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

Subluxations of the lumbar vertebrae are rare. Clinically, they often occur under the guise of "bruises" of the spine or "stretching" of its ligamentous apparatus. They are easily reduced in a position of moderate extension of the spine and, as a rule, are not detected radiographically by the time the victim is admitted to hospital.

Unlike the cervical spine, pure dislocations of the lumbar and lower thoracic vertebrae are also extremely rare in clinical practice. Their clinical manifestations, symptomatology, diagnostics and treatment have much in common with fracture-dislocations of this localization, which is why it is advisable to consider them together. It is possible to differentiate a pure dislocation from a fracture-dislocation only on the basis of radiographic data.

The lumbar and lower thoracic spine are the most common locations for fracture-dislocations. Fracture-dislocations in the thoracic spine are very rare due to the anatomical and functional features of the thoracic spine.

Fracture-dislocations are the most severe injuries of the lumbar and lower thoracic spine. They occur under the influence of massive violence, are accompanied by associated injuries, severe shock and are almost always combined with damage to the contents of the spinal canal.

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What causes fractures and dislocations of the thoracic and lumbar spine?

Mechanism. Fracture-dislocations occur due to the flexion-rotation mechanism of violence, but can also occur with flexion violence, when violence, overcoming the strength of the anterior sections of the vertebra, causes a fracture of the body and, continuing to act, violates the integrity of the posterior support complex. In rarer cases, the occurrence of fracture-dislocations is also possible with the extension mechanism of violence. However, the most typical is the flexion-rotation mechanism. Fracture-dislocations often occur due to falls, car and train accidents.

Symptoms of fractures and dislocations of the thoracic and lumbar spine

Anamnestic data that allow us to clarify the circumstances of the injury, the immediate material causes that caused the injury, and the mechanism of the violence suggest the presence of a fracture-dislocation.

The victim's complaints depend on his general condition, the degree 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. Concussion or bruise of the brain can lead to retrograde amnesia and complicate the clarification of the anamnesis. The victim may be unconscious, which makes it even more difficult to identify complaints and circumstances of the injury.

The most typical complaints are pain in the area of injury, which intensifies when trying to reproduce certain movements, complaints of abdominal pain, varying degrees of sensitivity disorder and limitation or loss of active movements below the site of injury. Complaints largely depend on the time that has passed since the injury occurred. At a later stage, the victim complains of the inability to urinate independently (in complicated fractures and dislocations with pelvic dysfunction), pain in the kidney area, general weakness, etc. In severe degrees of traumatic shock, the victim may not present any complaints, he is apathetic, does not react to the environment.

Objective data largely depend on the nature of the injury. As a rule, the victim is in a forced position. The skin and mucous membranes are pale. In the area of the shoulder girdle or scapula, there may be traces of a bruise in the form of abrasions, bruises, swelling. Detection of these data allows us to confirm the flexion-rotation mechanism of violence and suspect the presence of an unstable injury. There may be no traces of a bruise in typical places if the injury occurred during a fall, a car or train accident. In these cases, bruises and abrasions are localized in various areas of the victim's body. In complicated injuries, which are almost a rule for fractures and dislocations, symptoms of damage to the spinal cord or its roots are observed. The nature of the sensory disorder 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 equine tail, the nature and degree of their damage. Neurological manifestations should be identified based on a detailed and qualified neurological examination. The most typical local symptom of a fracture-dislocation is a violation of the length of the line drawn through the tops of the spinous processes. In the presence of lateral displacement of the cranial segment of the spine, the line drawn through the tops of the spinous processes becomes bayonet-shaped - from the level of the fracture, it deviates at a right angle to the side in which the cranial segment of the spine has shifted. With anterior displacement, the spinous processes of the vertebrae located directly above the site of injury seem to fall forward and are palpated less clearly than the underlying ones. More often, the displacement is combined - to the side and forward, which is reflected in a change in the line of the spinous processes. Local pain and swelling are usually noted in this place, spreading to the lumbar and perirenal regions. The victim's torso may be deformed due to displacement of the vertebrae and local swelling of the soft tissues due to hemorrhage.

From the anterior abdominal wall, as a rule, symptoms of peritoneum are detected, which is associated with the presence of a retroperitoneal hematoma and damage to the spinal cord roots, which can simulate the clinical picture of an “acute abdomen”.

To clarify the nature of the damage to the contents of the spinal canal, if indicated, a spinal puncture is performed with subsequent examination of the cerebrospinal fluid (presence of blood, cytosis, protein). During the spinal puncture, Quekenstedt and Stuckey cerebrospinal fluid dynamic tests are performed to determine the presence or absence of a subarachnoid space block. A partial or especially complete subarachnoid space block indicates compression of the spinal cord and is an indication for urgent revision of the contents of the spinal canal. The absence of obstruction of the subarachnoid space is not a guarantee of well-being in the spinal canal.

Diagnostics of fractures and dislocations of the thoracic and lumbar spine

Spondylography is performed in two typical projections. Since fracture-dislocation is an unstable injury, X-ray examination should be performed with all precautions to prevent additional displacement of the vertebrae or damage to the contents of the spinal canal. Direct and profile spondylograms should be performed without changing the position of the victim, due to the possibility of secondary trauma.

Possible variants of vertebral damage and displacement are described by us in the classification given above.

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

Conservative treatment of dislocations and fracture-dislocations 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 reliable early stabilization of the damaged section of the spine, which is so necessary in these cases;
• closed reduction of interlocking unilateral or bilateral dislocations or fracture-dislocations occurring in this area, as a rule, turns out to be ineffective;
• the concomitant damage to the spinal cord or its elements that often occurs with these injuries is often an indication for revision of the contents of the spinal canal, which can only be carried out surgically;
• The complex plane of separation (dislocation, fracture) of the vertebral elements that often arises with these injuries makes it impossible for the displaced fragments to adapt.

Forced one-stage reduction for these injuries is contraindicated.

Of the existing methods of conservative treatment, traction along an inclined plane or with the help of axillary traction or skeletal traction according to Z. V. Bazilevskaya can be used. However, these methods, as a rule, do not succeed in eliminating the existing displacement of fragments. In our opinion, these methods can be used in cases where a fracture-dislocation or dislocation, for some reason, cannot be reduced and stabilized surgically, i.e. when there are absolute contraindications to surgical intervention and when this surgical intervention is more dangerous than the existing injury.

In case of fracture-dislocations of the "traumatic spondylolisthesis" type in the lower lumbar region, in the absence of absolute indications for revision of the contents of the spinal canal, an attempt can be made to reduce the displaced body of the lumbar vertebra using the Johnson method. The victim is placed on his back. Anesthesia is given. The head, shoulders and thoracic region of the body rest on the table, and the lumbar region of the body and pelvis hang freely. The legs are bent at a right angle at the knee and hip joints and in this position, together with the pelvis, they are pulled up and fixed in this position on a higher table. Sagging of the lumbar spine and simultaneous pulling of the pelvis together with the sacrum up facilitate the reduction of the body of the vertebra that has shifted forward. In the position of achieved reduction, a plaster corset is applied with the thighs captured. We have never been able to achieve reduction in this way.

An attempt to reduce "traumatic spondylolisthesis" can be made by gradual skeletal traction. For this, the victim is placed on a bed with a hard board in a supine position. Both legs are placed on standard Boehler splints. Skeletal traction is applied to the epicondyles or tuberosities of the tibia using pins. The traction is carried out with large weights along the axis of the femurs. This method is rarely successful.

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

Since dislocations and fracture-dislocations of the spine are the most unstable of all known spinal injuries, it is especially important to make them stable as quickly and reliably as possible. This applies equally to uncomplicated fracture-dislocations and to fracture-dislocations complicated by damage to the spinal cord elements. In the first case, this is important, since significant mobility of the vertebrae in the area of damage can lead to secondary damage to the spinal cord elements. The slightest careless movement, a sharper turn in bed, a careless movement when placing a bedpan or changing bed linen can lead to a catastrophe. In the second case, this is important so as not to aggravate the existing damage to the spinal cord elements and to create conditions for the treatment of trophic disorders and bedsores. Reliable and good stability is achieved by internal fixation using metal plates screwed together with bolts.

Indications for surgery of internal fixation of the spine with metal plates and bolts are fractures and dislocations of the lumbar, lumbar-thoracic and thoracic localization.

The goal of surgical intervention is to stabilize the damaged section of the spine. In the presence of a complicated fracture-dislocation, it is necessary to simultaneously assess the condition of the spinal cord elements.

The optimal time for intervention is early, if there are no absolute vital contraindications. If the victim's condition is severe, a wait-and-see approach should be used for a while.

Preoperative preparation consists of the most careful transfer of the patient to the operating table, symptomatic drug treatment, and shaving of the surgical field.

Endotracheal anesthesia is used. The introduction of muscle relaxants significantly facilitates the reduction of fracture-dislocation.

The victim is placed on the operating table in a prone position.

The metal fiquerator used to stabilize fractures and dislocations of the lumbar and thoracic spine consists of two metal plates with holes for bolts made of stainless steel of the factory brand. The plates are rectangular 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, the thickness is 3 mm. Every 7 mm in the plates there are holes with a diameter of 3.6 mm. The bolts are 30 mm long, 3.6 mm in diameter.

Surgical approach. The skin, subcutaneous tissue and fascia are dissected by a linear incision along the line of the spinous processes. The skin incision is made with the calculation of exposing the damaged vertebra - two overlying and two underlying vertebrae. The damaged vertebra should be located in the middle of the incision. The tops of the spinous processes covered by the supraspinous ligament are exposed. The site of injury is easily determined by the torn supraspinous and interspinous ligaments, by the displacement of the overlying spinous process, depending on the nature of the displacement - to the side, upward or downward. Since anterolateral dislocations are more common, the spinous process is displaced upward, to the side and forward. The interspinous space is enlarged. If little time has passed since the injury, the paravertebral tissues are imbibed with blood. The thoracolumbar fascia is dissected on both sides of the spinous processes. Using vertebral raspators and scissors, the muscles are separated from the spinous processes and arches. The separated muscles are moved to the sides. The wound reveals exposed spinous processes, arches, and articular processes of the vertebrae. After moving the muscles to the sides, the torn yellow ligaments, broken articular processes, and displaced arches become clearly visible. The dura mater is visible through the torn yellow ligaments. It can be examined through the interanterior space. The presence or absence of cerebrospinal fluid can be used to judge the presence or absence of damage to the membranes of the spinal cord. If indicated, the necessary intervention is performed on the membranes of the spinal cord and brain.

Technique of spine adjustment and fixation

Reduction is performed under visual control. The spine is stretched lengthwise using elastic screw tractions secured with leather cuffs on the ankle joints, head and armpits. Stretching is performed carefully, in doses, slowly. Often such stretching is quite sufficient to eliminate lateral and anteroposterior displacement of the vertebrae. Reduction can be supplemented by the surgeon, in the wound with bone forceps for the spinous processes or arches of the displaced vertebrae. In rare cases, it is necessary to resort to lateral screw tractions. Usually, reduction in fresh cases is achieved quite easily. In interlocking dislocations, it is sometimes necessary to resort to resection of the articular processes. After reduction, the metal plates of the fixator are placed along the lateral surfaces of the bases of the spinous processes so that the middle of the length of the fixator falls on the site of injury. Depending on the degree of displacement, the size of the spinous processes, and the strength of the victim's muscles, 3 or 5 vertebrae are fixed. In addition to the displaced vertebra, 1-2 overlying and 1-2 underlying vertebrae are subject to fixation. Fixation is performed with bolts inserted through holes in the plates and the base of the corresponding spinous process. Minimal displacement of the plates at the moment of inserting the bolt leads to a misalignment of the corresponding holes and complicates the insertion of the bolts. To prevent this, bayonet-shaped awls are inserted through the holes in the plates and the base of the spinous processes, which make holes and do not allow the plates to shift. The awl is successively removed, the bolt is inserted and secured, the next awl is removed, the bolt is secured, etc. The bolts are secured with two wrenches. It is better to first secure the bolts passing through the outer spinous processes. Careful hemostasis is performed. Antibiotics are administered. Layered sutures are applied to the edges of the wound.

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

After spontaneous breathing is restored, extubation is performed. The victim is placed on his back in a bed equipped with two Balkan frames and a wooden board. To relax the muscles and hold the spine in a position of slight extension, a cloth hammock is placed under the damaged section of the spine, with 3-5 kg weights suspended from the ends. The legs are placed in a position of moderate flexion at the knee and hip joints.

Symptomatic drug treatment is carried out, antibiotics are administered. On the 7-8th day, the stitches are removed. From the first days, the victim is allowed active movements of the lower limbs, massage. Breathing exercises, arm movements are mandatory from the first hours after the intervention. The victim spends 3-4 weeks in bed. In some cases, after this period, a plaster corset is applied for 1.5 g - 2 months.

As a rule, by the end of the 5th-6th week the victim is discharged for outpatient treatment. The retainer should be removed no earlier than 1 year after the operation.

Internal fixation with a metal fixator for fracture-dislocations and dislocations in the lumbar, lumbar-thoracic and thoracic spine can be combined with osteoplastic fixation by the type of posterior spondylodesis. For this, compact bone is removed from the arches and posterior surfaces of the articular processes until the bleeding spongy bone is exposed. Bone grafts (auto- or homobone) are placed in the prepared bed. Due to the serious condition of the victim, autoplastic surgery is undesirable.

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

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

Early internal fixation in fracture-dislocations of the thoracic, thoracolumbar and lumbar spine allows for immediate adjustment of displaced vertebrae, transfer of the injury from unstable to stable and reliable prevention of secondary damage to the contents of the spinal canal. Care for the victim is significantly facilitated.

Surgical intervention on the contents of the spinal canal in case of closed complicated fractures of the spine

It is not our task to describe in detail all the subtleties of interventions on the contents of the spinal canal in complicated closed injuries of the spine. A trauma surgeon providing assistance to a victim with a spinal injury must 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.

Disruption of the active function of the spinal cord in complicated closed spinal injuries may depend on concussion and contusion of the spinal cord, extra- and subdural hemorrhage, hemorrhage into the brain substance (hematomnelia), varying degrees of damage to the spinal cord substance up to its complete anatomical rupture, compression of the spinal cord by fragments of damaged vertebrae, damaged intervertebral disc and deformed spinal canal.

In the first hours and days after injury, it is not easy to determine the cause of the spinal cord dysfunction. A detailed dynamic neurological examination of the victim, high-quality X-ray examination, the use of special tests to determine the patency of the subarachnoid space (Pussep, Stuckey, Quekenstedt liquorodynamic tests, Ugryumov-Dobrotvorsky breathing test), contrast X-ray examination methods facilitate this task and help to determine the cause of the spinal cord conductivity disorder. Naturally, liquorodynamic tests and simple spinal puncture should be performed only with the victim lying down. Contrast X-ray examination methods should be used with caution and only when absolutely necessary.

The optimal time for intervention should be considered to be 6-7 days from the moment of injury. In case of damage to the cervical spine, these periods are significantly reduced.

Indications

Most authors cite the following indications for revision of the contents of the spinal canal in complicated closed spinal injuries:

• an increase in symptoms from the spinal cord in the form of paresis, paralysis, loss of sensitivity and pelvic disorders;
• violation of the patency of the subarachnoid spaces, determined using LPKvorodynamic tests; V. M. Ugryumov emphasizes that maintaining the patency of the subarachnoid space is not an absolute sign of the lack of interest of the spinal cord and its elements;
• detection of bone fragments in the spinal canal during X-ray examination;
• acute anterior spinal cord injury syndrome.

In addition to the usual preoperative preparation (easily digestible food, general hygiene measures, cleansing enema, emptying the bladder, general strengthening and sedative treatment, etc.), serious attention should be paid to immobilizing the spine when moving and shifting the victim. It should be remembered that the slightest careless movement of the victim himself or the slightest carelessness when shifting him to the gurney or operating table, especially in the case of unstable injuries, will cause additional damage to the spinal cord. In the case of cervical localization of the injury, this can cost the victim his life.

The position of the victim on the operating table depends on the level and nature of the injury. The victim should be in a position that will not aggravate the displacement of the fragments of the damaged section of the spine and will be convenient for the intervention.

Preference should be given to endotracheal anesthesia, which facilitates not only the intervention, but also the subsequent reduction and stabilization of the damaged section of the spine. Laminectomy can also be performed under local infiltration anesthesia.

Technique of intervention on the spine and contents of the spinal canal

A posterior median approach is used. A linear incision is made along the line of the spinous processes. Its length should be such that it begins one vertebra above and ends one vertebra below the intended laminectomy level. A semi-oval skin incision on the lateral base can also be used. The skin, subcutaneous tissue, and superficial fascia are dissected layer by layer. The edges of the skin-fascial wound are spread apart with sharp hooks. The supraspinous ligament covering the tops of the spinous processes is exposed. The supraspinous ligament is dissected to the bone strictly along the midline. The lateral surfaces of the spinous processes, the arch, and the area of the articular processes are skeletonized subperiosteally. Particular caution and care must be taken when separating soft tissues at the site of damaged vertebrae, since mobile fragments of the broken arch can cause additional damage to the spinal cord with careless manipulations. Bleeding from the muscle wound is stopped by tight tamponade with gauze compresses moistened with hot saline. Using a retractor, the edges of the wound are spread apart. In one of the interspinous spaces, the supraspinous and interspinous ligaments are crossed. At the bases, the spinous processes are bitten off with Dyston nippers along the intended laminectomy. The severed spinous processes are removed together with the ligaments. In the area of one of the interspinous spaces, resection of the arches is started with a laminectomy. Biting is performed from the middle to the articular processes. If a wider resection is necessary, including the articular processes in the removed part, one should remember about possible bleeding from the veins. Resection of the arches of the cervical vertebrae lateral to the articular processes is fraught with the possibility of injury to the vertebral artery. When scaling the arches, care must be taken to ensure that the laminectom does not injure the underlying membranes and the contents of the dural sac. The number of arches removed depends on the nature and extent of the injury. After removing the spinous processes and arches, the epidural tissue containing the internal venous vertebral plexus is exposed in the wound. The veins of this plexus have no valves and do not tend to collapse, since their walls are fixed to the tissue. If they are damaged, significant bleeding occurs. Air embolism is also possible. To prevent air embolism, tamponade with wet gauze strips should be performed immediately in case of damage to these veins.

The arches are removed upwards and downwards until the intact epidural tissue is exposed. The epidural tissue is moved to the sides using wet gauze balls. The dura mater is exposed. The normal, intact dura mater is greyish in colour, slightly shiny, and pulsates synchronously with the pulse. In addition, the dural sac does not vibrate in accordance with respiratory movements. The damaged dura mater is darker in colour, even cherry-bluish, and loses its characteristic shine and transparency. If there is compression, the pulsation disappears. The dural sac may be stretched and tense. Fibrin clots, blood, free bone fragments, and ligament scraps are removed. The presence of cerebrospinal fluid indicates damage to the dura mater. Small linear ruptures of the dura mater can be detected by increasing the CSF pressure by compressing the jugular veins.

When intervening 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 remains intact, a 1.5-2 cm long test incision is made along the midline. The presence or absence of a subdural hematoma is determined through this incision.

The edges of the dissected dura mater are sutured with provisional ligatures and moved apart. When widening the incision of the dura mater, it should not reach the edges of the bone wound (unremoved arches) by 0.5 cm. If a subarachnoid hemorrhage is detected, the spilled blood is carefully removed. If the arachnoid mater is unchanged, it is transparent and protrudes into the incision of the dura mater in the form of a light bubble. It is subject to opening in the presence of subarachnoid accumulation of blood and damage to the brain matter. The absence of cerebrospinal fluid in the wound after opening the arachnoid mater and performing cerebrospinal fluid dynamics tests indicates a violation of the patency of the subarachnoid space. The posterior and lateral surfaces of the spinal cord are examined. According to indications, its anterior surface can also be examined by carefully moving the spinal cord with a narrow brain spatula. Cerebral detritus is removed. Careful palpation may reveal bone fragments in the thickness of the brain. The latter are to be removed. The anterior wall of the dural sac is examined. The prolapsed substance of the damaged intervertebral disc is removed. If there is a deformation of the spinal canal, it is corrected by repositioning the displaced vertebrae. The dura mater is sutured with a continuous hermetic suture. In the presence of significant edema and swelling of the spinal cord, according to some authors (Schneider et al.), it is not necessary to suture the dura mater. If necessary, plastic surgery of the dura mater can be performed.

It is necessary to reduce the fracture and stabilize it using one of the methods 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 treatment of complicated spinal injuries. Stabilization eliminates mobility in the area of injury, creates conditions for fracture fusion in an anatomically correct position, prevents the possibility of early and late complications, and significantly facilitates postoperative care for the victim.

The wound is sutured layer by layer. Antibiotics are administered. During the operation, blood loss is carefully and meticulously replenished.

Postoperative management of the victim is dictated by the level and nature of the injury and the method of surgical stabilization of the injured section of the spine. Its details are set out above in the relevant sections devoted to surgical treatment of various spinal injuries.

In patients with complicated spinal injuries, other special measures must be taken in the postoperative period.

The cardiovascular and respiratory systems require close attention in the first hours and days after the operation. Intravenous administration of blood and blood substitutes is stopped only after stable alignment of arterial pressure indicators. Systematic monitoring of arterial pressure is extremely important. Everything in the ward should be ready for immediate blood infusion, and if necessary, for arterial blood administration and other resuscitation measures. In case of respiratory disorders, lobelia or cytitone are administered intravenously. Subcutaneous administration is ineffective. In case of increasing respiratory disorders, it is necessary to resort to the imposition of a tracheostomy and be ready to switch to artificial respiration.

Since patients with complicated spinal injuries are prone to various infectious complications, massive and prolonged courses of treatment with broad-spectrum antibiotics should be administered. It is necessary to determine the sensitivity of the microflora to antibiotics and use those to which the microflora of a given patient is sensitive.

The closest attention should be paid to the prevention of bedsores. Clean linen, smooth sheets without the slightest folds, careful turning of the patient, and careful skin care prevent the development of bedsores. A rubber ring is placed under the sacrum, and cotton-gauze "balls" under the heels. A heating pad should be used with extreme caution, remembering that these patients may have impaired sensitivity.

Serious attention should be paid to emptying the bladder and intestines. In cases of urinary retention, it is necessary to remove urine with a catheter 1-2 times a day. In this case, strict adherence to the rules of asepsis and antisepsis is mandatory. In case of persistent urinary retention, the imposition of the Monroe system is indicated and only in extreme cases of a suprapubic fistula. It is recommended to impose not a labial, but a tubular fistula - when the bladder mucosa is not sutured to the skin. A tubular fistula closes on its own when it is no longer needed. An indication for closure of a suprapubic fistula is 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 rinsing of the bladder with antiseptic solutions is mandatory, and it is recommended to change the type of antiseptic periodically. General strengthening treatment, vitamin therapy, and rational nutrition are mandatory. At a later stage, massage, therapeutic exercises, and physiotherapy should be used.