Spine ( columna vertebralis ; synonym for the vertebral column). It is an axial skeleton, consists of 32-33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral, connected to the sacrum, and 3-4 coccygeal), between which there are 23 intervertebral discs.
A typical vertebra has a body and an arc closing the vertebral foramen, from which the spinous, two transverse, two upper and two lower articular processes depart. The vertebral bodies are composed of a cancellous substance covered with a layer of compact bone. They differ in shape, curvature of the upper and lower surfaces, the height of the anterior and posterior sections. The spinous processes also differ from each other in size, shape, and orientation in space; they limit P.’s extension, especially in the thoracic region. All, except for the thoracic, transverse processes include the rib rudiments merged with them. In the cervical vertebrae, the transverse processes contain holes that make up a canal for the passage of vertebral vessels and a nerve. The spatial orientation of the articular processes of different vertebrae is not the same. I and II cervical vertebrae (atlas and axial) have a special design, due to which, as well as due to the structure of the connections between them and with the occipital bone, they provide mobility of the head in three planes.
The forms of connections between the vertebrae include all major types of connections. All vertebral bodies, with the exception of the sacral ones, in adults are separated by intervertebral discs, consisting of an annulus fibrosus and nucleus pulposus. The peripheral part of the annulus fibrosus is formed of plates of collagen fibers, which have a helically crossing direction. The inside of the ring is made up of fibrous cartilage. The fibers of the annulus fibrosus are connected with the surfaces of the vertebral bodies, the anterior and posterior longitudinal ligaments, and in the thoracic region – with the intra-articular connections of the rib heads. The intervertebral discs are separated from the bone tissue of the vertebral bodies by a thin layer of hyaline cartilage. The plastic nucleus pulposus contains a lot of amorphous intercellular substance. liquefied in the central part, in the lower thoracic and lumbar regions, it is somewhat displaced posteriorly. This anatomical formation acts as an elastic shock absorber. In an adult, the intervertebral discs are approximately 1/4 to 1/5 of the length of the spine.
The arcs of each pair of vertebrae are connected by two flat joints, yellow ligaments and a developed ligamentous apparatus between the spinous, transverse processes. The vertebral notches of the edges of the arches make up the intervertebral foramen through which the spinal nerves and their accompanying vessels pass.
The cervical and lumbar sections of P. are curved anteriorly (Lordosis), the thoracic and sacral sections are curved posteriorly (Kyphosis).
The spine is usually examined in connection with the patient’s complaints of local changes, which can be manifested by pain, deformity, or limited mobility. Each of the complaints can relate to the entire spine or a specific part of it. Sometimes local changes are not very pronounced and the reason for P.’s research are secondary changes caused by dysfunction of the spinal cord or its roots. However, back pain is not always associated with P.’s pathology, they are often noted in a number of diseases of internal organs and in other pathological processes. Deformity of the spine or other changes in it can occur with a disease of the spinal cord, its membranes or roots, for example, lateral curvature of the spine is secondary to syringomyelia, poliomyelitis.
The spine is examined while the patient is standing, sitting and lying, both at rest and in motion (head, trunk, limbs). The level of P.’s defeat is determined by counting the number of vertebrae from certain anatomical landmarks or according to a special scheme. So, the transverse process of the 1st cervical vertebra is located on the diameter of the finger below the apex of the mastoid process, the transverse process of the VI cervical vertebra in an adult is at the level of the cricoid cartilage (higher in children, lower in seniors). The spinous process of the VII cervical vertebra usually protrudes posteriorly and is clearly visible under the skin with a slight tilt of the head forward, II thoracic vertebra is at the level of the episternal fossa, III thoracic – at the level of the lower edge of the scapular spine, VII thoracic – at the level of the lower angle of the scapula, VIII – at the level of the angle of the sternum, IX – at the level of the junction of the sternum with the xiphoid process. Level II of the lumbar vertebra corresponds to the lower point of the X rib, and level IV of the lumbar vertebra – to the line drawn through the upper edges of the iliac crests. I sacral vertebra lies at the level of the posterior spines of the iliac bones.
When examining P. pay attention to posture, features of the structure of the body. Special markings, for example, with bold chalk or dye, or with a glance (with sufficient experience in research P.) mark the line of spinous processes (median groove of the back), lower angles of the shoulder blades, crests of the iliac bones, lateral contours of the waist and neck, position of the shoulder girdle , deviation of the intergluteal groove from vertical. When examining the spinous processes, their protrusion is revealed; a sharp protrusion of one process relative to the others does not normally occur. Examining the back, pay attention to the relief of the muscles located next to the spine.
P.’s palpation allows to supplement the examination data (presence or absence of deformation), to determine the localization, degree and nature of pain. It should be remembered that normally the spinous process of the II lumbar vertebra projects more posteriorly than the adjacent spinous processes. To identify pain when pressing on the spinous process, put the thumb on it and press, moving from the higher to the lower process. With a pathological process involving the articular and transverse processes, pain is noted when pressed in the paravertebral points along a line running parallel to the spinous processes 1.5-2 cm to the side (in the lumbar region by 2-3 cm). To identify pain, tapping is sometimes used: on the spinous processes, pressure on them from the side and other special diagnostic techniques, for example, pressure along the P. axis (on the head or on the shoulder girdle). When palpating, the tension of the muscles located next to the spine is also noted. most of P.’s injuries and diseases are accompanied by increased muscle tone. Feeling of the front surface of P. at the level of three – four cervical upper vertebrae is carried out through the mouth, usually with the index finger. At the level of the cricoid cartilage in front of the sternocleidomastoid muscle, the tubercle of the VII cervical vertebra is probed. In thin people, with bimanual palpation of the abdomen, palpation of the body of the lumbar vertebrae is available. The sacral and coccygeal sections of P. are palpable from the front through the rectum.
P.’s flexion to a greater extent occurs due to his lumbar spine, to a large extent – cervical and relatively small – thoracic. In P.’s cervical spine, it is manifested by smoothing of the lordosis existing in the norm. P.’s mobility changes with age and depends on the constitution.
In outpatient practice, it is convenient to use standard techniques in order to determine the range of motion in various departments of P. So, measure the distance from the chin to the sternum when the head is tilted anteriorly and posteriorly. When the head is tilted to the side, the distance from the earlobe to the shoulder girdle is measured , for example: the cromial process of the scapula (the shoulder girdle is relaxed). When bending the torso forward, the tips of the fingers or palms should touch the floor if the patient is standing with his knees bent. This is normally easy to do in childhood and adolescence, and in elderly people, knees bend when performing such a task. To assess the total value of P.’s flexion when it is limited, measure the distance from the floor to the fingertips. Asymmetry of lateral movements of P. is easy to establish when the body bends to the side. To assess the amplitude of lateral movements, measure the distance from the floor to the fingertips of the hand, which, as it were, slides on the side of the slope along the outer surface of the thigh. The amplitude of rotational movements is clearly visible from above: in the cervical region – according to the position of the head, in the lumbar region of P. – the shoulder girdle. Often, Schober’s clinical test is used to assess P.’s mobility . When examining the thoracic spine, 12 vertebrae (about 30 cm) are counted from the spinous process of the VII cervical vertebra in a standing position, when bending forward normally this distance increases by 8 cm.When examining the lumbar spine, the distance between I and V lumbar vertebrae is measured (about 10 cm ); after bending the body, this distance increases in adults by 4-6 cm. For a more accurate determination of P.’s mobility, a special device is used — a goniometer. An important role in P.’s research is assigned to radiography, incl. with a radiopaque substance, tomography, etc.
Developmental defects. Among the malformations of P. there are wedge-shaped vertebrae and hemivertebrae (complete and additional), splitting of the vertebrae with the formation of the so-called butterfly – shaped vertebrae, synostosis of the vertebral bodies, arches, articular processes, or their underdevelopment. In the thoracic region, malformations of the vertebrae, as a rule, are combined with malformations of the ribs (a decrease in their number, synostosis), aggravating the deformation of the chest, reducing its volume and excursion. Treatment is aimed at maintaining P.’s mobility and improving chest excursion (exercise therapy, swimming).
In the cervical spine, a severe defect is a decrease in the number of vertebrae, their synostosis with the formation of a single bone block.
Congenital wedge-shaped vertebrae in the thoracolumbar region can cause severe kyphosis or scoliosis. Splitting of the arches of the vertebrae in the lumbosacral region is common and belongs to the variants of normal ossification . In other parts of the spine, they are considered a sign of pathological development.
In the lumbosacral region, the splitting of the vertebral bodies and arcs can be combined with malformations of the spinal cord and its roots ( myelodysplasia , spinal hernia), which are accompanied by trophic disorders, paresis, contractures and deformities of the lower extremities, disorders of the function of the pelvic organs.
The so-called transitional vertebrae are the borderline vertebrae of one section of the spine, morphologically similar to the vertebrae of another section. In this case, there is a corresponding decrease or increase in the number of vertebrae of adjacent departments. In the cervical and thoracic regions, they do not appear clinically. In the lumbosacral region, transitional vertebrae (sacralization and lumbarization ) often contribute to the early development of a dystrophic process in P. Sacralization of the V lumbar vertebra is more common. It is usually characterized by elongation and expansion of the transverse process on one or two sides (incomplete form of the transitional vertebra), deformation of the transverse process, which connects to the lateral masses of the sacrum through cartilage or connective tissue. The bony junction of the transitional vertebra is usually not a source of pain, and osteoarthritis, accompanied by pain, can develop in the cartilaginous and connective tissue. Lumbarization is rare.
Diagnosis of P.’s malformations requires an x-ray examination. Pictures are taken in two projections, and if there is a suspicion of transitional vertebrae, X-rays of two adjacent parts of the spine are performed.
P.’s injuries are less common than limb injuries, but are more severe more often. P.’s injuries occur with various injuries: when falling from a height to the legs, buttocks, on the head, on the back, when the weight falls on the bent back, when struck in the chest, in the back, at the moment of a sharp (sudden) turn of the head or body.
P.’s damage is classified by the nature of the damage and anatomical localization. Distinguish bruises, P.’s sprains, ruptures of P.’s ligaments, subluxations and dislocations, fracture- dislocations, fractures , P. wounds, which can be localized in the cervical, thoracic, lumbar, sacral and coccygeal parts of P. P.’s damage can be isolated, multiple (several vertebrae) or combined (for example, a combination of fractures of the arches, articular and transverse processes). P.’s injuries are encountered that are not accompanied by dysfunction of the spinal cord and its roots and are combined with their damage or dysfunction. Some types of damage to P. lead to a violation of its stability (the so-called unstable damage to P., for example, fracture- dislocation of the cervical vertebrae), in these cases, as a rule, the spinal cord is also damaged. By localization in P.’s structures distinguish between injuries of intervertebral discs, ligaments and vertebrae. Disc trauma can be isolated if, as a result of external force, a herniated disc occurs, or it can be combined with a violation of the integrity of other structures of the spine, for example, a fracture of the vertebral body is accompanied by hemorrhage into adjacent discs.
P.’s bruises occur with direct application of traumatic force. They can only damage soft tissues (minor bruises) or be accompanied by neurological disorders due to spinal cord injury (severe bruises). At light bruises P. note a local diffuse swelling, hemorrhage, a slight restriction of P.’s mobility and pain on palpation. Unlike more severe P.’s injuries (for example, fractures), the axial load on P. is not accompanied by increased pain, P.’s deformation is absent. To clarify the diagnosis, P.’s x-rays are taken in direct and lateral projections. Treatment of light bruises of P. is conservative, it can be carried out on an outpatient basis. Anesthetize the site of injury, appoint rest, locally cold in the first few days, and then light massage, exercise therapy. Ability to work is usually restored after 1-2 weeks, but if P.’s injury occurred in persons with osteochondrosis and especially spondylosis, then the pain syndrome can be much longer. In such cases, a set of therapeutic measures is prescribed to eliminate pain, and then to strengthen the muscles that support the spine. Before stopping the pain syndrome, limit the load on P., use orthoses ( head support , lumbar brace, etc.).
P.’s stretches more often arise in its most mobile departments – cervical or lumbar. P.’s distortion is caused by forced movements, the amplitude of which exceeds the physiological limits of mobility, usually movements combined with a turn. In the cervical spine of P., there is often a stretch that occurs in the driver or passenger of a car in the absence of head restraints in the event of a sudden stop as a result of inertial movement of the head (the mechanism of the so-called whip blow). At the same time, stretching and partial tears of the bag- ligamentous apparatus occur without noticeable deformations and persistent violations of the P.’s function. Clinically, pain in the corresponding section of P., a forced position, and a limitation of the range of motion are noted. The pain syndrome increases with movements and palpation.
To exclude more severe P.’s injuries, an x-ray examination is required. Treatment is conservative. Apply local anesthesia at the points of maximum pain. In case of injuries of the cervical spine, a soft Shants collar or another head holder (for example, made of expanded polyethylene) is used for immobilization . With sprains of the lumbar section of P., the patient is placed on a shield, and bed rest is prescribed. Starting from the 3-4th day after the injury, physiotherapy is carried out, from the 2nd week – massage, therapeutic exercises. Ability to work is restored in 2-4 weeks.
Ruptures of P.’s ligaments as isolated damage are extremely rare, much more often they are observed in dislocations and fracture dislocations . As well as sprains, they usually occur in the cervical and lumbar regions of P. The mechanism of injury is indirect. Ligaments can be torn with P.’s sharp bending or crushed by adjacent spinous processes during forced extension. The clinical picture is very similar to distortion. Fresh isolated injuries of P.’s posterior ligaments are accompanied by local back pain corresponding to the level of rupture. The pain increases with movement, especially with extension. On examination, bulging is sometimes noted due to a hematoma over the area of damage. Palpation of the interspinous spaces in this zone is sharply painful. In case of damage to the interspinous ligaments, pronounced soreness is detected when pressing on the interspinous gap not along the midline, but somewhat to the side of it. Sometimes it is possible to palpate the defect of the damaged ligaments, and with their complete rupture, the finger can almost freely penetrate between the spinous processes. In fresh cases of isolated rupture of the ligaments, the separation of the spinous processes usually does not occur. Old ligament injuries clinically resemble lumbago, patients complain of increased back muscles fatigue. In the future, signs of dysfunction of the spinal roots may appear due to the progression of the dystrophic process in the intervertebral disc at the level of damage. As a rule, during a clinical examination of patients with chronic injuries of the ligaments, the limitation of P.’s mobility, especially its extension, as well as pain on palpation and expansion of the interspinous gap (weakness of the interspinous ligaments) are noted. In the later periods after injury of the supraspinatus or interspinous ligaments, the clinical picture resembles osteochondrosis. To clarify the diagnosis, an X-ray examination is performed – X-ray in frontal and lateral projections, functional profile X-rays in the flexion and extension position, X-ray contrast study ( ligamentospondylography ): thermography, etc.
Treatment of fresh ruptures of P.’s ligaments is conservative. It is usually started in a hospital setting. On admission, local anesthesia of the damaged ligaments is performed. In the future, it is repeated with an interval of 3-4 days. The patient is placed on the backboard. With the flexion mechanism of injury in the damaged lumbar spine, an enlarged lordosis is created to bring the ends of the torn ligaments closer together, and with the extensor mechanism, they provide an average physiological position of the trunk. The duration of bed rest is 4-6 weeks, but a corset can be prescribed for the same period. After the pain subsides, exercise therapy, massage and physiotherapy are indicated. In the later periods after the injury, conservative treatment usually does not give an effect. If, within 1 year after the injury, it is not possible to achieve recovery with the help of conservative measures, then an operation is performed – plastic surgery of the interspinous ligaments according to Yumashev – Silin. Bed rest in the postoperative period is prescribed for 2 weeks, from the first days, patients are engaged in therapeutic exercises. For 8-10 weeks, the forward bending of the trunk is limited. Ability to work is restored after 11-12 weeks.
Dislocations of the vertebrae occur under the influence of significant traumatic force. Usually, the displacement (dislocation) of the vertebra is observed in the most mobile cervical spine of P. This is due to the peculiarities of its structure: the horizontal direction of the articular processes of the cervical vertebrae, the extensibility of the ligamentous ligamentous apparatus, which, under certain conditions, predispose to their slipping. In the thoracic section of P., an isolated dislocation of the vertebrae without fractures of the articular processes does not occur. In the lumbar spine of P., complete dislocations of the vertebrae are observed very rarely and are accompanied by fractures. In this case, first a fracture of the body or articular process occurs, and then the overlying vertebra, devoid of support, slides and shifts, tearing the ligamentous ligamentous apparatus.
Dislocations of the cervical vertebrae can occur under the influence of an external traumatic force or active muscle contraction. Depending on the degree of displacement in the facet joints, subluxations are distinguished (displacement not for the entire length of the articular surface), apical subluxations (displacement for the entire length of the articular surface, the tops of the articular processes remain in contact), interlocking dislocations (the lower articular processes are displaced into the upper vertebral notches of the underlying vertebra). Depending on the degree of inclination of the displaced vertebra with complete dislocation, two types of anterior dislocations are distinguished: overturning dislocations (the displaced vertebra is inclined anteriorly) and sliding dislocations (without inclination of the displaced vertebra).
The latter type of dislocation is much more often accompanied by damage to the spinal cord. the spinal canal is sharply deformed.
Dislocations of the cervical vertebrae are unilateral (or rotational) and bilateral. Bilateral dislocation of the 1st cervical vertebra anteriorly can occur with a fracture of the odontoid process of the 2nd cervical vertebra (the so-called transdental dislocation), with a rupture of the transverse ligament of the atlas ( transligamentous dislocation), and with the slipping of the odontoid process from under the transverse ligament ( peridental dislocation). Rotational displacements of the 1st cervical vertebra can occur as a result of rotation around the odontoid process, in this case, anterior dislocation occurs in one joint, and posteriorly in the other. Such dislocations are called opposite. If the axis of rotation passes in one of the atlantooccipital joints, then a typical rotational subluxation of the atlas occurs.
Depending on the age of the dislocation, there are fresh (up to 10 days), stale (up to 4 weeks) and old (more than 4 weeks) dislocations. Dislocations of the vertebrae can be combined with damage to various bone structures (vertebral bodies, arches, processes) – dislocation fractures . Such injuries of P. include the so-called bursting fracture of the atlas (or Jefferson’s fracture), multiple fractures of the arches of the atlas with lateral displacement of the lateral masses in relation to the occipital condyles and the upper articular surfaces of the second cervical vertebra.
The clinical picture with dislocations of the cervical vertebrae is characterized by a pronounced pain syndrome that occurs at the time of injury. In some cases, patients notice a crunch in the neck with damage, sometimes a feeling of “darkening in the eyes”, “sparks in the eyes”, dizziness, which indicates a violation of blood circulation in the basin of the vertebral artery. In case of damage to the spinal cord at the time of injury, pain radiating down the P. and in the extremity usually occurs . With injuries of the upper cervical vertebrae (both complicated and uncomplicated), neck pain can radiate to the back of the head, with injuries of the middle cervical vertebrae – in the shoulder girdle and upper limbs, with injuries of the lower cervical vertebrae – in the interscapular region and upper limbs. With dislocations of the cervical vertebrae with damage to the spinal cord, the patient is usually in a forced lying position. Other injuries of P.’s cervical spine are accompanied by a forced position of the head. So, with a unilateral subluxation or dislocation, the head is turned and tilted in the opposite direction, with an interlocking dislocation, it is tilted towards the dislocation and turned in the opposite direction, with a bilateral dislocation or subluxation, the head is tilted and displaced (pushed) anteriorly, with an interlocking overturning head, the dislocation is expressed very strongly, and when the slide is engaged, the head is tilted back.
One of the important clinical signs of damage to the cervical section of P. is an unstable position of the head. There are three degrees of head instability: severe (the head is not held relative to the body – the so-called guillotine symptom), medium (the patient holds his head with his hands) and light (the patient holds his head with muscle tension). As a rule, the degree of instability corresponds to the severity of the injury. Active movements in P.’s cervical spine are disturbed (impossible or limited) because of pain. On palpation, local pain at the level of damage, deformation (for example, a protruding spinous process or its displacement to the side), an increase in the distance between the spinous processes, and when dislocation is combined with some fractures, bone crepitus are determined. Through the mouth on the back of the pharynx, it is sometimes possible to feel the protruding vertebral bodies (up to the CIV level). The absence of deformity does not mean that there was no dislocation of the vertebra; the subluxation that arose at the time of injury could adjust spontaneously. A patient with suspected dislocation of the cervical vertebra must be examined by a neurologist. The results of X-ray examination are crucial for determining the type of dislocation of the vertebra and the level of damage. The most informative are profile radiographs taken in a position of slight inclination anteriorly and posteriorly (manipulate very carefully!). To determine the ratio of the occipital bone, atlas and epistrophy, a special image is also made through the mouth in a direct projection. Normally, the joint spaces between the vertebrae increase caudally. The unevenness of their height or the divergence of the articular processes indicate subluxation or dislocation.
Eliminate the dislocation of the vertebra as quickly as possible. Reduction is carried out simultaneously, by skeletal traction or operatively. Anesthesia is pre-performed. Closed one-stage reduction is indicated for fresh dislocations (both complicated and uncomplicated) at the CII – CVI level. In case of dislocations of the Atlantean, traction behind the head with a Glisson loop is usually used to eliminate them , and in case of stale interlocking dislocations, their reduction is shown by the method of constant skeletal traction. One-step manual reduction can only be performed by an experienced traumatologist, because there is a great risk of secondary damage to the spinal cord. The most famous method of reducing Richet – Hüther : with the help of a Glisson loop , which is fastened at the surgeon’s waist, stretching is carried out along the length. Then the head is deflected to the side opposite to the dislocation, rotated towards the dislocation and unbend. After the reduction of a fresh dislocation for immobilization of the cervical spine of P., a soft collar of Shants is used, and with a tendency to relapse of the displacement of the vertebra, a thoracocranial bandage is applied . Sometimes a leather collar with a retractable strut is used for immobilization. Duration of immobilization after closed elimination of dislocation from 4-6 weeks (with subluxation) to 8-10 weeks (with dislocations).
It usually takes another 2-4 weeks to recover. During this period, therapeutic exercises and massage are prescribed to strengthen the muscles of the neck. In case of complicated dislocations, after their elimination, traction is performed using a Glisson loop . Old dislocations are corrected by the method of constant skeletal traction, less often (with complicated dislocations) forced traction is used. In the future, a thoracocranial bandage is applied for 10-12 weeks , which is then replaced with a soft Shants collar, and a course of active rehabilitation treatment is carried out for about 2 more months. With uncomplicated dislocations, the ability to work is restored after 5-6 months. The prognosis in relation to the restoration of working capacity in complicated dislocations depends on the nature of the damage to the spinal cord and its roots.
Surgical elimination of dislocations of the cervical vertebrae is performed with complicated fresh dislocations, if there is deformation of the spinal canal by displaced P.’s structures, with recurrent dislocations, and also with old irreducible dislocations. The operation includes the stage of reduction and the stage of stabilization of the damaged section of P. ( spinal fusion ).
Fractures. There are fractures of the spinous processes, transverse processes, arches and vertebral bodies. They can be isolated, combined with each other, accompanied by damage to other P.’s structures, dislocation of the vertebra ( fracture dislocation ). P.’s fractures are possible without disturbance and with dysfunction of the spinal cord. A special group is made up of the so-called unstable fractures of the spine, i.e. tending to displacement of the damaged vertebra. In most cases, P.’s fractures are closed, much less often open (for example, as a result of a knife or gunshot wound). Often P.’s fractures are combined by localization (for example, P.’s cervical fractures, P.’s lower thoracic fractures, P.’s upper lumbar fractures ) on the basis of similar mechanisms of damage, clinical picture and treatment. Some types of P.’s fractures are called according to the mechanism of their occurrence, for example, compression fractures of the vertebral bodies, avulsion fractures of the spinous processes of the VII cervical and I thoracic vertebrae (the so-called fracture of mole rats, which occurs with a sharp tension of the back muscles).
Fractures of the spinous processes are rare, occur as a result of either the direct application of traumatic force, or excessively intense muscle contraction (usually trapezius and rhomboid). On examination, local swelling is noted in the area of damage, which can increase in the first hours after injury. Palpation determines the pathological mobility of the broken processes and their sharp soreness. With a slight displacement of the fragments, bone crepitus can be detected. The muscles located in the damaged area are usually sharply tense, P.’s mobility is significantly limited. The diagnosis is clarified using radiography. Treatment is conservative, includes local anesthesia, bed rest (lying on the back) for about 1 month, after the pain subsides – exercise therapy, physiotherapy. With severe pain syndrome, a corset is prescribed (for fractures of the spinous processes of the lumbar or lower thoracic vertebrae) or a thoracocranial bandage (for fractures of the vertebrae located above). The ability to work is usually restored 6 weeks after injury. In the case of ineffectiveness of conservative therapeutic measures (long-term pain syndrome), removal of a fragment of the spinous process is indicated.
Fractures of the transverse processes of the vertebrae often occur in the lumbar spine of P. and are detachable due to a sharp contraction of muscles or are caused by direct injury. There are fractures of one process or several, located on one or both sides. Displaced fractures are usually accompanied by damage to the surrounding soft tissues (muscles, fascia, blood vessels, etc.), which is often further complicated by an extensive scarring process with persistent pain syndrome. In some cases, these fractures occur with extensive hemorrhage. Constant symptoms are strictly localized pain in the paravertebral region with lateral movements of the spine, incl. in the opposite direction ( Payr’s symptom ). This clinical sign of fracture usually persists up to 2-3 weeks after injury. In addition, in the supine position, the patient cannot lift the leg on the side of the injury (the so-called sticking heel symptom). Passive hyperextension of the leg in the hip joint causes severe pain at the fracture site due to the stretching of the iliopsoas muscle. Dysfunctions of the lumbar roots are also often noted, usually hyper – or hypoesthesia . The diagnosis is clarified using X-ray examination. Sometimes various shadows are mistaken for fragments of the transverse processes of the vertebrae, for example, gas in the intestine, the shadow of the edge of the lumbar muscles, the nuclei of ossification of the processes preserved in adults, additional ribs, calcified lymph nodes. Treatment is conservative. An anesthetic solution is injected locally , bed rest is prescribed for isolated fractures of one process for 2 weeks, and for multiple fractures up to 4 weeks. In case of recurrence of pain syndrome, repeat the introduction of a local anesthetic. As the pain subsides, they begin remedial gymnastics, in which torso turns are excluded. The ability to work is restored after 1-2 months.
Arc fractures are usually combined with fractures of other structures of the vertebrae, in particular their bodies, spinous, transverse and articular processes. More often, wide and insufficiently strong arches of the cervical vertebrae are damaged as a result of a direct blow or a fall on the head. With a unilateral fracture of the arch, the displacement is insignificant; with a bilateral fracture, the broken arch, together with the spinous process, sometimes with the articular process, is displaced backward or anteriorly. Anterior displacement usually occurs with direct trauma and is accompanied by spinal cord injury. With an indirect mechanism of injury, the arc shifts back. All variants of vertebral arch fractures occur with a pronounced pain syndrome, characterized by a forced position of the head, limitation of active movements. To clarify the type of fracture, x-rays are taken in standard and oblique projections. In the absence of neurological disorders, bed rest is prescribed with light traction on the Glisson loop or fixation of a thoracocranial plaster cast for up to 4 weeks. Subsequently, it is recommended to wear a Shants collar or a head holder made of expanded polyethylene for 6-8 weeks. Prescribe exercise therapy, massage aimed at strengthening muscles, physiotherapy. Ability to work is restored in 3-4 months after injury. In case of unstable fractures of the vertebral arches, surgical fixation is indicated, and in case of fractures with compression of the spinal cord, an urgent operation for its decompression, followed by fixation of the cervical spine.
Fractures of the upper cervical vertebrae are distinguished into a special group. In the area of the atlas, its lateral parts (lateral masses) and arcs are isolated in isolation, and the fracture line passes more often in the place of the groove of the vertebral artery. Spinal cord injuries at this level are less common, because here the spinal canal is wide enough and the ligaments are strong, which prevent the displacement of fragments. Clinically, this fracture presents with head stiffness, pain in the neck and (often) in the back of the head. Head mobility is significantly limited, sometimes patients support it with their hands. X-ray diagnostics is difficult, a thorough analysis of radiographs made in both standard and oblique projections is required. Often, the diagnosis is made only with the help of tomography. With a fracture of the lateral part of the atlas, rupture of the vertebral artery with a fatal outcome is possible. Treatment of fresh fractures is conservative. If the closed reduction is successful, a plaster cast is applied with the capture of the head for 4-6 months. Often, a pseudarthrosis forms at the site of the fracture, which is accompanied by prolonged pain syndrome. In these cases, operative fixation of two cervical vertebrae with the occipital bone is performed.
In the area of the axial vertebra, a fracture of his tooth is most often observed. As a result of the lack of stability in the atlantoaxial joints, dislocation of the atlas can occur, especially often anteriorly, which is accompanied by compression of the spinal cord. The clinical symptoms of a fracture are not typical. Most often, pain in the occipital region, protective rigidity of the cervical spine P. are noted. Sometimes pain and difficulty in swallowing are observed. The diagnosis is clarified using X-ray of the spine, incl. through the mouth. Treatment is conservative. If one-stage reduction fails, constant traction is used, for example, using a Glisson loop . After reduction, a plaster cast is applied for 4-6 months, and then a Shants collar or head holder is prescribed for 2-3 months . Callus forms very slowly, sometimes the tooth is completely absorbed. In case of repeated sudden injury of the cervical spine of P. (even insignificant), dislocation of the atlas may occur. Some traumatologists use distraction- compression devices for fixation , and in case of unstable fractures, they perform operative fixation of the cervical vertebrae with the occipital bone.
Fractures of vertebral bodies are the most frequent injuries of P. Usually, fractures occur at the place of transition of the moving part of P. to a less mobile one – the connection of the cervical spine with the thoracic or thoracic with the lumbar Most often I, II, IV lumbar, XI, XII chest and V, VI are damaged. cervical vertebrae. Fractures of the vertebral bodies can occur as a result of indirect (impact of force along the axis of P.; sharp and excessive flexion of P.; sharp extension of it; rotational effect on P.) and direct injury. P.’s stability is associated with the state of the so-called supporting complexes of the spinal column. Allocate anterior (vertebral bodies, anterior and posterior longitudinal ligaments, intervertebral discs) and posterior ( facet joints P., supraspinous , interspinous and yellow ligaments) support complexes. The rear support complex plays a leading role in ensuring stability. Fractures of the vertebrae with a dangerous tendency to displacement in the horizontal plane are referred to as unstable. Fractures of the vertebral bodies without neurological disorders are called uncomplicated, and with such disorders – complicated.
The impact of the traumatic force along the P.’s axis (usually straightened) leads primarily to damage to the intervertebral disc – the annulus fibrosus breaks and the nucleus pulposus falls out. If the nucleus shifts towards the spinal canal, then the function of the spinal cord and (or) its roots is impaired. A more significant effect of force leads to a fracture of the endplate with the penetration of the nucleus pulposus into the vertebral body, destruction of its spongy structure, in some cases – to fragmentation (the so-called explosive fracture). In this case, the back support complex remains intact. When bending, mainly the anterior parts of the vertebrae suffer – they are compressed (wedge-shaped deformation). In the thoracic and lumbar sections of P., these injuries are usually stable, and in the cervical, more often unstable, tk. the structures of the posterior support complex are damaged.
Depending on the magnitude and direction of action of the traumatic force, as well as the elasticity of the bone tissue, various fractures of the vertebral body are observed, up to its complete destruction. Thus, minor trauma in elderly people with systemic osteoporosis can lead to significant compression; an easy jump in a child suffering from osteogenesis imperfecta can cause fractures of several vertebrae. Some of the bone bars and bone marrow destroyed as a result of a fracture undergo traumatic necrosis, the severity of which depends both on the degree of damage and on localization. The closer to the center is the damage to the vertebral body, the more pronounced the necrotic changes. In case of marginal fractures, the bone bars and bone marrow almost do not undergo necrosis, and therefore the restoration of the structure of the damaged vertebrae ends relatively quickly (in 3-4 months). Recovery processes in the center of the vertebral body are much slower. Reconstruction of the bone structure of damaged vertebrae in comminuted (explosive) fractures with interposition between fragments of intervertebral disc tissue takes longer.
With a compression fracture, pain is noted in the area of damage, stiffness (P.’s fixation as a result of muscle tension). In the case of compression of the thoracic vertebrae, a short-term breath holding often occurs at the time of injury. On examination reveals swelling and bruising in the relevant department P., increasing the distance between the spinous processes, while largely vertebral body compression – withstand posterior spinous process. When pressing on the spinous processes, the pain increases at the level of damage. Lordosis is often smoothed out. With severe pain syndrome, a reins symptom (a sharp tension in the muscles of the back) can be observed. Unstable fractures and dislocation fractures , as a rule, are accompanied by dysfunctions of the spinal cord and its roots. With fractures of the vertebral bodies against the background of dystrophic changes in the spine, for example, osteochondrosis or spondylosis, there is a more common and prolonged pain syndrome, often pain and signs of exacerbation of the pathological process above or below the compression site. In a number of cases, after some time, post-traumatic pain syndrome stops, and the preexisting process takes the first place .
The leading place in the diagnosis of vertebral body fractures is X-ray examination. The most informative X-ray is in the lateral projection, but both projections (frontal and lateral) are required to recognize concomitant injuries.
With compression of I degree (light), the height of the body of the damaged vertebra on the roentgenogram decreases by no more than a third, II degree (moderate) – up to half, III degree (severe) – more than half. The so-called explosive fracture is characterized by a decrease in the height of the vertebral body and its fragmentation, an increase in the width of the vertebra, a violation of the integrity of the endplates, and a decrease in the space between the vertebrae. In children, a compression fracture of the vertebral bodies is often mistakenly diagnosed if the injury occurred against the background of kyphotic deformity of the spine, for example, family forms of structural kyphosis, osteochondropathy ( Scheuermann’s disease – May ); to clarify the diagnosis, tomography is performed. In adults, it is sometimes difficult to establish which vertebral body fracture (fresh or old) is the cause of the pain syndrome. In these cases, the data of a radionuclide study are used (a fresh fracture is characterized by an increased accumulation of a radiopharmaceutical in the damaged area).
Timely and correctly provided first aid is of great importance for vertebral fractures. Its main task is to prevent additional trauma during transportation, transfer and examination of the patient, because movement, especially flexion, and axial loading can further damage the spine and spinal cord. The victim should be transported on a stretcher with a shield in order to exclude flexion, lateral and rotational movements of the P. When admitted to the hospital, it is necessary to ensure the complete unloading of P., to prevent further compression of the damaged vertebra and to create favorable conditions for its regeneration. In order to reduce the pain syndrome, local anesthesia of the damaged area is performed. The patient is put on bed (with a shield); to unload P., it is recommended to raise the head end of the bed and, depending on the level of damage, use various methods of traction: Glisson’s loop , skeletal traction for the parietal tubercles, zygomatic arches (in case of damage to the cervical or upper thoracic section of P.), special straps, cotton-gauze rings … The method of fixing the damaged section of P. with the help of distraction and compression devices also became widespread .
Along with stretching, reclination is carried out . It is carried out by gradually increasing the height of the rollers placed under the wedge deformation region, or by using special mechanical devices, e.g. schita- recliner Kaplan mechanical reklinatsionnoy installation Tserlyuka , hammock for reclination lumbar vertebrae. Reclination contributes to the restoration of physiological lordosis, tension of the anterior longitudinal ligament and, accordingly, fan-shaped stretching of the vertebral bodies. Reclination is usually effective for fresh fractures (I-II degree of compression); if it begins after 2-3 weeks, then, as a rule, it is not possible to eliminate the wedge-shaped deformation. The rate at which the degree of reclination is increased depends on the nature of the pain syndrome. If the fracture occurs against the background of dystrophic changes in P. with persistent pain syndrome, then the deformation is eliminated more slowly, and in some cases it is not performed at all (for example, if in the process of reclination there are signs of compression of the roots of the spinal cord). In case of fractures of the vertebral bodies in the elderly or those suffering from diseases in which the strength of bone tissue is reduced (for example, systemic osteoporosis), in the presence of contraindications to prolonged bed rest (for example, in diseases of the respiratory, cardiovascular systems with a tendency to decompensation), deformity of the vertebrae do not eliminate, but (with stable uncomplicated fractures) are limited to short-term bed rest until the pain is relieved.
Simultaneously with stretching and reclination in compression fractures of the vertebral bodies (I-II degrees), functional treatment is used, which is most effective in uncomplicated compression fractures of the thoracic and lumbar vertebrae. Its main principle is to create a natural muscle corset with the help of special physical exercises, massage of the back and abdominal muscles .
With uncomplicated neurological disorders of compression fractures, the so-called functional method of treatment developed by V.V. Gorinevskaya and E.F. Dreving (1939), in which exercise therapy, used according to differentiated methods, is the main and essentially the only method of therapy and rehabilitation of patients with such a severe pathology. In this case, the exercise therapy technique is divided into three periods in accordance with the clinical course of the fracture.
In the first period, in order to normalize the psychoemotional state of the victim and general hygienic effects on the body in the initial position lying on the back horizontally or on an inclined plane with fixation of the webbing in the axillary region, a set of special physical exercises is performed from the 2nd or 3rd day after the injury. Initially, the complex contains 8-10 general toning exercises for small and medium muscle groups of the limbs, which are performed alternating with respiratory exercises in a 2: 1 ratio, and from the 6-7th day large muscle groups are also involved in the work. At the same time, patients are trained in rhythmic tension of the extensor muscles of the back and abdominal wall in isometric mode, alternating the phase of tension and relaxation every 2, 3, 4 s (in the rhythm of voluntary breathing). Classes are held at least 3 times a day for 10-15 minutes. Taking into account the severity of the pain syndrome, the amount of compression of the vertebral bodies and the age of the patients, on the 7-10th day, the patients, without bending their backs, turn over on their stomach and from that time start exercise therapy according to the method of the second period.
In the second period, the main task of exercise therapy is to build up the strength and endurance of the extensor muscles of the back and abdominal muscles, i.e. the formation of the so-called muscle corset of the trunk. Against the background of general tonic and breathing exercises in the initial positions lying on the back and stomach, and by the end of the month and standing on all fours, a targeted training of the trunk muscles is carried out using dynamic and static exercises of increasing intensity.
Classes are held 3-4 times a day for 30-40 minutes. The criterion of functional readiness for transferring patients to an upright position is the ability to hold for 30-45 s in a prone position with the head, shoulders and both legs raised above the plane of the bed. Such an opportunity usually appears at 4-6 weeks, when patients from the initial position lying on their stomach or standing on all fours, without bending their backs, rise to their feet and stand for 1-3 minutes, gradually adapting to an upright position.
During these periods, patients learn the skills of stable walking, master the exercises of the third period, after which they are discharged from the hospital for outpatient rehabilitation treatment in a polyclinic or a specialized rehabilitation center.
In the third period, the tasks of exercise therapy are the further formation of the muscular corset of the trunk, restoration of P.’s mobility, adaptation to everyday and industrial loads, medical and professional rehabilitation of patients. Exercise therapy classes should be of sufficient intensity and carried out at least 3 times a day for 40-45 minutes. During this period, for the first time, lateral tilts and amplitude flexion of the trunk are performed, which do not cause pain in the fracture area. The criterion of the functional state for transfer to the sitting position is painless walking for 2-3 hours, which is usually achieved no earlier than 3-4 months after the injury.
Disability in persons doing light physical labor with compression fractures with I-II degrees of compression lasts up to about 6 months. A patient with a similar injury can return to hard physical labor no earlier than 1 year after the fracture. If functional treatment is impossible, for example, in persons with mental disorders who have refused to engage in therapeutic exercises, then a reclining corset is applied after reduction . Some traumatologists prescribe a corset of a special design that allows gradual reclination , for example, using a pneumatic device. In case of compression fractures of the vertebral bodies in children, it is recommended to use a reclining corset more widely , since in most cases the child does not adhere well to the necessary motor mode of unloading the spine. But in parallel with this, functional treatment is necessarily prescribed.
In case of stable fractures with significant wedge-shaped deformity of the vertebral bodies (compression of the III degree) in the lower thoracic or lumbar sections of P., they resort to one-stage reduction – they produce the maximum forced extension of the spine. In this case, the anterior longitudinal ligament is stretched, which is tightly fused with the vertebral bodies, as a result of which the damaged vertebral body returns to its normal cylindrical shape. This method is contraindicated in elderly people suffering from severe concomitant diseases, as well as in extension (extensor) fractures with damage to the structures of the posterior support complex, in fractures of arcs, articular processes, damage to the anterior wall of the spinal canal, traumatic spondylolisthesis . Reposition is performed under general or local anesthesia, usually 8-10 days after injury. In the future, a functional method of treatment is used or a plaster corset is applied, which should perform a reclining function. For this, it is necessary that the corset has three points of support: the sternum, the pubic symphysis and the lumbar spine in the area of lumbar lordosis. Support should be carried out on the wings of the ilium. At the same time, the patient’s back remains free, which makes it possible to engage in therapeutic exercises, perform massage and physiotherapy procedures during the period of immobilization. The patient is allowed to stand in a corset about 1 week after a one-stage reduction, if the pain syndrome regresses. Duration of immobilization in this case is at least 4 months. The duration of the incapacity for work of persons whose profession is not related to physical activity is 4-8 months, with light physical labor – 8-12 months, and with heavy labor – at least 12 months.
Fractures of the vertebral bodies of the upper and middle third of the thoracic section of P. are usually not accompanied by significant deformation. Attempts to expand compressed bone structures are usually ineffective. Treatment includes a regimen of unloading P. and remedial gymnastics, and about 3-4 weeks after injury, massage of the back muscles. In compression fractures of the cervical vertebral bodies, traction, gradual reclination and fixation are also used . With flexioin fracture, traction is carried out along the P.’s axis posteriorly, and with extensional – anteriorly. After about 4-6 weeks, a thoracocranial bandage is applied for 2-3 months, and then Shants’s collar is applied.
At severe P.’s deformities as a result of vertebral bodies fractures, a number of traumatologists prefer surgical treatment. The reclinated vertebrae are fixed with the creation of posterior fusion . Indications for such interventions are: pronounced wedge-shaped deformity, comminuted fractures with concomitant injuries of the intervertebral discs, unstable fractures and dislocation fractures , fractures with a violation of the integrity of the anterior wall of the spinal canal. In the conditions of some specialized clinics, anterior stabilizing operations are performed, for example, anterior corporodesis , discectomy with the introduction of a graft into the space between the vertebrae, partial or complete replacement of the vertebrae with a graft. The terms of restoration of working capacity and the peculiarities of the motor regime in the postoperative period depend on the nature of the injury and the characteristics of the surgical intervention.
The outcome of most vertebral body fractures, especially with a significant degree of compression, incomplete reclination or early axial load and inadequate functional treatment, are post-traumatic deforming spondylosis and kyphotic deformity, which disrupt the normal biomechanics of P., which creates conditions for the progression of dystrophic changes in intact parts of P. Almost complete restoration of P.’s function is possible in children and young people with a small degree of compression. To prevent late complications, a systematic spa treatment and compliance with measures aimed at preventing the progression of the degenerative process in the spine are recommended.
P.’s diseases are often accompanied by his deformations. Curvatures in the sagittal plane are called either kyphosis (with posterior bulge) or lordosis (anterior bulge); curvature in the frontal plane – scoliosis. These deformities are often manifestations of various diseases. The nature of P.’s curvature is often a pathognomonic symptom of this or that pathology (for example, a long-term fixed acute-angled kyphosis in the thoracic region is an absolute sign of tuberculous spondylitis).
Scheuermann ‘s disease – May (juvenile kyphosis, osteochondropathic kyphosis) is described as aseptic necrosis of the apophysis of the vertebral bodies. The main symptom of the disease is kyphosis, however, with lumbar localization of the process, kyphosis is not pronounced.
During the process, three stages are distinguished. The first stage is usually asymptomatic; it is only by chance that an X-ray examination reveals a slight wedge-shaped deformation of the vertebral bodies. The second stage corresponds to the appearance of the first nuclei of ossification of the apophyses of the vertebral bodies. Clinically, kyphosis is revealed, the apex of which is displaced caudally, tenderness on palpation of the spinous processes, limitation of the inclination of the body forward, meningeal-radicular symptoms. Radiographically , all the cardinal signs of osteochondropathy are noted : a flat-wedge-shaped shape of the vertebral bodies with an increase in dorsoventral size, a violation of the integrity of the end plate with the formation of Schmorl’s nodes , a narrowing of the disc. At the third stage, the wedge-shaped deformity of the vertebral bodies is somewhat reduced, but their dorsoventral lengthening and flattening remains, their endplates are aligned, most of Schmorl’s nodes disappear, the narrowing of the disc remains.
The dysontogenetic process in P. is not amenable to treatment, however, its painful manifestations (back pain, meningeal-radicular symptoms, limiting the inclination of the body) can be reduced with the help of systematic gymnastics, acupuncture, traction, physiotherapy, water procedures in the form of a warm or contrast shower, swimming.
Coccygodynia (pain in the coccyx) is a common occurrence in adolescents and adults.
The pain occurs and intensifies while sitting. On palpation at the level of the transition of the sacrum to the tailbone, severe pain is determined. On the roentgenogram in this department, osteochondrosis is revealed, sometimes a slight displacement of the coccygeal vertebra. Treatment is conservative: warm baths, phonophoresis of hydrocortisone, acupuncture, laser therapy, candles with belladonna. If conservative treatment is unsuccessful, removal of the coccyx is indicated.
In the region of the sacrum, inflammatory processes can occur, fistulas can form, for example, with suppuration of a teratoma. On the roentgenogram of the sacrum, pathology, as a rule, is not detected, and on the fistulogram , a blindly ending cavity is determined. Treatment is determined by the characteristics of the process. With relapses of exacerbations and long-term non-healing fistulas, excision of the fistulous passage along with pathological tissues is indicated.
Hematogenous osteomyelitis of the vertebrae is relatively rare, usually diagnosed late. Computed tomography can detect the focus much earlier than radiography. In the presence of a fistula, a few days before fistulography , enzymes are injected into the fistula, which, by dissolving purulent plugs in the fistulous passages, make them more passable, and the fistulogram more reliable. Treatment includes antibiotic therapy and often radical surgery.
Spinal tuberculosis is a serious disease, diagnosed and treated in a specialized hospital.
Spondylolisthesis is the slipping of the overlying vertebra relative to the anteriorly underlying one. This is facilitated by spondylolysis – non – union of the arch with the vertebral body. Most often, there is a displacement of the body of the V lumbar vertebra. Clinically, the disease is manifested primarily by pain, a decrease in the ability to support P. The diagnosis is accurately established by a profile roentgenogram. In the initial stage of the disease, conservative treatment is indicated, with progression – operative stabilization of the spine.
Tumors and tumor-like diseases of P. make up from 2.5 to 9.4% of tumors and tumor-like diseases of the skeleton. The variety and abundance of morphological structures that make up both an individual vertebra and the spine as a whole predetermine a wide variety of tumor lesions of the spine.
Distinguish between benign and malignant tumors, as well as tumor-like diseases of P. Benign tumors occur more often than other primary diseases. Among them, the most frequently diagnosed (in decreasing order of frequency) are osteoblastoclastoma (giant cell), chordoma (benign) and neurogenic tumors ( neurilemmomas and neurofibromas ), less often hemangiomas, osteoid osteoma and osteoblastoma , parostal osteoma, chondroma.
The most common malignant tumors include malignant chordomas , chondrosarcomas , and plasmacytomas . Less common are osteosarcoma, Ewing ‘s sarcoma , fibrosarcoma .
Metastases of malignant tumors account for 2/3 of all tumor lesions of P. Most often, breast cancer, renal adenocarcinoma, stomach and intestinal cancer, and lung cancer metastasize in P..
The predominant localization of benign tumors is the sacrum. The cervical, thoracic and lumbar sections of P. are affected less often, but equally often. And if chordoma and neurogenic tumors are overwhelmingly localized in the sacrum, then osteoblastoclastoma is observed with the same frequency in all parts of the spine.
Malignant tumors almost equally often affect the thoracic, lumbar and sacral parts of P. and much less often cervical. At the same time, malignant chordoma and chondrosarcoma are more often localized in the sacrum, and plasmacytoma – in the thoracic region of P. Often several vertebrae are affected.
Among tumor-like diseases of P. the most common are aneurysmal and “elite cysts”, Paget’s disease and osteochondral exostoses. Tumor-like diseases of P. are almost equally often detected in the thoracic and lumbar regions and less often in the cervical and sacral regions.
The clinical symptomatology of tumors and tumor-like diseases of P. depends both on the biological characteristics of the tumor and on its localization and spread to the surrounding tissues and organs. In the initial stages of the disease, the symptoms remain nonspecific for a long time, and tumors such as hemangioma, parostal osteoma, neurilemmoma , neurofibroma and osteochondral exostoses are asymptomatic for a long time and are often an accidental finding during examination for other diseases.
The first and leading symptom in most cases is pain that is different in nature and intensity. They are noted by almost all patients. Intermittent, low-intensity pain is most typical for parostal osteoma, benign neurilemma and neurofibroma , small osteochondral exostoses. Mostly nocturnal pains, which disappear when taking analgesics, are observed with osteoid osteoma and osteoblastoma . Sharp, exhausting, more often constant pains bother with malignant tumors. General weakness, weakness, pain of a shingles character are inherent in myeloma . The sharpest local tenderness on palpation is characteristic of osteoid osteoma and osteoblastoma .
Complications often arise, sometimes as formidable as a fracture of the vertebra (vertebrae), compression of the spinal cord or its roots.
The leading place in the diagnosis of P.’s tumors is taken by the x-ray method of research, while the generally accepted survey and sighting radiography, tomography, in most cases, provide sufficient information about the localization, length, structure of the pathological process, sometimes it is possible to reveal its relationship with the surrounding organs and tissues.
Most tumors are characterized by a tendency to infiltrative growth, damage to all elements of the vertebra, and often to the transition to the nearby vertebrae, rib or sacroiliac joint. A decrease in the volume of the vertebral body due to its compression is noted in myeloma, eosinophilic granuloma. Its increase, swelling are characteristic of hemangioma, osteoblastoclastoma , neurogenic tumors, Paget’s disease . With cartilaginous tumors, their spotty calcification is revealed. Limited sclerosis of the spongy substance is observed with Paget’s disease , diffuse osteoporosis – with multiple myeloma . With the same disease, a shadow resembling a congestion is quite often found in the paravertebral zone . The hemangioma is characterized by the so-called hypertrophic osteoporosis with thickening of the remaining bone bars, which creates a lattice type of rearrangement.
A comprehensive study of P. with suspicion of a tumor also includes contrast myelography , retropneumoperitoneum , angiography, radionuclide research, computed tomography, nuclear magnetic resonance imaging, which allow you to obtain comprehensive information about the localization of the tumor, its structure, prevalence and relationship with surrounding organs and tissues … Puncture biopsy is of great importance for diagnosis and determination of treatment tactics.
The choice of the method of treatment depends not only on the histological structure of the tumor, but also on the localization and prevalence of the pathological process, its relationship with surrounding organs and tissues, the patient’s condition, sensitivity or resistance to radiation exposure, the degree of risk of surgery.
Indications for surgery are all types of benign tumors, secondary chondrosarcomas from osteochondral exostoses, chondrosarcomas , osteosarcomas and some other P.’s tumors, in which spondylectomy is possible , plasmacytoma causing compression of the spinal cord, vascular tumors accompanied by or compression of the spinal cord pain syndrome. The combined treatment is indicated for radiochemically sensitive tumors of P. with developed symptoms of spinal cord compression ( Ewing’s tumor , reticulosarcoma , plasmacytoma , lymphogranulomatosis).
Contraindications to surgical treatment are: the presence of multiple tumor metastases and the severe general condition of the patient; radiochemically sensitive malignant tumors that did not cause severe compression of the spinal cord; P.’s multiple defeats by a malignant tumor; vascular tumors affecting several vertebrae without spinal cord compression.
With a certain convention, it is possible to distinguish several main types of surgical interventions on P. Radical operations are aimed at reorganizing destructive foci. Depending on the volume of the intervention, necrectomy (curettage of the focus) and resection (excision of pathological tissues) are distinguished .
Stabilizing surgery ( spinal fusion ) can restore the broken support ability. This is usually achieved by bone grafting of the anterior or posterior vertebrae. The introduction of a linear graft into the splitting of the spinous processes is the first stabilizing operation that has not lost its importance until now. Stabilization is provided by bone adhesion of the affected vertebrae to the grafts.
Corrective surgery consists in correcting deformities with or without special ties and distractors . The correction is preceded by a dissection of the vertebrae at the level of their bodies or discs ( vertebretomy , discotomy ).
Decompression operations – opening the spinal canal with removal of the tumor, necrotic masses, bone fragments, etc. In some cases, decompression operations are radical operations. Laminectomy (removal of the vertebral arch), in addition to decompression of the spinal cord, often provides prompt access to it. In addition to operations on the vertebrae and discs, interventions are often performed on paravertebral soft tissues ( abscessotomy , for example, for spondylitis, fistulotomy – opening the fistulous tract , etc.).
Spine surgeries are very traumatic and require, as a rule, the use of intubation anesthesia with controlled breathing.