КУТОВОЙ ИГОРЬ АЛЕКСАНДРОВИЧ: +38 050 300-25-50; +38 098 447-26-32 город Харьков, ул. Акад. Павлова, 46 Государственное учреждение "Институт неврологии, психиатрии и наркологии НАМН Украины"
web: kutovoy.umi.ru
mail: igorKutovoy@gmail.com

Class 7

Class 7

Methodological recommendations on the theme:

Osteochondrosis. Diagnostics and neurosurgical methods of treatment of the pathology of intervertebral disks the vertebral-spinal trauma. Principles of diagnostics, rendering first medical and specialized neurosurgical aid

  1. 1.     Importance of the theme: Osteochondrosis is significant general medical and social problem. The doctor should be able to put the preliminary clinical diagnosis in primary inspection of the sick spine with pathology and the spinal cord and to render adequate medical aid.
  2. 2.     The aims of the class:

2.1.         The practical aims:

To acquaint students with classification of osteochondrosis            I level

-                     the student should know the basic clinical signs of osteochondrosis.      II level

-               the student should be able to examine the patient with a pain syndrome in the area of the spine, to diagnose a pathology of the intervertebral disk, to plan examination and adequate treatment.                                                           III level

-               to teach the student to examine the sick spine with a pathology and the spinal cord.                                                                  IV level

2.2.              The educational aims: To take part in formations principles of deontology medical ethics, professional responsibility in general and in contact with patients with a vertebral - spinal pathology.

  1. 3.     Interdisciplinary integration.

 Disciplines

 To know

 To be able

1 PREVIOUS:

Human anatomy

 

The topographer. Anatomy with operative surgery.

 

 

 

Nervous diseases

 

 

 

Orthopedics and traumatology

 

 

 

INTRADISCIPLINARY INTEGRATION:

Nervous diseases

 

Anatomy of the spine and spinal cord.

To know the basic surgical approaches in pathology of the spine with the purpose of decompression of the spinal cord.

 

To know clinical signs of transversal affection of the spinal cord at various levels.

 

To know peculiarities of clinical course and additional methods of investigation in trauma of the spine at various levels.

Congenital pathology of the spine and spinal cord, clinical signs of tumours of the spinal cord, pathology of intervertebral disks with signs of a radicular pain syndrome.

 

 

 

To state principles of the basic surgical approaches in pathology of the spine and a spinal cord.

 

 

To be able to examine the patient, to study the psychoneurologic status of patients with pathology of the spine and spinal cord.

 

 

 

 

To be able to take an anamnesis, to carry out general clinical inspection and to plan special inspection of the patients with pathology of the spine and spinal cord.

 

  1. 4.                The contents of the class. Pathology of intervertebral disks. Pathogenesis. Classification. Clinical course of osteochondrosis of cervical, thoracic, lumbosacral part of the spine. Main principles of diagnostics. Indications to surgery. Principles of surgical interventions. Preventive maintenance and conservative treatment.

The diagnosis of pain in the spine often requires the assistance of a neurologist and neurosurgeon. His task is to determine whether a disease of the spine has implicated spinal roots and nerves.

Up to three-quarters of the population have low-back pain at some time in their lives; by the age of 50 years, about 85 to 90 % of adults will be found at autopsy to have degenerative disc disease. This is also revealed by imaging studies of the lower spine. Our purpose is to focus on the neurologic implications of back and neck pain and to assist the clinician in developing a systematic mode of inquiry and method of examination. Since pains in the lower part of the spine and legs are caused by rather different types of disease than those in the neck, shoulder, and arms, they are considered sep­arately.

PAIN IN THE LOWER BACK AND LIMBS

The lower parts of the spine and pelvis, with their mas­sive muscular attachments, are relatively inaccessible to palpation and inspection. Although some physical signs and radiographs are helpful, diagnosis often depends on the patient's description of the pain and his behavior dur­ing the execution of certain maneuvers.

The stability of the spine depends on the integrity of the vertebral bodies and intervertebral discs and on two types of supporting structures, the ligamentous (pas­sive) and muscular (active). Although the ligamentous structures are quite strong, neither they nor the vertebral body-disc complexes have sufficient integral strength to resist the enormous forces that act on the spinal column, and the stability of the lower back is largely dependent on the voluntary and reflex contractions of the sacrospinalis, abdominal, gluteus maximus, and hamstring muscles.

The vertebral and paravertebral structures derive their innervation from the meningeal branches of the spinal nerves (also known as recurrent meningeal or sinuvertebral nerves). These meningeal branches spring from the posterior divisions of the spinal nerves just dis­tal to the dorsal root gangia, re-enter the spinal canal through the intervertebral foramina, and supply pain fibers to the intraspinal ligaments, periosteum of bone, outer layers of the annulus fibrosus, and capsule of the articular facets.

The main ligamentous structures of the spine. A. Buckling of the yellow ligament may compress the nerve root or the spinal nerve at its origin in the intervertebral foramen, particularly if the foramen is narrowed by osteophytic overgrowth. B. Posterior aspect of the vertebra/bodies. Fibers of the posterior longitudinal ligament merge with the posteromedial portion of the annulus fibrosus, leaving the posterolateral portion of the annulus relatively unsupported.

General Clinical Features of Low-Back Pain

Types of Low-Back Pain. Of the several symptoms of spinal disease (pain, stiffness, limitation of movement, and deformity), pain is of foremost importance. Four types of pain may be distinguished: local, referred, radicular, and that arising from secondary (protective) muscular spasm. These several types of pain can often be discerned from the patient's description; reliance is placed mainly on the character of the pain, its location, and conditions that modify it.

Local pain is caused by any pathologic process that impinges upon structures containing sensory end­ings. Involvement of the periosteum, capsule of apophyseal joints, lumbodorsal fascia, muscles, annulus fibrosus, and ligaments is often exquisitely painful, whereas destruction of the vertebral body or nucleus pulposus alone produces little or no pain. Inflammatory or traumatic swelling of the affected tissues is not appar­ent if it is located deep in the back. Local pain is most often described as steady and aching, but it may be inter­mittent and sharp and, though not sharply circumscribed, is always felt in or near the affected part of the spine. Usually there is involuntary protective splinting of the corresponding spinal segments by reflex activity in para-vertebral muscles, and certain movements or postures that counteract the spasm and alter the position of the injured tissues tend to aggravate the pain. Also, the superficial structures in the involved region are tender and direct pressure evokes pain. Muscles that are contin­ually in-reflex spasm may also become tender and sensitive to deep pressure.

Referred pain is of two types, one that is projected from the spine to viscera and other structures lying within the territory of the lumbar and upper sacral dermatomes and another that is projected from pelvic and abdominal viscera to the spine. Pain due to disease of the upper part of the lumbar spine is often referred to the flank, lateral hip, groin, and anterior thigh. This has been attributed to irritation of the superior cluneal nerves, which are derived from the posterior divisions of the first three lumbar spinal nerves and innervate the superior portions of the buttocks. Pain from the lower part of the lumbar spine is usually referred to the lower buttocks and posterior thighs and is due to irritation of lower spinal nerves, which activate the same pool of intraspinal neu­rons as the nerves that innervate the posterior thighs. Pain of this type is usually rather diffuse and has a deep, aching quality, but it tends at times to be more superficially projected. In general, die intensity of the referred pain parallels that of the local pain. In other words, maneuvers that alter local pain have a similar effect on referred pain, though lacking the pre­cision and immediacy of so-called root pain. Usually pain from visceral diseases is felt within the abdomen, flanks, or lumbar region and may be modified by the state of activity of the viscera. Its character and temporal relationships are those of the particular visceral structure involved, and posture and movement of the back have relatively little effect on either the local pain or that referred to the back.

Radicular, or "root, " pain has some of the char­acteristics of referred pain but differs in its greater intensity, distal radiation, circumscription to the territory of a root, and factors that excite it. The mechanism is stretching, irritation, or compression of a spinal root, within or central to the intervertebral foramen. The pain is sharp, often intense, and usually superimposed on the dull ache of referred pain; it nearly always radiates from a central position near the spine to some part of the lower limb. Coughing, sneezing, and straining characteristi­cally evoke this sharp radiating pain, although each of these actions may also jar or move the spine and enhance local pain. In fact, any maneuver that stretches the nerve root—e.g., "straight-leg raising" in cases of L4, L5, or S1 root involvement or thigh extension with L3 root involvement—evokes radicular pain; jugular vein com­pression, which raises intraspinal pressure and may cause a shift in position of the root, may have a similar effect. Involvement of L4, L5, and SI roots, which form the sci­atic nerve, causes pain that extends down the posterior aspects of the thigh and the postero- and anterolateral aspects of the leg, into the foot—so-called sciatica. The region of the leg and foot in which the pain is experi­enced depends upon the nerve root that is affected: with L5 radiculopathy, pain radiates to the medial aspect of the foot into the great toe, and with SI involvement, into the lateral part of leg and foot. Involvement of the L3 and sometimes L4 root causes pain in the groin and anterior thigh. Paresthesias or superficial sensory loss, soreness of the skin, and tenderness in certain circum­scribed regions along the nerve usually accompany radicular pain. If the anterior roots are involved as well, reflex loss, weakness, atrophy, and fascicular twitching may also occur.

In patients with severe circumferential constriction of the cauda equina due to spondylosis, sensory-motor impairment, and sometimes referred pain is elicited by standing and walking. The neurologic symptoms involve the calves and the back of the thighs, simulating the exer­cise-induced symptoms due to vascular insufficiency— hence the term spinal claudication.

Examination of the Lower Back.

Some information may be gained by inspection of the back, buttocks, and lower.

Passive straight-leg raising (possible up to 90° in normal individuals except in those who have unusually tight hamstrings), like forward bending in the standing posture with the legs straight, places the sciatic nerve and its roots under tension, thereby producing radicular radi­ating pain. It may also cause an anterior rotation of the pelvis around a transverse axis, increasing stress on the lumhosacral joint and causing pain if this joint is arthritic or otherwise diseased. Consequently, in diseases of the lumbosacral joints and roots, passive straight-leg raising evokes pain and is limited on the affected side and, to a lesser extent, on the opposite side (Lasegue sign). It is important to remember that the evoked pain is always referred to the diseased side, no matter which leg is elevated. While in the supine position, leg length (anterior-superior iliac spine to medial mallcolus) and the circumference of the thigh and calf should be mea­sured.

Abdominal, rectal, and pelvic examinations, in addition to assessment of the integrity of the peripheral vascular system, are essential elements in the study of the patient with low-back symptoms which fail to be clari­fied by these simple spinal maneuvers. Neoplastic inflammatory, or degenerative disorders may produce symptoms referred to the lower part of the spine.

Ancillary Diagnostic Procedures.

  1. X-Ray
  2. MRI
  3. CT
  4. Electromyography (EMG)
  5. Discography

Depending on the circumstances, these may include a blood count and erythrocyte sedimentation rate (especially helpful in screening for infection or myeloma); measurement of the serum proteins, calcium, phospho­rus, uric acid, alkaline phosphatase, acid phosphatase and prostate specific antigen (if one suspects metastatic carcinoma prostate): a serum proiem eleciropnoresis (myeloma proteins): a tuberculin test or an agglutination test for Brucellti, and a test for rheumatoid factor. Radi­ographs of the lumbar spine (preferably with the patient standing) in the anteroposterior, lateral, and oblique planes are still useful in the routine evaluation of low-back pain and sciatica. Readily demonstrable in plain films are narrowing of the intervertebral disc spaces. bony facetal or vertebra] overgrowth, displacement of vertebral bodies (spondylolisthesis), and an unsuspected infiltration of bone by cancer. In cases of suspected disc herniation or tumor infiltration of the spinal canal, one proceeds directly to CT or MRI. Although these imaging procedures have largely replaced conventional myelography, the latter examination, when combined with CT, provides detailed information about the dura sleeves that surround the spinal roots, at times disclosing subtle truncations caused by laterally situated disc herniations and revealing surface abnormalities of the spinal cord, such as arteriovenous malformations. Administration of gadolinium at the time of MRI enhances regions of inflammation and tumor.

Injection of contrast medium directly into the intervertebral disc (discogram) is still practiced in a few institutions but is more difficult to interpret than CT-myelography and MRI and carries the risk of damage to nerve roots or the introduction of infection. the discography is indicated only in special circumstances and should be undertaken only by those who are specialized in its performance. Isotope bone scans are useful in demonstrating tumors and inflamma­tory processes. Nerve conduction studies and electromyography (EMG) are particularly helpful in suspected root and nerve diseases, as indicated further on, in the discussion of protruded lumbar discs.

Spondylolisthesis consists of a bony defect in the pars interarticularis (the segment al the junction of pedicle and lamina) of the lower lumbar vertebrae. The defect is remarkably common: it affects approximately 5 % of the North American population, is probably genetic, and predisposes to fracture at this location. Radiographically, the pars interarticularis defect is best visualized on oblique projections. In some persons il is unilateral and may cause unilateral aching back pain that is accentuated by hyperextension and twisting. It is not uncommon in athletes. In the usual bilateral form, the vertebral body, pedicles, and superior articular facets move anteriorly, leaving the posterior elements behind. This latter dis­order, known as spondylolisthesis, is mainly a disease of young persons (peak incidence between ages 5 and 7 years). It may cause little difficulty at first but eventu­ally becomes symptomatic. The patient complains of pain in the low back radiating into the thighs and of lim­itation of motion. Examination discloses tenderness near the segment that has "slipped" (most often L5, occasion­ally L4), a palpable "step" ol the spinous process forward from the segment below, hamstring spasm, and, in severe cases (spondylolisthesis), shortening of the trunk and pro­trusion of the lower abdomen (both of which result from the abnormal forward shift of L5 on SI), and signs of involvement of spinal roots-—pareslhesias and sensory loss, muscle weakness, and reflex impairment. These neurologic symptoms and signs lend not to be severe.

Herniation of Lumbar Intervertebral Discs. This condition is a major cause of severe and chronic or recur­rent low-back and leg pain. It occurs mainly during the third and fourth decades of life, when the nucleus pulposus is still gelatinous. The disc between the fifth lumhar and first sacra] vertebrae is the one most often involved, and, with lessening frequency, that between the tourth and fifth, third and fourth, second and third, and first and second lumbar vertebrae. Rare in the thoracie portion of the spine, disc disease is again frequent at the filth and sixth and sixth and seventh cervical vertebrae.

The cause of a herniated lumbar disc is usually a flexion injury, but a considerable proportion of patients do not recall any traumatic episode. Degeneration of the nucleus pulposus, the posterior longitudinal ligaments, and the annulus fihrosus may have taken place silently or have been manifested by mild, recurrent lumbar ache. A sneeze, lurch, or other trivial movement may then cause the nucleus pulposus to prolapse, pushing the frayed and weakened annulus posteriorly. Fragments of the nucleus pulposus protrude through rents in the annulus, usually to one side or the other (sometimes centrally), where they impinge upon a root or roots. In more severe cases of disc disease, the nucleus may protrude through the amiulus 01 be extruded and he epidurally. as a free fragment. A large protrusion may compress the root(s) against the articular apophysis or lamina. The protruded material may he resorbed to some extent and become reduced in si/.e, hut often it does not. causing chronic irritation of the root or a discarthrosis with posterior ostcophyte formation.

The Clinical Syndrome. The fully developed syn­drome of prolapsed intervertebral lumbar disc consists of: (1) pain radiating into the buttock, thigh, call. and foot, (2) a stiff or unnatural spinal posture, and (3) some combination of paresthesias, weakness, and reflex impairment.

The pain of herniated intervertebral disc is of sev­eral types. First there is "spontaneous" pain that ranges from a mild discomfort to the most severe knife-like stabs that radiate the length of the leg and are superim­posed on a constant intense ache. With the most acute and severe pain, the patient must stay in bed, avoiding the slightest movement: a cough, sneezing, or strain is intolerable. The patient is usually most comfortable lying on his back with legs flexed at the knees and hips (dorsal decubitus position) and with the shoulders raised on pil­lows to obliterate the lumbar lordosis. For some patients, a particular lateral decubitus position is more comfort­able. As mentioned earlier, free fragments on disc that find their way to a lateral and posterior position in the spinal canal may produce the opposite situation, one of being unable no extend the spine and lie supine. When the condition is less severe, walking is possible, though laligue sets in quickly, wilt a feeting on heaviness and drawing pain. Sitting and standing up from a sitting posi­tion are particularly painful. The pain is usually located deep in the buttock, just lateral to and below the sacroiliac joint, and in the posterolateral region on the thigh, with radiation no the calf and infrequently to the heel and other parts on the foot. Radiation on pain into the foot should at least raise the possibility of an alternative cause of nerve damage. Pain is also characteristically provoked by pressure over the course of the sciatic nerve at the classic points of Valleix (sciatic notch, retrotrochanteric gutter, posterior surface of thigh, head of fibula). Pressure at one point may cause radiation of pain and tingling down the leg.

The signs of severe spinal root compression are hypotonia, impairment of sensation, loss or diminution of tendon reflexes, and muscle weakness. The hypotonia is evident on inspection and palpation of the buttock and calf, and the Achilles tendon tends to be less salient. Paresthesias (rarely hyperesthesia or hypoesthesia) are reported by one-third of patients; usually they are felt in the foot, sometimes in the leg. Often there is a diminution of pain perception over the appropriate dermatome. Muscle weakness occurs, but less frequently. The ankle or knee jerk is usually diminished or lost on the side of the lesion. The reflex changes have little relationship to the severity of the pain or sensory loss. Furthermore, compression of the fourth or fifth lumbar root may occur without any change in the tendon reflexes. Bilaterality of symptoms and signs is rare, as is sphincteric paralysis, but they may occur with large central protrusions.

The CSF protein is then predictably elevated, usually in me range of 55 to 85 mg/dL, sometimes higher.

With lesions of the first sacral root the pain is felt in the midgluteal region, posterior part of the thigh, pos­terior region of the calf to the heel, outer plantar surface of the foot, and fourth and fifth toes. Tenderness is most pronounced over the midgluteal region (in the region of the sacroiliac joint), posterior thigh areas, and calf. Paresthesias and sensory loss are mainly in the lower part of the leg and outer toes, and weakness, if present, involves the flexor muscles of the foot and toes, abduc­tors of the toes, and hamstring muscles. The Achilles reflex is diminished or absent in the majority of cases. In fact, loss of the Achilles reflex is often the first and only objective sign. Walking on the toes is more difficult and uncomfortable than walking on the heels because of weakness of the plantar flexors.

The rarer lesions of the third and fourth lumbar roots give rise to pain in the anterior part of the thigh and knee and anteromedial part of the leg (fourth lumbar), with corresponding sensory loss. The knee jerk is dimin­ished or abolished. L3 motor root lesions may weaken the quadriceps, thigh adductor, and iliopsoas; L4, me anterior tibial innervated muscles. LI root pain is pro­jected to the groin and L2, to the lateral hip. Motion of the spine and certain positions are most evocative of root pain; if the pain is constant in all positions, root irritation is seldom the cause.

Rarer still are protrusions of thoracic intervertebral discs (0.5 % of all surgically verified disc protru­sions). The four lowermost thoracic interspaces are the most frequently involved. Trauma, particularly hard falls on the heels or buttocks, is an important causative factor. Deep boring spine pain, root pain circling the body or pro­jected to the abdomen or thorax (sometimes simulating visceral disease), paresthesias below the level of the lesion, loss of sensation, both deep and superficial, and paraparesis or paraplegia are the usual clinical manifes­tations. Careful CT-myelography and MRI are the most important diagnostic maneuvers.

When all components of the syndrome are present, diagnosis is easy; but most neurologists pre­fer to corroborate their clinical impression by CT, with or without contrast myelography, or preferably by MRI of the L3-S1 spine. Usually this will demonstrate the extruded disc at the suspected site and will also exclude hemiations at other sites or an unsuspected tumor.

Spondylotic Spurs and Lateral Recess Stenosis. Symptoms due to these disorders need to be distin­guished from those of hemiated disc. Disabling pain in one or both legs on standing and walking, relieved by squatting and lying down, with variable motor, reflex, and sensory changes referable to a root or roots are present. Radiologically there was stenosis at one vertebral level. Most often the superior facet of L5 narrowed the lateral recess at the upper border of the pedicle, com­pressing the L5 root and sometimes the S1 as well. This is one of the anatomic configurations that is consistently shown to advantage by CT-myelography and may not be appreciated by conventional CT or MRI. This is particu­larly true, as already mentioned, if there is an associated far lateral disc hemiation. This condition is more properly designated as a unilateral lumbar spondylosis, or as a spondylolysis. The adjacent articular capsules may suffer injury and add direct and referred pain to a radicular syndrome. Intraarticular lidocaine relieves the pain, according to some orthopedists.

Spondylotic Caudal Radiculopathy or Lumbar Stenosis Syndrome. In the lumbar region, osteoarthritic or Spondylotic changes, superimposed on a smaller-than-normal spinal canal, may lead to compression of the caudal roots. The roots are actually caught between the posterior surface of the vertebral body and the ligamentum flavum posterolaterally. Upon standing or walking (downhill walking is especially difficult), there is in many cases a gradual onset of numbness and weakness of the legs, which forces the patient to sit down. When this condition is more severe, the patient gains relief by lying down with the legs flexed at the hips and knees. Usually the numbness begins in one leg, spreads to the other, and ascends as standing or walking continues. Tendon reflexes may disappear, only to return on flexing the spine. Pain in the low back is variable. Disturbances of micturition and impotence are rare. In some patients with lumbar stenosis, neurologic symp­toms persist without relation to body position. The clinical picture, with its intermittency, corresponds to the so-called intermittent claudication of the cauda equina. Soon thereafter to be due not to ischemia but to encroachment on the cauda by hypertrophied apophyseal joints, thickened ligaments, and small protrusions of disc material engrafted upon a canal that is developmentally shallow in the anteroposterior diameter. Sometimes a slight subluxation at L3-L4 or at L4-L5 is also present. Later it became evident that the canal in these cases is also narrow from side to side (reduced interpedicular dis­tance radiographically). Decompression of the spinal canal relieves the symptoms in a considerable proportion of the cases.

The Facet Syndrome. This syndrome has been clari­fied in recent years, but its definition is still somewhat imprecise. Some authors use the term to designate a painful state that responds to the injection of analgesic medications into the facet; others use the term in a more general sense, to describe pain that emanates from the facet joint and lateral recess. In either case, the condition is closely related to the one described above. At operation, the spinal root are compress against the floor of the intervertebral canal by over­growth of an inferior or superior facet. Foraminotomy and facetectomy, after exploration of the root from the dural sac to the pedicle, relieved the pain in operated cases. Denervation of lumbar facets by radio-frequency electrodes introduced percutaneously onto nerves supplying the zygoapophyseal joints has been proposed as therapy.

  1. 5.     The general material and methodical maintenance of the lecture:

-         Class-rooms;

-         educational tables;

-         codoscope:

-         slides.

 

6. Materials for self-preparation of the students:

 The literature on the theme of the lecture.

 

1.1 Иргер И.М., “ Нейрохирургия “ М.,”МЕДИЦИНА “, 1982 г.

1.2 Пастор Э. “ Основы нейрохирургии” Будапешт , 1985 г.

  1. Preventive measures of osteochondrosis at children's age.
  2. Methods of control of urosepsis.
  3. Preventive measures of bed sores in patients with affection of the spinal cord.
  4. Principles of treatment of osteochondrosis.

(Situational tasks in a theme are enclosed)

Questions:

1. Classification of osteochondroses.

2. Name the basic causal factors of osteochondroses.

3. What auxiliary methods of examination are applied to diagnostics of osteochondroses?

4. Name preventive methods maintenance of osteochondroses.

7. The literature used by the lecturer for preparation of the lecture:

  1. Greenberg J.O. (ed): Neuroimaging: A companion to Adams and Victor's Principles of Neurology, New York, mcgraw-Hill, 1995.
  2. Latchaw R.E. (ed): Computed Tomography of the Head, Neck, and Spine, 2nd ed. St. Louis, Mosby-Year Book, 1991.
  3. Lindsay K., Bone I. Neurology and Neurosurgery Illustrated. 3th ed. Churchill Livingstone, New York, Edinburgh, London, Madrid, Melbourne, San Francisco and Tokyo, 1997.
  4. Modic M.T., Masaryk T.J., Ross J.S., et al: Magnetic Resonance Imaging of the Spine, 2nd ed. St. Louis, Mosby-Year Book, 1993.
  5. Runge V., Brack M., Garneau R., Kirsch J. Magnetic resonance imaging of the brain. J.B.Lippincott Company, Philadelphia, 1994.
  6. Гусев Е.И., Коновалов А.Н., Бурд Г.С. Неврология и нейрохирургия. Москва, Медицина, 2000.
  7. Полищук Н.Е. Рассказов С.Ю. Принципы ведения больного в неотложной неврологии и нейрохирургии. Киев, 1998.
  8. Ромоданов А.П., Мосійчук М.М. Цимбалюк В.І. Нейрохірургія. Київ, Спалах, 1998.

The additional literature.

  1. Bonica J.J. (ed): The Management of Pain, 2nd ed., Philadelphia, Lea & Febiger, 1990.
  2. Dyck PJ et al (eds): Peripheral Neuropathy, 3rd ed. Philadelphia, Saunders, 1992.
  3. Finneson B.E. Low Buck Pain, 2nd ed. Philadelphia, Lippincott. 1981.
  4. Louis R. Surgery of the Spine. Surgical Anatomy and Operative Approaches. Berlin-Heidelbery New York, Springer Verlag, 1983.
  5. Берснев В.П., Давыдов Е.А., Кондаков Е.Н. хирургия позвоночника, спинного мозга и периферических нервов. СПб, Специальная литература, 1998.
  1. Гусев Е.И., Коновалов А.Н., Бурд Г.С. Неврология и нейрохирургия. Москва, Медицина, 2000.
  2. Полищук Н.Е. Рассказов С.Ю. Принципы ведения больного в неотложной неврологии и нейрохирургии. Киев, 1998.
  3. Ромоданов А.П., Мосійчук М.М. Цимбалюк В.І. Нейрохірургія. Київ, Спалах, 1998.
  1. Справочник по нейротравматологии. Под ред. Коновалова А.Н., Лихтермана Л.Б., Потапова А.А. Москва, Вазар-Ферро, 2001.