Symptoms of spinal cord injury

Symptoms of damage to the interstitial and suprainfacial ligaments depend on the duration of injury and associated spinal injuries.

At the same time, the clinical diagnosis of these lesions is rather complicated: a palpation injury is often not always detected, since displacements in the vertebral region are minor, and also radiographs may not always help in making a diagnosis. This is especially true for fairly frequent sprains in the upper segment of the cervical spine. In the following sequence, the articular joints of the middle and lower parts of the cervical spine are damaged. Depending on the location of the damage, they are defined as post-traumatic suboccipital syndrome, median and lower cervical syndrome. The clinical picture is characterized by the appearance of typical neurological pain in the occipital region with scant objective signs. The cause of occipital neuralgia (Kuhlendahl) is the compression of the occipital nerves, which, being formed from the posterior roots of two cervical segments, “pierce the yellow ligament” between the bow of the atlas and the epistrophy, near the intervertebral joints. On spondylograms no changes are detected.

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

Pain

Persistent pains in the area of damage according to the type of cervicalgia, lumbago are characteristic of damage to the interspinal and supraspastic ligaments in late periods after injury. Patients note rapid fatigue of the muscles of the neck, back. Later, radicular pains may appear, which more often depend on secondary degenerative changes in the intervertebral disk at the level of damage with the formation of posterior and posterolateral hernias of the disk.

[6], [7], [8], [9]

Forced position

It is known that the lateral joints of the bodies of the cervical vertebrae are located in the oblique plane, which passes from behind to the front and from the bottom up. The deviation from the horizontal plane increases from top to bottom: it is less pronounced in the joints between the vertebrae C ₁ - C ₂, more between C ₇ -Th ₁. Therefore, the forward movement of the vertebra (with hypermobility or instability) is accompanied by its elevation until the lower articular process of the vertebral body slips into the upper vertebral notch of the underlying vertebra, when the displaced vertebra again approaches the underlying.

With different types of displacements, the head assumes a characteristic position, which is considered typical. The maximum height of displacement of the lower articular process with hypermobility (instability) - I-III Art. Does not exceed 0.7 cm. If there is a forced tilt of the head anteriorly, then when viewed, the kyphosis is clearly visible, the top of which is formed by the spinous process of the affected vertebra.

The listed so-called typical positions of the head are not always clearly pronounced when stretching the ligaments in old cases, as they are masked by compensatory displacements in adjacent intact joints.

For diagnostics in unclear cases of “tilting of the head”, it is recommended to be oriented according to the height of standing of the corners of the lower jaw with a straightened neck (“unbent head”). On the convex side of the curvature, the angle of the lower jaw occupies a higher position on the side of the injury, especially if the patient first makes several nodding movements.

Better forced position of the head is detected when examining the patient in the I. P. - standing, which is not always possible and permissible, especially in recent cases. Therefore, many authors emphasize the unreliability of diagnosis based on the symptoms of a typical head position. However, the identification of the forced position of the head serves as a sufficient basis for an in-depth clinical and radiological examination, without which the assumption of damage to the ligamentous apparatus of the cervical region cannot be rejected.

[10], [11], [12], [13]

Head imbalance

The instability of the head is a consequence of disorders of the spinal support due to the violation of the relationships between the vertebrae, damage to the ligamentous apparatus, the displacement of the load axis and the direction of muscle traction.

The degree of instability can be different, which depends on the severity of the damage, and on the development of compensatory phenomena.

In severe lesions of the ligament apparatus (III.), The instability of the head is detected immediately after the injury and is held for a long time (weeks, months). In milder cases (Stage I-II), this symptom is less pronounced, disappears more quickly due to scarring of damaged tissues and compensatory devices in the ligamentous-muscular apparatus of the neck. In a number of patients, the instability of the head remains permanently upright, or it occurs when the body position is changed, with a more or less prolonged load (for example, when walking, prolonged sitting, especially with the head tilted forward).

A classification of the degrees of head instability, based on clinical studies, is proposed.

Classification of the degree of instability of the head (Epifanov VA, Epifanov AV, 2002)

Degree of instability	Clinical picture	Struck by the PDS of the spine
Lightweight (I)	The tension of the muscles of the neck, holding the head in a forced position. During movements of the trunk and limbs, the position of the head remains unchanged (due to the tension of the neck muscles). Movement of the patient makes slowly, carefully. If compensation is observed, it is not resistant, it is easily disturbed at work, especially related to the inclination of the head in front	One segment
Medium (II)	Tension of the neck muscles holding the head. The patient supports his head with his hands in the upright position of the body, when trying to get up or lie down, while bending the torso forward (Thomsen's symptom). The patient can stand up and lie down without hands supporting the head, but only sideways to the horizontal plane (safety of lateral stability)	1-2 segments
Heavy (III)	Tension of the muscles of the neck, shoulder girdle and paravertebral muscles. The patient constantly supports his head with his hands. The head of the patient is not kept and falls when raising the "bedridden" patient (a symptom of "guillotine")	Two or more segments

Movement disorders in the cervical spine

Movement disorders	Damage to the cervical spine
	Acute injury	An aging injury
Complete immobility	6 (13%)	3 (2.9%)
Movement restriction in all directions	8 (17.5%)	55 (52.3%)
Movement restriction in the direction of damage	32 (69.5%)	47 (44.8%)

Head imbalance is a frequent and important symptom of damage to the ligamentous apparatus of the cervical spine, but it can also occur with fractures of the vertebral bodies, injuries of the intervertebral discs, spinal osteochondrosis, paresis and atrophy of the neck muscles, some developmental abnormalities. Therefore, this syndrome cannot serve as an independent test for the differential diagnosis of traumatic injuries of the spinal ligaments.

[14], [15]

Disturbed movements in the cervical spine

Displacement in the lateral joints of the cervical spine at any localization is accompanied by a violation of movements. These violations are more pronounced, the less time has passed since the injury. Later, with the development of compensatory processes, the instability of the head decreases, the range of movements increases.

There are three possible violations of the movement.

In the study of movements should be borne in mind that:

• Movement impairment in the same patient is more pronounced in the vertical position than in the horizontal.
• In the initial lying position, the limitation of the inclination and rotation of the head is more accurately determined in cases where the patient's head is located along the axis of the torso, since with the extension of the cervical spine, these movements can be limited without damage.
• Simultaneously with the violation of movements when the ligamentous apparatus is damaged, tension of the muscles of the neck and crepitus are observed during movements.
• Simultaneously with the violation of movements in case of damage to the ligaments of the cervical spine in patients with observed tension of the muscles of the neck, crunch or crepitus during movements. The tension of the muscles in this case may be due to their reflex tension or tension with increasing distance of attachment points.
• Crunching, clicking, or crepitus during movements in the cervical spine, experienced by patients or determined by palpation of the affected area, may be a manifestation of degenerative-dystrophic changes in the lateral joints, intervertebral discs and ligaments of the spine that are not accompanied by other clinical symptoms.

Disturbance of movements in the cervical spine is a common symptom of damage or impairment of compensation in some diseases of the spine and cannot serve as a reliable basis for a differential diagnosis between damage to the ligamentous apparatus and other injuries and diseases. However, a study of movements in the cervical spine can confirm the assumption that the spine is damaged, and the restoration of movements after the treatment with exercise therapy is the most valuable clinical sign of a cure.

Symptoms of ligament damage detected by palpation

• Deviation of the spinous processes in one direction or another, as a result of which their location in one sagittal plane is disturbed. However, it is possible to identify such a displacement only in individual cases, and this depends on the unequal length of the spinous processes, on the unequal form of split ends, on the masking effect of the hypostosis of the ligament in case of its separation from the spinous processes, on the large thickness of muscles and their tension. The curvature of the line of the spinous processes is more easily detected only in the area of C ₆ - ₇ and C ₂ - ₃.
• On palpation of the zone of damage to the PDS of the spine, pain is determined, and in the first hours, or even days, it can be detected far beyond the affected area. It depends on a greater extent of damage to the ligament, on the displacement of damaged tissues that occurs during the palpation of the mobile formations (supraspastic ligament, muscles) and away from the site of injury.
• With anterior displacement of the vertebral bodies (hypermobility, instability), accompanied by their inclination anteriorly, the posterior ligaments rupture and the distance between the spinous processes of the affected and underlying vertebrae increases.

[16], [17], [18], [19], [20], [21]