BACKBONE [columna vertebralis (PNA, JNA, BNA); synonym rachis] — the main part of a skeleton of a trunk, serves as body of a support and the movement, a receptacle of a spinal cord. The item consists of 32 — 33 vertebrae which conditionally combine in departments (segments) — cervical (C), chest (Th), lumbar (L), sacral (S), coccygeal (Co) (tsvetn. fig.). The item creates a support to a body, being the place of an attachment of muscles, takes part in the movements of a body. Vertebrae connect with each other in various departments of P. by means of preryvny and continuous connections that provides big stability of P., on the one hand, and sufficient mobility — to another.
The comparative anatomy
Phylogenetic an initial form P. serves a chord (a back string) — cellular tyazh an entomezodermalny origin. As the constant body a chord exists only at nek-ry lowest vertebrata. At the majority of vertebrates in adulthood the chord remains in vertebrae (at fishes), in bodies of vertebrae (at amphibiouses) and in the form of a jellylike kernel of intervertebral disks (at mammals). At selakhiya in a chord cartilaginous bodies of vertebrae, at tselnogolovy and two-breathing — limy deposits of a ring-shaped form are formed. The item of fishes is subdivided into truncal and tail departments. Since amphibians cervical and sacral departments are differentiated, between to-rymi remains chest (truncal). The number of vertebrae can be various, reaching at legless lizards and snakes 400.
At birds the truncal department of P. is not mobile because of accretion of vertebrae with each other, the cervical department is extended and very mobile; the sacral department consists of a large number of accrete vertebrae. At mammal P. has the most differentiated structure, including 6 — 9 cervical, 9 — 24 chest, 1 — 10 sacral and 3 — 46 coccygeal vertebrae.
P. of the person passes webby, cartilaginous and bone stages in the development. According to N. V. Popova's data - Lat - 'kinoy, elements P. appear at a germ 7 mm long. The chord and segments (in number of 21) at this stage of development well come to light. At a germ 9 .sh long of laying of bodies of vertebrae will far defend from each other, being divided by layers of a germinal mesenchyma. With a length of germ of 13,5 mm arches of vertebrae clearly are expressed, cross and joint shoots begin to form. The item of embryos 18 — 25 mm long has uniform dorsal curvature at a ventral bend of the last coccygeal vertebrae. The differences inherent in vertebrae of different departments come to light. At embryos of 33 — 37 mm of P. will bend to a lesser extent, than at the previous stage. Vertebrae are differentiated almost completely (acanthas still are absent). The chord is reduced and remains only in the form of a jellylike kernel of intervertebral disks. Idiosyncrasy of P. at early stages of development is similarity of bodies of vertebrae in their form. At the end of the 2nd month of pre-natal development sharply increase in sizes of a body of cervical vertebrae. At embryos of late age and fruits bodies of Th12 and L1 of vertebrae have the largest size. Increase in bodies of lumbar and sacral vertebrae is not observed even at newborns due to the lack of pre-natal graviostatichesky influences. Laying of longitudinal teams of P. occurs at embryos 17 — 19 mm long on the dorsal surface of bodies of vertebrae. Intervertebral disks at embryos 10 — 13 mm long consist of a mesenchyma. At embryos 16 — 21 mm long on the periphery of a disk fibrous connecting fabric develops. Knutri from it arises a perikhordalny zone where around a chord the hyaline cartilage begins to develop. Hondrofikation P. begins on 5 — 7th week, and ossification — on 10 — 12th week. The centers of ossification appear in the lower chest and upper lumbar vertebrae in the beginning, then are traced also in other departments (after everything in coccygeal). Each vertebra has three primary nucleuses of ossification — one in a body and on one in each half of an arch. They grow together only by third year of life. The secondary centers appear at the edges of a body of a vertebra in 6 — 8 years at girls and 7 — 9 years at boys. Their union happens to a body of a vertebra after 20 years. Sacral vertebrae grow together in a uniform bone — a sacrum — in 17 — 25 years.
Age changes the Accelerated P.'s growth in length with achievement of 30 — 34% of the final size comes from the birth up to 3 years. At girls the chest department, then lumbar and cervical most intensively increases. At boys lumbar and chest departments grow equally intensively. From 3 to 7 years P.'s growth are slowed down. Activation of growth happens before approach of puberty again.
By the time of P.'s birth has uniform and insignificant dorsal curvature though already then in it poorly expressed are differentiated lordosis (see) and kyphosis (see). Changes of a form P. after the birth are connected with development of motility. When the child begins to hold the head, its cervical lordosis is fixed. Acquisition of ability to sit down, to stand and go creates a lumbar lordosis. At the same time a chest and sacral kyphosis amplifies. Thus, on the first year of life all four bends of P. in the sagittal plane are designated. Existence of bends considerably increases P.'s durability since causes its spring properties.
Change of a form P. during the aging is shown by the increase in curvature of verkhnegrudny department resulting in stoop (a senile kyphosis). Degenerative changes of P. are shown after 20 years. Weakening of the copular device leads to expansion of intervertebral intervals and shift of separate vertebrae. Ruptures of a fibrous ring lead to implementation of a jellylike kernel in a body of a vertebra that is quite often visible on matserirovanny vertebrae. Places of an attachment of fibers of a front longitudinal sheaf Obyzvestvlyatsya that leads to education osteophytes (see). Age osteoporosis (see) clearly it is shown in P. after 50 — 60 years.
Each vertebra (vertebra), except the I cervical, consists of a body, an arch and shoots — awned, two cross and four joint (two upper and two lower). The relative size of components of a vertebra and their situation are not identical in different departments (tsvetn. fig. 2 — 6).
I cervical vertebra (C1; the Atlas) consists of the front and back arches connected by lateral masses (tsvetn. fig. 1); II cervical vertebra (C2; axis — axial or epistrofy) has the shoot which grew together with a body — the tooth turned up for a joint with a front arch of St and a cross team of the Atlas. Upper joint shoots are located on a body of a vertebra from tooth on each side (tsvetn. fig. 2).
Other cervical vertebrae (C3-7) have a small body, the acantha forking on the end, cross shoots penetrated by openings, the located horizontally joint shoots (tsvetn. fig. 3). Acanthas are not identical on length. At a ducking on a back surface the top of an acantha is probed. In 70% of cases it is C7 (vertebra prominens), in 20% of C6, in 10% of cases — Th1
Chest vertebrae (vertebrae thoracicae; ThT_Xn) have the big sizes a body, the acanthas located in the frontal plane joint shoots inclined down cherepitseobrazno. On a side surface of a body cross shoots have top and bottom costal poles and — costal poles of cross shoots for connection with hillocks of edges (tsvetn. fig. 5).
Lumbar vertebrae (vertebrae lumbales; L1-5) have a massive body and turned horizontally kzad the acantha increased in a vertical size. Joint shoots are oriented sagittalno (tsvetn. fig. 6).
Sacral vertebrae (S1-5) at the adult grow together in a uniform bone — a sacrum (os sacrum). The sacrum has the form flattened in front back and a curved kzada of the pyramid turned by the basis to L5, and a top — to a tailbone. In the conjunction of L5 and S1 on border of a lumbar lordosis and sacral kyphosis the ledge turned kpered — the cape (promontorium) is formed. The front surface of a sacrum is bent and has four couples of openings; back — convex with roughnesses of a relief in the form of the crests which arose from merge of shoots of sacral vertebrae, also with four couples of openings (tsvetn. fig. 7).
Tailbone (os coccygis; Co 1-4 ) has the form of the pyramid turned by the basis up to a sacrum (tsvetn. fig. 8).
The item maintains a big static and dynamic load that is reflected in its structure. Massiveness of bodies of vertebrae increases from cervical to lumbar, and from the last most massiven L5. In sacral department reduction of the sizes of a body from S1 to S5 by 3,8 times in the sagittal direction, twice — in the diameter and by 1,8 times — in height is observed. The reduction takes as well other parts S2-5.
In the center of a vertebra between a body and an arch the pozvogochny opening is located. On the whole backbone these openings, proceeding one in another, form the vertebral channel (canalis vertebralis). In it the spinal cord with covers is located.
Between two adjacent vertebrae intervertebral foramens (foramina intervertebra-lia) serving as the place of an exit of roots of spinal nerves are formed. The greatest opening is in cervical department between C2 and C3, the smallest — between C3 and C4; in chest — the greatest between Th7 and Th8, the smallest — between Th2 and Th3.
Vertebrae are jointed with each other by means of any connections: cartilaginous (intervertebral disks — disci intervertebrales) between bodies of vertebrae, connective tissue between arches (yellow sheaves — ligg, flava) and shoots, bone (synostoses) in an accrete sacrum and a tailbone, true joints between joint shoots. In P. there are 23 intervertebral disks. Their total height reaches V4 of length of the Item. They have the greatest thickness in lumbar department. Intervertebral disks perform shock-absorbing function, incorporating a little compressed jellylike kernel (nuci, pulposus) and the fibrous ring (annulus fibrosus) which is not allowing it to go beyond a disk. Different types of connections provide combination of functions of stability and mobility. Cervical and lumbar departments have the greatest mobility, the midthoracic department of P. differs in the minimum mobility. Degree of mobility of P. depends on age, sex, degree of fitness and other reasons.
Durability of structures of P. is various. For vertebrae ultimate load makes 40 — 80 kg/cm 2 , for sheaves with dominance of collagenic fibers (e.g., a lobby longitudinal) — 5 — 9 kg/mm 2 , at dominance of elastic fibers (a yellow sheaf) — 1 kg/mm 2 .
As a source of arterial blood supply of chest and lumbar departments of P. serve intercostal and lumbar arteries, cervical department — vertebral, ascending and deep cervical, ascending pharyngeal, outside sleepy, lower thyroid, a shchitosheyny trunk, a cross artery of a neck, subclavial, upper and the first intercostal arteries. The vertebra can have up to 5 sources of blood supply. On outside perednebokovy and on internal the surfaces of bodies of vertebrae arterial networks are formed. Intraorganny arteries of bodies are united in perednebokovy and back groups.
Ways of venous outflow are presented front, back and outside by the vertebral textures, juxtaspinal side venous paths formed by vertebrata, the deep ascending cervical veins (cervical department of P.), the unpaired and semi-unpaired veins (chest department) ascending lumbar and lumboiliac (lumbar department). In the vertebral channel there are front and back internal vertebral veniplexes (plexus venosi vertebrales interni ant. et post.).
Taking away limf, P.'s vessels begin from network limf, capillaries of a periosteum of bodies of vertebrae, arches and shoots, a nadkhryashchnitsa of intervertebral disks. They go to regional limf, nodes, various for different departments
of P. V of an innervation of a periosteum of the vertebral channel the Meningeal branches of spinal nerves forming front and back neuroplexes participate. In them amyelenic fibers prevail. The largest nervous stipitates in textures are characteristic of upper cervical and upper lumbar vertebrae. Sympathetic trunks are a source of a sympathetic innervation; 3 — 7 stipitates 0,3 — 0,5 mm thick approach an intervertebral disk.
For X-ray anatomic studying most often use P.'s (spondilogrammam) roentgenograms in direct and side projections. For clearer image for the purpose of detailed studying of intervertebral joints (dugootrostchaty joints, T.) and interarticular sites of arches of vertebrae apply roentgenograms in slanting projections. In fig. 1 — 3 schemes of roentgenograms of departments of P. in the main projections are submitted.
On the direct roentgenogram of P. vertebrae with their anatomic details and intervertebral disks in the form of light intervals between dense shadows of bodies of vertebrae clearly are visible. The last at the adult have an appearance of quadrangles of bone density with accurate equal contours on top and bottom edge and a little concave on side surfaces. In process of removal from cervical department to lumbar vertebrae become massivny, and bodies are higher than them. In bodies of vertebrae on the centerline shadows of acanthas are visible. At the same time the acantha which is projected on this vertebra belongs to the above-located vertebra, and only acanthas of the lower lumbar vertebrae are projected on their bodies. In side departments of bodies of vertebrae oval shadows of legs of arches, and are visible above and below them shadows of top and bottom joint shoots are located.
On the side roentgenogram bodies of vertebrae, their upper, lower, front and back contours, and also joint shoots, arches, acanthas, intervertebral foramens and intervertebral spaces clearly are visible, in to-rykh intervertebral disks are located.
Distinctions find the display on roentgenograms in an anatomic structure of different departments of P. and can be revealed by use of simple receptions. So, on the direct roentgenogram of cervical department of P. (fig. 1) upper cervical vertebrae do not come to light because of imposing on them a massive shadow of a mandible. Make for the clear image of the first two cervical vertebrae tomography (see) or their X-ray analysis in a direct back projection, directing the central bunch of x-ray emission through an open mouth of the patient.
On the direct roentgenogram of chest department of P. (fig. 2) all chest vertebrae having an appearance of dense rectangles on which shadows of acanthas and legs of arches are projected are displayed. On correctly removed roentgenogram acanthas are located strictly on the centerline of a body. Intervertebral disks in verkhnegrudny department of P. come to light insufficiently accurately since the planes of disks owing to fiziol, a kyphosis of chest department do not match the direction of the central bunch of radiation. To receive their clear image, make a direct X-ray analysis of this department of P. with a small inclination of a bunch of radiation in kaudokranial-number the direction. Except acanthas, on the direct roentgenogram the cross shoots covered with heads and necks of the jointed edges are visible.
On the side roentgenogram of chest department of P. of a body of vertebrae and intervertebral disks are displayed more clearly, than on a straight line. However and in this case verkhnegrudny the department comes to light insufficiently accurately because of projective stratification of clavicles and shovels. To eliminate their shadow image, it is recommended to make the side roentgenogram of this department of P. at a sitting position of the patient with the raised chin and with the belt of an upper extremity displaced from top to bottom and kpered.
On the direct roentgenogram of lumbar department of P. (fig. 3) massive shadows of bodies of vertebrae, awned and cross shoots, legs of arches and intervertebral joints are visible (dugootro-stchaty joints, T.). Vertebrae are separated from each other by wide intervertebral disks which are more fully reflected in a middle part of lumbar department since their projection matches the direction of the central bunch of radiation. As in this case the intervertebral crack between the V lumbar and the I sacral vertebrae does not match the central bunch of radiation, she is almost not visible. Apply the special laying leveling a lumbar lordosis by pulling of the lower extremities to a stomach to its identification or make a X-ray analysis at the kaudokranialny direction of a bunch of radiation. On the side roentgenogram of lumbar department of P. bodies of vertebrae, intervertebral disks and openings, joint and acanthas clearly come to light.
Owing to fiziol. curvature of a sacrum and a tailbone the direct roentgenogram does not reflect rather clearly all vertebrae of these departments of the Item. The X-ray analysis at the direction of a bunch of radiation can clear up at an angle 25 ° in the cranial direction or the roentgenogram in a side projection.
Final formation of a rachis of the person comes to an end by 22 — 24 years of life. Till this period formation of bone elements continues that finds the clear display on roentgenograms. Vertebrae of the newborn on the direct roentgenogram are represented in the form of small oval educations, their height is equal or even slightly less than height of intervertebral disks, except for lumbar department where a bone part of a vertebra is equal on height cartilaginous. In a side projection of a body of vertebrae have also oval form with the cracks in lobbies and the rear edges caused by vascular channels. Further at top and bottom edges of bodies of vertebrae the step impressions formed by cartilaginous rollers in to-rykh by 10 — 14 years are noted ossification centers appear. The stiffened cartilaginous rollers are apophyses of bodies of vertebrae. Substrate of changes of a shape of vertebras — the ossification of apophyses of bodies of vertebrae continuing with age, gradual merge of handles to bodies of vertebrae, formation of apofizarny kernels of ossification in awned and cross shoots. Features rentgenol. pictures of a backbone at children need to be considered in order to avoid mistakes at radiodiagnosis.
Methods of a research
most often investigate P. in connection with complaints to dorsodynias, deformations, restrictions of movements. Patol, signs are result of P.'s disease or arise owing to nek-ry diseases of internals or extremities. Feed-back is possible: the first symptoms of pathology of P. can be shown by extremity pains or in internals, i.e. have the reflected, irradiating character.
For definition of localization patol. the center it is necessary to know identification points of P. (fig. 4).
P.'s inspection is performed in position of the patient standing, sitting and lying, at rest and at the movements. The patient shall be completely naked. First of all pay attention to disturbances of a shape of a body: level over-plechy, position of shovels, contours of a waist, the line of acanthas etc. Determine by their symmetry or asymmetry whether there is no side curvature of the Item. At unsharply expressed curvature it is possible to note each acantha ink points, then the line of acanthas will be accurately visible, or to incline the patient forward and to study a back, looking from the head along the line of acanthas. In this situation the side rachiocampsis — scoliosis (if such is available) is well visible, and also the unilateral juxtaspinal muscular roller and the costal hump beginning to form is swept up. The muscular roller in lumbar area can be caused also by an inclination of a basin with a different length of legs. In the absence of a side curvature of P. the plumb fixed to area of an acantha of the VII cervical vertebra passes along the line of acanthas through a mezhjyagodichny fold. Then reveal whether is not present patol, P.'s curvatures in the sagittal plane taking into account that normal P. in cervical and lumbar departments has fiziol, a lordosis, and in chest department — a kyphosis, and also taking into account a possibility of various disturbances of a bearing, patol, a kyphosis and a lordosis. Disturbances of a shape of a backbone and a trunk can be measured by means of special devices — a skoliograf, a kifoskoliograf etc. (see. Skoliozometriya ).
The palpation and P.'s percussion are carried out in position of the patient standing, lying and sitting. Palpating acanthas and interspinal intervals, establish a painful point or area. It is helped by percussion of acanthas a tip of the III finger while as II and IV fingers of the same hand lying on the parties from a shoot feel a muscle tension at the moment of the greatest morbidity. On the parties from acanthas (at distance of 1 — 1,5 cm) define morbidity by a palpation, edges it can be caused by pathology in intervertebral joints (dugootrostchaty joints, T.), and even more knaruzha (in lumbar department on 2 — 3 cm) — in cross shoots. The body of the VI cervical vertebra is probed kpered from grudino - a clavicular and mastoidal muscle at the level of a cricoid, and upper cervical — through a back wall of a throat. The palpation of bodies of lumbar vertebrae at lean subjects is carried out through a stomach. If there are no suspicions on destruction of vertebrae, check reaction of the patient to axial loading (pressure upon the head) and unloading (a pandiculation for the head) the Item.
P.'s mobility is investigated during the bending, extension, inclinations in the parties and rotation. The cervical department of the Item is most mobile. At pathology in the relevant department there is a restriction of its mobility. For judgment of disturbances of mobility of P. it is necessary to know the normal amplitude of movements in each department. P.'s bending happens hl. obr. in cervical, nizhnegrudny and lumbar departments. Total amplitude of bending of P. — apprx. 90 °, and is the share of cervical department 40 °. During the bending normal P. forms a smooth arch (fig. 5, a) while at pathology the relevant department of P. does not participate in bending, napr, in lumbar department the lordosis remains (fig. 5, b). At a research of amplitude of extension in a standing position it is very important to fix a basin by pressure upon it behind. Amplitude of extension of P. is normal equal about 30 °. Side inclinations of P. investigate at the fixed basin that is reached when the patient costs with the legs which are moved apart on 50 — 60 cm. At side inclinations of P. deviates aside approximately on 60 °. The rotational movements P. in the parties are possible on 90 °, and on nizhnegrudny and lumbar departments it is necessary only 30 °. The stated above figures of amplitude of the movements P. are average for young people and change depending on age of the patient and his physical development. Essential information is given by a research of the patient in a prone position. At the child lying on a stomach at passive extension of P. it is possible to reveal a painful point in it, and also to define existence of rigidity of the muscle straightening a backbone (fig. 6). Rigidity it can be defined also at position of the patient on spin (fig. 7). For this purpose the doctor, having clasped legs investigated in ankle joints, lifts them up, the back at the same time is not bent (a symptom of a board of Marx). Identification of restrictions of mobility or morbidity at the movements in costovertebral joints is important. For this purpose the patient is deeply asked to breathe and at this time check an excursion of edges. For detection of pathology in P. usually investigate also some neurologic symptoms (e.g., Laset's symptoms, Wasserman, etc.)*. The symptoms revealed by means of the listed methods of a research are the most general and are characteristic of the majority of diseases of the Item.
Techniques rentgenol, researches P. are diverse and are applied depending on a research objective. The simplest and available technique, about a cut it is necessary to begin a research normal and patholologically the changed P., the X-ray analysis in a straight line is, side and slanting projections. For identification patol, changes in separate vertebrae apply aim pictures, a tomography (see), a computer tomography (see. Tomography computer ). For identification possible patol, changes in intervertebral disks use discography (see), and for studying of the copular device — ligamentografiya (see). With a research objective of a condition of the vertebral channel carry out miyelografiya (see). For definition of degree of functional mobility and possible patol, shifts of vertebrae carry out side roentgenograms in a condition of the maximum bending and extension of the relevant department of P. (functional X-ray analysis). Resort to a contrast research of vessels much less often — venospondilografiya (see. Flebografiya ), vertebralny angiography (See).
On morphogenetic classification of V. A. Dyachenko, anomaly of development of P. are divided into two groups: anomalies of ontogenetic value and anomaly of phylogenetic value. Anomalies of development of bodies of vertebrae (crevices, defects, wedge-shaped vertebrae, a platyspondylia, a brakhispondiliya, etc.), anomalies of development of arches of vertebrae (cracks, an underdevelopment, anomalies of development of joint shoots), and also inborn are referred to the first group synostoses (see). os odontoideum, assimilation of the Atlas, cervical edges are carried to the second group, sacralization (see) and lumbalization (see).
Inborn crevices of vertebrae meet in all departments of P., but a thicket in lower lumbar. The crevice only of arches carries the name spina bifida (see), and full splitting of a vertebra (a body and an arch) — rakhishizis. Rakhishizis with a median arrangement of a crack can not be followed by P.'s deformation; at an asymmetric or slanting arrangement of a crack, especially in combination with other malformations of vertebrae in this segment P. (e.g., from a unilateral micro-spondiliyey half of a vertebra, anomaly of joint shoots), essential deformation of P. (fig. 8) develops. Quite often rakhishizis, as well as spina bifida, is followed by a hypertrichosis (fig. 9).
Wedge-shaped vertebrae and semi-vertebrae can be localized in any department of P., but are usually observed on border of departments. Side wedge-shaped semi-vertebrae meet more often. The typical wedge-shaped semi-vertebra (fig. 10) consists of a half-body, a cross shoot and a semi-arch with a joint shoot. In chest department of P. the semi-vertebra bears an additional edge. Single, double and multiple wedge-shaped semi-vertebrae meet. If two semi-vertebras are located from the opposite sides of P. at different height (through 2 — 3 normal vertebras), call them alternating (fig. 11). As growth of vertebrae in height happens at the expense of epiphyseal plates (adjacent to top and bottom to the surfaces of bodies of vertebrae), at a unilateral arrangement of side semi-vertebrae a scoliotic curvature of P. (see. Scoliosis ) it is more expressed. Even in the presence of one semi-vertebra if it has two epiphyseal plates (a «active» semi-vertebra according to I. A. Movshovich), P.'s curvature is inclined to progressing. In the presence «inactive» semi-vertebrae (they have on one epiphyseal plate) P.'s curvature does not progress. It is especially well visible in the presence of the so-called babochkovidny vertebra consisting of one active, and other inactive semi-vertebra (fig. 12). However progressing of a curvature of P. is connected not only with activity of a semi-vertebra — this process is more difficult and caused by a combination of the whole complex of factors.
Platyspondylia and brakhispondiliya. The platyspondylia is characterized by expansion of a body of a vertebra in the diameter, and a brakhispondiliya — its reduction on height, flattening and shortening. The combination of specified - types of deformation carries the name «platibrakhispondiliya». Similar deformation is characteristic of a disease to Kalva (see. to Kalva disease ), however at a platibrakhispondiliya plurality of defeat, existence of other malformations and normal structure of the deformed vertebra is observed. At a multiple brakhispondiliya disproportionate shortening of a trunk is noted.
Malformations of joint shoots are, as a rule, observed in lumbar and sacral departments of P. and shown in the following forms: anomalies of provision of joint surfaces of joint shoots in relation to the sagittal plane, anomaly of size of one of shoots, anomalies of a joint of a joint shoot with an arch of the next vertebra, lack of joint shoots etc. These anomalies usually do not lead to P.'s deformation, however adverse statico-di-namicheskiye create the conditions promoting more prematurity here osteochondrosis (see) and deforming spondylarthrosis (see). In a lumbosacral segment P. some more malformations meet. Among them it is necessary to pay attention to a spondylosis and spondylolisthesis (see).
Inborn synostoses (blocking, concrescense) of vertebrae are observed in all departments of the Item. They can be full and partial. At full synostosis (see) blocked there are bodies, arches and shoots of vertebrae, at partial — only bodies or only arches. At a full synostosis of essential deformation of a backbone does not come. The partial synostosis causes deformation in the course of P.'s growth, the form a cut depends on localization of a synostosis. So, e.g., during the blocking only of bodies of vertebrae the kyphosis (fig. 13) develops. Emergence of such deformation finds an explanation in an embryogenesis of the Item. Formation of an intervertebral disk happens in the direction behind beforehand: behind a body of vertebrae at a certain stage of embryonic development are already divided by the created disk, and in front they still have the general structure. And if at this stage (5 — 7th week of an embryogenesis) P.'s development stops, the front synostosis of vertebrae is formed. A typical example of a full widespread synostosis of cervical department of a backbone is the syndrome of Klip-pelya — Feylya (see. Klippelya — Feylya a disease ).
Inborn synostoses of vertebrae often lead to development at rather early age of deforming spondylarthrosis (see) above and below than the blocked vertebrae owing to the strengthened functional load.
Os odontoideum — the malformation connected with not merge of an ossification center of an odontoid shoot of an axial vertebra to a body of the last. This malformation of P. is the potential reason of instability of an upper part of cervical department of P. Otsutstviye of bone communication of tooth with a body of an axial vertebra at an injury easily leads to transdental dislocation of the Atlas (see below Damages). Lack of tooth is very seldom observed.
Assimilation (occipitalization) of the Atlas is expressed in merge of the Atlas to an occipital bone. Perhaps full and partial merge. Can be merged one or both lateral mass of a vertebra, its arch, at the same time the Atlas can be displaced forward or aside. Deformation can be followed by flattening of the Atlas, his rotation, disturbance of a form of a big (occipital) opening that creates unfavorable conditions for a myelencephalon: tooth of an axial vertebra (C2) at turns of the head can make on it the injuring impact. At incomplete asymmetric occipitalization of the Atlas it is usually observed wryneck (see), to-ruyu in this case carry to a bone form of this pathology.
Cervical edges — seldom found malformation. Usually they are combined with other malformations. More often they are connected with the VII cervical vertebra. Can be the size from a little expressed rudimentary education to the created edges reaching a breast or soldered by the front ends to the I edges. At children cervical edges usually do not prove, adults can have symptoms of irritation of a brachial plexus and a prelum of a subclavial artery — pains, paresthesias, a hypotrophy of muscles of an extremity, the pulsation of arteries on the corresponding hand is weakened. At permanent neurovascular frustration removal of an edge surely together with a periosteum is shown.
At the asymptomatic course of anomalies of development of P. of treatment it is not required. At development of deformation of P. or complications of malformations (e.g., a spondylarthrosis) apply different types of conservative and operational treatment.
Damages arise at various mechanism of action of the injuring force on the Item. Generally this bending, bending in combination with rotation, extension and a compression. The isolated injuries of ligaments, most often interspinal and nadostisty, fractures of bodies, arches, shoots of vertebrae, damages of intervertebral disks, dislocations or dislocation-fractures of vertebrae are possible.
Damage interspinal and nadostisty sheaves is quite often observed in combination with a change of the Item. Most often it is observed in cervical, then in average and nizhnegrudny departments.
At the isolated damage interspinal or nadostisty P.'s teams the localized pain is observed, at its combination with a fracture of a vertebra, especially an arch or an acantha, pain has the irradiating character. At the same time reflex reduction of the muscle straightening a backbone with sharp restriction of mobility of the injured P.'s department is noted, in lumbar department sometimes «the symptom of reins» — tension of this muscle determined by an eye in the form of rollers on each side of acanthas accurately comes to light. At a palpation in the field of a rupture of an interspinal sheaf pain is defined in an interspinal interval, the palpation of acanthas is a little painful. At a rupture of a nadostisty sheaf at a palpation retraction in the field of an interspinal interval and discrepancy of acanthas often is defined that it is well visible on the side roentgenogram. At doubts available of a rupture of interspinal teams of P. and provided that on roentgenograms other damages of P. are not defined, it is possible to resort carefully to a functional X-ray analysis (side roentgenograms in the provision of bending and P.'s extension). The method can be applied to diagnosis of fresh injuries of interspinal ligaments ligamentografiya (see).
Treatment of the isolated damages interspinal and nadostisty P.'s teams conservative: novocainic blockade (on the parties from acanthas) the fields of damage, a bed rest on a bed with a board. The immobilization of cervical department of P. is carried out rollers with sand or Gleason's loop with a load to 2 kg. Appoint physiotherapeutic procedures, massage, LFK. After elimination of the acute phenomena carrying headholders and an ekstenzionny corset (for lumbar department) during 4 — 6 weeks is shown.
Spinal fractures belong to heavy damages of a musculoskeletal system and make apprx. 2 — 2,5% of all changes. P.'s changes result from an indirect injury more often — during the falling from height on legs, buttocks, the head and prya-my injuries — at direct stab in the back. P.'s changes can be single and polyfocal (multiple), with damage and without injury of a spinal cord and roots of spinal nerves, with damage of an intervertebral disk (getting, according to Ya. L. Qi-vyanu) and without his damage. Depending on defeat of an anatomic component of a vertebra distinguish a fracture of a body (compression, splintered), arches of shoots of a vertebra. Essential practical value has division of changes of P. on stable and unstable. The last arise at joint damage to front and back departments of a vertebra.
A wedge, displays of a fracture by P. are various — from total absence of symptomatology at nek-ry types of an injury to heavy a wedge, pictures: severe pains, paresis of intestines, nevrol, frustration and dysfunction of bodies of a small pelvis at heavy spinal fractures with injury of a spinal cord or roots of spinal nerves (see. Vertebral and spinal injury ). The diagnosis of a change is made on the basis of studying of the mechanism of an injury, data of a visual and palpa-even examination, a X-ray analysis of the Item. At a fresh injury, i.e. before reparative changes, rentgenol, symptoms of a compression fracture of body of a vertebra are deformation of the last and strengthening of a shadow of bone substance along its upper platform. Wedge-shaped flattening with reduction of height of front department of a body of a vertebra in only one side projection at preservation of normal height of an intervertebral crack is most often observed. This deformation can not be followed radiological by the documented structural changes at minimum impressions of an upper horizontal plate. Only upper plates are pressed, lower remain intact. This sign is the most important in differential diagnosis of traumatic changes with patol, compressions and congenital anomalies.
The option of a compression change should be considered traumatic implementation of a cartilaginous intervertebral disk in a body of a vertebra — so-called traumatic cartilaginous hernia (fig. 14). The disk is implemented into a cranial plate at its first line. Radiological at insignificant or at all the absent deformation of a body of a vertebra narrowing of «a x-ray intervertebral crack» comes to light (it is caused on the roentgenogram by narrowing of a cartilage). Lack of signs at similar traumatic implementation of an intervertebral disk is replaced afterwards by development of limited impression of a contour and sclerosis about-labirovavshego a disk around.
Radiological the documented outcomes of an injury of P. depend on the nature of an injury. At a «pure» compression change rentgenol, the picture of the affected vertebra directly after an injury is also long after quite often identical. At the same time at the ruptures of sheaves and disks accompanying a change or a dislocation-fracture, X-ray negative in the early period, later a nek-swarm time appear rentgenol. signs of ossification, calcification etc. (fig. 15). At the same time sometimes there are bone blockings of bodies of vertebrae, ossification of sheaves, calcifications of disks, ankiloza.
At children fractures and dislocations of vertebrae make about 0,2% of all types of injuries (N. G. Damye, 1950). Compression fractures of chest vertebras are more often observed. Diagnosis of a change of P. at children is complicated owing to incompleteness of ossification of vertebrae, especially in the presence of an osteochondropathy of bodies of vertebrae. Quite often wedge-shaped deformation of a body of a vertebra, edge at the same time it is observed, regard as a compression change. At children of younger and middle age compression fractures of separate vertebras at the correct treatment can recover completely with recovery of a normal form and height of the compressed vertebra (fig. 16).
Rentgenol, signs of a compression of vertebrae at children are: 1) straightening of horizontal platforms of bodies of vertebrae at children at the age of 6 — 8 years or concavity at more advanced age; 2) thickening of horizontal platforms; 3) consolidation of structure of spongy substance of the compressed vertebrae; 4) increase in height of intervertebral disks in their front department in comparison with normal.
At elderly and old people at the expressed osteoporosis of vertebrae compression changes result from an insignificant injury, napr, during the falling on a floor and even as a result of jolting during driving by car. Quite often at the same time compression fractures of vertebras remain unnoticed and come to light accidentally at a X-ray analysis of P. in other occasion. Besides, at old people of a body of vertebrae can gradually be deformed also without change. Therefore at diagnosis careful studying of the anamnesis and a wedge, manifestations at the time of an injury is necessary.
Fractures and dislocations in cervical department of a backbone occur preferential at men of young age, most often as a result of influence of an indirect injury, napr, during the falling from height on the head (at divers) or during the falling of weight on the head. Dislocations and incomplete dislocations of cervical vertebrae, especially the Atlas, often result from the in-coordinate movement of the head, napr, the passenger at a sharp stop has cars.
At a dislocation-fracture the difficult damage consisting of the following components is created anatomically: 1) fracture of a body (bodies) of vertebra of this or that look (compression, compression and regional separation, only a regional separation); 2) rupture of the copular device; 3) rupture of a disk; 4) dislocation (shift) of a vertebra in the field of joint shoots (it is frequent in combination with a change of joint shoots).
Injuries of I and II cervical vertebras hold a specific place among other damages of cervical department of P. Smeshcheniye of the Atlas forward at transdental or transli-gamentozny dislocation (fig. 17) can cause instant death owing to a prelum of a spinal cord. Changes of the Atlas are observed in the form of a change of a front or back arch and in the form of a splintered or explosive change (Jefferson's change). At injury of the II cervical vertebra the line of a change can pass in area of tooth (fig. 18) or its basis (differential diagnosis with os odontoideum is necessary), in the field of a plate of an arch or her legs (in the latter case the traumatic front spondylolisthesis of the II cervical vertebra is possible; such damage is called a change hung up), regional fractures of a body of a vertebra are possible.
Fractures of bodies, arches, shoots, dislocations, incomplete dislocations, dislocation-fractures are characteristic of injuries of the III—VII cervical vertebras. At a bilateral fracture of legs of arches traumatic is possible spondylolisthesis (see). The change arising at heading about a bottom of a reservoir during the diving (a change of the diver) differs in special weight. Most often at the same time the V—VII cervical vertebrae suffer. Owing to sharp bending of a neck in combination with violence along a vertical axis there is a compression splintered fracture of a body of a vertebra. The change of divers quite often is complicated by paralysis of extremities and pelvic bodies.
A wedge, signs at fractures of cervical vertebras: forced position of the head, tension of cervical muscles, sharp pains at the movements of the head. In diagnosis of fractures of cervical vertebras the main role is assigned to X-ray inspection (for the I—II cervical vertebrae — surely through widely open mouth); also the tomographic method is important.
Fractures of chest and lumbar vertebras most often happen in nizhnegrudny and verkhnepoyasnichny departments i.e. where less mobile department passes into more mobile. Most often there are compression fractures of bodies of vertebrae with their wedge-shaped deformation, i.e. reduction of height of a body in front department. Distinguish three degrees of a compression: the 1st degree — regional fractures of a body of a vertebra without compression or a compression with decrease in height of a body of a vertebra to 1/3 it; the 2nd degree — with decrease in height of a body of a vertebra on 1/3 — 1/2; the 3rd degree — with decrease in height of a body of a vertebra more than on 1/2. Changes of the 2nd and 3rd degree can be combined with damage of an intervertebral disk. Less than compression, there are shattered fractures of bodies of vertebrae and dislocation-fractures at damage to front and back departments of vertebrae. The last damages are unstable. Different types of typical fractures of vertebras are presented in fig. 19. At once after an injury the girdle pain, difficulty of breath (at a fracture of chest vertebras) irradiating an abdominal pain (is noted at injury of lumbar vertebras), local morbidity at a palpation of acanthas, a muscle tension on the parties from acanthas, a forced pose of the victim. At a change of cross shoots of lumbar vertebrae, in addition, the symptom of «the stuck heel» — impossibility to tear off a direct leg and, as a rule, a psoas symptome from a bed — sharp pain in lumbar area is observed at violent extension of the extremity bent in a hip joint. The final diagnosis is established at rentgenol. research.
At a fracture of nizhnegrudny or lumbar vertebras and the retroperitoneal hematoma arising at the same time manifestations from a stomach from local morbidity and unsharply expressed muscle tension of a stomach to the phenomena reminding acute intraperitoneal bleeding or a rupture of hollow body are possible patol — acute abdomen (see), paresis intestines (see). At a combination of a change of P. to injury of a spinal cord disturbances of various degree develop nevrol (see. Spinal cord ).
Changes of shoots of vertebrae are most often observed in the form of single and multiple separations of cross shoots of lumbar vertebrae. On the roentgenogram the shift of fragment, characteristic of a change of a cross shoot (or fragments) from top to bottom and lack of cortical substance on site of a change is visible. The same picture is noted at the isolated changes of joint shoots (which should be distinguished from the additional kernels of ossification which are found sometimes at tops of joint shoots). Avulsion fractures of acanthas (most often at the lower cervical vertebrae, is more rare than lumbar) on the direct roentgenogram are characterized by the shift of a top of an acantha from top to bottom. The roentgenogram in a side projection well documents such separation of a free part of an acantha. The isolated separations of acanthas of the V lumbar vertebra and acanthas of a sacrum are possible at gunshot gutter wounds. The traumatic dislocation-fracture with a dislocation of the vertebra of a kpereda or aside is followed, as a rule, by smashing of an arch, a fracture or dislocation of joint shoots, but never gives the pictures of a spondylosis typical for not traumatic shift.
Treatment of injuries of a backbone
At first-aid treatment it is necessary to lay the victim on a rigid stretcher, at a change of chest and lumbar departments of P. — it is possible on a stomach. Transportation of the patient in a sitting position is inadmissible. At a change of cervical department of P. fixing is carried out rigid vorotni or or the wire tire bent in a shape of a neck, or, at last, by the bags with sand laid on each side necks, the patient at the same time shall lie on spin on a rigid stretcher (see. Immobilization ).
Character and terms of treatment depend on a form, localization and a damage rate of P., and it is necessary to adhere to the philosophy — early elimination of shift, reliable fixing and functional treatment. At a rotational incomplete dislocation of the Atlas treatment is carried out extension (see) Gleason's loop (1,5 — 2 kg) during 2 — 3 weeks; after removal of extension appoint an immobilization to the same term Shants's collar or a plastic headholder (fig. 20). At fractures of I and II cervical vertebras treatment is carried out in a kranio-thoracic plaster bandage (see. Plaster equipment ). At a fracture of tooth of the II cervical vertebra without shift or after its single-step reposition the plaster immobilization is carried out within 6 — 8 months. Treatment of dislocation-fractures and unstable changes is carried out by method of skeletal traction for a skull a load to 7 — 8 kg with the subsequent (in 6 — 8 weeks) imposing of a kraniotorakalny plaster bandage (fig. 21). Extension by means of Gleason's loop is inefficient. Failure of union of an odontoid shoot owing to the wrong treatment leads to development of the atlantoaksialny instability which is followed by traumatization of a spinal cord, roots of spinal nerves and development of paralyzes. This complication is the direct indication to operational treatment — decompressive laminectomies (see) with single-step spondylodesis (see), more precisely ok-tsipitospondilodezom. At fractures of the III—VII cervical vertebras if there is an insignificant compression of a body of one-two vertebrae, and also at splintered fractures of a body without the shift of fragments, at changes of awned and joint shoots and arches without shift treatment is carried out by Gleason's loop (2 — 3 kg) with the subsequent (in 2 — 3 weeks) imposing of a kra-niotorakalny plaster bandage for 2 — 3 months. At dislocation and an incomplete dislocation of cervical vertebrae carry out single-step reposition with fixing by a plaster bandage. However in cases of unstable reposition skeletal traction is shown. If the fracture of bodies of vertebrae with axial (kyphotic) deformation, the shattered change with Skhmeshcheny of fragments, an unstable dislocation-fracture, and also nevrol, complications, the most effectively skeletal traction for a skull takes place. At the unreducible dislocation-fractures which are especially followed nevrol, complications, showed the stabilizing operational treatment, at indications — with a decompression of a spinal cord.
At a compression fracture of chest and lumbar vertebras with insignificant wedge-shaped deformation of P. it is necessary to provide preservation of a lumbar lordosis and full-fledged tone of muscles. Therefore the patient is enough to be laid on a back on a bed with a board, under lumbar area to enclose the small roller and as soon as possible to begin to lay down. gymnastics. Allow to go the patient in a removable corset in 2 months after an injury. At a considerable compression of a body of a vertebra in nizhnegrudny or lumbar departments of P. reclination by single-step (forced) P.'s extension after the carried-out local anesthesia of a vertebra (fig. 22) or way of gradual extension P. Predpochtitelen the last method as he is better had by patients and usually, contrary to single-step reclination is shown, does not cause paresis of intestines. Gradual reclination of a vertebra can be carried out on Kaplan's reklinator or by extension on a gamachka (fig. 23): under a waist of the patient bring made of cloth hectares-machok 15 — 20 cm wide (with a vatnomarlevy lining), straps to-rogo are thrown via blocks on two Balkan frames with a cross crossbeam. Reclination is carried out loads (depending on the weight of the patient) by which provide formation of a lumbar lordosis (a shovel and buttocks shall not come off a bed). In 2 — 3 weeks it is usually reached reclination of a vertebra. After 2 months to the patient allow to go in a corset. A number of surgeons at compression fractures of lumbar vertebras apply an operational method of treatment. It allows early postavitbolny on legs and not to appoint a corset for the subsequent treatment. The essence of a method consists in preliminary single-step or gradual reclination of a vertebra and internal fixing of the injured vertebrae and the next P., intact for acanthas, a wire, special metal fixers, a mylar tape or cord. At multisplintered fractures of a body of a vertebra and at simultaneous damage of an intervertebral disk (the getting changes) some surgeons (Ya. L. Tsivyan) suggest to make a front spondylodesis at once. At a change with injury of a spinal cord and roots of spinal nerves decompressive operational treatment, elimination of the reason which caused a compression of a spinal cord or roots of spinal nerves and fixing of the Item is shown.
Unlike a technique of treatment of uncomplicated compression changes of P. at people of young and middle age, at elderly people with existence of widespread osteoporosis of P. it is not necessary to reklinirovat the affected vertebra as it creates unfavorable conditions of healing of a change. The patient is stacked on a bed with a board and after disappearance of pains allow to turn, but not to sit down and not to rise. In 1 — 1,5 month sick allow to go without corset. At children of reclination of vertebrae it is well reached in a plaster bed (see. Plaster equipment ).
The physiotherapy exercises play a large role in treatment of injuries of P., it recovers the natural muscular «corset» capable to hold P. in vertical position and providing its normal mobility, a ressornost and portability of static and dynamic loads.
At persons of young and middle age at small degree of a compression (decrease in height of a body of a vertebra no more than on 1/3) and the general satisfactory condition the functional method of treatment developed by E. F. Dreving, consisting in P.'s unloading, extension and systematic use to lay down is preferable. gymnastics with 2 — the 5th day after an injury. At compression fractures of cervical vertebras and an immobilization Gleason's loop apply a set of exercises from easy movements of top and bottom extremities at slow speed with frequent pauses to rest. Exclude exercises with bending of a trunk, turns and a ducking. In the period of an immobilization with a plaster bandage the motive mode is expanded, to the patient allow to sit and go. Apply the all-developing exercises for muscles of a trunk, top and bottom extremities which are carried out in a prone position, sitting and standing. It is necessary to exclude sharp turns of a trunk, head, jumps and jumpings up. After removal of gypsum, in addition to all-developing, it is reasonable to use the exercises strengthening muscles of a neck, exercise in balance and coordination of movements. At compression fractures of chest and lumbar vertebras in relation to phases of treatment course LFK shall be divided (fig. 24) into four periods. In the I period extent apprx. 2 weeks in the initial position lying on spin carry out the breathing and all-tonic exercises involving top and bottom extremities in the movements. Extension for the period of the occupations is sshshat. Exercises carry out at slow speed on 3 — 6 times within 10 — 15 min. In the II period proceeding on average 4 weeks use exercises for strengthening of muscles of a back and a stomach, a training of a vestibular mechanism, and also more active movements for top and bottom extremities on average speed on 8 — 10 times within 20 — 25 min. Transition from one period to another needs to be individualized strictly according to a condition of the patient, a sex, age, development of its movement skills. The III period lasts on average 2 weeks. Duration of occupations is increased up to 30 — 45 min., each exercise is repeated by 10 — 15 times. By the end of this period by means of physical exercises for P. the muscular support by considerable strengthening of muscles of a back and a stomach shall be created. In 7 — 10 days prior to walking it is necessary to include exercises for a training of the myshechnosustavny device of the lower extremities in occupations. Except physical exercises, it is necessary to apply to lay down. massage of muscles of the lower extremities and back. Pass to exercises of the IV period at the general satisfactory condition of the patient, at well developed muscular corset, absence of pains (at rest and after loading) in the field of a change. After adaptation of the patient to vertical position it is necessary to apply the dosed walking, gradually increasing its duration. Continue to lay down. massage of muscles of a back and lower extremities. More effectively recovery of the main functions P. takes place during the occupations in water. After an extract from a hospital it is necessary to continue LFK a long time in out-patient or sanatorium conditions where adaptation to the loadings identical to a primary activity of the patient is gradually recovered.
At elderly people of LFK apply to maintenance of the general tone and functional capacity of muscles, the prevention of osteoporosis, complications from internals, etc. The volume and duration of occupations, and also time of a bed rest at such patients are reduced. Throughout all course of treatment carry out massage of muscles of a back and stomach.» and before a rising — massage of the lower extremities. During carrying a corset of the patient LFK in a prone position continues to be engaged (without corset) and standing (in a corset).
At more expressed compression of bodies of vertebrae and the carried-out gradual reclination of P. during the first 2 weeks appoint exercises for maintenance of optimum level of activity of bodies of blood circulation, breath, digestion, the general tone of muscles. With the permission to turn over on a stomach (at horizontal position of a reklinatsionny bed) the patient makes extension of the case without active participation of muscles of a back due to straightening of the hands exposed forward. During this period in a dorsal decubitus it carries out also the exercises consisting in a progibaniye in chest department of a backbone with a support on elbows and lifting of a basin with a support on the legs bent in knees. Further gradually pass to the active exercises providing more intensive muscle tension of a back and stomach with alternation of exercises for top and bottom extremities. Apply massage of muscles of a back. At changes cross and acanthas of vertebrae of LFK carry out by a technique of treatment of changes by prolonged traction. However intensity of loadings and expansion of the motive mode a bit differents: exercises in a ventral decubitus can be carried out in 4 — 6 days, on all fours — in 10 — 15 days, costing the dosed walking and exercises — in 3 — 4 weeks.
In complex treatment of damages of P., in addition to LFK, the physical therapy which is carried out both in the period of treatment in a hospital and after an extract is of great importance.
The physical therapy at P.'s changes pursues the aim of anesthesia and acceleration of regeneration of the damaged fabrics. Against the background of anesthesia conditions for effective carrying out to lay down are created. actions, in particular a turning of patients from a back on a stomach, wedging of the injured vertebra on various reklinator, carrying out to lay down. physical cultures lying on a stomach, accelerations of transfer of patients in vertical position using an external immobilization or without that.
At treatment of patients with stable compression changes of P. by an eurysynusic functional method when with 2 — the 3rd day after an injury allow turns from a back on a stomach, apply UF-radiation by fields 150 — 200 cm2 along the Item. The first field — on area of a change, the second — below it on 2 — 3 cm, the third — above the first on 2 — 3 cm. Radiations begin with three biodoses, with the subsequent their increase (on a half of a biodose on each field). In total hold 12 sessions (on 4 on each field). Daily irradiate one of fields.
The electrophoresis by analgesic mixes is carried out longwise along P. or paravertebralno. It is possible to use 1 — 5% solution of novocaine or Parfyonov's solution including cocaine, Dicainum on 1,5 ml, solution of adrenaline 1: 1000 — 9 ml, distilled water of 450 ml. Simpler mix of Parfyonov consists of a sovkain, novocaine on 0,5 ml, solution of adrenaline 1:1000 — 2,5 ml, a distilled water of 200 ml. Current 12 — 15 ma, duration of influence is 15 — 20 min. (see. Electrophoresis ).
With 4 — the 5th day after a change apply induktoforez calcium directly on area of the injured vertebra. Galvanic electrodes of 150 cm 2 have longwise: active from 10% solution of calcium chloride — on area of a change, indifferent — below it on 5 — 8 cm. Force of a direct current 8 — 10 ma. Force of anode current — 160 — 180 ma. Influences spend daily 10 — 20 min.; in total on a course — 12 influences. After the first physiotherapeutic procedures the expressed pain considerably decreases, and after a course of treatment completely passes. It allows to be engaged in earlier terms to lay down. physical culture and to enter physical exercises with a bigger amplitude of movements.
The good anesthetizing action favorably affecting also reparative regeneration of area of the damaged P. renders low-frequency (50 Hz) the magnetic field generated by the device of magnetotherapy «Pole-1». If on the nature of damage of P. of patients it is impossible to turn on a stomach and they are treated in situation on spin, influences begin from the 2nd day after an injury, installing round inductors with the P-shaped core on inguinal areas (the mediated influence). In position of the patient on a stomach inductors establish from a back, above and below the place of damage. Induction of magnetic field of 30 — 35 T, a type of magnetic field sinusoidal or one-half-period in the continuous mode; on a course — 20 — 25 influences (see. Magnetotherapy ).
The favorable effect in the recovery period after P.'s change renders swimming in the pool and underwater shower massage (see).
For strengthening of muscles of extremities and a trunk carry out electrostimulation by the devices UEI-1, SNIM-1, «Amplipulse-3», «Amplipulse-4» and «Incentive-1» (see. Impulse currents ). The expressed therapeutic effect renders use in complex treatment mud cures (see), hydrosulphuric, brine and others bathtubs (see).
Dignity. - hens. treatment of patients with uncomplicated damages of P. is carried out in the balneological resorts of Pyatigorsk, Nalchik, Arch-man, the Hot Key, Yeysk, Sergiyevsky Mineralnye Vody, Sochi, Hop gardens, Ust-Kachka, etc., and also in the mud resorts of Birstonas, Druskininkai, Yeysk, Krainka, Odessa, Nalchik, etc.
From P.'s diseases allocate it to deformation, degenerative, inflammatory infectious diseases and tumors.
Deformations of a backbone conditionally divide into curvatures in the perednezadny and side directions. Kyphotic curvatures belong to the first look (see. Kyphosis ), the curvatures arising owing to an osteochondropathy of bodies of vertebrae (see. to Kalva disease ), curvatures at an osteochondropathy of apophyses of bodies of vertebrae (see. Sheyermanna — Mau a disease ), Kyummell's diseases (see. Kyummellya disease ). The kyphosis develops as a result of inflammatory diseases of P. (see. Spondylitis ) at out of time begun their treatment, at dystrophic diseases, tumors. The side deformation of P. to be exact combined with torsion of vertebrae represents scoliosis (see).
Bostrup's disease — degenerative change of interspinal linking of nizhnepoyasnichny and lumbosacral departments of the Item. «lumbar pains» make to patients with this pathology the diagnosis for a long time. However this pathology of P. — not so an unusual occurrence. Degenerative and dystrophic process of interspinal sheaves in lumbar department of the Item is the cornerstone of Bostrup's disease. Such localization of process is explained by the fact that lower than IV lumbar vertebras in most cases nadosti-pack the sheaf is absent. Therefore the lower interspinal sheaves experience big strain in comparison with upper and are exposed to more bystry «wear». Bostrup's disease is often combined with intervertebral osteochondrosis at this level (so-called diskoligamentoz). The special part in a course of a disease of Bostrup is assigned to mechanical influence in the form of friction of the next, especially pulled together, acanthas. As a result of long continuous mechanical influence in interspinal sheaves dystrophic process develops. The main complaint at this disease — pain at P.'s extension and sharp morbidity at a palpation of the affected interspinal ligament while the palpation of acanthas is painless. For specification of the diagnosis do roentgenograms (the pulled together acanthas are visible), and also make contrast ligamentografiya (see).
Conservative treatment in the form of thermal and other physiotherapeutic procedures (see above) often leads to disappearance of pains. At unsuccessfulness of conservative treatment at patients of young and middle age operation is shown. Operation on Movshovich comes down to removal of the affected interspinal ligament and plastics of a nadostisty sheaf by a podshivaniye to acanthas in the form of a duplikatura of a superficial leaf of a thoracolumbar fascia, and sometimes make a lavsanoplastika of a sheaf. To 2 months after operation appoint carrying a corset.
Inflammatory diseases. Carry Bekhterev's disease to inflammatory diseases of P. (see. Bekhtereva disease ), tubercular, typhus, brucellous spondylitis (see), nonspecific spondylitis, i.e. osteomyelitis of a backbone.
Acute osteomyelitis of P. arises in usually hematogenous way. A contagium is preferential golden staphylococcus, the streptococcus is more rare. Most often the lumbar department of P. is surprised, and process is localized in arches and shoots, is more rare in bodies of vertebrae. At break of an abscess to the vertebral canal there is nevrol, a symptomatology. Treatment of osteomyelitis of P. consists of the general and orthopedic. Early performing massive antibiotic treatment with disintoxication therapy usually blocks inflammatory process. At inefficiency of conservative treatment apply operational (see. Spondylitis ).
P.'s echinococcus (a bubbly bone cyst) — one of the most frequent bone localizations echinococcosis (see). Disease — from several months to one decades. P.'s defeat can be both primary, and secondary. In the first case the echinococcal cyst which developed by a hematogenous drift in a body of a vertebra, as a rule, extends further to surrounding P. soft tissues. In the second case the echinococcal cyst located in a mediastinum or retroperitoneal space in the subsequent involves in process of the Item. Destructive process in bodies of vertebrae, most often Thn_v, shoots and adjacent sites of edges is characteristic of P.'s echinococcosis. However intervertebral disks suffer a little. Usually does not show complaints of the patient. Kasoni's reaction is positive not always therefore absence does not tell it about a mistake in the diagnosis. In process of increase in an echinococcal cyst the bone collapses and there can come the break in soft tissues. A dangerous complication of the process proceeding rather favorably is the break to the vertebral canal. It involves heavy nevrol, frustration. For rentgenol, data (both for primary, and of a secondary Echinococcus alveolaris) existence of unilateral juxtaspinal consolidation of spherical outlines is characteristic. The body of a vertebra collapses as small cystiform depression in the beginning, then the massive destructive center with destruction of cortical substance is formed, it is frequent with patol, a compression. At break in soft tissues are characteristic: 1) destruction of edges and a cross shoot (a head and a neck of an edge with an adjacent cross shoot); 2) unilaterality of defeat; 3) sclerous border of an otgranicheniye; 4) insignificant defeat of disks; 5) reactive ossification of longitudinal sheaves.
At identification of the echinococcal center in a vertebra operational treatment is shown.
At a gidatidny echinococcus removal of a cyst leads to elimination of process. Operational stabilization of P. (according to indications) allows to recover its oporosposobnost. At an alveolar echinococcus the forecast is much worse since radicalism of its removal (even by a resection of bodies of vertebrae) is always doubtful.
Distinguish benign and malignant tumors of the Item. Malignant tumors, in turn, can be primary and secondary (metastatic).
(As the decreasing frequency) treat the most frequent benign tumors of P. hemangioma (see), osteoblastoclastoma (see), an osteochondroma (see. Chondroma ), osteoma (see), osteoid osteoma (see), aneurysmal bone cyst (see).
The hemangioma is more often localized in bodies of chest vertebrae, is more rare in cervical and lumbar. Usually the body of one vertebra is surprised, is more rare than two-three. Clinically the hemangioma is shown by pains, at defeat of arches and shoots — radicular and even spinal syndromes. Perhaps sudden developing of paresis or a plegiya at break of contents of a hemangioma in front in an epidural space. At patol, a change there are symptoms of damage of P. Techeniye more often long. On the roentgenogram it is visible cellular or a lattice with the expressed vertical beams, contours of a body equal or convex, the sagittal size of a body is increased, intervertebral spaces of an intaktna. It is standard roentgenotherapy (see), at spinal complications — laminectomy (see). Radical operation (Ya. L. Tsivyan) — a front frontal gemispon-dilektomiya or a spondilektomiya (fig. 25) is developed. The last is shown in case of simultaneous defeat of arches.
The osteoblastoclastoma arises in bodies of vertebrae, often extends to area of arches. Involvement in process of two and more vertebrae is possible. It is shown by pains, restriction of mobility, local morbidity, radicular and spinal symptoms are possible. On roentgenograms the blown-up bodies of vertebrae with a typical cellular structure are visible. Apply a roentgenotherapy, and also radical removal of the struck departments or the whole vertebrae with the subsequent their substitution to treatment by bone transplants.
Aneurysmal bone cysts carry to tumorous educations, they have a lot of similar to an osteoblastoclastoma. The differential diagnosis is sometimes very difficult. Treatment consists cysts at a distance.
The osteochondroma meets in all departments of P., proceeds more often from joint shoots. With a growth in a gleam of the vertebral channel causes its narrowing, at the same time into the forefront symptoms of a compression of a spinal cord act. It is shown by pains, radicular or spinal syndromes. On P.'s roentgenograms the spotty uneven structure of spongy substance of a body of a vertebra with an eminating hilly contour of a vertebra comes to light. It is informative, as well as at other tumors, epidurografiya (see). The osteochondroma can malignizirovatsya. Operational treatment thicket a sagittal gemispondilekto-miya with bone plastics is radical.
The osteoid osteoma is clinically characterized by the constant amplifying pristupoobrazny pains. On roentgenograms the center of a sclerosis in a body of a vertebra of a star-shaped form with a zone of an enlightenment is typical. Highly effectively operational treatment (removal of the center).
Carry to primary malignant tumors reticulosarcoma (see), Ewing's sarcoma (see. Ewing tumor ), osteosarcoma (see), chondrosarcoma (see), malignant osteoblastoclastoma, to angioendoteliy (see) and so forth Klin, and rentgenol. manifestations are very variable. The pain syndrome and instability of the Item prevails. Pains progress, amplify at night. Forecast adverse.
Secondary (metastatic) malignant tumors of P. meet very often. Cancer of any localization can give metastasises in P. Naiboley metastasises of a breast cancer, a prostate, kidney, cancer of a lung are frequent. Quite often metastasizes cancer of such bodies went to P. - kish. path, as pancreas, liver and gall bladder. Metastasises of a carcinoma of the stomach and intestines in P. are rare. The wedge, a picture has no characteristic signs. More often the amplifying pains prevail. Pains can sometimes be absent or disappear. The last matches destruction of a body of a vertebra and, probably, decrease in intra bone pressure. Rentgenol. the picture is motley, are frequent patol. fractures of bodies of vertebrae.
It is accepted to distinguish osteoklasti-chesky and osteosclerotic metastasises, also metastasises of the mixed type meet. Typical rentgenol, signs of osteoklas-tichesky metastasises are: 1) destruction of any anatomic element of a vertebra; 2) intaktnost of intervertebral disks (lack of narrowing of a x-ray intervertebral crack); 3) patol, a compression with impression of both (top and bottom) plates; 4) absence or very small expressiveness of consolidation of juxtaspinal fabrics and in general rentgenol, symptoms of germination in soft tissues, and also from a vertebra in a vertebra at a characteristic polifokalnost of defeat. Separate types of tumors can give symptoms of expansive growth («swelling» of a body of a vertebra) in the beginning. Metastasises of cancer of kidney and thyroid gland are that, at to-rykh also drift is quite often observed; other metastasises progress very quickly (e.g., metastasises of a pancreatic cancer and lungs).
Osteosclerotic metastasises are most frequent at cancer of prostatic and milk glands. At these hormonal and dependent tumors transformation of osteo-klastichesky metastasises in sclerous as under the influence of hormonal therapy is observed sometimes, and it is spontaneous, and also from the very beginning existence of the mixed type of defeat. The main signs of sclerous metastasises are: 1) diffusion, or spotty, sclerosis of bodies of vertebrae, sometimes arch and shoots; 2) absence patol, compressions; 3) intaktnost of disks; 4) sometimes increase in the sizes of a body of the affected vertebra. Sclerous metastasises easily are found radiological that cannot be told about diffusion osteoklastichesky defeats which at absence patol, compressions and destruction of cortical substance can have very scanty signs. Very effectively in these cases a layer-by-layer research, and also use of the computer tomography revealing destructive metastasises where the usual roentgenogram yields negative or doubtful takes.
Differential diagnosis of metastasises (in sense of their reference to this or that primary tumor) is possible only in limited limits taking into account type of innidiation and a wedge, pictures especially as detection of a metastasis quite often precedes detection of primary tumor. Considering difficulties of differential diagnosis between metastasises of cancer and multiple myeloma (see), it is necessary to investigate proteins of a blood plasma, to make a puncture of a breast, and it is even better — a puncture or a biopsy of an edge on site radiological than the revealed center of destruction. Lymphogranulomatosis (see) gives the picture similar to metastasises of cancer at P.'s involvement. At a lymphogranulomatosis also secondary defeat of P. owing to germination of tumoral fabric from limf, nodes and cellulose (retroperitoneal, a postmediastinum) and formations of the regional destructive centers with destruction of cortical substance of a body of a vertebra, a cross shoot, head of an edge is observed.
The main method of differential diagnosis of osteoklastiche-sky metastasises is the research of other departments of a skeleton, in particular skulls, a basin, large tubular bones. Essential from a platyspondylia the syndrome of unceasing and non-interlaced pains is important for difference of osteoklastichesky metastasises, at Krom observe rather weak, times at all the calming-down pains.
The sclerous and mixed metastasises demand differentiation with P.'s defeats at deforming osteodystrophies (see), hemangioma, marble disease (see), osteosclerotic anemia (see. Osteomyelofibrosis ), nek-ry other types of system osteoscleroses of focal and diffusion type. In most cases it is reached by rentgenol, researches of other departments of a skeleton.
Treatment of metastatic defeats of P. symptomatic. At single metastasises reasonablly operational removal of the affected body of a vertebra and substitution by its plastic or metal prosthesis, and also that is less desirable, a bone transplant. During the involvement in patol, process of a spinal cord and pains of high intensity — a section of sensitive roots.
Operations on P. are characterized by rather big injury, the considerable blood loss raised by danger of shock. Anesthesia is performed usually by means of the endotracheal anesthesia with the managed breath providing a sufficient relaxation of muscles. Accesses to P. are subdivided on back, posterolateral, perednebokovy and front. Back accesses apply usually to approach to acanthas and arches of vertebrae and carry out by a linear section on the centerline. From the same access after preliminary laminectomies (see) some interventions on back departments of bodies of vertebrae and intervertebral disks can be executed. Posterolateral accesses carry out most often in chest department in a look costotransversectomies (see) and in lumbar department — in the form of a lyumbo-vertebrotomiya. Perednebokovy and front accesses provide the best review at the majority of operations on bodies of vertebrae and intervertebral disks. In cervical department for this purpose usually use accesses of Burgkhardt and Rozanov (fig. 26) differing with the relation to muscles and a neurovascular bunch of a neck. The chest department applies thoracotomy (see), usually right-hand, at the level of the fifth — the seventh mezhreberiya about a trance - or extrapleural (a so-called extrapleural pneumolysia) an exposure of bodies of vertebrae and intervertebral disks (fig. 27). In lumbar department perednebokovy accesses are provided with various options lumbotomies (see), from apply accesses according to Southwick-rykh to a thicket of others — to Robinson, Chuck-linu, to Mitbreyt. The lumbosacral department is bared in front by means of Müller's access — nizhnesredinny laparotomies (see) — with a section of a parietal peritoneum under the cape and an exposure of the affected vertebras of Lv — ST (fig. 28).
There is no standard classification of operations on P. They can be conditionally divided, according to the purposes and technical features, into radical, decompressive, corrective, stabilizing, auxiliary (palliative). The indication for radical operations are some inflammatory processes (spondylitis), tumoral and parasitic defeats (echinococcus). Radical operations carry out in a look necretomies (see) or resections of bodies of vertebrae, at to-rykh delete not only necrotic masses, but also excise conditionally intact fabrics, next to it, resect intervertebral disks (fig. 29). Also the resection of shoots of vertebrae at their defeat is possible, napr, osteomyelitis. Resections are more radical, than necretomies, but quite often they aggravate disturbance of an oporosposobnost of a backbone, without that broken patol, process. Therefore they are usually supplemented with the stabilizing operations. Operations, on the equipment similar to radical, can be carried out at nek-ry changes of the Item. They consist free fragments of bodies of vertebrae and the destroyed intervertebral disks at a distance.
Decompressive operations are intended for elimination of a prelum of a spinal cord and its elements. The most typical decompressive operations — a laminectomy and its derivative — a gemilaminektomiya (removal of a half of an arch of a vertebra). The last in combination with radical intervention on bodies of vertebrae carries the name «anterogemilaminektomiya» or «rakhiotomiya on Seddona». As decompressive operation sometimes use a transposition of a spinal cord. Napr, at the scoliosis complicated by paresis or paralysis half of arches from the concave party can be resected. The spinal cord is moved at the same time to more direct bed, for reduction of its tension and elimination nevrol, disturbances. Option of a transposition of a spinal cord — excision of a so-called wedge of Urban, i.e. the remains of the bodies of the vertebrae displaced kzad destroyed at a tubercular spondylitis.
Corrective operations aim at correction of deformations of P. and vertebrotomiya (a section or excision of a part of a vertebra, fig. 30) or a diskotomiya (a section of a disk) come down to disturbance of its continuity (full or partial) by means of respectively vertebrektomiya (removal of all vertebra). In the subsequent make single-step or gradual correction of a curvature (reclination) with the simultaneous or delayed stabilization P. Reklination carry out by means of stage plaster bandages (see. Redressment ) or special distractors (see. Orthopedic tools ).
Apply osteoplastic operations to stabilization, in particular spondylodesis (see), or special metal fixers. At nek-ry changes of P. for stabilization use a mylar tape, Tsivyan's fixer coupler — Ramikh (fig. 31), and also various plates, springs and other devices. The stabilizing operations can be also independent interventions.
Palliative operations aim to liquidate any adverse effects patol, process without intervention on the main center, napr, removal of an intervertebral disk (see. Diskektomiya ), the vertebral channel which dropped out in a gleam, at osteochondrosis, a back spondylodesis at conservative treatment of a tubercular spondylitis.
Bibliography: Urgent problems of treatment of the complicated injuries of a backbone, under the editorship of N. I. Hvisyuk, page 55, M., 1979; Andrianov V. L. and Volkov M. V. Tumors and opukholepodobny dysplastic processes in a backbone at children, Tashkent, 1977; B and t x e of m of U. P. and d river. Clinical trial of joints, the lane with English, M., 1970; Bogdanov F. R., Rock it yansky V. I. and Finogenov G. H. Physical methods of treatment in traumatology and orthopedics, page 142, Kiev, 1970; Buldakova G. E. Physical therapy and remedial gymnastics in complex treatment of injuries of a backbone, in book: Travmat, and the orthoitem, under the editorship of JI. P. Sokova, etc., page 57, Barnaul, 1972; Dyachenko V. A. Anomalies of development of a backbone in rents-geno-anatomic lighting, M., 1949; it, Radiodiagnosis of diseases of bones and joints, M., 1958; Zhedenov V. N. A comparative anatomy of primacies (including the person), page 65, M., 1962; Zatsepin S. T. and Burdygin V. N. Ossiform osteoma of a backbone, Ortop, and travmat., No. 12, page 4, 1979; Ilizarov G. A. and Mar-x and sh about in A. M. Blood supply of a backbone and influence on its form of changes of a trophicity and loading: clinical and anatomo-experiment lny research, Chelyabinsk, 1981; Kaplan A. V. Injuries of bones and joints, M., 1979; Kaptelin A. F. Recovery treatment at injuries and deformations of a musculoskeletal system, M., 1969; To N y sh I. T. and G. S Oxen. Diagnosis and treatment of primary bone tumors of sacrococcygeal area, Vestn, hir., t. 110, No. 5, page 50, 1973; Kolarzh I., etc. Primary tumors of a backbone, Vestn, rentgenol, and radio-gramophones., No 3, page 12, 1980; To about r A. A., Talyshinsky R. of River and X in and - with yu to N. I. Quick accesses to chest and lumbar vertebrae, M., 1968; Kornev P. G. Bone and joint tuberculosis, M., 1953; Maykova-Stroganov V. V. and Fincke of l ý-matte M. A. Bones and joints in the x-ray image, t. 2, JT., 1952; Marx V. O. Orthopedic diagnosis, Minsk, 1978; M and t r e y t I. M. Spondilolistez, M., 1978; Movshovich I. A. Scoliosis, M., 1964; M about in-shovich I. A. and Vilensky V. N. Polymers in traumatology and orthopedics, page 115, M., 1978; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1 — 2, M., 1964; Rokhlin D. G. Radiodiagnosis of diseases of joints, p.1 — 2, L., 1939 — 1940; Selivanov V. P. and Nikitin M. N. Diagnosis and treatment of dislocations of cervical vertebrae, M., 1971; Starikova M. N., etc. Our experience of complex treatment of patients with compression uncomplicated spinal fractures, in book: Pathology of a backbone, under the editorship of M. Preysas, page 230, Vilnius, 1971; Tager I. JI. and D ya-the p e of N to about V. A. Radiodiagnosis of diseases of a backbone, M., 1971, bibliogr.; Tager I. L. and M and z about I. S. Radiodiagnosis of shifts of lumbar vertebrae, M., 1979, bibliogr.; Umyarov G. A. and Andrianov of V. L. Osteoblastoklastom of a backbone at children, Ortop, and travmat., No. 6, page 47, 1968; Watson-Jones R. Fractures of bones and injury of joints, the lane with English, M., 1972; X risanfo-in an E. H. Evolutionary morphology of a skeleton of the person, page 5, M., 1978; Tsiv-yan Ya. L. Surgery of a backbone, M., 1966; it, Injuries of a backbone, M., 1971; it, Operational treatment of humps, M., 1973; Tsyvkin M. V. Aneurysmal bone cyst of a backbone, Vopr, neyrokhir., No. 6, page 43, 1974; it, Surgical treatment of hemangiomas of a backbone, in book: Vopr, bone onkol., under the editorship of M. V. Volkov and S. T. Zatsepin, p.1, page 139, M., 1977; Chepy V. M. Inflammatory and degenerative diseases of a backbone, M., 1978; Yumashev G. S. and Dmitriyev A. E. About diagnosis of damages of the copular device of a backbone, Vestn. hir., t. 106, No. 5, page 77, 1971; In of ocher J. E. W. Die Wirbelsaulenleiden und ihre Differentialdiagnose, Stuttgart, 1962; Griffin J. B. Benign osteoblastoma of thoracic spine, J. Bone Jt Surg., v. 60-A, p. 833, 1978; J e d d i M. Contribution h l ’6tude clinique et radiologique des tu-meurs malignes primitives du rachis chez l’enfant, Lyon, 1969; Kohler R. Contrast examination of the lumbar interspi-nous ligaments, Acta radiol. (Stockh.), v. 52, p. 21, 1959; Raycroft J. F., Hockman R. P. a. South-w i with k W. O. Metastatic tumors involving the cervical vertebral, surgical palliation, J. Bone Jt Surg., v. 60-A, p. 763, 1978; Rissanen P. M. The surgical anatomy and pathology of the supraspinous and interspinous ligaments of the lumbar spine with special reference to ligament ruptures, Copenhagen, 1960; SchmorlG. u. Junghanns H. Die Gesunde und Kranke wirbelsaule in Rontgenbild und Klinik, Stuttgart, 1957; Steindler A. Post-graduate lectures on orthopedic diagnosis and indications, v. 1 — 4, Springfield, 1950 — 1954.
I. A. Movshovich; V. P. Illarionov (to lay down. physical.), E. R. Mathis (hir.), I. M. Mitbreyt (baln. and fizioter.), B. A. Nikityuk (An.), I. L. Tager, L. M. Freydin (rents.), Ya. L. Tsivyan (PMC.).