1.General information
Dislocations of the vertebrae are rare injuries: the structure of the spinal column ensures its high strength and flexibility, therefore, even with a very strong blow or pressure, fractures or so-called injuries occur much more often. fracture-dislocations than isolated dislocations of the vertebrae relative to each other. However, the “mechanics” of the cervical spine are somewhat different, and it is the cervical spine that accounts for two-thirds of vertebral dislocations (another 25% are dislocations in the lumbar region).
Such an injury is always dangerous; it is accompanied by rupture of the spinal ligamentous apparatus, often combined with fractures, “couplings” of articular processes, and damage to the spinal cord. With significant displacement and rupture of the spinal cord (for example, dislocation of the atlanto-occipital joint), the victim dies on the spot.
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Consequences
The first symptoms may disappear on their own, especially with slight displacement of the vertebrae. But over time, an adult develops complications of subluxation that disrupt the functioning of internal organs, as well as the nervous system.
When the atlas is displaced, vision is impaired and hearing deteriorates. The spine gradually curves in the cervical segment. With a sudden change in body position, the patient experiences dizziness and periodic headaches.
With subluxation of the axis and third vertebra, the tongue, larynx, and esophagus become numb. The patient has problems swallowing food. If the normal position of the 3rd and 4th vertebrae is disturbed, chest pain occurs, the heart rhythm is disrupted, as well as the functionality of the colon.
The consequences of subluxation of the cervical vertebra include torticollis (tilting the head to the affected side), retardation in mental and physical development.
2. Reasons
The most common cause of vertebral dislocation is a mechanical blow to the neck from behind, or a fall upside down with a traumatic brain injury with the neck tilted anteriorly. Rotational (one-sided bending) dislocation is less common.
Typical situations in which victims receive such an injury are landslides in the mining industry or collapse of buildings, diving from a height in an unfamiliar place (where the depth is much less than expected), road traffic accidents, falls during exercises on gymnastic equipment (horizontal bars, uneven bars, rings, log). Sometimes a dislocation is caused by lifting an unbearable weight.
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Risk factors
The risk of vertebral dislocation occurs when:
- Engaging in hazardous sports that involve the possibility of collisions or falls, as well as any activity that increases the risk of spinal injury.
- Proneness to falls: When a person has other diseases, such as neurological or spinal-related, the risk of vertebral dislocation is also high.
- Hereditary factors: People with more flexible ligaments due to some hereditary characteristic are also more prone to sprains.
3. Symptoms and diagnosis
The clinical picture differs depending on the degree of dislocation (complete, incomplete), the nature of the displacement (tipping, sliding, anterior, posterior, unilateral or bilateral), the presence or absence of spinal cord injuries, as well as the location of the injury. However, in all cases there is severe pain at the site of dislocation and a sharp limitation of mobility in the affected area and below.
Dislocation of the cervical vertebrae is often accompanied by compression of the vertebral arteries, which causes cerebral circulation disorders with corresponding symptoms; damage to the spinal cord in this section can lead to complete or partial paralysis in the limbs, lack of reflexes, and loss of tactile sensitivity. The patient strives to take a forced position in which the pain is least intense, and the position of the head in such a position is a diagnostically significant sign when a doctor assesses the nature of the dislocation.
Dislocations in the thoracic region are the least common, but they are fraught with paralysis of the legs and death (if the spinal cord is damaged).
The mobility of the legs also decreases sharply when the vertebrae in the lumbar region are dislocated. The sensitivity of the skin is also impaired, pain can radiate to adjacent areas (pelvis, abdominal area, etc.).
In diagnosis, information about the circumstances and nature of the injury and examination of the victim are of utmost importance.
An X-ray examination is mandatory. If a combined, complex injury involving vessels and/or spinal cord structures is suspected, magnetic resonance imaging is prescribed.
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Classification
Spinal dislocations are classified depending on how the displacement occurred:
When tilting your head sharply forward or backward:
- Anterior dislocation - the upper (dislocated) vertebra is displaced anteriorly in relation to the lower ones;
- Posterior dislocation - the upper vertebra is displaced posteriorly in relation to the lower ones.
Depending on whether the injury occurs on the back or side of the spine:
- Bilateral dislocation - the vertebra moves sideways, anteriorly or posteriorly, completely moving out of the articular surfaces;
- Unilateral dislocation - displacement of the upper vertebra occurs only on the right or left side of the articular surface.
Depending on the strength of the dislocation:
- Complete dislocation - displacement of the upper vertebra occurs with complete disruption of the articular surface;
- Incomplete dislocation (subluxation) - the displacement of the upper vertebra is not complete, with partial adhesion of the articular surfaces.
Depending on the position of the displaced vertebra:
- Tipping dislocation - the upper (dislocated) vertebra not only moves from the articular surface, but also tilts anteriorly or posteriorly;
- Sliding dislocation - the upper vertebra is displaced from the articular surface only in a straight line, without tilting posteriorly or anteriorly.
Classification depending on the time of injury and detection of dislocation:
- Fresh dislocation - diagnosed no later than 10 days after injury;
- Stale dislocation – diagnosed within 10-28 days from injury;
- Old dislocation – diagnosed later than 28 days from injury.
4.Treatment
When providing first medical (or pre-hospital) aid, it is necessary to immobilize the victim and transport him to a medical facility as soon as possible. Further actions are determined by the clinical characteristics of the individual case.
Thus, conservative treatment includes the prescription of analgesics and non-steroidal anti-inflammatory drugs, reduction of the dislocation (under local anesthesia) or traction of the vertebrae (followed by wearing a mobility-limiting collar); however, this applies only to uncomplicated subluxations and dislocations, including old ones, in the cervical region.
Dislocations in the thoracic and lumbar region require reduction through open surgical approach.
It should be emphasized once again that vertebral dislocation is one of the most dangerous injuries. Even if it was possible to straighten it without any seemingly special problems, the likelihood of complications in the future is very high: persistent pain syndrome, curvature of the spine, and various neurological symptom complexes often develop. Therefore, reasonable precautions and safety requirements must be observed in all situations.
Publications in the media
Most often in adults, less durable vertebrae break at the points of transition from one physiological curvature to another: lower cervical, upper thoracic, lower thoracic and upper lumbar. Causes: axial load on the spine, sudden or excessive flexion or extension of the spine. Classification of fractures by stability. Stability is determined by the integrity of the posterior ligamentous apparatus and intervertebral joints • Stable injuries •• Angle avulsion •• Wedge-shaped compression of less than 50% of the height of the vertebral body •• “Blast” fractures that occur under axial load without flexion and extension of the spine; in this case, the vertebral end plates break, the central sections of the intervertebral disc are embedded in the vertebral body and tear it from the inside into several fragments according to the principle of water hammer • Unstable injuries •• Dislocation and fracture dislocation of the vertebra •• Fracture with wedge-shaped compression of more than 50% of the height of the vertebral body in the anterior section •• Flexion-rotation fracture.
Clinical picture • Pain in the damaged part of the spine • Bruising and abrasions at the point of application of force • Changes in physiological curvature: smoothing of the lumbar lordosis, increased thoracic kyphosis, scoliosis • Symptom of the reins - tension of the long back muscles in the form of rollers on both sides of the spinous processes of the damaged vertebrae • Pain upon palpation of the spinous processes of damaged vertebrae • Protrusion of the spinous process posteriorly and an increase in the interspinous spaces at the level of injury • With a fracture of the lumbar vertebrae - abdominal pain, tension in the muscles of the anterior abdominal wall, pseudo-abdominal syndrome - clinical picture of an acute abdomen, developing with irritation or damage to the solar plexus and border sympathetic trunk retroperitoneal hematoma • Silin's symptom - increased pain on palpation of the spinous processes while raising straight legs in a supine position. Diagnostics . An X-ray examination is carried out in two projections, and, if necessary, targeted radiography, tomography of the spine, radiography in lateral projections, CT, MRI. Radiographs reveal a wedge-shaped deformity of the vertebral body in the lateral projection.
Treatment • Fracture of the lower thoracic and lumbar vertebrae •• The patient is transported on a special stretcher with a shield that prevents flexion of the spine •• Simultaneous reposition followed by application of a corset is indicated for wedge-shaped compression of more than 50% of the vertebral body ••• Anesthesia: 20 are injected into the interspinous space above the broken vertebra ml of 0.5% procaine solution (Behler's method), an analgesic is administered subcutaneously ••• Reposition is carried out according to the Watson-Jones-Behler method (extension of the spine on tables of different heights) or Davis (pulling up by the legs of a patient lying down face) ••• An extension plaster corset is applied, leaving the back open for 4–6 months ••• Physiotherapy, massage, exercise therapy are prescribed •• The Dreving-Gorinevskaya functional method is indicated for compression of less than 1/3 of the height of the vertebral body ••• Bed rest is prescribed and longitudinal traction for the axillary fossae on an inclined board for 1.5–2 months ••• Exercise therapy is prescribed from the first days of bed rest to create a muscle corset •• Method of gradual reposition ••• Reposition is carried out by gradually increasing the extension of the spine by placing wide rollers under lumbar region for 7–10 days ••• Exercise therapy, massage, physiotherapy are performed ••• On 15–20 days an extension corset is applied for 4–6 months •• Open posterior fixation of the spine is used for uncomplicated flexion fractures ••• A broken vertebra is straightened before surgery, simultaneously or gradually ••• Fixation of the spinous processes, arches, transverse processes of the damaged part of the spine is used ••• After the operation, exercise therapy and massage are prescribed to strengthen the back muscles •• In case of “burst” fractures, bone fragments are removed, the vertebral body is replaced with a bone graft • Fracture of the midthoracic and upper thoracic vertebrae. For fractures of the upper thoracic vertebrae up to TV, traction is applied not to the axillary fossae, but to the head with a Glisson loop.
M KB-10. T08 Spinal fracture at unspecified level
Bibliography
- Chechik O, Wientroub S, Danino B, Lebel DE, Ovadia D. (2013) “Successful conservative treatment for neglected rotatory atlantoaxial dislocation.”, Journal of Pediatric Orthopedics, 33(4), pp. 389-392.
- Iizuka H, Iizuka Y, Kobayashi R, Takechi Y, Nishinome M, Ara T, Sorimachi Y, Nakajima T, Takagishi K. (2013) “Characteristics of idiopathic atlanto-axial subluxation: a comparative radiographic study in patients with an idiopathic etiology and those with rheumatoid arthritis.”, European Spine Journal, 22(1), pp. 54-59.
- Ordonez BJ, Benzel EC, Naderi S, Weller SJ. (2000) “Cervical facet dislocation: techniques for ventral reduction and stabilization.”, Journal of Neurosurgery, 92(1), pp. 18-23.
- M. B. Royo-Salvador (2014), “Filum System® Guía Breve.”
- Sun Y. Yang, Anthony J. Boniello, Caroline E. Poorman, Andy L. Chang, Shenglin Wang, and Peter G. Passias (2014) “A Review of the Diagnosis and Treatment of Atlantoaxial Dislocations,” Global Spine Journal, 4( 3), pp. 197-210.
- M. B. Royo-Salvador (2014), “Filum System® Bibliography” (PDF).
results
In our Institute, in case of vertebral dislocation, arthrodesis of all types is performed, with excellent results and minimal complications.
Example
-Case No. 312
A 16-year-old patient suffered a dislocation in the area of the second and third cervical vertebrae while playing football and was successfully operated on. (Fig.1,2,3,4).
Fig. 1 A normal lateral x-ray showing no abnormality.
Fig. 2 X-ray in flexion of the spine, the arrow shows the level of dislocation.
Fig.3 and Fig.4. The x-ray shows a titanium plate with two holes and screws connecting the second and third cervical vertebrae, where the central part of the damaged intervertebral disc was previously removed and replaced with a hydroxylapatite implant.
Causes of displacement of the lumbar vertebra
As practice shows, the main reasons are a sedentary lifestyle and excess weight. Lack of physical activity causes the muscles to become weaker and unable to support the spine. And as a result, any sudden movement leads to damage. Other causes of the disease include the following:
- Degenerative diseases of the musculoskeletal system
- Surgical interventions
- Heavy physical work and lifting heavy objects can also cause subluxation.
- Mechanical spinal injuries