Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Partial lesions include twists or sprains, isolated dislocations of articular processes, isolated fractures of the arches and spinous processes, and isolated fractures of the vertebral bodies. The most important complete lesions are total dislocations and fracture-dislocations.

In partial lesions, the continuity of the column as a whole is not broken, and the cord sustains little damage, or may entirely escape; in complete lesions, on the other hand, the column is broken and the cord is always severely, and often irreparably, damaged.

Twists and dislocations are most common in the cervical region, that is, in the part of the spine where the forward range of movement—flexion—is greatest. Fractures are most common in the lumbar region, where flexion is most restricted. Fracture-dislocations usually occur where the range of flexion is intermediate, that is, in the thoracic region.

In all lesions accompanied by displacement, the upper segment of the spine is displaced forwards.

Twists or sprains are produced by movements that suddenly put the ligamentous and muscular structures of the spine on the stretch—in other words, by lesser degrees of the same forms of violence as produce dislocation. When the interspinous and muscular attachments alone are torn, the effects are confined to the site of these structures, but when the ligamenta flava are involved, blood may be extravasated and infiltrate the space between the dura and the bone and give rise to symptoms of pressure on the cord. The nerve roots emerging in relation to the affected vertebræ may be stretched or lacerated, and as a result radiating pains may be felt in the area of their distribution.

In the cervical region, distortion usually results either from forcible extension of the neck—for example from a violent blow or fall on the forehead forcing the head backwards—or from forcible flexion of the neck. The patient complains of severe pain in the neck, and inability to move the head, which is often rigidly held in the position of wry-neck. There is marked tenderness on attempting to carry out passive movements, and on making pressure over the affected vertebræ or on the top of the head. The maximum point of tenderness indicates the vertebra most implicated. In diagnosis, fracture and dislocation are excluded by the absence of any alteration in the relative positions of the bony points, and by the fact that passive movements, although painful, are possible in all directions.

In the lumbar region sprains are usually due to over-exertion in lifting heavy weights, or to the patient having been suddenly thrown backwards and forwards in a railway collision. The attachments of the muscles of the loins are probably the parts most affected. The back is kept rigid, and there is pain on movement, particularly on rising from the stooping posture.

Treatment.—Unless carefully treated, a sprain of the spine is liable to cause prolonged disablement. The patient should be kept at rest in bed, and, when the injury is in the cervical region, extension should be applied to the head with the nape of the neck supported on a roller-pillow. Early recourse should be had to massage, but active movements are forbidden till all acute symptoms have disappeared. In patients predisposed to tuberculosis, the period of complete rest should be materially prolonged.

Isolated Dislocation of Articular Processes.—This injury, which is most frequently met with in the cervical region and is nearly always unilateral, is commonly produced by the patient falling from a vehicle which suddenly starts, and landing on the head or shoulders in such a way that the neck is forcibly flexed and twisted. The articular process of the upper vertebra passes forward, so that it comes to lie in front of the one below.

The pain and tenderness are much less marked than in a simple twist, as the ligaments are completely torn and are therefore not in a state of tension. The patient often thinks lightly of the condition at the time of the accident, and may only apply for advice some time after on account of the deformity. The head is flexed and the face turned towards the side opposite the dislocation, the attitude closely resembling that of ordinary wry-neck, only it is the opposite sterno-mastoid that is tight. The bony displacement is best recognised by palpating the transverse process of the dislocated vertebra. In the case of the upper vertebræ this is done from the pharynx, in the lower between the sterno-mastoid and the trachea. There is pain on attempting movement, and tenderness on pressure, particularly on the side that is not displaced, as the ligaments there are on the stretch. There are often radiating pains along the line of the nerves emerging between the affected vertebræ. As the bodies are not separated, damage to the cord is exceptional. The lesion can usually be recognised in a radiogram.