Rotation of the vertebrae of the thoracic and cervical spine

Violation of the structure of the spinal column does not always lead to serious complications that give pronounced clinical symptoms. Quite often, the deformation occurs latently (hidden) and the patient learns about the existing health problem too late, when a serious surgical operation is already required to restore the integrity of the damaged structure.

Vertebral rotation is one of these conditions. A gradual change in the position of the vertebra with rotation around its axis does not cause pain or cause any discomfort. But this is temporary. As the angle of rotation increases, the rotation of the vertebral bodies leads to disruption of the innervation of certain parts of the body, which leads to negative consequences that are very difficult to eliminate.

Rotation and torsion of the vertebrae occur against the background of weakened muscles and excessive mobility when the height of the intervertebral discs changes. Rotation is a process in which the bone structure is not destroyed. Torsion – twists the vertebra with a violation of its integrity, reducing the height and occupied area.

A decrease in the tone of the muscular corset of the back and collar zone of the neck leads to stretching and loss of elasticity in the tendon and ligament tissues. The vertebral bodies begin to move freely relative to each other. At the initial stage, deformation of the intervertebral joints occurs. As the height of the intervertebral discs decreases, the vertebral body gradually shifts to the left or right. With any sudden movement, a circular movement around the axis begins. The displacement of the spinous process occurs slowly, so it will be possible to notice any deviations from the physiological norm after a few months.

Rotation of the vertebrae can be observed in the cervical, thoracic and lumbar spine. The sacrum, after its vertebrae fuse into a single bone, is not susceptible to such pathology.

The condition is dangerous because numerous complications develop:

1. the diffuse nutrition of the intervertebral discs is disrupted and the process of degeneration of cartilage tissue begins, leading to the appearance of protrusion and intervertebral hernia;
2. the structure of the spinal canal changes, stenosis and compression of the spinal cord may occur, which can impair the functioning of individual parts of the body;
3. a violation of posture occurs and deformation of the spinal column begins, leading to gross curvature in the form of scoliosis, hyperkyphosis or hyperlordosis;
4. when the chest is deformed, internal organs suffer (the vital volume of the lungs decreases, the heart muscle, aorta and other large blood vessels are displaced);
5. with deformation of the lumbar spine, dysfunction of the pancreas, gallbladder, large and small intestines, and bladder are often observed;
6. during rotation in the cervical spine, the process of blood supply to the structures of the brain suffers (a person develops constant drowsiness, decreased performance, constant headaches, and reduced hearing and visual acuity).

Without timely treatment, rotation of the vertebral bodies can lead to tilting of the body to one side or the other. This will entail lateral curvature of the spinal column and impaired mobility. To prevent such a complication, you need to see a doctor at an early stage of the development of rotation or torsion. To do this, you should pay attention to the primary signs described in this article.

If you find signs of torsion or rotation of the vertebral body, immediately visit a vertebrologist. You can make an appointment for a free appointment with a specialist in Moscow at our manual therapy clinic. Call the administrator and agree on a time convenient for your visit.

What is vertebral rotation?

Rotation of vertebral bodies - what is it? This is the vertical displacement or rotation of the vertebra around its axis. The structure of the vertebra itself does not change. Rotation is dangerous because it leads to deformation of posture and negatively affects cartilage tissue. Accompanied by scoliosis and osteochondrosis. An advanced disease can cause complications in the form of protrusion and hernia, and subluxation can form. You can also consider the term "torsion", which is close to rotation. This pathology is a “twisting” of the vertebrae. Vertebral rotation is divided into two types: absolute and relative. The absolute type occurs as a consequence of vertebral diseases. And the displacement of some vertebrae also shifts neighboring vertebrae. The relative type of rotation is not directly related to spinal problems and occurs against the background of third-party diseases.

General idea of ​​the disease

During rotation, the patient’s entire spine is not deformed , but its individual vertebrae are rotated. In the most severe, advanced cases, the spine also rotates. It leans to the side. How far the spine is tilted is not at all related to the degree of rotational change.

It is quite possible to have a high degree of mobility of the vertebrae and a slight tilt of the back to the side, and low mobility of the spine in the presence of a large angle of tilt of the back to the side.

From a cosmetic point of view, rotation gives the body an incorrect appearance. The aesthetic defect is reversible : if the muscles and ligaments are restored, it can be eliminated.

During rotation, one or more vertebrae rotate around their axis

Classification

The division of rotational changes into classes is based on the factors that caused them. absolute and relative rotation .

With an absolute type of pathology, the patient has another back disease. In this case, rotational changes occurred against the background of back disease (scoliosis, osteochondrosis). Excessive mobility of the vertebrae is caused by a negative factor of back disease: the lateral axis of the spine is displaced.

With relative , or functional, rotation, the patient has a disorder that is not related to back diseases: injuries, hard work, incorrect lifestyle, incorrect surgical intervention, somatic diseases, old age. This deviation was a factor in rotational changes in the vertebrae.

The most common pathology occurs together with the disease Poliomyelitis . The disorder is caused by a weakened muscle corset: the spine has no support, which contributes to a change in its physiological position. Then there is a curvature of the back and displacement of the vertebrae.

Changes in the spine do not occur spontaneously. They are characterized by a gradual transition to each stage with a difference not of days, but of months or years. If concerns are detected in any part of the back, you should contact a specialist in the field of traumatology or orthopedics.

This will help avoid complications: hernia, lameness. The patient cannot detect rotational changes in the vertebrae on his own, so you should not expect it. Treatment needs to start as early as possible. The rotation can be corrected and, if all recommendations are followed, this cosmetic defect can be eliminated.

Severity

There are five degrees of development of vertebral rotation: 0, 1, 2, 3, 4.

At the very first - zero - there is no rotation: the vertebral axis is in a normal, perpendicular position relative to the spine.

From the first to the third stages the axis shifts. At the first, there is a slight deviation of the leg towards the center. On the second it is two thirds in the same direction. On the third, the leg is located in the center.

The fourth degree is distinguished by the fact that the leg is located behind the central part of the spine, the vertebral axis is normal, perpendicular to the back.

Vertebral rotation occurs in 5 stages

ICD-10 code and prevalence

Rotation is not distinguished separately in the ICD-10 classification.

Scoliotic changes in the back occur in all people, the most severe ones being less common. The degree of violation determines the angle of inclination. In the second degree of scoliosis, rotation of the vertebrae is present if the angle is more than 15 degrees and does not exceed 25. In this case, X-ray films of the back show signs of rotational changes. Rotation also occurs in other back diseases in adults and children.

Symptoms

Painful sensations when the vertebrae are displaced largely depend on where the problem area is located. It is worth noting that the cervical region most often suffers from displacement of the vertebral bodies.

Rotation of the cervical vertebrae

Symptoms of rotation of the cervical vertebrae:

• excessive neck mobility;
• regular headaches or dizziness;
• speech, vision, hearing impairment;
• insomnia;
• excitability, irritability;
• the occurrence of muscle spasms.

The vertebrae in the cervical region are located very close to the skull, therefore they are closely connected to the brain. If treatment is not started in time, the consequences can be very serious.

Thoracic region

Symptoms of rotation of the vertebrae of the thoracic spine:

• aching pain in the chest area or between the ribs;
• acute pain when a nerve is pinched;
• feeling of stiffness, especially after sleep;
• numbness of the limb on the side where the vertebral pathology occurred;
• noticeable displacement of the ribs.

If the disease is advanced, it may be accompanied by partial or complete paralysis of the limbs, sternal distortion, and disruption of the body’s cardiac and respiratory systems.

Lumbar

Symptoms of rotation of the lumbar vertebrae:

• sharp pain when trying to sit or bend over;
• referred pain in the legs or buttocks;
• muscle spasms;
• numbness or decreased sensitivity of the lower extremities;
• inability to lift the load.

In severe cases, motor coordination may be impaired.

Pathology of the cervical spine. Cervical spine instability

V.A. MITSKEVICH, Institute of Rheumatology, Russian Academy of Medical Sciences, Moscow

Summary

The article describes the development, anatomical and functional features of the cervical spine. The concepts of mobility, stability and instability of the spine are defined, support complexes according to Holdsworth, Denis, instability criteria according to White, radiological manifestations of instability, methods for calculating various types of subluxations of the cervical vertebrae are described in detail. Neurological manifestations of cervical instability are presented. The main approaches to conservative and surgical treatment are reflected.

Spine development

Normally, the development of the spine continues until the age of 20-22. Ossification of different parts of the spine is carried out in the following order: upper cervical, mid-thoracic, cervical, lower thoracic, lumbar, sacral. The apophyses of the vertebrae become ossified from 8 to 15-16 years of age. Ossification of the CII vertebra occurs at the age of 4-6 years. Physiological curves of the spine are outlined between the ages of 2 and 4 years, and at 6 years they become distinct. The amount of cervical lordosis decreases up to 9 years. With age, there is a change in the orientation of the facets of the intervertebral joints. In early childhood, the facets have a relatively horizontal arrangement. The increase in the angle of inclination of the facets continues up to 10 years, until they assume a vertical position, after which they are able to limit the movement of the vertebrae [1].

Anatomical and functional features of the upper cervical spine

The cervical spine has characteristic structural and functional features.

The first cervical vertebra, the atlas (CI), and the second cervical vertebra, the axis, or epistropheus (CII), connect the spine to the skull and form the atlantoaxial-occipital complex. The CI vertebra does not have a body, but there are anterior and posterior arches that limit the lumen of the spinal canal. The upper surface of the CI vertebra has slightly concave articular processes that are connected to the condyles of the occipital bone. Vertebra CII has a body that passes into the odontoid process. It protrudes upward, articulates with the inner surface of the anterior arch of the atlas and reaches the level of the foramen magnum. The CI vertebra is connected to the condyles of the occipital bone. There are three joints between vertebrae CI and CII: two paired joints between CI and CII and one between the odontoid process of CII and the arch of the CII vertebra.

Functionally, these joints are combined into a combined joint, in which rotational movements of the head together with the CI vertebra are possible. Approximately half of all neck movements occur at the atlantooccipital and atlantoaxial joints. The articulation of the odontoid process with the atlas and the atlas with the occipital condyles is truly synovial. The joint capsules of these joints have a low degree of tension. The occipital bone is connected to the atlas by the occipitovertebral membrane, which is covered in front by the anterior longitudinal ligament. Between the posterior arch of the atlas and the edge of the foramen magnum is the posterior occipitovertebral membrane. Vertebral vessels and spinal nerves pass through it. The posterior longitudinal ligament is located on the posterior surface of the vertebral bodies. Below the posterior longitudinal ligament is the cruciate ligament, which consists of a transverse ligament and two crura. The ligament is stretched between the inner surfaces of the lateral masses of the CI vertebra on both sides. It wraps around the odontoid process, limiting its posterior displacement and thereby preventing compression of the spinal cord. Between the posterior surface of the odontoid process and the anterior surface of the ligament there is a mucous bursa. On the sides of the apex of the tooth lies a fatty lump, which protects the odontoid process from friction against the arch of the atlas. Under the cruciate ligament are the ligament of the apex of the odontoid process, which runs from it to the edge of the occipital foramen, and the pterygoid ligament, stretched between the lateral surface of the odontoid process and the articular processes of the occipital bone.

In the spine, axial and rotational loads are placed on the vertebral bodies and intervertebral discs. Combined into a single structure, they ensure a vertical position of the body, withstand axial loads, absorb and distribute shock loads. Intervertebral discs connect the vertebrae to each other and provide the stabilizing function of the spine. Fixation of the intervertebral disc to the vertebral body is carried out by the fibers of the fibrous ring. The nucleus pulposus distributes the load applied to the spine. Intervertebral joints, reinforced by articular capsules, do not bear axial load. They determine the direction of movement of the vertebrae. Spinal ligaments fix the vertebrae and intervertebral discs together and influence the range of motion of the spine. The anterior longitudinal ligament prevents extension of the spine, the posterior longitudinal ligament, supraspinous, interspinous ligaments, as well as the nucleus pulposus limit flexion of the spine, intertransverse ligaments limit lateral bending [2]. Of all the ligaments of the spine, the anterior longitudinal ligament is the strongest. With age, the strength of ligaments decreases. The extensibility of the ligaments is most pronounced in places of maximum physiological kyphosis and lordosis, where vertical loads on the spine are absorbed. The greatest extensibility is found in the posterior longitudinal ligament in the cervical spine, which results in greater mobility. The ability of the vertebrae to move is related to their location and the direction of the shear force. The displacement at the level of the apex of lordosis and kyphosis occurs in the direction of the convexity of the curvature [1]. The mobility of the entire spine is the sum of movements of individual segments, which on average fluctuates within 4° [2]. The spine moves around three axes: 1) flexion and extension around the transverse axis, 2) lateral bending around the sagittal axis, 3) rotational movements around the longitudinal axis. Circular movements along all three axes are possible, as well as movements along the vertical axis.

Mobility and stability of the spine

The spine combines the properties of mobility and stability. The mobility of the spine depends on the structural features of the vertebrae, the size of the intervertebral disc, and the mechanical strength of the structures that provide stability in this section. The most mobile part of the spine is its cervical region. In the cervical region, one half of all movements are carried out in the atlantoaxial and atlantooccipital joints, and the other half in the lower cervical region.

Spinal stability is the ability to maintain such relationships between the vertebrae that protect the spine from deformation and pain under physiological load. The main stabilizing elements of the spine are the fibrous ring and the nucleus pulposus of the intervertebral disc, the spinal ligaments and the capsule of the intervertebral joints. The stability of the entire spine is ensured by the stability of its individual segments. A vertebral segment consists of two adjacent vertebrae connected by an intervertebral disc. The segment contains several supporting complexes that perform a stabilizing function. According to Holdsworth, the spine has two supporting complexes:

• Anterior:
  anterior and posterior longitudinal ligaments;
• anterior and posterior parts of the annulus fibrosus;
• anterior and posterior halves of the vertebra.

According to Denis, there are three support complexes in the spine. Compared to the Hodsworth division, the posterior complex remains unchanged, and the anterior complex is divided into anterior and middle.

Spinal instability

Instability is pathological mobility in the spinal segment. This can be either an increase in the amplitude of normal movements, or the emergence of new degrees of freedom of movement that are uncharacteristic for the norm. An indicator of spinal instability is the displacement of the vertebrae. Vertebral displacement is a radiographic finding, while spinal instability is a clinical concept. Displacement of the vertebrae can occur without pain, but instability is characterized by pain. Instability has characteristic signs:

• Violation of the load-bearing capacity of the spine occurs when exposed to external loads, both physiological and excessive. The spine loses its ability to maintain certain relationships between the vertebrae.
• Instability indicates a failure of the supporting complexes that protect the spine from deformation, and the spinal cord and its structures protect from irritation.
• The disorder manifests itself in the form of deformation, pathological movement of the vertebrae or destruction of spinal elements. Instability causes pain, neurological disorders, muscle tension and limitation of movement [3-5].

There are factors that predispose to excessive mobility of spinal segments. Normally, for the cervical spine, excess mobility is determined by two factors: age and vertebral location. The range of mobility of the spine in children exceeds the range of mobility in adults. The amplitude of displacement of the CI and CII vertebrae during flexion is 4 mm, and during extension – 2 mm [4]. Increased mobility of the CII-CIII segment is observed up to the age of 8 years [1]. In children, excessive mobility is observed in the upper cervical spine in 65% of cases [6], which is associated with the absence of an intervertebral disc at the CI-CII level. In children, the CII-CIII segment is the most mobile. Disorders at this level are diagnosed in 52% of cases of spinal instability [6].

The main symptom of instability is pain or discomfort in the neck. In the cervical spine in patients with instability in the atlanto-occipital joint, irritating pain can be periodic and intensify after physical activity. Pain is the cause of chronic reflex tension of the neck muscles. In children, instability is the cause of the development of acute torticollis. At the onset of the disease, there is increased tone of the paravertebral muscles, which leads to their overwork. Microcirculation disorders occur in the muscles, the development of malnutrition and decreased tone. There is a feeling of uncertainty when moving in the neck. The ability to withstand normal load is impaired. There is a need for means of additional immobilization of the neck, including supporting the head with the hands. In the clinic, cervical spine instability in adults is measured using a clinical scoring system [2].

Radiological manifestations of instability

Normally, on a lateral projection radiograph, the posterior contours of the vertebral bodies form a regular arc. A manifestation of instability is displacement of the vertebrae. With instability, the continuity and smoothness of the line of the posterior contour of the vertebral bodies is disrupted, and the line itself acquires a bayonet-like deformity. The articular surfaces of the intervertebral joints lose their parallelism. An angle is formed between them, open anteriorly. These changes can be detected on standard radiographs, as well as on functional radiographs, which are taken in the position of maximum flexion and extension of the spine. Compared to a standard x-ray, in functional photographs the degree of vertebral displacement appears to be increased. Normally, with the maximum possible movements of the spine, a change in the height of the intervertebral discs is observed. With maximum flexion, the height of the anterior part of the disc decreases, and with extension, the height of the rear part of the disc decreases. A sign of instability is the convergence of adjacent areas of the vertebral bodies, which exceeds the boundaries of the physiological norm. Most often, spinal instability develops in areas of increased vertebral mobility. In the cervical region, these are the atlantoaxial and lower cervical levels. Subluxation is determined based on radiometric data from lateral radiographs. The x-ray is taken so that the lower part of the occipital bone and the hard palate are visible along with the cervical vertebrae. The relationships of the upper cervical vertebrae and the dimensions of the spinal canal are determined using a series of x-ray calculations.

• Determination of the posterior atlantoaxial space or longitudinal size of the spinal canal. This is the distance between the posterior surface of the odontoid process of the CII vertebra to the anterior surface of the arch of the CI vertebra. Normally it is 17±0.5 mm. A decrease in the size of the canal to less than 10 mm indicates anterior subluxation.
• Determination of the anterior atlantoaxial space. This is the distance between the inner surface of the anterior arch of the CI vertebra and the anterior surface of the odontoid process of the CII vertebra (Cruvellier's joint). Normally, in an adult, when bending the head forward, this gap does not exceed 3 mm, and in a child, 5 mm. If this distance increases, anterior subluxation may be suspected.
• McGregor's method. A line is drawn from the posterior edge of the hard palate to the anterior edge of the foramen magnum. The perpendicular to the center of the odontoid process is restored and the distance from this line to the apex of the odontoid process is measured. Normally it is 4-5 mm. An increase in this distance indicates vertical subluxation.
• Ranawat method. A line is drawn through the center of the front and rear arms. The perpendicular to the center of the root of the CII vertebral arch is restored, which on the radiograph looks like a sclerotic ring. The distance from this line to the center of the bow is measured. Normally it is 15 mm. If this distance decreases, vertical subluxation is suspected.
• Redlund-Ionell method. Distance between McGregor's line and the center of the lower edge of the CII vertebral body. For men this distance is 34 mm, and for women it is 29 mm. A decrease in this size indicates vertical subluxation.

Subluxation in the upper cervical region is of four types: 1) anterior, 2) posterior, 3) lateral, 4) vertical. Anterior subluxation is more common than all others. In an adult, a displacement of the CI vertebra by 3 mm is considered pathological. A displacement of 10-12 mm indicates destruction of the entire ligamentous complex. Lateral subluxation is determined if the displacement exceeds 2 mm. Subluxation is accompanied by lateral rotation of the head.

Normally, increased mobility in the lower cervical region is more common in segments CIII-CIV, CIV-CV and CV-CVI [6, 7]. Normally, the size of the spinal canal at level CIII ranges from 14 to 18 mm, and the displacement of the vertebrae in the anteroposterior direction is no more than 2 mm. This amount of displacement is relatively stable due to the preservation of the fixing function of the anterior longitudinal ligament.

Subaxial subluxations occur in the lower cervical spine. The earliest sign of instability is an increase in the angle between two adjacent vertebrae on functional radiographs. The most reliable sign of instability is a combination of vertebral displacement in the sagittal plane of more than 2 mm and the formation of an angle between the endplates of adjacent vertebral bodies of more than 10° [2].

Spinal instability may be accompanied by the development of kyphotic curvature of the spine. With degenerative instability, local kyphosis is observed in 40% of cases. It is a variable symptom of instability that can either worsen or disappear over time [5]. Increased mobility, characteristic of instability, occurs with almost the same frequency as lack of movement until its complete disappearance. Variants of spinal mobility impairment occur in different combinations:

• increasing mobility at the level of instability;
• decreased mobility at the level of instability in combination with increased mobility at the higher level;
• decreased mobility in all segments of the spine [5].

Spinal instability is accompanied by the development of compensation. The severity of compensatory manifestations is associated with the degree of damage to the supporting structures of the spine, the intensity of the process of fibrotization of the disc, the age of the patient and the duration of the disease, the treatment performed, as well as the strength and tension of the muscles. When instability develops, the muscles perform the main compensatory work. There are two options for compensating for muscle instability:

• Instability is compensated by muscle work. Muscle tension can keep the vertebrae from pathological movements, relieve the patient of discomfort and reduce the intensity of pain. The degree of compensation is proportional to muscle volume and muscle tone. Muscle tension is more pronounced in the early stages of the development of the pathological process.
• Instability is not compensated by muscle tension. Displacement of the vertebrae leads to their subluxation, constant pain and arthrosis of the intervertebral joints.

The severity of compensation determines the condition of the patient with spinal instability. Disc fibrosis leads to an increase in its rigidity, a decrease in mobility in the spinal segment, a decrease in irritation of the nervous structures and a decrease in pain intensity. Instability that begins early in life may have a relatively worse prognosis than vertebral misalignment that develops in an older person. Over time, the mobility of the vertebrae decreases due to the development of fibrosis, spondylosis and spondyloarthrosis. As a result of these processes, people over 50 years of age experience a decrease in the frequency of neck pain compared to the younger population [8].

Neurological manifestations of instability

With spinal instability, displacement of the vertebrae leads to a narrowing of the spinal canal, irritation of the dura mater, spinal cord and its roots, resulting in the development of neurological disorders, which are grouped into three groups of syndromes:

• Radicular syndromes: lumbago, cervicalgia, radiculitis.
• Neurodystrophic syndromes: anterior scalene muscle, pectoralis minor muscle, glenohumeral periarthritis, epicondylopathy, vertebral artery syndrome, cardiac syndrome.
• Spinal syndromes: anterior horn syndrome, posterolateral syndrome, posterior column syndrome, conduction disorders.

Types of instability

The following main types of spinal instability are distinguished:

• post-traumatic;
• degenerative;
• postoperative;
• dysplastic.

Post-traumatic instability

Develops as a result of trauma, which includes fracture, fracture-dislocation and dislocation of the vertebrae. When the spine is damaged, flexion, flexion-rotation, extension and compression mechanisms of injury operate. The first two mechanisms operate in road and sports injuries and account for 70% of the total number of spinal injuries. The extensor mechanism occurs when the head is thrown back sharply and is found in whiplash-like motor vehicle injuries. The compression mechanism is associated with a sharp load along the axis of the spine and acts when falling from a height. Post-traumatic instability complicates about 10% of cases of vertebral fractures and fracture-dislocations. After an injury, the segment of the spine in which damage to either the anterior or posterior supporting complexes occurs is unstable. Post-traumatic instability produces spinal or radicular symptoms. In case of traumatic injury, displacement of the vertebrae by more than 3.5 mm and an increase in the angle between the endplates of adjacent vertebral bodies by more than 11° are interpreted as the result of gross damage to the ligamentous apparatus. According to A. White [2], damage to the posterior supporting complex with displacement of the vertebral body up to 2 mm and articular processes up to 1/3 can be considered a favorable variant of the course of instability. At the same time, complete destruction of the anterior supporting complex with displacement of the vertebral bodies of 2 mm or more is considered unfavorable in terms of prognosis. In such patients there is reason for the progression of instability.

Post-traumatic instability occurs in all age groups. In children, instability develops both as a result of intranatal trauma to the cervical spine during obstetric care, during which damage to the cervical spine ligaments occurs, and as a result of postnatal compression fractures of the vertebral bodies with unstable damage to the intervertebral discs and ligaments [4]. In adults, after a spinal injury, a decrease in the height of the intervertebral discs, pathological mobility and displacement of the vertebrae caused by disc damage and ligament rupture are found in the damaged area. In isolated vertebral fractures, which are not accompanied by ligament rupture and vertebral displacement, there is residual stability due to the preservation of the supporting complexes of the spine.

Degenerative instability

Degeneration of intervertebral discs occurs with spinal osteochondrosis. Degenerative-dystrophic changes consist in the disintegration of the fibrous ring and fragmentation of the disc tissue, which leads to a decrease in its fixation ability. Degeneration of the intervertebral disc can be either primary, due to a violation of cartilage metabolism, or secondary, due to a violation of the statics of the spine [7]. When a load is placed on a segment of the spine with a degenerated defective disc, pathological mobility and displacement of the vertebrae occurs, which is called degenerative spondylolisthesis or pseudospondylolisthesis. Displacement of the vertebra causes overload in the posterior supporting complex with the development of degenerative spondyloarthrosis. When the vertebrae are displaced, extensive changes develop in both supporting complexes, from where pain impulses come. In 85% of cases, instability with severe disc degeneration is observed at the CIII-CIV, CIV-CV and CV-CVI levels [2, 7].

Postoperative instability

Postoperative spinal instability is associated with disruption of the integrity of supporting complexes during surgery. In practice, postoperative instability is most often observed after laminectomy, the extent of which has a significant impact on spinal stability. Unilateral laminectomy is a relatively gentle operation, while bilateral laminectomy with resection of the articular facets significantly worsens the support ability of the spine. A decrease in the load-bearing capacity of the posterior supporting complex leads to a redistribution of the load in the spine, resulting in an increased load on the vertebral bodies and intervertebral discs, which contributes to the further progression of their degeneration after a significant period of time after the intervention. The development and progression of postoperative spinal instability is associated with the influence of several factors:

• inadequate load on the spine in the postoperative period;
• ongoing disc degeneration and recurrent hernia;
• errors and shortcomings in surgical technique in the form of an unreasonably large volume of resection of bone and ligamentous structures and lack of fixation of the spine;
• development of instability at a level adjacent to the level of surgery. Spinal fusion after laminectomy can lead to overload of segments ranging from 60 to 180% [7], which are located above and below the level of spinal fixation.

To eliminate postoperative instability, repeated operations are required, which are not inferior in complexity to the primary intervention.

Dysplastic instability

Dysplastic instability of the spine develops due to dysplastic syndrome. Signs of dysplasia are found in the vertebral body, intervertebral disc, intervertebral joints and spinal ligaments.

Instability at the lower cervical level is associated with congenital inferiority of the intervertebral disc. A manifestation of dysplasia is the eccentric position of the nucleus pulposus, narrowing of the intervertebral disc, disruption of the integrity and parallelism of the endplates, as well as wedge-shaped vertebral bodies. In dysplasia, a change in the structure of collagen fibers leads to disruption of the hydration process of the tissue of the nucleus pulposus, which causes a violation of the mechanical properties of the intervertebral disc, a decrease in the rigidity of fixation of the vertebrae, and a violation of the relationship between the nucleus pulposus and the fibrous ring. These changes lead to the development of spinal instability at levels from CI to CII [5, 9].

In the atlantoaxial region, signs of dysplasia are found in the vertebral bodies, intervertebral joints and the entire ligamentous complex. Patients with craniovertebral pathology have a number of characteristic radiographic changes: asymmetry and inclined position of the odontoid process of the CI vertebra, hypoplasia of the atlas and condyles of the occipital bone, asymmetry of the atlantoaxial and atlantooccipital joints, asymmetry of the lateral masses of the atlas, synostosis of the CI and CII vertebrae, basilar impression and platybasia, rotation and flexion-extension instability of the spine [6]. Craniovertebral pathology is accompanied by multiple signs of dysplastic development in the form of a high hard palate, malocclusion, asymmetry of the face and shoulder girdle, shoulder blades, waist triangles, as well as flat feet, dysplastic instability of the shoulder, elbow, metacarpophalangeal and knee joints. Congenital inferiority of the ligamentous apparatus in the craniovertebral region leads to the development of decompensated instability.

With congenital concrescence of the CI and CII vertebrae, as well as with assimilation of the atlas, restriction of movement occurs at the upper cervical level with a decrease in the amplitude of movements, which leads to compensatory development of hypermobility in the lower cervical spine. The increased load creates conditions for rapid wear of the intervertebral discs and the development of instability at the CIV-CV and CV-CVI levels.

Dysplastic changes can affect any element of the spine. Congenital underdevelopment of the bursa-ligamentous apparatus forms the syndrome of the posterior support complex, described by A.V. Demchenko in adolescents [9]. Dysplastic changes lead to the early development of a degenerative process at a young age with impaired spinal stability. Congenital asymmetry of intervertebral joints, or tropism, manifests itself in changes in the size and position of the articular facets. Changes in the plane of the intervertebral joints cause changes in the rigidity of the posterior supporting complex, redistribution of the load on both supporting complexes, and early degeneration of the spinal segment, which is complicated by its instability. Underdevelopment of the articular processes leads to overstretching of the joint capsule, displacement of the articular surfaces, narrowing of the intervertebral foramina, looseness of the intervertebral joints, a decrease in the rigidity of the posterior supporting complex and an increase in the load on the anterior supporting complex. Disproportionately large articular processes lead to increased rigidity of the posterior supporting complex, which contributes to an increase in the load on this part of the spine.

In adulthood, dysplasia of the intervertebral joints is the cause of the development of dysplastic osteochondrosis, which can lead to both spinal instability and spondyloarthrosis.

Conservative treatment

Conservative treatment is based on the controlled process of fibrosis of the intervertebral disc in an unstable segment of the spine. Wearing a head support promotes the development of disc fibrosis and stops the progressive displacement of the vertebrae. In an adult patient, the development of fibrosis can lead to gradual relief from pain. As a rule, treatment of spinal instability begins with the use of conservative methods. Conservative treatment methods are indicated in patients with instability of minor severity, which is not accompanied by severe pain and spinal symptoms. Conservative treatment methods include the following:

• compliance with a gentle regime;
• wearing a soft or hard head holder;
• taking non-steroidal anti-inflammatory drugs (NSAIDs);
• novocaine blockades for exacerbation of pain syndrome;
• massage and physical therapy of the back muscles;
• physiotherapy (electrophoresis, ultrasound).

Surgical treatment

The main principles of surgical treatment of cervical spine instability are spinal stabilization and decompression of neural structures. The operation eliminates compression of the nerves and creates conditions for ankylosis of the spine. Surgical treatment has the following indications:

• Unsuccessful treatment of pain syndrome for 1-1.5 months. [7].
• Persistent radicular and spinal symptoms caused by compression of nerve structures by exostoses, disc herniation, hypertrophied ligamentum flavum.
• Subluxation due to instability [7].
• Intolerance to certain types of conservative treatment (NSAIDs, physiotherapy, etc.).
• Frequent exacerbations of pain syndrome with short remission.

Spinal stabilization is achieved with anterior or posterior spinal fusion.

Posterior spinal fusion surgery has disadvantages. These include graft resorption and pseudarthrosis formation in the postoperative period. Compared with posterior spinal fusion, anterior stabilization has a number of advantages:

• low invasiveness of the intervention and short period of immobilization after surgery [7];
• the ability to perform open reduction of vertebral subluxation and anterior decompression;
• reducing compression of the nerve root by increasing the intervertebral space;
• preventing recurrence of intervertebral disc herniation.

The choice of treatment method depends on the type of instability. In severe post-traumatic instability with vertebral subluxation, the most reliable stabilization of the spine is achieved with a combination of intervention by anterior and posterior approaches. A combined intervention provides the opportunity to take advantage of the benefits of each approach. A wide laminectomy is performed using a posterior approach to decompress all nerve structures. An anterior approach is used to perform spinal fusion, which achieves spinal stabilization.

Based on materials from the journal: Consilium-medicum. - 2004. - T. 06, No. 8.

References 1. Kasai T. et al. Spine. - 1996. - 21 (18). - 2067-71. 2. White A, Southwick W, Panjabi M. Spine. - 1976. - 1 (1). — 15-29. 3. Kolesov S.V. Old injuries of the ligamentous apparatus of the upper cervical spine in children and adolescents. dis. ...cand. honey. Sci. - M., 1992. 4. Kolesov S.V., Palatov A.E. Pain syndrome in the cervical spine in children and adolescents with craniovertebral pathology // Vertebrology - problems, searches, solutions. Scientific Conference. - M., 1998. - P. 112-3. 5. Prodan A.I., Khvisyuk N.I., Makovoz E.M., Lygun L.N. Kinematic characteristics of the spinal segment in degenerative instability // II All-Union Conference on Problems of Biomechanics. - 1979. - T. 4. - P. 107-11. 6. Orlova M.A. Diagnosis and treatment of instability of the cervical spine in children. dis. ...cand. honey. Sci. - St. Petersburg, 1996. 7. Yumashev G.S., Furman M.E. Osteochondrosis of the spine. - M., 1973. 8. Selby D. Conservative treatment of nonspecific pain in the lumbar spine. Osteocondritis of the spine. Soviet-American Symposium. - M., 1992. - P. 44-57. 9. Demchenko A.V. Early degenerative-dystrophic lesions of the spine in children and adolescents. Vertebrology - problems, searches, solutions. Scientific Conference. - M., 1998. - P. 98-9.

Degrees of vertebral rotation

• First. Usually asymptomatic. The detection of the disease, as a rule, occurs by chance during the diagnosis of another pathology. Pain may occur occasionally with increased physical activity or sudden changes in body position.
• Second. The pain does not go away as quickly as during the first stage of rotation and manifests itself as more pronounced unpleasant sensations. This becomes especially noticeable after physical activity.
• Third. The person feels stiffness in movements. Disturbances in the functioning of the genitourinary system may occur. There is a possibility of pinching the spinal cord nerves. In this case, the pain will be severe.
• Fourth. At the last stage of rotation of the vertebral bodies, the disease clearly progresses and makes irreversible changes to the structure of the spine. The patient feels severe weakness in the legs, lameness or changes in gait may appear. Severe chronic pain usually forces you to see a doctor. But if no measures are taken, the disease becomes a disability.

Diagnostics

Methods for diagnosing the disease are determined by a specialized specialist: a neurologist

,
surgeon
,
orthopedist-traumatologist
. At the first visit, the doctor conducts an external examination, and then additional diagnostic procedures may be prescribed:

• radiography
  ;
• magnetic resonance imaging
  (MRI);
• computed tomography
  (CT).

All these modern methods give an idea of ​​the overall picture of the disease, on the basis of which the doctor chooses the correct treatment tactics.

Treatment of rotational injuries of the spine

All treatments are different. depending on the stage of the disease, the location of the displacement, the age of the patient and his/her health status. Severe advanced diseases require surgical intervention, through which the vertebra is fixed with a screw or plate. Such operations are prescribed for the last degree of rotation of the vertebral bodies. In most cases, non-surgical treatment methods can be used:

• reduction and extension of the vertebra;
• wearing a special corset;
• massage;
• physiotherapy;
• physiotherapy affects the painful area with a magnetic field, laser beam or current pulse;
• manual therapy and acupuncture affect active points in the body.

With the right treatment tactics, the symptoms of the disease will begin to fade and gradually disappear.

How to treat spinal osteoporosis

Therapy for this disease includes significant dietary adjustments, taking special medications, lifestyle changes and, in some cases, physical therapy.

Features of nutrition for osteoporosis

The main thing is the high calcium content in food. To restore bone tissue, a person needs 1000-1200 mg of calcium per day. For comparison: usually the daily dose when consuming dairy products is 600-800 mg. Therefore, it is necessary to add calcium supplements. In addition, calcium can be “raised” by eating as many foods high in calcium as possible: nuts, dried fruits, dairy products, vegetables, olives, celery, white cabbage, onions, fish.

Important! If you drink 0.5 liters of milk, you will satisfy the daily need for protein by 20%, phosphorus by 10%, calcium by 72%, iodine by 22%, and various vitamins by 30%.

If a person is lactose intolerant, then other foods containing calcium should be consumed. This is a glass of calcium-fortified orange juice per day (500 mg of calcium), ¾ cup of cereals (200-250 mg), ½ cup of boiled soybeans (90 mg), 1 orange (50 mg), ½ cup of boiled broccoli (35 mg) .

In order for calcium to be better absorbed, vitamin D is necessary. It is synthesized in the body under the influence of ultraviolet radiation. However, in the middle zone, people often experience a deficiency of it due to the small number of sunny days per year. Therefore, it is necessary to consume more foods containing vitamin D: meat, eggs, butter. However, it is possible to get up to 100 IU per day from food, which is not enough, because you need from 600 to 1000 IU. Therefore, vitamin D is added in tablet form.

Vitamin A, phosphorus and magnesium are also needed for good calcium absorption. The latter element is found in large quantities in buckwheat, bananas, oatmeal, millet, peanuts, sunflower and pumpkin seeds, cheese, peas, beans, and green peppers. If you simply consume magnesium, then 2/3 of the amount received will be excreted from the body. You can increase digestibility with vitamin B6.

The diet should contain enough protein - 1 g per kg of weight per day. To do this, you need to eat more meat, egg whites, and green vegetables. You can include protein shakes in your diet.

The balance between phosphorus and calcium is important. There should be twice as much calcium. The content of these substances in the body should be regularly checked by donating blood as prescribed by a doctor. Phosphorus is found in large quantities in veal, beef, millet, hard cheese, pumpkin seeds, egg whites, beef and pork liver, milk, white beans, nuts, grain bread, chicken, turkey, and duck. Your doctor should also explain how to maintain proper sodium levels.

In women, osteoporosis most often develops when estrogen production is disrupted. To maintain the level of female hormones, you need to eat foods containing phytoestrogens - all types of greens, soy, legumes, raw nuts.

Possible complications

A disease that is not cured in time can lead to irreversible destructive consequences for the human body. Spinal pathology is dangerous because it affects both the musculoskeletal system and the central nervous system. Possible complications:

• partial or complete paralysis;
• arachnoiditis, spinal cord abscess;
• periarthritis;
• neurological problems of the muscles of the back of the head;
• impairment of motor functions of the legs and arms;
• loss of skin sensitivity in the affected area;
• complete prolapse of the vertebra.

There are currently a lot of methods for treating vertebral rotation, and the disease detected in time is very treatable. To avoid serious complications, it is extremely important to seek medical help at the first symptoms of displacement.