Vertebral subluxation and dislocation
Dislocation of vertebrae - a rare phenomenon. Vertebral fractures complicated with dislocation occurred significantly more often. In pure form, vertebral dislocations occur almost exclusively on cervical spine level. An upper vertebra considered as dislocated. There are flexion and rotation type of vertebrae dislocations. Excessive cervical spine extension encounters an obstacle at rapprochement of the vertebral arches, which prevents vertebral dislocation. Excessive head forward bending (to the chest), can displace upper vertebra's articular processes relatively to the lower vertebra (partial dislocation, subluxation). Upon subsequent spine straightening upper vertebra articular surface may slip further, stopping ahead lower vertebra's articular processes (complete dislocation). In this case, the head acts as a force lever on both articular surfaces front edges of underlying vertebra. Therefore, flexion dislocation of the cervical vertebrae is always bilateral.
An excessive extension or flexion of the neck in trauma may displace neck vertebrae and form a dislocation.
In rotary dislocation with excessive lateral flexion and sprains (ligaments stretches) an upper vertebra articular process rests against the bottom arc (like on fulcrum). With further movement articular processes on one side is diverge, as in flexion dislocation, partial or complete chained dislocation. On the opposite side, during rotation, superior articular process (due to stretching of the joint capsule) moved backward from the bottom vertebra. Thus, when a rotary dislocation is occurs vertebra displacement on both sides, but in opposite directions. Due to the fact that the chain of articular processes are happening on one side, a rotary dislocation otherwise called unilateral.
As flexion, as well rotation dislocation observed only in the cervical spine - neck's sudden flexion (in the horizontally disposed articular processes):
- flexion dislocation - both intervertebral joint capsules complete rupture;
- rotary dislocation - intervertebral joint capsule rupture on rotation side.
On cervical spine radiography in lateral projection is not possible to see the displacement of the vertebral body after injury, because of patient's shoulders hinder the overview to this level.
Symptoms of cervical spine flexion dislocation:
- patient's head is tilted forward,
- chin is almost touching the patient's sternum.
Due to the significant mobility and nape, neck and shoulders acute pain, the patients often hold his head on the go. On cervical spine spinous processes examination can be seen the protrusion of the underlying vertebra spinous process. Underlying vertebra impression palpated above. Overlying vertebral body anterior protrusion impedes swallowing process. Dislocated cervical vertebra palpated through the pharynx or visualized at laryngoscopy.
On cervical spine computed tomography (CT) can be seen the C5 vertebra body anterior displacement after injury (white arrow).
Neck and head position in a patient may be different in rotary unilateral cervical vertebra dislocation, depending on dislocation degree. In the case of partial dislocation neck is stretched out, patient's head tilted and rotated towards the healthy side. In complete dislocation, patient's head tilted to the chest and dislocation side and rotated towards the healthy side. Spinous processes of the upper vertebrae tilted towards the dislocation. In both types of the cervical vertebrae dislocations occurs associated neurological symptoms:
- radicular character changes of sensitivity (hypoesthesia, paresthesia, analgesia),
- upper limbs muscles paresis and paralysis - as a result of the neural roots compression or damage (mono- or paraparesis, paraplegia).
Paralysis of four limbs (quadriplegia) indicates to the spinal cords substance lesion. The severity of these neurological symptoms is critical for prognosis and fatal outcome is not rare.
Reposition of patient's vertebral dislocation and subluxation - is a hard problem, even under anesthesia. Incomplete unilateral dislocation of the cervical vertebrae is easier to reduce - by head traction in longitudinal direction (loop of Glisson) and its rotation in opposite direction. Complete cervical vertebrae dislocations require facet joints release from coupling. Cervical spine flexion dislocation with coupling and head flexion into the dislocation direction, with its subsequent rotation into the healthy side, with constant traction. Freed from the coupling and traction continues, a reverse maneuver: the head diverting to healthy side, with followed rotation into the dislocation direction.
Gardner-Wells tongs applied in emergency room; cervical traction pulley with adjustable arm clamped to examining table.
Cervical spine flexion dislocation is recommended to turn into the rotation (unilateral dislocation), and then produce its reposition. After reposition is performed stabilizing surgery for vertebral fixation (discectomy with anterior and posterior fusion). For this purpose, use various constructions of fixing plates, implants (cage), and pedicle fixation screw.
Such dislocations in the cervical spine most often occur at the C3-C5, C5-C6 vertebrae level, i.e. in the middle part of the cervical spine, where the overall anterior mobility is higher. In the upper two cervical vertebrae (C1 and C2), where there is no cartilage discs and junctions are wide, they are reinforced by powerful ligaments, and its sprains at this level a rare and exceptional phenomenon. Dislocation of the C1 vertebra (skull dislocation relatively to atlas), it is possible during head's heavy flexion, or its rotation, which is usually fatal for patient.
The same can be said about dislocations of C1 vertebra (atlas) relatively to the underlying C2 vertebra (axis) if it is not accompanied by its odontoid process fracture. Cervical vertebra C2 firmly connected with the anterior arch of the atlas (C1 vertebra) by:
- transverse ligaments,
- alar ligaments,
- cruciform ligaments with the anterior edge of the foramen magnum (foraminis occipitalis magni) in the occipital bone.
Neck braces (Philadelphia collar) used for the injured joints and sprains (ligaments stretches) ligaments treatment.
With the rapid head tilting and traction (hanging), these ligaments can be ruptured. During the forward shifting of C1 vertebra (atlas), odontoid process of C2 vertebra will crushes the spinal cord in spinal canal and causes instantaneous death. Fractured C2 vertebra odontoid process displaced forward from the front side of C1 vertebra (atlas) arc, and in this case, the spinal cord is not subjected to compression. In case of neck increased flexion (hyperflexion) are often possible of jointed vertebral bodies’ fractures.
Conservative treatment of the cervical spine articular processes dislocation will conclude in a temporary neck fixation (6 to 12 weeks). During this immobilization period, neck has damaged ligaments, tendons and muscles, at rest, have time to recover. Observance of these terms is particularly important for ligaments, because of much more slower metabolism, than in the muscle with the well-developed vasculature. For cervical spine fixation used neck brace (Philadelphia collar) or external immobilization are system (Halo System).
Wearing a neck brace (Philadelphia collar) is used for the articular processes (cervical facet joints) dislocation or subluxation treatment.
Surgical treatment of the cervical vertebrae articular processes dislocation performed in two stages:
- immediately closed reposition of dislocation, subsequent MRI, then - the surgical stabilization of the cervical vertebrae;
- immediately MRI, then - open reposition of dislocation with surgical stabilization of the cervical vertebrae.
Sequence of these steps depends only on the clinical status of the patient and the type of existing damage.
The first option is useful in the treatment of unilateral or bilateral dislocation of the cervical spine articular processes with neurological symptoms in patients with an adequate consciousness and behavior. Closed reduction not performed in patients with impaired consciousness and inappropriate behavior. Surgical stabilization performed after a successful closed reduction of dislocation. Unilateral dislocation is technically difficult to reduce, but much more stable after reduction. Bilateral facet joints dislocation is technically easier to reduce a (due to rupture of the posterior longitudinal ligament), but less stable after reduction.
After the stage of reposition performed MRI and subsequent surgical stabilization of the cervical vertebrae. Operations of posterior transpedicular fusion and, sometimes, anterior discectomy with fusion can be performed in the absence of intervertebral discs sizeable bulging or protrusion. Anterior discectomy with fusion always indicated in expressed intervertebral disc injuries. About a third of all closed reduction cases can be ineffective and require open reduction technique.
Cervical vertebrae and occipital bone posterior fusion operation in the case of a neck injury at the axial vertebrae (C1-C2) and the cervico-occipital junction level.
The second option is useful in the treatment of unilateral or bilateral dislocation in patients with impaired consciousness and inappropriate behavior. In addition, this option used in patients with dislocation, which could not reposition by closed method. MRI examination conducted, followed by an operation of open reduction and stabilization (fusion) of the cervical vertebrae. If the hernial protrusion localized anteriorly, the discectomy performed with anterior approach.
Reduction techniques of articular processes (cervical facet) dislocation:
|Closed reduction||Under cervical spine axial traction, gradually increase intension by adding a weight. Additional motion for the neck flexion (head forward tilt) may contribute dislocation reduction. With weight (traction force) adding the doctor performs neurological examination and the cervical spine radiographs. In case of neurologic symptoms worsening cervical traction must be stopped and performed MRI. For closed reduction of dislocation vertebrae is required:
|Anterior open reduction and fixation with discectomy||This treatment method indicated for:
|Posterior reduction and transpedicular stabilization||This treatment method is applicable to:
|Combined anterior decompression and posterior reduction / stabilization||This operation method indicated in case of anteriorly herniated disc, requiring decompression in patients with dislocation, which was not eliminated in the closed or open anterior reposition. Features of operation technique:
Thoracic spine connected with ribs, not mobile and can dislocate only after fractures of adjacent (articulated) vertebrae.
Anterior cervical disk fusion surgery in the case of a neck injury at the subaxial vertebrae (C4-C5-C6) level.
The same occurred in the more mobile lumbar spine, fortified with powerful long and short ligaments. Range of motion (ROM) in flexion at the lumbar spine level more expressed, than its rotation and tilt. At the lumbar spine articular processes located in frontal plane. This anatomical feature also prevent lumbar spine dislocation during flexion.
Chronic L5 body forward and downward sliding from the sacrum is described first by Killian (in the guise of spondylolysis and spondylolisthesis), and called "spine self-dislocation" by Lambl. Spondylolisthesis - an inevitable consequence of the vertebral arches (the area between the articular processes) congenital malformations, and its most common in the L5 vertebra arc. Described by Turner the clinical picture of spondylolysis and spondylolisthesis occurs in both women and men. Clinical manifestations of this defect (in the form of spondylolisthesis) occur after sudden physical exertion, lifting of gravity, etc. In women, subsequent pregnancy can cause the gradual development of the same symptoms (spondylolisthesis), because of ligaments softening during fetal growth. Softening of ligaments provide the necessary mobility of the joints of the pelvis for the fetus smooth passage during labor.
If you have any questions on the diagnosis or treatment of vertebral subluxation and dislocation, you can ask them to our neurosurgeon or neurologist: (499) 130–08–09
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