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Vinnitsa National Medical University
Course of Neurosurgery
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.
Approved at a methodological meeting of the
course of Neurosurgery
The minute № 1
Head of the department
Moskovko S.P.
Head of the course
Olkhov V.M.
THEME of the class: “Osteochondrosis of the spine. 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.”
(For students)
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. 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.
2.2.
IV level
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.
3. Interdisciplinary integration.
Disciplines
To know
To be able
1 PREVIOUS:
Human anatomy
Anatomy of the spine and
spinal cord.
The topographer. Anatomy
with operative surgery.
To know the basic surgical
approaches in pathology of
the spine with the purpose
of decompression of the
spinal cord.
To state principles of the
basic surgical approaches in
pathology of the spine and a
spinal cord.
Nervous diseases
Orthopedics and
traumatology
INTRADISCIPLINARY
INTEGRATION:
Nervous diseases
4.
To know clinical signs of
transversal affection of the
To be able to examine the
spinal cord at various levels. patient, to study the
psychoneurologic status of
patients with pathology of
To know peculiarities of
the spine and spinal cord.
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 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.
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 posteroand 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 CTmyelography 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 knifelike 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 L4L5 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.
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.
2.
3.
4.
5.
6.
7.
8.
9.
Bonica J.J. (ed): The Management of Pain, 2nd ed., Philadelphia, Lea & Febiger, 1990.
Dyck PJ et al (eds): Peripheral Neuropathy, 3rd ed. Philadelphia, Saunders, 1992.
Finneson B.E. Low Buck Pain, 2nd ed. Philadelphia, Lippincott. 1981.
Louis R. Surgery of the Spine. Surgical Anatomy and Operative Approaches. BerlinHeidelbery New York, Springer Verlag, 1983.
Берснев В.П., Давыдов Е.А., Кондаков Е.Н. хирургия позвоночника, спинного
мозга и периферических нервов. СПб, Специальная литература, 1998.
Гусев Е.И., Коновалов А.Н., Бурд Г.С. Неврология и нейрохирургия. Москва,
Медицина, 2000.
Полищук Н.Е. Рассказов С.Ю. Принципы ведения больного в неотложной
неврологии и нейрохирургии. Киев, 1998.
Ромоданов А.П., Мосійчук М.М. Цимбалюк В.І. Нейрохірургія. Київ, Спалах, 1998.
Справочник по нейротравматологии. Под ред. Коновалова А.Н., Лихтермана Л.Б.,
Потапова А.А. Москва, Вазар-Ферро, 2001.