Cervical spine injuries: causes, symptoms, diagnosis, treatment

Cervical spine injuries account for approximately 19% of all spinal injuries. But compared to thoracic vertebrae injuries, they occur in a ratio of 1:2, and lumbar - 1:4. Disability and mortality from cervical spine injuries are still high. Mortality from these injuries is 44.3-35.5%.

The cervical vertebrae that are most often injured are the V and VI cervical vertebrae. This level accounts for 27-28% of all cervical vertebrae injuries.

Among spinal injuries, dislocations, fracture-dislocations and fractures of the cervical spine occupy a special place. This is explained by the fact that injuries to the cervical spine are quite often combined with injuries to the proximal spinal cord, which directly passes into the brain stem.

Often, victims of this category, who have successfully passed the acute period of injury, subsequently develop secondary displacements or an increase in the primary, previously unresolved deformation. Observations show that many victims, even with timely reduction of a dislocation or fracture-dislocation, timely and correct treatment of a penetrating fracture, subsequently quite often develop complications, which are explained by the involvement of the intervertebral discs and posterior-external intervertebral synovial joints. Even simple head contusions without visible damage to the cervical spine very often entail the occurrence of severe degenerative changes in the cervical intervertebral discs.

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Causes of Cervical Spine Injuries

Most often, cervical spine injuries occur as a result of indirect violence.

The main mechanisms of violence that cause damage to the anterior spine are extension, flexion, flexion-rotation and compression.

The importance and role of extension force in the origin of cervical spine trauma have been underestimated until recently.

Flexion and flexion-rotation mechanisms of violence entail the occurrence of dislocations, subluxations, fractures of dislocations and fractures. Compression type of violence causes the occurrence of crushed comminuted compression fractures of vertebral bodies with damage to adjacent intervertebral discs.

Dislocations and fractures, like etching, are accompanied by a rupture of the ligamentous apparatus and are considered unstable.

Comminuted comminuted compression fractures, although they are classified as stable injuries, often cause paresis and paralysis due to the posterior fragment of the damaged vertebral body displaced towards the spinal canal.

It is known that in case of cervical spine injuries, sometimes one awkward turn of the neck and head is enough to cause sudden death. The mentioned features of cervical spine injuries force to eliminate existing displacements as quickly as possible and reliably immobilize the damaged section of the spine. Apparently, these considerations are followed by those who are supporters of early internal surgical fixation of the damaged section of the cervical vertebrae.

Providing assistance to victims with cervical spine injuries requires some special conditions. It is highly desirable that this assistance be urgent. It is necessary that it be provided by a team of specialists consisting of a trauma surgeon who is proficient in the technique of surgical interventions on the spine and its contents, an anesthesiologist, a neurologist and a neurosurgeon.

If surgery is required for cervical spine injuries, the best method of pain relief is endotracheal anesthesia. The fear of spinal cord injury during intubation is exaggerated and unfounded. With caution and secure head fixation, intubation is easy to perform and safe for the victim.

The loss of consciousness of the victim, relaxation of the muscles and freedom of manipulation for the surgeon allow the necessary intervention to be fully carried out, and controlled breathing to cope with possible respiratory disorders in these cases.

In the treatment of cervical spine trauma, both non-operative and operative methods of treatment are used. Passion for only conservative or, conversely, only operative methods of treatment is wrong. The art of a trauma surgeon is the ability to choose the only correct method of treatment from the existing ones that will be useful to the victim.

Anatomical and functional features of the cervical spine

The severity of the cervical spine injury is determined by the anatomical and functional features of this area. Extremely important anatomical structures are concentrated in a small area of the neck, the disruption of the normal function of which makes human life impossible.

Due to the fact that the complex of the largest and most important vascular and nerve formations, as well as the median formations of the neck, are located in front and outside the spine, it is not surprising that surgical approaches to it until recently were limited to the back. To no lesser extent, this was facilitated by the complexity of the structure of the fascia of the neck. The bodies of the vertebrae and the deep muscles of the neck are covered by the prevertebral (scalene) fascia. In addition to the formations indicated, this fascia surrounds the scalene muscles and the phrenic nerve.

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Tears and ruptures of ligaments

Isolated ligament tears and ruptures are most often the result of indirect violence. They can occur with sudden, uncoordinated movements without control of the neck muscles. They are manifested by local pain, limited mobility. Sometimes the pain can radiate along the length of the spine. If a ligament tear or rupture is suspected, the diagnosis becomes reliable only after the most pedantic and thorough analysis of X-rays and the exclusion of more severe spinal injuries. This circumstance should be especially emphasized, since more severe spinal injuries are often seen under the guise of ligament damage.

Treatment is limited to temporary rest and relative immobilization, novocaine blockades (0.25-0.5% novocaine solution), physiotherapy, and gentle therapeutic exercises. Depending on the profession and age of the victim, working capacity is restored in 1.5-6 weeks. More massive damage to the ligamentous apparatus usually does not occur in isolation and is combined with more severe damage to the skeletal spine. In these cases, treatment tactics are dictated by the damage to the skeletal spine that has occurred.

Intervertebral disc ruptures

Most often, ruptures of intervertebral discs occur in middle-aged people whose intervertebral discs have undergone partial age-related degenerative changes. However, we have observed acute ruptures of cervical intervertebral discs in people aged 15-27 years. The main mechanism of violence is indirect trauma. In our observations, acute ruptures of cervical intervertebral discs occurred when lifting relatively small weights and forced movements in the neck area.

Symptoms of acute ruptures of cervical intervertebral discs are very diverse. Depending on the level of the rupture, the localization of the rupture of the fibrous ring and the degree of prolapse of the nucleus pulposus, clinical manifestations range from local pain during movement, coughing, sneezing, more severe pain "shooting" with a forced position of the head and neck, significant limitation of their mobility to severe radicular and spinal lesions up to tetraplegia.

In diagnostics of acute ruptures of cervical intervertebral discs, a comprehensive clinical and radiological examination should be used with the participation of an orthopedic traumatologist and a neurologist. Clarification of a detailed anamnesis with special attention to the condition of the neck is absolutely necessary. In addition to the most pedantic orthopedic examination, if indicated, a spinal puncture is necessary with a study of the patency of the subarachnoid spaces and the composition of the cerebrospinal fluid. Often, simple survey spondylograms are insufficient. In addition, in these cases, functional and contrast spondylograms should be used.

As variable as the symptoms of acute ruptures of the cervical intervertebral discs are, so diverse and varied are the methods and techniques for their treatment. Depending on the nature of the symptoms, various treatment complexes are used - from the simplest short-term immobilization to surgical interventions on the disc and vertebral bodies. Since the primary cause of the clinical symptoms is a rupture of the intervertebral disc, the main ones in any complex are orthopedic manipulations. Only a combination of orthopedic manipulations with physiotherapy and drug treatment allows us to count on a favorable therapeutic effect.

Treatment of cervical spine injuries

The simplest orthopedic manipulations include unloading and stretching the spine.

Unloading of the spine is carried out by immobilization of the cervical spine with simple plaster (such as the Shantz collar) or removable orthopedic corsets. When applying the corset, the cervical spine should be slightly extended and the head should be given a position comfortable for the patient. There is no need to try to eliminate anterior flexion if it is habitual and comfortable for the patient. Sometimes it is advisable to apply a corset with support on the shoulders and an emphasis on the back of the head and chin area.

A number of patients may experience a good effect from using a semi-rigid corset such as the Shantz collar, which combines elements of unloading and heat exposure. To make such a collar, take thick elastic cardboard and cut it to the shape of the neck. Its edges are rounded at the front and have a slightly lower height than at the back. The cardboard is wrapped in a layer of white cotton wool and gauze. Gauze ties are sewn to the front edges of the collar. The patient wears the collar constantly for 24 hours and takes it off only for the toilet. If at first the patients feel some discomfort, then after a few days, having gotten used to the collar and received relief, they willingly use mm. After 3-6 weeks the pain usually goes away.

The cervical spine is stretched using a Glisson loop or in a lying position on an inclined plane or in a sitting position. It is better to perform intermittent stretching with 4-6 kg weights for 3-6-12 minutes. The stretching time and the weight are determined by the patient's sensations. Increased pain or other unpleasant sensations are a signal to reduce the weight or stop stretching. The stretching time should be gradually increased and the weight increased. Such stretching sessions are repeated daily and last 3-5-15 days depending on the effect achieved.

Drug treatment of cervical spine injury consists of administering large doses of antirheumatic drugs and vitamins B and C: vitamin B1 - in the form of a 5% solution of 1 ml, vitamin B12 - 200-500 mg intramuscularly 1-2 times a day, vitamin B2 - 0.012 g 3-4 times a day, vitamin C - 0.05-0.3 g 3 times a day per os. Nicotinic acid can be useful at 0.025 g 3 times a day.

Various types of thermal physiotherapeutic procedures in the absence of general contraindications have an undoubted effect. A good pain-relieving effect is noted with electrophoresis of novocaine.

Intradermal and paravertebral novocaine (5-15 ml of 0.5% novocaine solution) blockades are effective.

To relieve acute pain in some patients, intradiscal blockades with the introduction of 0.5-1 ml of 0.5% novocaine solution and 25 mg of hydrocortisone are very useful. This manipulation is more responsible and requires a certain skill. It is performed as follows: the anterolateral surface of the neck on the affected side is treated twice with 5% tincture of poda. A projection of the level of the damaged intervertebral disc is applied to the skin. With the index finger of the left hand at the appropriate level, the sternocleidomastoid muscle and carotids are pushed outward, simultaneously penetrating deep and slightly forward. An injection needle of medium diameter with a gentle bevel, 10-12 cm long, is injected along the finger in the direction from the outside to the inside and from the front to the back until it stops in the body or intervertebral disc. As a rule, it is not possible to immediately enter the desired disc. The position of the needle is controlled by a spondylogram. With a certain amount of skill and patience, it is possible to penetrate the desired disk. Before introducing the solution, it is necessary to re-check the position of the coccyx of the needle in the disk. Using a syringe, 0.5-1 ml of 0.5% novocaine solution and 25 mg of hydrocortisone are injected into the damaged disk. Injection of these drugs even paravertebrally near the damaged disk gives an analgesic effect.

After the acute symptoms of the injury have passed and the muscle spasm has been eliminated, a course of massage is very useful. Therapeutic gymnastics should be carried out with extreme caution under the supervision of an experienced specialist. Unqualified therapeutic gymnastics can cause harm to the patient.

The listed orthopedic, medicinal and physiotherapeutic methods of treatment should not be used in isolation. Correct individual selection of the necessary treatment complexes for the patient in most cases allows achieving a positive effect.

If conservative treatment methods are ineffective, surgical treatment is necessary.

The main objective of the surgical treatment undertaken is to eliminate the consequences of the disc rupture and prevent subsequent complications, i.e. decompression of the spinal cord elements, prevention of the development or progression of degenerative phenomena in the damaged disc and creation of stability at the level of damage. Since an acute rupture of the intervertebral disc often occurs against the background of already existing degenerative changes in the disc, the surgical treatment undertaken develops into the treatment of cervical intervertebral osteochondrosis complicated by an acute rupture of the intervertebral disc. Since the indications and surgical tactics for acute ruptures of intervertebral discs and cervical intervertebral osteochondrosis with prolapse of the disc substance or its protrusion are absolutely identical.

Among the surgical methods of treating cervical intervertebral osteochondrosis, the most widespread and recognized are interventions aimed at eliminating only one of the complications of intervertebral osteochondrosis - compression of the spinal cord elements. The main element of the intervention is the removal of part of the prolapsed nucleus pulposus of the ruptured disc and the elimination of the compression caused by it.

The intervention is performed under local anesthesia or general anesthesia. Some authors consider endotracheal anesthesia dangerous due to the possibility of acute compression of the spinal cord during hyperextension of the cervical spine and subsequent prolapse of the masses of the nucleus pulposus. Our experience of surgical interventions on the cervical spine in case of its injuries and diseases allows us to express the opinion that the fear of using endotracheal anesthesia is exaggerated. Technically correctly performed intubation with appropriate immobilization of the cervical spine does not pose any danger to the patient.

The essence of palliative surgical intervention is that the spinous processes and arches of the cervical vertebrae are exposed at the required level using a posterior median surgical approach. A laminectomy is performed. Allan and Rogers (1961) recommend removing the arches of all vertebrae, while other authors limit laminectomy to 2-3 arches. The dura mater is dissected. After dissection of the odontoid ligaments, the spinal cord becomes relatively mobile. The spinal cord is carefully pushed aside with a spatula. The anterior wall of the spinal canal, covered by the anterior leaf of the dural sac, is inspected. With sufficient retraction of the spinal cord, the fallen part of the disc can be seen with the eye. This is most often done with a thin button probe inserted between the roots. When a prolapsed nucleus pulposus of a ruptured disc is detected, the anterior leaflet of the dural sac is dissected above it and the prolapsed masses are removed using a small bone spoon or curette. Some authors recommend performing a posterior radiocatomy for better access to the posterior parts of the intervertebral disc.

In addition to the transdural route, there is also an extradural route, when the fallen part of the ruptured disc is removed without opening the dural sac.

The positive side of the posterior surgical approach with laminectomy is the possibility of wide revision of the contents of the spinal canal located in the dorsal half of the contents of the dural sac, the possibility of changing the surgical plan if the diagnosis is not confirmed. However, this method has a number of serious disadvantages. These include: a) palliative nature of the surgical intervention; b) direct contact with the spinal cord and manipulations near the spinal cord; c) insufficient space for manipulations; d) impossibility of examining the anterior wall of the spinal canal; d) the need for laminectomy.

A very serious disadvantage is the need for laminectomy. During laminectomy, the posterior supporting structures of the vertebrae are removed in the area of the damaged intervertebral disc. Due to the existing inferiority of the intervertebral disc, its function as an organ stabilizing the cervical vertebrae relative to each other is lost. From an orthopedic point of view, this is completely unacceptable. Laminectomy leads to a complete loss of stability of the spine, fraught with very serious complications. Therefore, we believe that the described palliative intervention, as not meeting orthopedic requirements, should be used according to forced indications. In those cases when the surgeon is forced to resort to palliative surgery and is forced to perform a laminectomy, he must ensure reliable stabilization of the lampectomized section of the spine. The doctor must remember about orthopedic prevention of possible complications in the future.

Undoubted advantages are provided by surgical interventions performed through the anterior surgical approach. Such surgical interventions include total discectomy with corporodesis.

Total discectomy with corporodesis. Total discectomy with subsequent corporodesis has all the advantages of radical surgery. It meets all orthopedic and neurosurgical guidelines for treating a damaged intervertebral disc, as it ensures radical removal of the entire damaged disc, restoration of the height of the intervertebral space and reliable stabilization of the damaged section of the spine, as well as decompression of the root when it is compressed. The most important advantage of this surgical intervention is the preservation of the posterior supporting structures of the vertebrae and the prevention of all possible complications caused by laminectomy.

The main condition for the possibility of carrying out this surgical intervention is the precise determination of the level of damage.

The level of damage is determined on the basis of clinical data, general and functional spondylograms, and, if indicated, pneumomyelography.

In some cases, it is advisable to resort to contrast discography when there is a need to detail the condition of the damaged disc. Contrast discography is performed similarly to the cervical intradiscal block described above.

In most cases, it is possible to localize the damaged disc based on clinical and radiological data.

Preoperative preparation includes the usual general hygiene measures. The appropriate medication preparation is carried out. Immediately before the start of the operation, it is necessary to monitor the emptying of the bladder and intestines. The head is carefully shaved.

Pain relief - endotracheal anesthesia.

The patient is placed on his back. A thick oilcloth pillow 10-12 cm high is placed under the shoulder blades; the pillow is positioned along the spine between the shoulder blades. The patient's head is slightly tilted back, the chin is turned to the right at an angle of 15-20° and slightly forward.

The first stage of the intervention is the application of skeletal traction to the cranial vault bones. The traction maintains the specified position of the head. The cervical spine is given a position of some hyperextension.

Skeletal traction of the cranial vault bones is performed using special clamps. The ends of the clamp, immersed in the thickness of the parietal bones, are a cylinder with a diameter of 4 mm and a height of 3 mm. To prevent the end of the clamp from penetrating the cranial cavity and damaging the internal vitreous plate, there is a limiter at the outer edge of the cylinder immersed in the bone. The technique for applying the clamp is as follows. On the lower slope of the parietal tubercle, an incision is made to the bone with a sharp scalpel. The direction of the incision should correspond to the long axis of the spine - the direction of traction. A transverse incision can subsequently cause necrosis of the soft tissues under the pressure of the clamp limiter. The edges of the wound are spread apart with sharp two-pronged hooks. Hemostasis is performed. Using an electric drill with a diameter of 4 mm and a limiter that allows the drill to penetrate into the thickness of the bone only by 3 mm, an opening is made in the outer compact plate of the parietal tubercle and the adjacent spongy bone. A similar manipulation is repeated on the opposite side. The cylindrical ends of the clamp are inserted into the holes formed in the parietal bone. The position of the ends of the clamp in the thickness of the bone is fixed with a lock on the opposite ends of the clamp. Sutures are applied to the skin wounds. The cable from the clamp is thrown over the black block, fixed at the head end of the operating table. A weight of 4-6 kg is suspended from the end of the cable. Only after this can the assistant release the victim's head.

The second stage of the intervention is exposure and removal of the damaged disc. Two types of skin incisions can be used to expose the damaged disc. If it is necessary to expose only one disc, a transverse skin incision can be used along one of the cervical folds at the level of the damaged disc. This incision is more cosmetic. A skin incision along the anterior-inner edge of the sternocleidomastoid muscle is more convenient; it provides better access to the anterior parts of the cervical vertebrae. Preference should be given to the left-sided approach.

The skin and subcutaneous tissue are dissected layer by layer using a slightly oblique vertical incision along the anterior edge of the left sternocleidomastoid muscle (a transverse incision can also be used). The subcutaneous venous trunks are ligated and transected. The subcutaneous muscle of the neck is dissected. The sternocleidomastoid and omohyoid muscles are moved apart. The pretracheal fascia, covering the entrance to the space between the carotid artery and the median structures of the neck, becomes visible and accessible. Having retreated slightly inward from the carotid artery, determined by the palpable pulsation, the pretracheal fascia is dissected strictly parallel to the course of the carotid artery. In the space limited above by the superior thyroid artery and below by the inferior thyroid artery, it is easy to penetrate through the pretracheal tissue to the anterior surface of the vertebral bodies covered by the prevertebral fascia. This space is free of nerve trunks and blood arterial vessels. If necessary, the superior and inferior thyroid arteries or any of them can be ligated and dissected without causing any damage. The prevertebral fascia appears as a thin, transparent, shiny plate. It is dissected longitudinally along the spine; when dissecting, one should remember about the nearby wall of the esophagus and not damage it. After dissection of the prevertebral fascia, the median formations of the neck are easily displaced to the right, and the anterior surface of the bodies of the cervical vertebrae and intervertebral discs is exposed. This surgical approach easily exposes the anterior sections of the cervical vertebrae from the caudal section of the second cervical vertebra to the first thoracic vertebra inclusive.

It is necessary to remember that the recurrent nerve lies in the groove between the esophagus and trachea on their lateral surface. The loop formed by the recurrent nerve is somewhat longer on the left than on the right. Therefore, preference should be given to left-sided surgical access, but if necessary, a right-sided one can be performed. The edges of the wound are spread apart with wide, deep hooks. The anterior longitudinal ligament, intervertebral discs, and bodies of the cervical vertebrae become accessible for manipulation. During the intervention, when the edges of the wound are stretched, the hooks compress the carotid artery and ascending sympathetic fibers, therefore, every 8-10 minutes, the hooks should be loosened for 1-2 minutes to restore blood flow in the carotid artery. Unlike the bodies of the lumbar and thoracic vertebrae, the bodies of the cervical vertebrae do not protrude forward, but are located in a depression formed by the muscles covering the anterior surface of the transverse processes and the anterolateral surface of the bodies of the cervical vertebrae. Under these muscles are located the ascending sympathetic fibers, damage to which is fraught with complications (Horner's symptom).

If it is necessary to expand the access, the sternocleidomastoid muscle can be dissected transversely. We have never encountered any practical need for this.

It is necessary to make sure that it is the anterior surface of the cervical vertebrae that is exposed. The damaged disc is easily identified by the narrowed intervertebral space, the possible presence of osteophytes (in comparison with spondylograms). If there is the slightest doubt about the correct localization of the required level, a control spondylography with marking should be used, for which an injection needle is injected into the suspected damaged disc and a profile spondylogram is produced.

At the required level, the anterior longitudinal ligament is dissected in an H-shape and peeled apart. The anterior section of the fibrous ring is dissected. The extension of the cervical spine increases slightly - the intervertebral space widens and gapes. Using a small sharp bone curette, the damaged disc is removed. In order to create conditions for the subsequent formation of a bone block between the bodies of adjacent vertebrae, it is necessary to expose the spongy bone of the bodies of adjacent vertebrae. Usually, the endplates of the vertebral bodies are quite dense due to the existing siochoidal sclerosis. Even a sharp bone spoon cannot remove them. For this purpose, we use narrow chisels. They should be used very carefully. The hammer blows should be soft and gentle. When removing the endplates, one should strive to preserve the bone limbs of the bodies. Their preservation ensures reliable retention of the transplant placed between the bodies of adjacent vertebrae in the intervertebral space. The endplates are removed over an area of approximately 1 cm ². When removing the disc in the endplates, it is necessary to adhere to the midline and not deviate to the sides. Do not go more than 10 mm back. After removing the damaged disc and endplates from the adjacent surfaces of the vertebral bodies, an intervertebral defect of up to 6 mm is formed. If the anterior osteophytes are significant in size and prevent entry into the intervertebral space, they should be cut off with a resection knife or bitten off with bone nippers. This completes the second stage of the intervention.

The third stage of the intervention involves taking a spongy autograft and placing it in the prepared bed between the vertebrae in place of the removed damaged disc. The graft is taken from the crest of the iliac wing.

A small linear incision 4-5 cm long along the crest of the iliac wing is used to dissect the skin, subcutaneous tissue, and superficial fascia layer by layer. The periosteum is dissected. The periosteum is separated from the crest on both sides with a thin chisel along with the adjacent compact bone. A cubic transplant with a 10-15 mm edge is taken from the spongy bone. Hemostasis is performed. The periosteum, fascia, and skin are sutured.

The extension of the neck is increased slightly. The graft is placed in the intervertebral defect so that the bone limbus of the adjacent vertebrae hangs over it slightly. After eliminating the excess extension, the graft is well held between the vertebral bodies. The anterior longitudinal ligament is sutured. Antibiotics are administered. The wound is sutured layer by layer. An aseptic bandage is applied.

The patient is placed in bed with a hard shield. A hard oilcloth pillow is placed under the shoulder blades. The head is tilted back slightly. Skeletal traction is continued for the cranial vault bones with a weight of 4-6 kg. Extubation is performed after spontaneous breathing is restored. Symptomatic drug treatment is performed. Dehydration therapy should be started if appropriate indications are present. Everything should be prepared for emergency intubation in case of respiratory distress. The patient's condition is closely monitored. The anesthesiologist should pay special attention to the patient's breathing.

On the 6th-8th day, the stitches are removed. Skeletal traction is stopped. A thoraco-cranial bandage is applied. Removing skeletal traction and applying a bandage should be treated as a responsible and serious procedure. This must be done by a doctor. The period of immobilization with a thoraco-cranial bandage is 2.5-4 months.