The nature of damage to the structure of the spine and spinal cord in combined blunt trauma

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Abstract

Background. Vertebral-spinal injuries (VSIs) account for 6.3–26% of skeletal injuries. However, despite the relevance of VSIs in all branches of medicine, the forensic aspects of this injury are insufficiently assessed. Material and methods. The study included three groups: people who died following multiple injuries from falling from a height (82 cases); those who died following collision with moving cars (172 cases); and drivers of passenger cars who died in road accidents (61 cases). Results. The article describes in detail the results of the analysis. As part of combined injury during falls, VSI was observed in 41.5% of cases with lesions of other body parts and often covering 2 or more parts of the spine, and in terms of localization, most often in the lower neck, upper chest, and lumbar regions. Compression fractures were often noted, which resulted from falls on the legs and buttocks. In pedestrians who were injured in collisions with cars, VSI was noted in 25% cases; of these, most cases involved distraction and rotational fractures of the vertebral bodies, with detachments at the level of vertebral fractures prevailing primarily with mainly trauma of the posterior processes. Injuries to the spine structure often included cervical -occipital trauma and damage to the cervical region, as well as combined injuries to the cervical-thoracic regions; VSI in affected drivers was noted in 14.5% cases and was characterized by cervical-occipital trauma as well as lesions of the cervical, upper thoracic, and lumbar vertebrae. Сonclusion: The revealed nature of damage to the noted structures should be taken into account in the process of forensic medical diagnosis and differential diagnosis of blunt injuries, especially in conditions of non-obviousness of the circumstances of the damage. The nature, volume and localization of injuries arising from these types of blunt mechanical trauma can be important in the process of organizing and providing medical care to victims at various stages of treatment, and information on the circumstances of the origin of injuries can become the basis for developing preventive measures to prevent injuries.

Full Text

Introduction. Injuries tothe spinal cord structure in the structure of skeletal injuries range from 6.3% to 26% on average. Disability as a result of PSMP varies from 60 to 100%, and the mortality rate is on average up to 7% at the prehospital stage and from 8 to 58.3% in the hospital [1-6]. About 70.1-88.6% are closed PSPs. There are fractures of the bodies of the arches, processes and dislocations of the vertebrae.  Spinal cord injuries can be in the form of concussions, bruises, compressions, bruises, and detachments. The main causes of PSMP are road accidents (36-43%), mainly various types of accidents, falls from a height (24.2-63.2%), diving in shallow water (3-32%), and impact with blunt hard objects [7-11].

Despite the relevance of PSMP for all branches of medicine, the forensic aspects of this injury are insufficiently studied. In particular, the features of the formation and morphology of PSMP, depending on the mechanogenesis of trauma, have not been clarified [12-13]. In this regard, the problem of studying the features of the formation of PSMP attracts the attention of research around the world.

Purpose of the study.  To study the nature and features of the formation of structural injuries of various parts of the spine and spinal cord in combined blunt trauma and to evaluate the mechanism of injury to these structures. 

        Materials and methods of research. Based on the purpose of the work and the tasks set, the research was conducted in the following 3 groups::

  1. A forensic medical examination of 82 corpses, persons who died from combined polytrauma as a result of falls from a height, was performed. The age of victims in 80 cases ranges from 16 to 84 years. Among the dead men -64, women -18. The height of the falls varied from several to tens of meters. Circumstances of falls: falls from windows and roofs of 4-5 and 6-8-storey buildings-78, falls from a pole – 1, from a carousel-1, from a walnut tree-1. In 48 cases, the victims died at the scene of injury, in the remaining 34 cases-in hospitals.
  2. The results of forensic medical examinations of the corpses of 172 people who died in collisions with moving cars were analyzed. Among the dead were 135 men and 37 women. The age of the victims is from 16 years; up to 84 years. In 140 cases, pedestrian collisions occurred with modern passenger cars, of which the most frequent (66 cases) occurred with cars of modern brands (Daewoo.uz Nexia), in 21 cases - with cars of old brands and in 3 cases-brands of passenger cars are not established. According to the materials of the preliminary inquiry (investigation), in most cases the collisions were front and front–edge.
  3. Forensic medical examination of 61 corpses of persons-drivers of passenger cars who died in road accidents-was carried out. Among the dead drivers, 60 men and 1 woman were killed, and the victims ranged in age from 17 to 65. Mortality in 47 cases occurred at the site of injury, in the remaining 14 cases, the injured drivers died in medical institutions.

Research results and discussions. The aggregate of injuries in persons affected by falls from a height differs in severity and is characterized by the formation of most often (65 cases out of 82) combined trauma (CT) of 3 or more body parts. Isolated traumatic brain injury (TBI) was detected only in 5 cases, and CT of two body parts was noted in 11 cases.

In 68.5% of cases (56 out of 82 cases), victims of falls from a height as part of CT have severe traumatic brain injury (TBI), which is often accompanied by fractures of the skull bones (36 out of 56 cases).  TBI in almost all cases (52 out of 56 cases) was combined with trauma to more than 2 parts of the body.

Part of the ST falls spinal cord injury (PHC) was observed in 41.5% of cases (34 of 82). PHC is often combined with head injury, chest, abdomen, and extremities (6), Breasts and belly (7), head, chest, abdomen, pelvis and limbs (6). PHC is often covered 2 or more parts of the spine and localization were characterized by: cervico-occipital injury (C1-C2) - 4, lower cervical (C3-C7) – 9, upper thoracic (T1-T4) – 5, lower thoracic – 8, lumbar - L1-L2 (3), L3-L5 (8). In 20 cases (34) noted vertebral compression fractures, rotational -7, distraction fractures – 3. In 3 cases there was a complete separation of the spinal cord in the neck (2) and breastfeeding (1) departments (table 1). It should be noted that PSMP as separate injuries can be observed in any variant of landing falls, but compression fractures of the spine were the results of falls on the legs.

M, 32 years old. Falling from a height. MSCT of the spinal column-lateral projection. Comprensionic fracture of the body LII

 

 

M, 32 years old. Falling from a height. MSCT of the spinal column-lateral projection. Comprensionic fracture of the body LII

 

 

M, 32 years old. Falling from a height. MSCT of the spinal column-lateral projection. Comprensionic fracture of the body LII

 

 

Table 1.

Characteristics of the PSMP when falling from a height

Localization of PSMP

Frequency of occurrence

1.

Cervical-occipital injury (CRT)

-

2.

Verkhnesheynykh (from 1-2)

4

3.

Nizhnesheynykh (from 3-7)

9

4.

Верхнегрудных Upper Chest (Th1-6)

5

5.

Нижнегрудных Lower Chest (Th7-12)

8

6.

Lumbar

8

7.

CT of the cervical and thoracic vertebrae

-

8.

CT of the cervical and lumbar vertebrae

-

9.

CT of thoracic and lumbar vertebrae

-

Total

34 (41.5%)

 

The following model has been developed to identify the most significant element among the indicators of the table for PSMP when falling from a height:

                                (1)

Equation (1)shows that in the case of falls from a height, injuries to the structure of the lower neck, thoracic and lumbar vertebrae and, accordingly, the spinal cord predominate in the structure of PSMP. (t=0,0626, p=0,05.)

 In pedestrians who were injured in collisions with cars, bruises and fractures of the skull bones accounted for 3.5% and in 93 cases, the victims had CT of the body parts with fractures of the limb bones (50.4%), in the remaining 47.1% of cases, CT of the head, chest, abdomen, spine and pelvis was noted. In this type of injury, most often the victims had CT of two or more body parts with fractures of the limb bones, which differs from other types of blunt trauma.

In 43 cases (25%) of injured pedestrians, PSMP was noted: compression-explosive fractures of the vertebrae were noted in 6 cases, in the remaining 37 cases distraction and rotation fractures occurred. Vertebral fractures were often observed (23 cases) between the vertebrae, while in 17 cases of PSMP there was a complete separation of the spinal cord at the level of vertebral structure fractures. Localities of PSMP are shown in Table 2.

Table 2.

Localization of PSMP in pedestrians in collisions with cars

Localization of PSMP

Frequency of occurrence

1.

Cervical-occipital trauma (CRT)

2

2.

Verkhnesheynykh (From 1-2)

5

3.

Nizhnesheynykh (From 3-7)

13

4.

Верхнегрудных Upper Chest (Th1-6)

8

5.

Нижнегрудных Lower Chest (Th7-12)

2

6.

Lumbar

3

7.

CT of the cervical and thoracic vertebrae

7

8.

CT of the cervical and lumbar vertebrae

1

9.

ST of thoracic and lumbar vertebrae

2

 

Total

43 (25 %)

 

From Table 2. It can be seen that PSMP in pedestrians prevailed in the lower neck (13), upper chest (8) departments and ST of the cervical and thoracic departments (7). As part of the PSMP of the cervical department , SST and damage to the structure of the C1-2 were often noted, which differed from the PSMP formed during falls. In addition, vertebral fractures in the thoracolumbar regions were of a rotational and distraction nature, accompanied by traumatization of the processes, mainly the posterior processes.  

          Identification of the most significant element among the indicators in Table 2 was performed using the following model:

                                    (2)

       Equation (2) shows that fractures of the lower cervical (C 3-7) and upper thoracic vertebrae ( Th 1-6) are most often observed in victims of falls from a height (t=0.636; p0.05).

       The combination of injuries in drivers with this type of AT was characterized by the formation of most often CT of the head, chest and abdomen 50%.

PSMP in affected drivers was noted in 14.5% of cases and was characterized by cervical-occipital trauma (CRT) – 3, fractures of the upper and lower cervical vertebrae with complete separation of the spinal cord (2), fractures of 4-5-6 thoracic vertebrae with spinal cord contusion and ligament rupture (2) and 4-5 lumbar vertebrae with brain contusion (1) (Table 3).

Table 3.

Localization of PSMP in drivers with an in-car automated control system

Localization of PSMP

Frequency occurs

1.

Cervical-occipital trauma (CRT)

3

2.

Verkhnesheynykh (from 1-2)

1

3.

Nizhnesheynykh (from 3-7)

1

4.

Верхнегрудных Upper Chest (Th1-6)

2

5.

Nizhnegrudnykh (Th7-12)

0

6.

Lumbar

1

7.

CT of the cervical and thoracic vertebrae

1

8.

CT of the cervical and lumbar vertebrae

0

9.

ST of thoracic and lumbar vertebrae

0

Total

of 9 (14.5%)

 

The search for the largest element from the table parameters was performed using the following model:

                                    (3)

Equation (3) shows that in this type of AT, drivers are more likely to have a cervical-occipital injury (CRT) and fractures of the upper thoracic vertebrae. 3.26 (t = 0.406; p 0.03).

In different types of blunt trauma, the cervical spine (SHP) is most often damaged-20 - up to 55%. Fractures of the cervical vertebrae are more often combined with TBI, while fractures of the thoracic region are associated with chest trauma, and when the lumbar region is damaged, combined injuries of the pelvis, abdominal organs, and lower extremities can occur [14-16].

The nature and morphology of PSMP injuries in different types of blunt trauma are determined by the damage mechanism. It is established that comminuted fractures of the vertebral bodies and processes are formed under the direct impact of a blunt object. When falling from a height - compression (explosive) comminuted fractures of the vertebral bodies. With excessive flexion of the spine-dislocations with ruptureзof the ligamentous apparatus, with excessive extension, for example, with intra-salon AT-dislocations and wedge-shaped compression of the cervical vertebral bodies (whiplash injuries). With sudden extension, for example, when hanging the SHOP, a transverse complete spinal cord injury is formed, causing instant death. When falling on the chin, fractures of the lower angleC2 СC5 С7 C7 occur (teardrop-shaped wedging), while rotation and excessive flexion develop unilateral dislocation with a rupture of the ligamentous apparatus [17].

PSMP is most often detected during in-car AT. At the same time, for diagnosis and differential diagnosis, it is necessary to determine the exact localization, nature of vertebral fractures and injuries to the ligamentous apparatus of the spinal cord. In drivers, PSMP of the cervical, thoracic, and lumbar vertebrae predominate [18-20].

According to some researchers, if the driver and passenger of the front seat have the same morphology and localization of injuries, the decisive role in determining the location of victims may be assigned to injuries to the head, spine and limbs [21-25].

Solokhin A. A. (1968) observed vertebral injuries in passengers 2 times more often than in drivers when they were injured in a car. According to the author, vertebral injuries in this case occur as a result of direct impact of traumatic force in the back area (hitting the back against a part of the cabin, against the door), in which the spinous processes and arches of the vertebrae are damaged, and less often-the vertebral bodies, usually of a compression nature. As a result of excessive flexion or extension, fractures occur more often in the thoracic region (IV-VIII thoracic vertebrae), less often in the lumbar and cervical regions. The spinal cord and its membranes do not always occur during spinal injury; hemorrhages under the membranes are more often observed [26]. Some of the author's opinions are not confirmed by modern data.  Thus, according to E. P. Sedykh, E. P. (2013,2014), PSMs of various departments in drivers are accompanied by a rupture of the TMO and spinal cord crushing, but the author does not provide criteria for substantiating the mechanism of injury [27-28].

Pigolkin Yu.Et al. (2015, 2016), on the example of analyzing a fairly large number of cases of examinations (studies) of corpses, studied the nature of spinal injuries in drivers and passengers of a modern passenger car. The prevalence of fractures of the cervical, thoracic and lumbar vertebrae in drivers was revealed, which is associated, according to the authors, with more intense flexion and extension of the spine in drivers with this type of injury. The authors describe in great detail the nature, localization, and morphological features of vertebral, ligament, and intervertebral disc fractures. However, in these works there is no information about the brands, features of car interior parts. In addition, the authors ' research was devoted only to the study of the features of the formation of vertebral injuries in relation to cases of frontal collisions of a car. Also, the paper does not contain data on comparative studies with other types of blunt trauma [29-30].

The mechanism of PSMP when moving cars collide with pedestrians (hit-and-run) is insufficiently studied. In the available literature of recent years, we have not found any works specifically devoted to the study of PSMP in this type of AT.

Solokhin A. A. (1968) believed that spinal injuries in this type of AT (hit-and-run) are formed both by the impact of protruding parts of cars (1st phase), and when extending the SCL in the 2nd phase of injury. Therefore, victims may have fractures of the bodies, arches, spinous processes of the thoracic and lumbar regions, as well as damage to the ligamentous apparatus of the intervertebral discs [26].

Matyshev A. A. (1969) when a car hit pedestrians, fractures of the thoracic spine were noted only in 10% of cases, while comminuted fractures of the vertebral bodies were detected. Fractures of the spinous processes were observed when a car hit only from behind the victim, while, as a rule, single processes (1-2-3) were damaged. Moving a car wheel over the victim's back often leads to the separation of spinous processes of the vertebrae, as well as to fractures of their arches and bodies. At the same time, injuries to the vertebral bodies are more often luxational and less often compression in nature, with a predominant localization in the thoracic region. However, fractures of the spinous processes of the vertebrae are also possible when a car is driven over the front surface of the chest, but fractures of a small number of spinous processes occur [31].

These data allow us to note that the literature data on the mechanism of PSMP in various types of AT are contradictory. There is no consensus on the character of PSMP or injuries to individual vertebrae, for one or another type of AT.

CONCLUSIONS. As part of combined injuries during falls, PSMP was observed in 41.5% of cases, which was often combined with injuries to other parts of the body and often covered 2 or more parts of the spine, and in terms of localization, most often in the lower neck, upper chest, and lumbar regions (t=0.301; p Compression fractures were the most common, while rotation and distraction fractures of the vertebral bodies were less common, and there were isolated cases of spinal column detachments in the area of fractures. PSMP as separate injuries can be observed in any variant of landing falls, but compression fractures of the vertebral bodies were the results of falls on the legs and buttocks;

In pedestrians-victims of collisions with cars, PSMP was noted in 25% of cases, in which in most cases distraction and rotational fractures of the vertebral bodies took place, detachments at the level of vertebral fractures prevailed with mainly traumatization of the posterior processes. Injuries to the spine structure often included cervical-occipital trauma and damage to the cervical structure, as well as combined injuries to the cervical-thoracic regions (t=0.636; p);

PSMP in affected drivers was noted in 14.5% of cases and was characterized by a cervical-occipital injury, as well as lesions of the structures of the cervical, upper thoracic and lumbar vertebrae (t = 0,406; р< 0,03).

×

About the authors

Sayit Indiaminovich Indiaminov

Samarkand State Medical Institute

Author for correspondence.
Email: antonina_amurovna@mail.ru
ORCID iD: 0000-0001-9735-0338

MD, Dr. Sci. (Med.), Professor

Uzbekistan, 18 Amir Temur str., Samarkand, 140100

Saidkosim Norkulovich Pardaev

Samarkand State Medical Institute

Email: said-03-10@mail.ru
ORCID iD: 0000-0002-9743-0482

MD, Cand. Sci. (Med.)

Uzbekistan, 18 Amir Temur str., Samarkand, 140100

Ravshonbek Alimbaevich Ismailov

Samarkand State Medical Institute

Email: ravshanbekismailov@gmail.com
ORCID iD: 0000-0002-8224-3545
Uzbekistan, 18 Amir Temur str., Samarkand, 140100

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