What are Vertebral Dislocations?
Dislocations of the vertebrae are most often found in the cervical spine. They arise as a result of pressure on the head with the neck bent forward during collapses in the shafts or from a blow to the occipital part of the head during gymnastic exercises on the horizontal bar, or when diving in a shallow spot.
The overlying vertebra is considered dislocated. Dislocation can be single or double-sided; complete or incomplete displacement of the articular processes of two adjacent vertebrae. Depending on the position of the lower articular process of the dislocated vertebra in relation to the upper articular process of the underlying vertebra, a dislocation with engagement and without engagement is distinguished.
Pathogenesis during Dislocation of the Vertebrae
With a flexion injury with a large and fast speed of violence, dislocations of the vertebrae occur, with simultaneous rotational movement – unilateral dislocations.
Dislocations are characterized by a rupture of the ligamentous apparatus.
Dislocation in the atlantooccipital joint is rare and practically never occurs in clinical practice. Dislocation of G is in most cases accompanied by a fracture of the C tooth (transdental dislocation of the atlas), the tooth remains intact much less frequently, and the transverse ligament (transligamenous dislocation) is torn. When the tooth emerges from under the transverse ligament, a peridental dislocation occurs. The occurrence of the lower articular processes of the displaced vertebra beyond the superior articular processes of the underlying vertebra is characterized as a mated dislocation. The presence of one freely lying articular site with a relatively small displacement of the vertebral body anteriorly, the correspondence of the other facet to the correct row is treated as a one-sided dislocation.
Symptoms of Dislocation of the Vertebrae
The clinical picture of dislocations is dominated by pain and a forced position of the head in combination with limited mobility. The presence of abrasions, wounds, bruises on the chin, face, head, in the forehead helps to establish the mechanism of injury.
Diagnosis of Dislocation of the Vertebrae
Palpation of the cervical spine in the projection of the spinous processes reveals local pain, swelling, the presence of deformation – kyphosis, persistence or retention of the spinous processes.
X-ray of the cervical spine is performed in the position of the injured lying on his back so as not to cause additional injury. Radiographs are performed in anteroposterior, lateral and oblique (3A) projections.
On lateral radiographs, it is necessary to pay attention to a change in the axis of the spine, the relationship between articular processes, the presence of violations of the integrity of bone tissue, deformations, structural changes, narrowing or expansion of the intervertebral spaces.
Vertebral Dislocation Treatment
Treatment for dislocations in the cervical spine involves conservative and surgical methods of reduction. Of the methods of conservative treatment, instantaneous closed reposition, the method of traction by the Glisson loop, and skeletal traction over the parietal tubercles were most widely used. Indications for conservative reduction are dislocations in the cervical spine in the acute period of injury.
Instantaneous closed reduction can be used both for complicated and uncomplicated dislocations. Urgent reduction in complicated dislocations helps to restore the normal anatomical shape of the spinal canal, restore cerebrospinal fluid and blood circulation, and eliminate compression of the spinal cord.
The most common method of reduction according to Richet-Guether. The patient is in a supine position, the head and neck will stand over the edge of the table. Anesthesia is preliminarily performed: 10-15 ml of a 0.5-1% solution of novocaine are administered paravertebrally at the lesion level.
Stage I: traction along the axis of the spine. It is carried out by the surgeon through the elongated traction of the Glisson loop, mounted on the lower back. Hands surgeon covers the head of the victim.
Stage II: the surgeon’s assistant stands opposite and covers the patient’s neck so that the upper edge of the palm is at the level of damage on one side with bilateral dislocation and “healthy” with unilateral dislocation. Continuing the extension along the axis, the operator tilts the head and neck to the “healthy” side.
Stage III: carrying out traction along the axis and not eliminating the inclination of the head and neck, turn the head toward dislocation, while the surgeon supports the head with its palms on the side surfaces, making it easier to perform manipulations. The head is brought to the average physiological position with moderate hyperextension. The direction of bilateral dislocations is achieved by manipulation first on one side, then on the other.
After reduction, the necessary fixation of the spine is achieved by a thoracocranial dressing with uncomplicated dislocations for up to 2-3 months. Reducing dislocations with the help of the Glisson loop is currently less commonly used because of its low efficiency in conjugated dislocations, as well as because of the inherent disadvantages of the method: the difficulty of using large weights, compression of the soft tissues of the face, neck, and difficulty in eating.
Forced skeletal traction is indicated for single and bilateral dislocation of the cervical vertebrae with neurological symptoms. With forced repositioning, large loads are used, up to 10-15-20 kg, which allows to achieve muscle relaxation, stretching of the ligamentous apparatus and repositioning of the vertebrae. Under local anesthesia, a brace is placed over the parietal tubercles, and the load is suspended. Traction begins with a minimum load, gradually bringing to the maximum. Reduction is carried out under constant x-ray control after 15-20 minutes. After setting, leave a load of 3-4 kg.
The disadvantages of forced reduction are the need for multiple x-ray control, lack of effectiveness, difficulty in caring for the patient.
Open reduction from posterior surgical access is used for non-corrected dislocations of the cervical vertebrae, repeated reluxes both in uncomplicated and complicated injuries.
The advantage of this method is the possibility, along with the reduction, to revise the spinal canal in case of complicated dislocations, to stabilize the damaged segment. This is especially important for patients with severe neurological disorders, in which early activation in the postoperative period is one of the important tasks of preventing serious complications and the possibility of rehabilitation.
Open reduction and decompression from the anterior surgical approach are indicated with an increase in neurological symptoms after closed reduction of dislocations with complicated injuries, compression of the spinal cord with a torn disc.