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ÑÓÄÎÂÀ ÌÅÄÈÖÈÍÀ © Ìèõàéëè÷åíêî Á. Â., *Ôðàí÷óê Â. Â., **Ãðèãîðîâ Ñ. Í., **Øêëÿð À. Ñ. ÓÄÊ 340. 6:616. 711. 1-001. 5-079. 5 Ìèõàéëè÷åíêî Á. Â., *Ôðàí÷óê Â. Â., **Ãðèãîðîâ Ñ. Í., **Øêëÿð À. Ñ. ÑÎ×ÅÒÀÍÍÛÅ ÒÅËÅÑÍÛÅ ÏÎÂÐÅÆÄÅÍÈß ØÅÉÍÎÃÎ ÎÒÄÅËÀ ÏÎÇÂÎÍÎ×ÍÈÊÀ È ×ÅËÞÑÒÍÎ-ËÈÖÅÂÀß ÒÐÀÂÌÀ: ÑÓÄÅÁÍÎ-ÌÅÄÈÖÈÍÑÊÈÉ ÀÑÏÅÊÒ Íàöèîíàëüíûé ìåäèöèíñêèé óíèâåðñèòåò èì. Î. Î. Áîãîìîëüöÿ (ã. Êèåâ) Òåðíîïîëüñêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò èì. È. ß. Ãîðáà÷åâñêîãî * (ã. Òåðíîïîëü) **Õàðüêîâñêèé íàöèîíàëüíûé ìåäèöèíñêèé óíèâåðñèòåò (ã. Õàðê³â) [email protected] Äàííàÿ ðàáîòà ÿâëÿåòñÿ ôðàãìåíòîì ïëàíîâîé íàó÷íî-èññëåäîâàòåëüñêîé ðàáîòû «Ä³àãíîñòèêà òà ë³êóâàííÿ çàõâîðþâàíü îðãàí³â òà òêàíèí ùåëåïíîëèöåâî¿ ä³ëÿíêè», ¹ ãîñ. ðåãèñòðàöèè 0113U002274. Âñòóïëåíèå. Ïîñëåäíèå ãîäû îòìå÷åí ðîñò êîëè÷åñòâà ïîñòðàäàâøèõ ñ ñî÷åòàííûìè ïîðàæåíèÿìè – òðàâìàìè äâóõ è áîëåå àíàòîìè÷åñêèõ ñåãìåíòîâ îäíèì ïîðàæàþùèì ôàêòîðîì [9]. Ïîâðåæäåíèÿ øåéíîãî îòäåëà ïîçâîíî÷íèêà (ØÎÏ) ñîñòàâëÿþò äî 30 %, â ñòðóêòóðå ïîâðåæäåíèé ïîçâîíî÷íèêà, è îòíîñÿòñÿ ê íàèáîëåå òÿæêèì òðàâìàì îïîðíî-äâèãàòåëüíîé ñèñòåìû. Ïîâðåæäåíèå íåðâíîé ñèñòåìû ïðè òðàâìàõ ØÎÏ âîçíèêàåò â 50,0-60,0 % ñëó÷àåâ [1, 6, 7]. Ïðè ýòîì ïîñòðàäàâøèå ñ òðàâìîé ØÎÏ è ïàðàâåðòåáðàëüíûõ òêàíåé, ìîãóò ñòàòü îáúåêòîì ñóäåáíî-ìåäèöèíñêîé ýêñïåðòèçû æèâûõ ëèö, êîòîðàÿ ïðîâîäèòñÿ â õîäå ñóäåáíîãî è äîñóäåáíîãî ñëåäñòâèÿ [16-18]. Ó ïîñòðàäàâøèõ ñ ïîâðåæäåíèÿìè ëèöåâîãî ñêåëåòà (ËÑ) ÷àñòîòà ñî÷åòàííûõ òðàâì äîñòèãàåò 10,0-12,0 % [10-12]. Òðàâìà øåéíîãî îòäåëà ïîçâîíî÷íèêà (ÒØÎÏ) è ÷åëþñòíî–ëèöåâàÿ òðàâìà (×ËÒ), ÿâëÿÿñü îäíîâðåìåííî ôèçè÷åñêèìè è ïñèõè÷åñêèìè ñòðåññîðàìè, ôîðìèðóþò ðàçâèòèå ñòðåññ-ðåàêòèâíûõ èçìåíåíèé ñî ñòîðîíû îñíîâíèõ ãîìåîñòàòè÷åñêèõ ñèñòåì îðãàíèçìà (íåðâíîé, èììóííîé, ýíäîêðèííîé) [4, 5]. Äàííûå ëèòåðàòóðû ñâèäåòåëüñòâóþò, ÷òî ó áîëüíûõ, êàê ñ ïðÿìîé, òàê è ñ íåïðÿìîé ÒØÎÏ îòìå÷àþòñÿ âûðàæåííûå ýíäîêðèííûå íàðóøåíèÿ, êîòîðûå ìîãóò îòðàæàòü òÿæåñòü ïîðàæåíèÿ ãîëîâíîãî ìîçãà è èãðàòü ðîëü ôàêòîðà âîçíèêíîâåíèÿ îñëîæí¸ííîãî òå÷åíèÿ ïîâðåæäåíèé, êàê øåéíîãî îòäåëà ïîçâîíî÷íèêà, òàê è ËÑ [2, 3]. Íåñìîòðÿ íà ïîñòîÿííûé ïîèñê è âíåäðåíèå íîâûõ ìåòîäîâ äèàãíîñòèêè, êîëè÷åñòâî âîçíèêàþùèõ îñëîæíåíèé îñòàåòñÿ äîñòàòî÷íî âûñîêèì, äîñòèãàÿ 36,5 % [3, 4]. Íå âûçûâàåò ñîìíåíèÿ, ÷òî ïðîáëåìà ëå÷åáíîé ïîìîùè ïàöèåíòàì ñ ÒØÎÏ è òðàâìàìè ËÑ ÿâëÿåòñÿ ìóëüòèäèñöèïëèíàðíîé, îïðåäåëÿÿ ïîòðåáíîñòü â ñîâìåñòíûõ äåéñòâèÿõ ÷åëþñòíî-ëèöåâûõ õèðóðãîâ è âðà÷åé äðóãèõ 392 ñïåöèàëüíîñòåé: òðàâìàòîëîãîâ, íåéðîõèðóðãîâ, îôòàëüìîëîãîâ, íåâðîïàòîëîãîâ [8-10, 13].  äîñòóïíîé ñóäåáíî-ìåäèöèíñêîé ëèòåðàòóðå îòñóòñòâóþò îáùåïðèçíàííûå äèàãíîñòè÷åñêèå êðèòåðèè, ïîçâîëÿþùèå îáúåêòèâíî îïðåäåëèòü ñòåïåíü òÿæåñòè òåëåñíûõ ïîâðåæäåíèé ïðè âñåõ âàðèàíòàõ òàêîé òðàâìû.  ëèòåðàòóðå íå îïðåäåëåí îïòèìàëüíûé îáúåì äèàãíîñòè÷åñêèõ èññëåäîâàíèé äëÿ îöåíêè èñõîäîâ òðàâì øåéíîãî îòäåëà ïîçâîíî÷íèêà è ïàðàâåðòåáðàëüíûõ òêàíåé. Íå ðàçðàáîòàí àëãîðèòì ïðîâåäåíèÿ ñóäåáíî-ìåäèöèíñêîé ýêñïåðòèçû. Öåëüþ ðàáîòû ÿâèëñÿ êîíòåíò-àíàëèç ïàòîãåíåòè÷åñêèõ ïðåäïîñûëîê ñîâåðøåíñòâîâàíèÿ ñóäåáíî-ìåäèöèíñêîé ýêñïåðòèçû òðàâì øåéíîãî îòäåëà ïîçâîíî÷íèêà (èçîëèðîâàííûõ è ñî÷åòàííûõ ñ òðàâìàìè ËÑ) ó æèâûõ ëèö. Îáúåêò è ìåòîäû èññëåäîâàíèÿ.  òå÷åíèå ïîñëåäíèõ ëåò â îòäåëå ñóäåáíî-ìåäèöèíñêîé ýêñïåðòèçû ïîòåðïåâøèõ, îáâèíÿåìûõ è äðóãèõ ëèö Îáëàñòíûõ áþðî ñóäåáíî-ìåäèöèíñêîé ýêñïåðòèçû áûëî ïðîâåäåíî 83 ýêñïåðòíûõ èññëåäîâàíèé ïî ïîâîäó òðàâì øåéíîãî îòäåëà ïîçâîíî÷íèêà è ïàðàâåðòåáðàëüíûõ òêàíåé, ÷òî ñîñòàâèëî îêîëî 2,3 % îò îáùåãî êîëè÷åñòâà ïîâðåæäåíèé øåè.  õîäå ïðîâåäåíèÿ èññëåäîâàíèÿ, èñïîëüçîâàëèñü òàêèå ìåòîäû: ðåãèñòðàöèîííûé – ïîëó÷åííûå äûííûå çàíîñèëèñü â ñïåöèàëüíî ðàçðàáîòàííûå ðåãèñòðàöèîííûå êàðòû; ìåòîä ñòàòèñòè÷åñêîãî àíàëèçà; ìîðôîëîãè÷åñêèé ìåòîä – îïðåäåëÿëñÿ õàðàêòåð ïîâðåæäåíèé; êëèíè÷åñêèé – àíàëèçèðîâàëîñü íàðóøåíèå ôóíêöèè, äëèòåëüíîñòü ðàññòðîéñòâà çäîðîâüÿ; ñóäåáíî-ìåäèöèíñêèé – àíàëèçèðîâàëàñü óñòàíîâëåííàÿ ýêñïåðòàìè ñòåïåíü òÿæåñòè òåëåñíûõ ïîâðåæäåíèé. Ðåçóëüòàòû èññëåäîâàíèé è èõ îáñóæäåíèå. Óñòàíîâëåíî, ÷òî ôàêòîðîì, ïðåäîïðåäåëÿþùèì ñî÷åòàíèå ÒØÎÏ è ×ËÒ, ÿâëÿåòñÿ àíàòîìè÷åñêîå, òîïîãðàôè÷åñêîå è ôóíêöèîíàëüíîå åäèíñòâî ìîçãîâîãî è ëèöåâîãî îòäåëîâ ÷åðåïà [11]. Îñîáåííîñòüþ ³ñíèê ïðîáëåì á³îëî㳿 ³ ìåäèöèíè – 2015 – Âèï. 2, Òîì 3 (120) ÑÓÄÎÂÀ ÌÅÄÈÖÈÍÀ ñî÷åòàííîé òðàâìû ÿâëÿåòñÿ òî, ÷òî ïîâðåæäåíèå ÃÌ ìîæåò âîçíèêàòü è ïðè îòñóòñòâèè óäàðà ïî ìîçãîâîìó îòäåëó ÷åðåïà, ò. å. äàííûå ïîâðåæäåíèÿ ìîãóò áûòü âûçâàíû âîçäåéñòâèåì òðàâìèðóþùåãî àãåíòà, ëèáî íà ëèöåâîé è ìîçãîâîé îòäåëû ÷åðåïà îäíîâðåìåííî [5, 8, 9]. Ñèëà äåéñòâóþùåãî ôàêòîðà, âûçâàâøåãî ïåðåëîì êîñòåé ËÑ, ïî èíòåíñèâíîñòè îáû÷íî ïðåâîñõîäèò ïðåäåë ýëàñòè÷íîñòè è ïðî÷íîñòè îòäåëüíûõ êîñòåé [5] è ïåðåäàåòñÿ íåïîñðåäñòâåííî íà ØÎÏ, âûçûâàÿ ãåìîäèíàìè÷åñêèå, ïàòîôèçèîëîãè÷åñêèå è ñòðóêòóðíûå èçìåíåíèÿ ðàçëè÷íîé ñòåïåíè [13-15]; ïîâðåæäåíèÿ ËÑ ïðåäîïðåäåëÿþò âûñîêèé ðèñê òðàâìû ØÎÏ [29-32]. Àíàëèç ÒØÎÏ ïðè ×ËÒ è åå ïîñëåäñòâèé ïîêàçàë, ÷òî ó ïîäàâëÿþùåãî áîëüøèíñòâà ïîñòðàäàâøèõ íàáëþäàþòñÿ ðàçëè÷íûå èíòðàêðàíèàëüíûå ïðîÿâëåíèÿ: ïî äàííûì êîìïüþòåðíîé òîìîãðàôèè (ÊÒ), äîìèíèðóþùèìè ÿâëÿþòñÿ î÷àãîâûå ïîâðåæäåíèÿ ëîáíûõ è âèñî÷íûõ äîëåé ÃÌ, à òàêæå ïåðåëîìû îñíîâàíèÿ ïåðåäíåé ÷åðåïíîé ÿìêè, ñîïðîâîæäàþùèåñÿ íàçàëüíîé ëèêâîððååé [33]. Êëèíè÷åñêè ÒØÎÏ ïðîÿâëÿåòñÿ îáùåìîçãîâûìè è ëîêàëüíûìè ñèìïòîìàìè; ê îáùåìîçãîâûì îòíîñÿò ïîòåðþ ñîçíàíèÿ, ãîëîâíóþ áîëü, ãîëîâîêðóæåíèå, òîøíîòó, ðâîòó, àìíåçèþ, à ê ëîêàëüíûì – íàðóøåíèå ôóíêöèè ÷åðåïíûõ íåðâîâ [26-29]. Èññëåäîâàíèå êëèíè÷åñêèõ ïðîÿâëåíèé îñíîâíûõ ôîðì ëåãêîé ×ÌÒ ïîêàçàëî, ÷òî ìèíèìàëüíûìè äèàãíîñòè÷åñêèìè êðèòåðèÿìè ñîòðÿñåíèÿ ÃÌ ñëåäóåò ñ÷èòàòü íàëè÷èå êðàòêîâðåìåííûõ íàðóøåíèé ñîçíàíèé è/èëè íåïðîäîëæèòåëüíûå íàðóøåíèÿ ïàìÿòè íà ñîáûòèÿ, íåïîñðåäñòâåííî ïðåäøåñòâîâàâøèå òðàâìå èëè ïîñëåäîâàâøèå âñëåä çà íåé. Ìèíèìàëüíûìè äèàãíîñòè÷åñêèìè êðèòåðèÿìè óøèáîâ ÃÌ ëåãêîé ñòåïåíè â ãðóïïå áîëüíûõ ñ ïðåäïîëàãàåìîé ëåãêîé ÒØÎÏ ìîæíî ñ÷èòàòü íàëè÷èå ëåãêîé î÷àãîâîé ñèìïòîìàòèêè ïåðåëîìîâ êîñòåé ñâîäà ÷åðåïà, ñóáàðàõíîèäàëüíîãî êðîâîèçëèÿíèÿ, îãðàíè÷åííûõ ÊÒ èçìåíåíèé âåùåñòâà ÃÌ [1-3]. Ê ñîæàëåíèþ, â ðÿäå ñëó÷àåâ, ÒØÎÏ, ñî÷åòàþùååñÿ ñ ïîâðåæäåíèÿìè ËÑ, äèàãíîñòèðóåòñÿ ëèøü â ñëó÷àÿõ ñ ÿðêî âûðàæåííîé íåâðîëîãè÷åñêîé ñèìïòîìàòèêîé [22-25]. Ìåæäó òåì, ÃÌ îòëè÷àåòñÿ âûñîêîé ÷óâñòâèòåëüíîñòüþ ê òðàâìàòè÷åñêîìó âîçäåéñòâèþ äàæå ïðè ëåãêîé ÒØÎÏ [19-21].  òîæå âðåìÿ, òÿæåëûå ×ËÒ íåðåäêî çàòðóäíÿþò îöåíêó òÿæåñòè ÒØÎÏ. Êðîâîòå÷åíèå â êëåò÷àòêó âåê è ñêëåðó ãëàç ñèìóëèðóåò ïåðåëîì îñíîâàíèÿ ÷åðåïà, çàòðóäíÿåò èññëåäîâàíèå ôóíêöèè ãëàçîäâèãàòåëüíûõ íåðâîâ, îñìîòð ãëàçíîãî äíà. Ïîâðåæäåíèå òðîéíè÷íîãî, ëèöåâîãî, ãëàçîäâèãàòåëüíîãî íåðâîâ ìîæåò ñèìóëèðîâàòü î÷àãîâóþ ñèìïòîìàòèêó. Ïîâðåæäåíèå ÷åëþñòåé, çàïàäåíèå ÿçûêà, îáòóðàöèÿ âåðõíèõ äûõàòåëüíûõ ïóòåé ñëèçüþ, êðîâüþ, îòëîìêàìè çóáîâ è çóáíûõ ïðîòåçîâ âûçûâàþò îáòóðàöèþ âåðõíèõ äûõàòåëüíûõ ïóòåé, äûõàòåëüíóþ íåäîñòàòî÷íîñòü, óñóãóáëÿÿ ãèïîêñèþ ÃÌ. Ïîâðåæäåíèå ïðèäàòî÷íûõ ïàçóõ íîñà, íàáëþäàþùååñÿ ïðè ïåðåëîìå ëîáíîé êîñòè, âåðõíåé ÷åëþñòè, êîñòåé íîñà ñïîñîáñòâóåò âîñõîäÿùåé èíôåêöèè, à ïðè ëèêâîððåå – îáðàçîâàíèþ ëèêâîðíûõ ñâèùåé. Ðåàêòèâíûé îòåê, ñîïðîâîæäàþùèé ïîâðåæäåíèå ëèöà è ÷åëþñòåé, ðàçâèòèå âîñïàëèòåëüíûõ èíôèëüòðàòîâ ïðèâîäÿò ê ñäàâëèâàíèþ ñîñóäîâ øåè, ãëóáîêèõ âåí ëèöà, âûçûâàþò âåíîçíûé çàñòîé, ñïîñîáñòâóÿ íàðàñòàíèþ îòåêà ÃÌ [5, 10]. Íà ìíîãî÷èñëåííîì êëèíè÷åñêîì ìàòåðèàëå óñòàíîâëåíî, ÷òî, òàê íàçûâàåìàÿ, ëåãêàÿ ÒØÎÏ âûçûâàåò â îòäàëåííîì ïåðèîäå ïðàêòè÷åñêè ó êàæäîãî âòîðîãî ïàöèåíòà ðàçíîîáðàçíûå íàðóøåíèÿ: îò ëåãêîé âåãåòàòèâíîé äèñòîíèè, àñòåíèçàöèè, óìåðåííûõ îáùåìîçãîâûõ ðàññòðîéñòâ äî ýïèëåïòè÷åñêèõ, äèýíöåôàëüíûõ ïðèñòóïîâ, íàðóøåíèé âèñöåðàëüíûõ ôóíêöèé è ïñèõè÷åñêîãî ñòàòóñà, ÷òî îáóñëîâëåíî âûðàæåííîñòüþ ñòðóêòóðíûõ è ôóíêöèîíàëüíûõ íàðóøåíèé [12-15]. Ïðè ýòîì ó 50 % áîëüíûõ ñ ëåãêîé ÒØÎÏ ïðîèñõîäèò ïðîãðåäèåíòíîå íàðàñòàíèå ïàòîëîãè÷åñêèõ ïðîÿâëåíèé, ïðè÷åì â ïîëîâèíå ñëó÷àåâ ïðîöåññû íå ñòàáèëèçèðîâàëèñü [12, 13]. Êàê ïîêàçàë àíàëèç ñîáñòâåííûõ íàáëþäåíèé, ïðåîáëàäàþò òðàâìû øåéíîãî îòäåëà ïîçâîíî÷íèêà è ïàðàâåðòåáðàëüíûõ òêàíåé ó ëèö ìóæñêîãî ïîëà (67,0 % íàáëþäåíèé), áîëüøå ïîëîâèíû ñëó÷àåâ ïðèõîäèòñÿ íà òðóäîñïîñîáíûé âîçðàñò 20-50 ëåò (65,5 % íàáëþäåíèé). Ñðåäè ïðè÷èí âîçíèêíîâåíèÿ ïîâðåæäåíèé øåéíîãî îòäåëà ïîçâîíî÷íèêà è ïàðàâåðòåáðàëüíûõ òêàíåé íà ïåðâîì ìåñòå – áûòîâûå òðàâìû.  ñòðóêòóðå òðàâì øåéíîãî îòäåëà ïîçâîíî÷íèêà è ïàðàâåðòåáðàëüíûõ òêàíåé äîìèíèðóþò ðîòàöèîííûå ïîäâûâèõè àòëàíòà – áîëåå 60,0 % íàáëþäåíèé. Ïåðåëîìû ïîçâîíî÷íèêà ñîñòàâèëè – 19,0 % íàáëþäåíèé, ïîñòòðàâìàòè÷åñêèé ìèîçèò, ïîâðåæäåíèå ñâÿçî÷íîãî àïïàðàòà øåéíîãî îòäåëà ïîçâîíî÷íèêà – 6,0 % íàáëþäåíèé, ïîñòòðàâìàòè÷åñêàÿ íåñòàáèëüíîñòü – 4,2 % íàáëþäåíèé, óøèá øåéíîãî îòäåëà ïîçâîíî÷íèêà – 9,0 % íàáëþäåíèé. Ïðè ñóäåáíî-ìåäèöèíñêîé ýêñïåðòíîé îöåíêå ê òÿæêèì òåëåñíûì ïîâðåæäåíèÿ ïî êðèòåðèþ «îïàñíîñòü äëÿ æèçíè» «Ïðàâèë ñóäîâî-ìåäè÷íîãî âèçíà÷åííÿ ñòóïåíÿ òÿæêîñò³ ò³ëåñíèõ óøêîäæåíü» (Íàêàç ÌÎÇ Óêðà¿íè ¹ 6 îò 17. 01. 95 ã.), ýêñïåðòàìè îòíåñåíû: â 12,0 % íàáëþäåíèé ïåðåëîìû øåéíîãî îòäåëà ïîçâîíî÷íèêà, â 3,0 % íàáëþäåíèé ðîòàöèîííûå ïîäâûâèõè àòëàíòà; ê ïîâðåæäåíèÿì ñðåäíåé ñòåïåíè òÿæåñòè ïî êðèòåðèþ äëèòåëüíîñòü ðàññòðîéñòâà çäîðîâüÿ «Ïðàâèë…» ýêñïåðòàìè îòíåñåíû: â 56,0 % ñëó÷àåâ ðîòàöèîííûå ïîäâûâèõè àòëàíòà; â 7,0 % ñëó÷àåâ ïåðåëîìû øåéíîãî îòäåëà ïîçâîíî÷íèêà; â 2,6 % íàáëþäåíèé ïîâðåæäåíèÿ ñâÿçî÷íîãî àïïàðàòà øåéíîãî îòäåëà ïîçâîíî÷íèêà. Ê ëåãêèì òåëåñíûì ïîâðåæäåíèÿì, ïîâëåêøèì çà ñîáîé êðàòêîâðåìåííîå ðàññòðîéñòâî çäîðîâüÿ, ýêñïåðòàìè îòíåñåíû: â 3,8 % íàáëþäåíèé ïîñòòðàâìàòè÷åñêàÿ íåñòàáèëüíîñòü, â 5,4 % íàáëþäåíèé ðîòàöèîííûå ïîäâûâèõè àòëàíòà. Äëèòåëüíîñòü ëå÷åíèÿ áîëüøèíñòâà ïîñòðàäàâøèõ â ýòèõ ñëó÷àÿõ, ñîñòàâèëà îò 7 äî 21 ñóòîê. Ê ëåãêèì òåëåñíûì ïîâðåæäåíèÿì ýêñïåðòàìè îòíåñåíû: â 9,6 % íàáëþäåíèé óøèá øåéíîãî îòäåëà ïîçâîíî÷íèêà, â 5,2 % íàáëþäåíèé ïîâðåæäåíèé ñâÿçî÷íîãî àïïàðàòà øåéíîãî îòäåëà ïîçâîíî÷íèêà, ïîñòòðàâìàòè÷åñêèé ìèîçèò, â 3,8 % íàáëþäåíèé ³ñíèê ïðîáëåì á³îëî㳿 ³ ìåäèöèíè – 2015 – Âèï. 2, Òîì 3 (120) 393 ÑÓÄÎÂÀ ÌÅÄÈÖÈÍÀ ðîòàöèîííûå ïîäâûâèõè àòëàíòà, â 2,4 % íàáëþäåíèé ïîñòòðàâìàòè÷åñêàÿ íåñòàáèëüíîñòü øåéíîãî îòäåëà ïîçâîíî÷íèêà. Äëèòåëüíîñòü ëå÷åíèÿ ïîñòðàäàâøèõ â ýòèõ ñëó÷àÿõ, ñîãëàñíî ñóäåáíî-ìåäèöèíñêèõ äîêóìåíòîâ, ñîñòàâèëà äî 7 ñóòîê. Îòäåëüíûå òðàâìû øåéíîãî îòäåëà ïîçâîíî÷íèêà â ýòèõ ñëó÷àÿõ, ïî íàøåìó ìíåíèþ äîëæíû áûëè áû îöåíåíû êàê áîëåå ñåðüåçíûå ïîâðåæäåíèÿ, ñ ó÷åòîì îáû÷íîé äëèòåëüíîñòè òå÷åíèÿ òðàâìàòè÷åñêîé áîëåçíè è èñõîäîâ. Òàêèì îáðàçîì, ñóäåáíî-ìåäèöèíñêèìè ýêñïåðòàìè, â áîëåå ÷åì 15,0 % íàáëþäåíèé, ïîâðåæäåíèÿ îöåíåíû êàê òÿæêèå; â 64,0 % íàáëþäåíèé êàê ñðåäíåé òÿæåñòè; 7,8 % íàáëþäåíèé, êàê ëåãêèå òåëåñíûå ïîâðåæäåíèÿ, ïîâëåêøèå çà ñîáîé êðàòêîâðåìåííîå ðàññòðîéñòâî çäîðîâüÿ; â 19,0 % íàáëþäåíèé, êàê ëåãêèå òåëåñíûå ïîâðåæäåíèÿ. Ïî-âèäèìîìó, â çàâèñèìîñòè îò ìåõàíèçìà ÒØÎÏ öåëåñîîáðàçíî èñïîëüçîâàòü äîïîëíèòåëüíûå ïðîåêöèè, ÷òî ïîçâîëèò îáúåêòèâèçèðîâàòü õàðàêòåð ïîâðåæäåíèé àíàòîìè÷åñêîé öåëîñòè òêàíåé øåéíîãî îòäåëà ïîçâîíî÷íèêà ó ïîñòðàäàâøèõ. Ïðè «õëûñòîâûõ» òðàâìàõ íåîáõîäèìî ïðîâîäèòü ôóíêöèîíàëüíóþ ñïîíäèëîãðàôèþ â áîêîâîé ïðîåêöèè äëÿ âèçóàëèçàöèè ðàçðûâîâ íàä- è ìåæîñòèñòûõ ñâÿçîê, è â êîñûõ (3/4) ïðîåêöèÿõ – äëÿ äèàãíîñòèêè ïîâðåæäåíèé êàïñóëüíî-ñâÿçî÷íîãî àïïàðàòà äóãîîòðîñòêîâûõ ñóñòàâîâ. Ïðè ñãèáàòåëüíî-âðàùàòåëüíûõ òðàâìàõ öåëåñîîáðàçíî ïðîâîäèòü ðåíòãåíîãðàôèþ â ïåðåäíå-çàäíåé ïðîåêöèè ÷åðåç ðîò äëÿ âûÿâëåíèÿ ðàçðûâîâ ñâÿçîê â ñóñòàâå Êðþâåëüå. Àíàëèç ðÿäà ýêñïåðòèç ïîêàçàë, ÷òî â ñëó÷àÿõ ïîâðåæäåíèé ïàðàâåðòåáðàëüíûõ òêàíåé ïîçâîíî÷íèêà, íå ïðîâîäÿòñÿ ñîíîãðàôèÿ, ïîâåðõíîñòíàÿ ñòèìóëÿöèÿ, ýëåêòðîìèîãðàôèÿ, ïîçâîëÿþùèå îáúåêòèâíîãî îöåíèòü õàðàêòåð òàêèõ ïîâðåæäåíèÿ. Îáðàùàåò íà ñåáÿ âíèìàíèå, ÷òî â òåõ ñëó÷àÿõ, êîãäà ó ïîñòðàäàâøèõ èìåþòñÿ ïîâðåæäåíèÿ òîëüêî ìÿãêèõ òêàíåé øåè, è îíè íå íàõîäèëèñü íà ëå÷åíèè, ýêñïåðòû íå íàïðàâëÿþò èõ íà êîíñóëüòàöèþ ê òðàâìàòîëîãó, íåâðîïàòîëîãó. Íå ïðîâîäÿòñÿ äîïîëíèòåëüíûå èññëåäîâàíèÿ, äàæå â òåõ ñëó÷àÿõ, êîãäà ïîñòðàäàâøèå ïðåäúÿâëÿþò ñîîòâåòñòâóþùèå æàëîáû. Òàêèì îáðàçîì, äàííûå ëèòåðàòóðû ñâèäåòåëüñòâóþò, ÷òî ×ËÒ ñîïðîâîæäàåòñÿ ÒØÎÏ, îäíàêî â ëèòåðàòóðå íåò îäíîçíà÷íûõ äàííûõ î ÷àñòîòå ýòîé ïàòîëîãèè è âåðèôèêàöèè åå ñ ïîìîùüþ ëàáîðàòîðíûõ è èíñòðóìåíòàëüíûõ èññëåäîâàíèé, â òîì ÷èñëå, ÊÒ, òîãäà êàê êðèòåðèè äèàãíîñòèêè íåâðîëîãè÷åñêèõ íàðóøåíèé ïðè, òàê íàçûâàåìîé ëåãêîé ÒØÎÏ, ÷àñòî ñîïðîâîæäàþùåé ×ËÒ, íå ðàçðàáîòàíû.  òîæå âðåìÿ, îöåíêà ñòåïåíè òÿæåñòè òåëåñíûõ ïîâðåæäåíèé, çà÷àñòóþ íå ó÷èòûâàåò ñîñóäèñòîðåôëåêòîðíûõ ðàññòðîéñòâ, íàðóøåíèé ôóíêöèé îïîðíî-äâèãàòåëüíîãî àïïàðàòà è íåêîòîðûõ äðóãèõ ïàòîãåíåòè÷åñêè âçàèìîñâÿçàííûõ ôóíêöèîíàëüíûõ è ñòîéêèõ ðàññòðîéñòâ çäîðîâüÿ. Âûâîäû. 1. Òðàâìû ØÎÏ çà÷àñòóþ èìåþò ñî÷åòàííûé õàðàêòåð ñ òðàâìàìè ËÑ è, íàîáîðîò òðàâìû ËÑ, âñëåäñòâèå îáùåãî áèîìåõàíè÷åñêîãî ôàêòîðà, ñîïðîâîæäàþòñÿ ïàòîãåíåòè÷åñêèìè íàðóøåíèÿìè â ØÎÏ, ÷òî â ïðàêòèêå ñóäåáíî-ìåäèöèíñêèõ èññëåäîâàíèé ïðåäîïðåäåëÿåò êîìïëåêñíîñòü îáñëåäîâàíèÿ ïðè ýêñïåðòèçå æèâûõ ëèö. 2. Îòñóòñòâèå åäèíûõ ñóäåáíî-ìåäèöèíñêèõ êðèòåðèåâ äëÿ îöåíêè ñòåïåíè òÿæåñòè ÒØÎÏ îïðåäåëÿåò ïåðñïåêòèâíûå íàïðàâëåíèÿ íàó÷íûõ ðàáîò ïî äàííîé òåìå, êîòîðûå äîëæíû áàçèðîâàòüñÿ íà êîìïëåêñíîì ó÷¸òå ôóíêöèîíàëüíûõ è ñòîéêèõ ðàññòðîéñòâ çäîðîâüÿ. 3. Ñðåäè ìåòîäîâ êëèíè÷åñêîé äèàãíîñòèêè è êëèíèêî-ìîðôîëîãè÷åñêîé âåðèôèêàöèè ïðè îöåíêå ñòåïåíè òÿæåñòè òåëåñíûõ ïîâðåæäåíèé ïðè ÒØÎÏ ïåðñïåêòèâíûìè ÿâëÿþòñÿ îöåíêà ñîñòîÿíèÿ öåðåáðàëüíîé ãåìîäèíàìèêè, ðåàêòèâíîñòè ÃÌ, ìåòîäû îöåíêè îïîðíî-äâèãàòåëüíûõ ôóíêöèé ïîçâîíî÷íèêà. Ïåðñïåêòèâû äàëüíåéøèõ èññëåäîâàíèé â ýòîì íàïðàâëåíèè ñâÿçàíû ñ îïðåäåëåíèåì èíôîðìàòèâíîñòè êðèòåðèåâ íåèíâàçèâíîé äèàãíîñòèêè äëÿ ïîâûøåíèÿ òî÷íîñòè ñóäåáíî-ìåäèöèíñêîé îöåíêè ñòåïåíè òÿæåñòè ïîâðåæäåíèé. Ëèòåðàòóðà 1. 2. 3. 4. 5. 6. 7. 8. 9. Àâäååâ Ì. È. Ñóäåáíî-ìåäèöèíñêàÿ ýêñïåðòèçà æèâûõ ëèö / Ì. È. Àâäååâ. – Ì. : Ìåäèöèíà, 1968. – 376 ñ. Àëåêñååíêî Þ. Â. Ñòðóêòóðà êëèíè÷åñêèõ ïðîÿâëåíèé è ìèíèìàëüíûå äèàãíîñòè÷åñêèå êðèòåðèè ëåãêèõ ÷åðåïíîìîçãîâûõ ïîâðåæäåíèé / Þ. Â. Àëåêñååíêî // Âåñòí. Âèòåá. ãîñ. ìåä. óí-òà. – 2002. – Ò. 1, ¹ 1. – Ñ. 90–95. Àëèìîâà Ì. ß. Ðàçâèòèå ìåæäèñöèïëèíàðíûõ âçàèìîäåéñòâèé ïðè ëå÷åíèè ïàöèåíòîâ ñòîìàòîëîãè÷åñêîãî ïðîôèëÿ / Ì. ß. Àëèìîâà, Ì. Ê. Ìàêååâà, À. Â. Àëèìîâà // Àííàëû õèðóðãèè. – 2006. – ¹ 5. – Ñ. 23–26. Àëü Àëàâíè Ñ. Â. Âëèÿíèå ðàñòèòåëüíûõ ïîëèôåíîëîâ íà èììóíîëîãè÷åñêèå è áèîõèìè÷åñêèå ïîêàçàòåëè ñëþíû ïðè ÷åðåïíî-ìîçãîâîé è ëèöåâîé òðàâìàõ / Ñ. Â. Àëü Àëàâíè, Î. Â. Äåíüãà // ³ñíèê ñòîìàòîëîã¿. – 2005. – ¹ 4. – Ñ. 39–41. Áåðíàäñêèé Þ. È. Òðàâìàòîëîãèÿ è âîññòàíîâèòåëüíàÿ õèðóðãèÿ ÷åðåïíî-÷åëþñòíî-ëèöåâîé îáëàñòè / Þ. È. Áåðíàäñêèé. – 3-å èçä., ïåðåðàá. è äîï. – Ì. : Ìåä. ëèò., 2006. – 456 ñ. Äìèòðèåâà À. Ì. Íåéðîðåíòãåíîäèàãíîñòèêà çàêðûòîé òðàâìû øåéíîãî îòäåëà ïîçâîíî÷íèêà (ìåòîäè÷åñêèå ðåêîìåíäàöèè) / À. Ì. Äìèòðèåâà, Â. Ä. Êðèâîùåêîâ, Ë. È. Áîðèñîâà. – Ïåðìü : ÏÃÌÀ, 2003. – 18 ñ. Åîë÷èÿí À. Ñ. Ìóëüòèäèñöèïëèíàðíûé ïîäõîä ê õèðóðãèè êðàíèîôàöèàëüíîé òðàâìû / À. Ñ. 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Ñóäåáíàÿ ìåäèöèíà : Ðóêîâîäñòâî äëÿ âðà÷åé / Ïîä ðåä. À. À. Ìàòûøåâà. – 3-å. èçä., ïåðåðàá. è äîï. – ÑÏá. : Ãèïïîêðàò, 1998. – 544 ñ.: èë., òàáë. – Áèáëèîãð.: ñ. 535-542. 22. Ñóäåáíî-ìåäèöèíñêàÿ îöåíêà êëèíè÷åñêèõ è áèîìåõàíè÷åñêèõ èçìåíåíèé ïðè ìåõàíè÷åñêèõ ïîâðåæäåíèÿõ ñâÿçî÷íîãî àïïàðàòà øåéíîãî îòäåëà ïîçâîíî÷íèêà / Å. Ñ. Òó÷èê, Â. À. Åïèôàíîâ, À. Â. Åïèôàíîâ, Ò. À. Èâàíåíêî // Ñóäåáíîìåäèöèíñêàÿ ýêñïåðòèçà : íàó÷íî-ïðàêòè÷åñêèé æóðíàë. – 2005. – ¹ 3. – Ñ. 14-18. 23. Òðàâìàòîëîãèÿ ÷åëþñòíî-ëèöåâîé îáëàñòè / Ïîä ðåä. Â. Î. Êåíáàåâà. – Øûìêåíò, 2006. – 118 ñ. 24. Óíæàêîâ Â. Â. Äèíàìèêà êîíöåíòðàöèè íåêîòîðûõ ãîðìîíîâ ñòðåññà â ïîñòòðàâìàòè÷åñêîì ïåðèîäå ó áîëüíûõ ñ òÿæåëîé ÷åðåïíî-ìîçãîâîé òðàâìîé / Â. Â. Óíæàêîâ // Ìàò-ëû III Ñúåçäà íåéðîõèðóðãîâ Ðîññèè, 4-8 èþëÿ 2002. – ÑÏá., 2002. – Ñ. 67. 25. Õîõëîâ Â. Â. Ñóäåáíàÿ ìåäèöèíà : Ðóêîâîäñòâî / Â. Â. Õîõëîâ. – Ñìîëåíñê, 2010. – 992 ñ. 26. Adams C. D. 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Stark M. M. Physician’s Guide to Clinical Forensic Medicine (Forensic Science) / M. M. Stark. – USA : Humana Press, 2000 – 326 p. 33. Weider L. Early versus Delayed Repair of Facial Fractures in the Multiply Injured Patient / L. Weider, K. Hughes, J. Ciarochi, E. Dunn // Amer. Surg. – 1999. – Vol. 65. – P. 790-793. ÓÄÊ 340. 6:616. 711. 1-001. 5-079. 5 ÏΪÄÍÀͲ Ò²ËÅÑͲ ÓØÊÎÄÆÅÍÍß ØÈÉÍÎÃΠ²ÄIJËÓ ÕÐÅÁÒÀ ÒÀ ÙÅËÅÏÍÎ-ËÈÖÜÎÂÀ ÒÐÀÂÌÀ: ÑÓÄÎÂÎ-ÌÅÄÈ×ÍÈÉ ÀÑÏÅÊÒ Ìèõàéëè÷åíêî Á. Â., Ôðàí÷óê Â. Â., Ãðèãîðîâ Ñ. Í., Øêëÿð À. Ñ. Ðåçþìå. Âèçíà÷åíî, ùî òðîàâìè øèéíîãî â³ää³ëó õðåáòà ÷àñòî ìàþòü ïîºäíàíèé õàðàêòåð ç óøêîäæåííÿì ëèöåâîãî ÷åðåïà, óíàñë³äîê ñï³ëüíîãî á³îìåõàí³÷íîãî ôàêòîðà, ùî â ïðàêòèö³ ñóäîâî-ìåäè÷íèõ äîñë³äæåíü âèçíà÷ຠïîòðåáó ó êîìïëåêñíîìó îáñòåæåíí³. Ñåðåä ìåòîä³â êë³í³÷íî¿ ä³àãíîñòèêè òà êë³í³êîìîðôîëîã³÷íî¿ âåðèô³êàö³¿ ïðè îö³íö³ ñòóïåíÿ òÿæêîñò³ ò³ëåñíèõ óøêîäæåíü ïðè òðàâìàõ øèéíîãî â³ää³ëó ïåðñïåêòèâíèìè º: îö³íêà ñòàíó öåðåáðàëüíî¿ ãåìîäèíàì³êè, ðåàêòèâíîñò³ ÃÌ, ìåòîäè îö³íêè îïîðíî-ðóõîâèõ ôóíêö³é õðåáòà. Êëþ÷îâ³ ñëîâà: øèéíèé â³ää³ë õðåáòà, ëèöüîâèé ñêåëåò, ñóäîâî-ìåäè÷íà åêñïåðòèçà, ò³ëåñí³ óøêîäæåííÿ. ³ñíèê ïðîáëåì á³îëî㳿 ³ ìåäèöèíè – 2015 – Âèï. 2, Òîì 3 (120) 395 ÑÓÄÎÂÀ ÌÅÄÈÖÈÍÀ ÓÄÊ 340. 6:616. 711. 1-001. 5-079. 5 ÑÎ×ÅÒÀÍÍÛÅ ÒÅËÅÑÍÛÅ ÏÎÂÐÅÆÄÅÍÈß ØÅÉÍÎÃÎ ÎÒÄÅËÀ ÏÎÇÂÎÍÎ×ÍÈÊÀ È ×ÅËÞÑÒÍÎËÈÖÅÂÀß ÒÐÀÂÌÀ: ÑÓÄÅÁÍÎ-ÌÅÄÈÖÈÍÑÊÈÉ ÀÑÏÅÊÒ Ìèõàéëè÷åíêî Á. Â., Ôðàí÷óê Â. Â., Ãðèãîðîâ Ñ. Í., Øêëÿð À. Ñ. Ðåçþìå. Ïîêàçàíî, ÷òî òðàâìû øåéíîãî îòäåëà ïîçâîíî÷íèêà çà÷àñòóþ èìåþò ñî÷åòàííûé õàðàêòåð ñ òðàâìàìè ëèöåâîãî ñêåëåòà è, íàîáîðîò òðàâìû ëèöåâîãî ñêåëåòà, âñëåäñòâèå îáùåãî áèîìåõàíè÷åñêîãî ôàêòîðà, ÷òî â ïðàêòèêå ñóäåáíî-ìåäèöèíñêèõ èññëåäîâàíèé ïðåäîïðåäåëÿåò êîìïëåêñíîñòü îáñëåäîâàíèÿ ïðè ýêñïåðòèçå æèâûõ ëèö. Ñðåäè ìåòîäîâ êëèíè÷åñêîé äèàãíîñòèêè è êëèíèêî-ìîðôîëîãè÷åñêîé âåðèôèêàöèè ïðè îöåíêå ñòåïåíè òÿæåñòè òåëåñíûõ ïîâðåæäåíèé ïðè òðàâìàõ øåéíîãî îòäåëà ïåðñïåêòèâíûìè ÿâëÿþòñÿ îöåíêà ñîñòîÿíèÿ öåðåáðàëüíîé ãåìîäèíàìèêè, ðåàêòèâíîñòè ÃÌ, ìåòîäû îöåíêè îïîðíî-äâèãàòåëüíûõ ôóíêöèé ïîçâîíî÷íèêà. Êëþ÷åâûå ñëîâà: øåéíûé îòäåë ïîçâîíî÷íèêà, ëèöåâîé ñêåëåò, ñóäåáíî-ìåäèöèíñêàÿ ýêñïåðòèçà, òåëåñíûå ïîâðåæäåíèÿ. UDC 340. 6:616. 711. 1-001. 5-079. 5 Combined Injuries of the Cervical Spine and Ma x illofacial Trauma: Forensic Medical Aspects Mikhaylichenko B. V., Franchuk V. V., Grigorov S. N., Shkliar A. S. Abstract. The aim of the work is the content analysis of pathogenetic preconditions of improving forensic e x pertise of the cervical spine injuries (isolated and combined with injuries of the facial skeleton) in living persons. Results and discussion. It has been found out that the factor, determining the combination of the cervical spine injuries (CSI) and ma x illofacial trauma, is an anatomical, topographical and functional unity of cranial and facial parts of the skull. The specific feature of the combined trauma is that the brain damage can occur in the absence of impact on the cranial vault as well, i. e. such injuries can be caused by the traumatic agent`s intervention, or by the influence on the cranial and facial parts of the skull simultaneously. The analysis of CSI when having a ma x illofacial trauma and its consequences has shown that the vast majority of victims have various intracranial manifestations: due to computed tomography (CT), focal damage of the frontal and temporal lobes of the brain is dominant, as well as fractures of the base of the anterior cranial fossa, accompanied by nasal cerebrospinal fluid. Minimal diagnostic criteria for mild brain injuries in patients with suspected mild CSI can assume the presence of mild focal symptoms of fractures of the cranial vault, subarachnoid hemorrhage and changes of brain matter. At the same time, heavy ma x illofacial traumas bother to assess the severity of CSI. Bleeding in the eyelid fiber and eye sclera simulates a fracture of the skull base and makes it difficult to study the function of oculomotor nerves and e x amine the eyeground. The trigeminal, facial, oculomotor nerve damage can simulate focal symptoms. Jaw injury, falling back of tongue, obstruction of the upper airway with mucus, blood, and bone fragments, teeth debris and dentures cause obturation of the upper respiratory tract, respiratory failure, worsening brain hypoxia. Sinus damage, being observed while fracture of the frontal bone, ma x illa or nasal bones, contributes to ascending infection; when liquorrhea it leads to the formation of cerebrospinal fluid fistula. Reactive edema, accompanied the facial and jaw injuries, the development of inflammatory infiltrates lead to compression of the neck vessels, deep facial veins, causing venous stasis and promoting the rise of brain edema. Due to analysis of our own observations, the CSI and traumas of paravertebral tissues in males (67.0 % of cases) are dominated, more than half of cases occur in working age of 20-50 (65.5 % of cases). Among the causes of the CSI and traumas of paravertebral tissues household injuries are on the first place. In the structure of the CSI and traumas of paravertebral tissues rotary sublu x ation of the atlas are dominated − more than 60.0 % of cases. Vertebral fractures are 19.0 % of cases; post-traumatic myositis, damage of ligamentous apparatus of the cervical spine cover 6.0 % of cases; post-traumatic instability − 4.2 % of cases, the cervical spine contusion − 9.0 % of cases. Noteworthy is that the forensic diagnosis is not always carried out with additional investigations and involving necessary professional consultants. Thus, only in 11.5 % of cases of rotary sublu x ation of the atlas computed tomography was carried out allowing to diagnose this type of injury objectively indeed. Only in 34.0 % of cases the victims with such injuries were consulted by a neurologist, who established the corresponding neurological symptoms. We should like to draw your attention of the fact that the x -rays of the cervical spine in most e x aminations are performed in standard projections; additional projections − functional lateral projection, oblique projections, the anteroposterior projection through the mouth − are not carried out. Radiography of traumatic changes of the intervertebral discs, joint capsules, ligament apparatus and paravertebral tissues is carried out at a scoping study only in two projections, which in some cases can be uninformative. It has been shown that the CSI are often combined with injuries of the facial skeleton, and vice versa injuries of the facial skeleton, due to the general biomechanical factors, are accompanied by pathogenic abnormalities in the cervical region, that in the practice of forensic research determines the comprehensive e x amination of living persons. Among the methods of clinical diagnosis, and clinical and morphological verification in evaluating the severity of injuries in case of the CSI the assessment of cerebral hemodynamics, brain reactivity, methods of assessment of locomotor spine function are considered to be prospective. Keywords: cervical spine, facial skeleton, forensic e x pertise, injuries. Ðåöåíçåíò – ïðîô. Àâåò³êîâ Ä. Ñ. Ñòàòòÿ íàä³éøëà 27. 02. 2015 ð. 396 ³ñíèê ïðîáëåì á³îëî㳿 ³ ìåäèöèíè – 2015 – Âèï. 2, Òîì 3 (120)
