranial vault, and in some cases surgical intervention to eliminate spinal cord compression and ensure stability in the atlanto- occipital joint. In the last decade, attention has been drawn to the so-called hyperextension injury of the cervical spine (a subspecies of which is the so-called whiplash injury). These injuries occur during transport (especially automobile), football injuries, when diving, falling from a height, face down from the stairs forward, with complicated tracheal intubation. At the same time, the so-called acute cervical syndrome develops, expressed to a varying degree and arising after forcing hyperextension of the neck, exceeding the anatomical and functional limits of mobility of this spine. In spondylograms , it is often not possible to identify bone pathology of the spine; in more severe cases, especially in road accidents with extensor mechanism of violence, there are fractures of the cervical vertebrae and damage to the ligamentous- disc apparatus.
Clinically, this injury is manifested to varying degrees of severity by syndromes of damage to the nervous system, among which there are:
1 Radicular syndrome (which occurs in about 25% of cases), manifested by pain in the cervical-occipital region for weeks, and sometimes months.
2 Syndrome of partial dysfunction of the spinal cord with the presence of pyramidal syndrome (also observed in about 25% of cases). At the same time, the occurrence of burning burning pains in the hands due to damage to the posterior columns and compression of the roots of Soup and Sush with a rapidly passing feeling of weakness in the lower extremities is typical.
3 Syndrome of transverse lesion of the spinal cord, detected in approximately 30% of cases. In cases where this syndrome is unstable and quickly regresses, there is reason to consider it a manifestation of spinal shock. With a partial regression of this syndrome, persistent dysfunctions of the spinal cord of varying severity remain.
4 Anterior spinal artery syndrome is detected in approximately 20% of cases and is manifested by distal paresis of the upper extremities with hypotension and muscle hypotrophy, lower paraparesis , and distant . dissociated sensitivity disorders, disorders of the function of the pelvic organs.
With hyperextension injury, a more rapid and complete restoration of movements in the lower extremities (compared with the upper ones) is observed due to the predominant damage to the anterior horns of the cervical thickening and the internal parts of the pyramidal bundle, where the fibers for the upper limbs are located. Sometimes, against the background of a rapid and almost complete regression of pronounced tetraparesis, a long time nevertheless pareticity of the upper extremities with atrophy of the muscles, especially small muscles of the hand, fibrillation in the muscles of the shoulder girdle and mild hypersthesia in the forearm region is noted.