Anatomical structure of the spinal ligaments
Ligaments are made up of connective tissue
. The structure of the ligaments allows the bones to fit tightly together and prevents the joints from moving in different directions.
The anterior longitudinal ligament rises upward from the sacrum to the first cervical vertebra
. It partially covers the lateral surfaces of the vertebrae. In the lower part this ligament is stronger and wider than in the upper part. The ligament is securely attached to each intervertebral disc. The job of the anterior longitudinal ligament is to prevent excessive extension of the spine.
The posterior longitudinal ligament stretches from the sacral canal up to the second vertebra in the cervical region
. It passes through the spinal canal and is adjacent to the back of the vertebrae. It also has a strong connection with the intervertebral discs and does not adhere tightly to the vertebral bodies.
There is also a group of small ligaments called yellow
. They fill the space between the vertebral arches. These ligaments are elastic and dense, helping to relieve stress from the muscles while we straighten the spine.
Between the vertebrae that are adjacent there are interspinous ligaments. The strongest are the interspinous ligaments in the lumbar region, and the thinnest and weakest are located in the neck. These ligaments are connected to the ligamentum flavum anteriorly and to the supraspinous ligament posteriorly.
The upper parts of the spinous processes in the lumbar and chest areas are covered by the supraspinous ligament
. Higher up, it transforms into a rudimentary nuchal ligament.
There are also intertransverse ligaments
- in the form of thin bundles in the sternum and neck area and stronger ones in the lumbar region. They prevent the spine from deviating too much to the side.
Cervical instability in children
Instability of the cervical spine in children is a manifestation of trauma, surgery or dysplastic processes in this area. Excessive load can provoke a spasm of the neck muscles and this will lead to displacement of the articular surfaces of the vertebrae relative to each other, which will lead to the formation of the condition “cervical instability”.
Treatment in children is carried out conservatively, the purpose of which is to relieve spasm and improve blood supply to the neck. Even at a young age, degenerative damage to the intervertebral joints can form, which will serve as a provocateur for the development of instability.
Classification and signs of spinal ligament injuries
The following degrees of damage to the ligamentous apparatus of the spinal column are distinguished:
- I degree - only some fibers of the ligament are damaged;
- II degree – partial rupture of the ligament;
- III degree – complete rupture of the ligament.
Ligament damage due to strain is also assessed:
- Stage I – pain appears after physical work;
- Stage II – pain is felt during work, but does not limit the ability to work;
- Stage III – pain prevents vigorous activity;
- Stage IV – the patient has constant pain, significantly reducing his quality of life.
Problems with ligaments are always associated with pain of varying degrees of intensity. Due to the fact that spinal ligament injuries can be diagnosed in different segments of the spinal column, pain can occur in the neck, chest or lower back. Based on this, complaints also differ: the victim may complain of discomfort, the inability to straighten the neck, nagging pain in the chest, discomfort when coughing or sneezing, etc.
Cervical spine injuries: consequences and rehabilitation
The method of treatment and subsequent rehabilitation depend on the cause, nature of the injury and the extent of the damage. Let's look at the types of most common neck injuries.
Sprain
Ligaments are bands of connective tissue that hold bones together. A sprain can be caused by a fall, sudden twisting of the neck, or excessive strain on the neck.
Symptoms of a sprain: pain in the back of the neck that gets worse with movement; headache; spasms in the upper shoulder; sore throat, numbness in the back of the head; tingling in the hands; general weakness. If you have symptoms of tingling in your hands, you should consult a doctor as soon as possible.
"Whiplash"
Most often it happens during car accidents, during sports, or unsuccessful diving into water. A strong blow to the back of the neck causes the neck to suddenly extend and then flex. In a frontal collision in a car accident, on the contrary, there is first flexion and then extension. With such a blow, a person may lose consciousness.
As a result of this injury, joints or discs are damaged, which can cause irritation of the spinal roots and the appearance of neurological symptoms. These include: pain, weakness, numbness, tingling in the hands, or other sensations that resemble an electrical shock. Stiffness, dizziness, or sleep disturbances are also possible. Some patients need to call an ambulance immediately after a neck injury. If symptoms appear several days after the injury, you should also consult a doctor.
Displacement of the cervical vertebrae
Displacement usually occurs as a result of injury or degenerative changes. Symptoms of vertebral displacement: headaches; drowsiness; general weakness; pain in the neck extending to the collarbone and shoulders; numbness in the hands.
In severe cases, the bone moves completely forward and becomes fixed in that position, causing the ligaments to tear. Displacement of the cervical vertebrae can damage the spinal cord and require surgery. With less serious injuries, the vertebrae may return to their place on their own, but in any case you should consult a doctor.
Vertebral Fracture Cervical spine fractures account for 20-30% of all vertebral fractures, of which 10-20% involve spinal cord injury. If a fracture occurs, immediate medical attention is required. Due to complications, most victims will not be able to return to their previous lives, some become disabled. Some of the most common fractures are those of the C5 and C6 vertebrae - they are the smallest and most fragile. The most common reason is a bad jump into the water.
Symptoms of a fracture of the lower cervical vertebrae: dizziness, nausea, complete or partial paralysis of the limbs, weakness, muscle tremors, difficulty breathing, pain at the fracture site, possible speech impairment. To make an accurate diagnosis, it is necessary to take an x-ray or MRI. Treatment will depend on the nature of the fracture and the presence of complications.
Treatment of spinal ligament injuries
After examination by a surgeon and traumatologist, the patient is usually sent for an X-ray examination to rule out fractures. Further, ultrasound examination of the ligaments and magnetic resonance imaging of the damaged area (if indicated) may be required.
During treatment, a cold compress is applied to the damaged area. The patient needs rest. Conservative treatment will also include applying a pressure bandage, taking analgesics and non-steroidal anti-inflammatory drugs, and physical therapy.
When the ligament is completely torn, only surgery can help, during which parts of the ligament are sutured.
Back pain in athletes Non-surgical methods for treating intervertebral disc herniation
Subluxation of the cervical vertebra
In case of a neck injury, it is necessary to completely immobilize the victim’s head and neck. If the victim is in a car, you should first securely secure the neck, and only then remove him from the vehicle. Special splints are used for fixation. If there are no splints, you can use a homemade collar made from several layers of cotton wool wrapped in gauze, the main thing is that it securely fixes the damaged area and does not interfere with breathing. Self-reduction of a subluxation is strictly prohibited; manipulation can only be performed by a qualified specialist in a hospital setting.
It is advisable to carry out the procedure in the early stages, since over time swelling of the soft tissues increases, and reduction of the subluxation becomes difficult. Typically a Gleason loop is used. The patient is placed on his back with a small flat pillow under his shoulders. It is possible to have both a gradual reduction using a small load and a one-stage manipulation, during which the traumatologist uses a loop to apply traction and then rotate the head.
At the moment of reduction, a characteristic soft click is heard, the patient notes a decrease in pain and the disappearance of obstacles to movement. Due to damage to the ligamentous apparatus after reduction, repeated subluxation can easily occur, so the patient is prohibited from moving his head and a Shants collar or craniothoracic bandage is applied for a period of 2 weeks to 3 months (depending on the level and nature of the subluxation). After reduction, a control x-ray must be performed.
Subsequently, drug therapy, physiotherapy, massage and exercise therapy are used. According to indications, tolperisone is prescribed to relax the neck muscles, B vitamins are prescribed to normalize the activity of the nervous system and improve blood circulation, and pentoxifylline is prescribed to improve microcirculation. Massage can be used from the first days after injury; its goal is to relax muscles, improve nutrition and blood supply to tissues. Mostly gentle techniques are used - stroking and rubbing.
Exercise therapy classes begin immediately after reduction and continue until recovery. At the initial stage, only exercises for the shoulders and shoulder girdle are performed. After removing the Shants collar, neck movements are added to the complex. All exercises must be done carefully and carefully, gradually increasing the load. Simultaneously with exercise therapy, physiotherapeutic restorative techniques are used: electrophoresis with novocaine, ultrasound and thermal procedures.
Medical Internet conferences
Pathology of the cervical spine, caused by a deficiency in the function of the ligamentous apparatus, is currently considered as a marker of connective tissue dysplasia syndrome. Changes in hemodynamics in the vertebral arteries against the background of instability of the cervical spine is one of the criteria for this pathology.
Over the past 30 years, there has been an increase in the incidence of vertebrobasilar insufficiency (VBI) specifically in people of working age against the background of instability of the cervical spine (CS). Despite the fact that most authors consider disruption of the supporting function of the intervertebral disc as the root cause of spinal instability, MRI examination does not always reveal disc protrusion or herniation.
The reason for the formation of hemodynamic disorders in the vertebrobasilar system in patients with instability of the cervical spine is irritation of the paravertebral nerve plexuses against the background of displacement of the cervical vertebrae, as well as a violation of the frame function of the walls of the vessels of the vertebrobasilar system, both arteries and veins.
Purpose of the study
Extended clinical and instrumental study of cerebral hemodynamics in patients of working age with radiologically confirmed instability of the spinal cord for early diagnosis of the leading pathogenetic mechanism of VBI in them and timely correction of these vascular disorders.
Material and methods
A total of 339 patients were included in our study, most of whom were women, and the average age was 36 years.
All patients were divided into 2 groups:
- The first, retrospective study, consisted of 83 patients in whom instability of the cervical spine became an x-ray finding. These patients underwent assessment of neurological status and ophthalmological examination, but, despite clinical signs of failure, they did not undergo a detailed study of cerebral hemodynamics.
- The second - a prospective group of 256 people, which was examined according to an expanded plan - the examination algorithm included not only the above diagnostic methods, but also ultrasound and electrophysiological methods for studying cerebral hemodynamics, and in a number of observations, if indicated, we recommended that patients undergo MRI of the cervical spine, head brain, as well as blood vessels of the head and neck.
results
When seeking outpatient medical care, in almost half of the cases, the symptoms were limited to one complaint, among which an isolated headache dominated, and less often, dizziness or tinnitus. 33.8% of patients had 2 complaints, most often in the form of a combination of headache with dizziness or dizziness with tinnitus. In more than 9% of observations, patients presented detailed complaints. And only 7.8% of patients had no complaints when contacted. The purpose of their visit to the doctor is a preventive neurological examination.
An objective neurological examination revealed in 96.6% of cases an imbalance detected in a simple or sensitized Romerga test. Slightly more than 90% of those examined had violations when performing coordination tests. Almost 80% of patients had nystagmus. 40% of patients were diagnosed with signs of venous discirculation.
To assess the clinical severity of vertebrobasilar insufficiency, all objective symptoms were summarized in a single table and they were assigned scores, based on the totality of which it was found that patients with instability of the cervical spine most often sought outpatient medical care with the clinical severity of vertebrobasilar insufficiency from 3 to 6 points. And only 3.4% of patients had no clinical signs of cerebrovascular insufficiency.
Additionally, we conducted an ophthalmological examination, which showed that all patients with instability of the cervical spine had a spasm of arterioles, in which changes in the arterioles of the fundus necessarily occur (E.A. Egorov, E.S. Tutaeva, 2006; A.B Sitel, 1990; G.M. Kushner, 1981). In approximately 40% of cases, the site was venopathy, which correlated with clinical data on intraocular pressure. One patient was diagnosed with anisocoria. But in none of the observations was pathology of the optic nerve head detected.
X-ray examination of the cervical spine confirmed the presence of instability in each observation, but the number of displaced vertebrae, the direction and extent of their displacement could be different. Thus, in the flexion position, instability was represented in approximately equal proportions by displacement of the cervical vertebrae forward or backward. In the extension position, it was most often represented by posterior displacement of the vertebrae. And instability diagnosed in both functional postures most often occurred in the form of posterior displacement of the vertebrae or their combined displacement.
When performing functional tests, simultaneous displacement of 2 vertebrae was most often noted. Displacement of one vertebra or three vertebrae at the same time is noted somewhat less frequently.
Functional radiography of the cervical spine showed the most frequent formation of instability of the CIII and CIV vertebrae. According to the literature, the area of greatest functional activity is the CIII-IV vertebral motion segment. MRI of the cervical spine revealed the most common formation of intervertebral disc pathology in the CV-VI vertebral motion segment, which was consistent with literature data. In our study, there were also clinical cases where intervertebral disc pathology was diagnosed in the area of an unstable spinal motion segment.
But there were also patients in whom intervertebral disc pathology could not be diagnosed in the area of unstable vertebral motion segments. The results of a study of cerebral hemodynamics using screening Dopplerography showed that the examined patients had intact carotid blood flow in all clinical observations and on average in the group. On average, arterial blood flow in the vertebral arteries in the group was at the lower limit of normal.
At the same time, normal blood flow was diagnosed in more than 30% of cases. But in 19.9% of patients it was physiological both initially and after performing functional tests with head turns. And in 12.9% of patients, functional loads revealed a vertebrogenic effect on the vertebral arteries. In almost 40% of patients, velocity parameters were reduced, in some cases less than 30 cm/sec. In a small percentage of cases, it was possible to diagnose spasm of the vertebral arteries, in which the LSC syst. exceeded 50 cm/sec. Asymmetric blood flow was detected in 22.7% of cases.
Duplex scanning confirmed the results of screening Doppler sonography. In 19.9% of cases, blood flow in the carotid and vertebrobasilar basins was adequate both in terms of arterial inflow and venous outflow; in addition, no morphological changes in the vessels of both basins were diagnosed. However, DS showed a high percentage of patients with vertebrogenic influence of the cervical vertebrae on the V2 segment of the vertebral arteries and a non-linear course in the canal of the openings of the transverse processes of the cervical vertebrae, which was not hemodynamically significant. More than 5th of the patients had atherosclerotic lesions of the carotid vessels, which also had no hemodynamic significance. Anomalies of the vertebral arteries (hypoplasia) and their entry into the canal were noted in only 3.6% of cases.
We analyzed the dependence of LSC sys. on the degree of displacement of the cervical vertebrae and obtained reliable data for patients with a displacement of up to 3 mm. It has been shown that the greater the displacement, the less physiological blood flow occurs in the vertebral arteries. In patients with a displacement of more than 3 mm, it was not possible to establish a reliable relationship, because these patients were less numerous in our study.
We also assessed the speed indicators of blood flow depending on the diameter of the vertebral arteries, but did not obtain reliable results, which indicates the independence of blood flow from the cross-section of the vessel.
We assessed changes in LSC system. in the vertebral arteries throughout the V2 and V3 segments. In a fourth of the patients it corresponded to the norm. In more than half of the examined patients, blood flow velocity indicators were physiological at the level of the V2 segment and decreased towards the V3 segment. In 15% of patients, LSC system. was low in both segments of the vertebral arteries, with values less than 30 cm/sec. on both sides in the V2 segment increased slightly in the V3 segment, but remained below physiological values. In 6.7% of those examined, asymmetric blood flow was diagnosed in the V2 segment, which persisted at the level of the V3 segment.
Considering that instability of the cervical spine can cause paravertebral venous discirculation, we assessed venous outflow through the paravertebral venous plexuses. Duplex scanning showed expansion of the paravertebral venous plexuses in 104 patients with difficulty in venous outflow. Based on the amplitude of the venous flow, it was possible to establish that in more than 80% of those examined, venous discirculation was of a moderate nature.
Considering that venous discirculation can cause intracranial hypertension, we performed echoEG in all patients with instability of the cervical spine. The study showed the presence of hypertension syndrome in 138 patients. At the same time, in 72 observations the cause was venous discirculation, and in 66 examined patients it was not possible to establish the cause of the increase in intracranial pressure, because we did not diagnose paravertebral venous circulation in these patients. However, MRI performed at the level of the head and neck did not reveal other reasons for the formation of intracranial hypertension syndrome.
EchoEG showed that most often the intracranial hypertension syndrome was mild or moderate in nature and in these patients it did not affect cerebral hemodynamics. And in patients with severe intracranial hypertension, a significant decrease in systolic LSV in both vertebral arteries was noted compared to the norm, regardless of the presence or absence of paravertebral venous discirculation.
Conclusion
Summarizing the results of our work, we proposed an algorithm for examining patients with instability of the cervical spine. If these patients have clinical signs of cerebral circulatory insufficiency and X-ray confirmation of cerebral vascular instability, we suggest performing screening Doppler ultrasound. If ultrasound diagnostic methods do not reveal hemodynamic abnormalities in both vascular systems, it is necessary to resort to EEG. If this research method does not reveal indirect signs of UMC, then patients are given traditional recommendations; if it is still possible to diagnose UMC, then these patients should be recommended vasoactive therapy. If screening Dopplerography, and then DS, confirms the presence of hemodynamic abnormalities on the part of the arterial or venous part of the VBD, then, depending on the established pathogenetic mechanism of VBD, drug therapy will be offered. At the end of the course of treatment, it is recommended to conduct a control study of cerebral blood flow to assess the adequacy of the selected therapy and the duration of its use.
For timely diagnosis and instability of the cervical spine and hemodynamic disorders in the vetebro-basilar system, as a result of connective tissue dysplasia syndrome, as well as to prevent decompensation of cerebral blood flow when performing medical care, continuity of doctors of different specialties is necessary.
Cervical instability treatment
Instability of the cervical spine - treatment should include physiotherapy and massage methods. Physiotherapy is completely painless, effective and modern. Improving the nutrition of muscle fibers and their relaxation will lead to the elimination of the main symptoms of the disease that make everyday life difficult.
Taking medications and performing surgery on people diagnosed with cervical instability is an ineffective treatment, since the recovery period is very long, the effectiveness is low, and most importantly, this method is not applicable to everyone. The golden “pill” is an integrated approach that includes physiotherapy and massage methods.