RU2154432C2 - Method for treating the cases of spondylolisthesis of lumbar vertebral column segment - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making skin cut along the spinous processes line, transecting thoracolumbar fascia, separating paravertebral muscles, resecting dislocated vertebra arches and yellow ligament, making diskectomy, reposition and fixation of the dislocated vertebra by means of two devices produced from a material possessing thermomechanical memory property, having hooks at the ends and two loops in the middle part. The loops and hooks are arranged in the same plane. A device is attached to transverse process of the dislocated vertebra with one hook and to the arch of the underlying one with its second hook. The last lumbar vertebra dislocation being the case, it is attached to the transverse process of the dislocated vertebra and sacral bone. EFFECT: enhanced effectiveness of treatment; prevented spinal cord compression; restored cerebrospinal canal parameters. 4 dwg

Description

 The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics in the treatment of spondylolisthesis.

 A known method for the treatment of spondylolisthesis, including the gradual extension of the displaced vertebra through a spoke drawn through the arch of the displaced vertebra and fixed in the supports of the Ilizarov apparatus (AS USSR N 566563).

 However, the known method does not provide adequate decompression of the neurovascular elements of the spinal canal and can be used only for mild spondylolisthesis, since significant spondylolisthesis causes gross changes in the articular-ligamentous apparatus and intervertebral disc of the affected vertebral segment, which complicates the reposition of the vertebra, and considerable effort necessary for traction can lead to teething. This method is often combined with anterior corporodesis according to Chaklin (V. Chaklin, “A New Method of Spinal Surgery,” Proceedings of Scientific Research Institutes, Sverdlovsk, 1933. From 113-121), which significantly increases the operation time and the risk to the patient’s life when it conducting and risk of postoperative complications.

 As a prototype, a method of treating spondylolisthesis of the lumbar spine is taken (patent RU N 2066140, A 61 B 17/56, 17/70, 1996).

 The operation is performed under endotracheal anesthesia, a soft tissue incision is made along the spinous processes. Skeletal arches of the displaced vertebra are performed, two above and two lower relative to the displaced vertebrae, the spinous process is removed from the displaced vertebra, and a yellow ligament is cut above and below it. The chisel performs discotomy of the underlying disc with respect to the displaced vertebra. A fixing unit is brought under the arch plate of the displaced vertebra, in addition, fixators in the form of screws are inserted into each leg of the arch of two above and two underlying vertebrae, onto which four supports are made in the form of plates. The supports are connected in pairs by a U-shaped bar. After traction during surgery, the ends of the clamps are brought out to the skin through punctures, the wound is sutured in layers, the device is mounted on the clamps above the skin and traction is performed until the listez is completely eliminated, periodically conducting x-ray control.

The disadvantages of the method are:
1. Extensive surgical access (two vertebrae above spondylolisthesis and two vertebrae below).

 2. The need to separate the paravertebral muscles at the level of the entire lumbar for access to the legs of the vertebral arches from two sides, which entails significant bleeding during surgery and subsequent degeneration of the muscle.

 3. Violation of the biomechanics of the spine due to the removal of the spinous process of the displaced vertebra, limiting posterior extension of the spine, supraspinatus and interosseous ligaments, limiting the body's forward inclination.

 4. The complexity of the device used both in manufacture and during installation.

 5. The risk of infectious complications associated with communicating the area of operation with the external environment by means of clamps inserted into the legs of the vertebral arches, the second ends of which are brought out through skin punctures, to install the external part of the device.

 6. Long term treatment.

 7. The need for inpatient medical rehabilitation.

 8. The need for reoperation to remove the subcutaneous elements of the device.

 The invention is aimed at creating a method of surgical treatment of spondylolisthesis of the lumbar spine, providing restoration of the parameters of the spinal canal, full decompression of the neurovascular elements of the spine, maximum preservation of its musculoskeletal elements, minimizing muscle trauma, blood loss, postoperative complications, reducing the patient’s stay in hospital and disability periods.

 The essence of the invention lies in the fact that a skin incision is made along the line of the spinous processes, the thoracolumbar fascia is cut, the paravertebral muscles are separated, the arch of the displaced vertebra, the yellow ligament are resected, the volume of the spinal canal is expanded, discectomy, reposition and fixation of the displaced vertebra are carried out using two parallel devices made of material with thermomechanical shape memory having hooks at the ends and two loops in the middle, made in one plane, with one hook com the device is fixed for the transverse process of the displaced vertebra, and the second for the bow of the subject, or for the transverse process of the displaced vertebra and the sacral bone in case of displacement of the last lumbar vertebra.

 The invention is illustrated by drawings, where in FIG. 1 shows a cross section of the spine, explaining the mechanism of compression of the neurovascular elements in spondylolisthesis. In FIG. 2 shows the device in its true form and after deformation for installation on the spine. In FIG. 3 is a diagram of the installation of structures on the spine after decompression.

 The drawings show: the vertebral body 1, the arch 2, the spinous process 3, the vertebral canal 4, the dural sac 5, the root 6, the supraspinatus ligament 7, the interosseous ligament 8, the device 9, the transverse process 10, the intervertebral disc 1.

 In FIG. 4 shows the vectors of forces acting on the displaced vertebra after the installation of devices.

 The method is as follows. Under endotracheal anesthesia, the patient is placed face down on the operating table, a roller is placed under the abdomen above the level of the leafy for positional reposition of the vertebra.

 A skin incision is made along the line of the spinous processes, the thoracic lumbar fascia is cut, the paravertebral muscles are separated from the spinous processes and vertebral arches, the arch of the 2 displaced vertebra, the yellow ligament are resected, diskectomy of the underlying disc 11 is performed relative to the displaced vertebra, if necessary, the upper vertebra and produce foraminotomy, which ensures adequate decompression of the vascular-neural formations of the spinal canal. Reposition and fixation of the displaced vertebra is achieved using a device 9 made of a material having a thermomechanical shape memory, having hooks at the ends and two loops in the middle, made in the same plane.

Cooled to 5-8 ^° C, the device is deformed for installation (Fig. 2), then one of the hooks is inserted behind the transverse process 10 of the displaced vertebra, the other behind the arch 2 of the underlying vertebra, or the sacral bone in case of damage to the L5-S1 segment. Similarly install the second device on the other hand. Then the device 9 is irrigated with physiological saline heated to 60-70 ^o C. Due to the memory effect, the forms of the device tend to take their original shape and act on the displaced vertebra with a force directed in the direction opposite to the deformation (figure 4). Thus, the force vector directed at an angle to the axis of the spine has two components - horizontal and vertical. Moreover, the closer the fixation points are located vertically to each other, and the greater the degree of leafesis, the greater the angle α and the magnitude of the horizontal corrective component. At the same time, the vertical component ensures a tight fit of the vertebral bodies and creates optimal conditions for the consolidation of the affected segment. After controlling hemostasis, the wound is sutured in layers tightly. On the second day, the patient is allowed to get up, discharged home on 9-10 days after surgery.

 If the patient’s profession is not associated with heavy physical exertion, he can immediately begin work after discharge.

 The inventive method of treating spondylolisthesis of the lumbar spine was used by us to treat 23 patients, long-term results were traced in terms from 4 months to 3 years.

 We give clinical examples (extracts from medical records).

 Example 1. Patient G ..., T.E., 45 years old, female employee, medical history N 563, was admitted to the clinic 1.02.96, with complaints of pain in the lumbar spine, radiating along the outer lateral surface of both legs , weakness in them, limitation of the distance of painless walking to 150 m, after which she is forced to stop for rest. There were dysfunctions of the pelvic organs according to the type of weakness of the sphincter of the bladder. An examination revealed the presence of spondylolisthesis L4 3-4 degrees. 02/14/96, according to the claimed method, an operation was performed, the arch of the fourth vertebra, the yellow ligament, the degeneratively changed intervertebral disc were removed. Installed devices with thermomechanical shape memory, having hooks at the ends and two loops in the middle, made in one projection. The pain disappeared immediately after the operation. On the second day the patient was allowed to get up, from the third day to walk and sit. The sutures were removed on the 10th day, 06/23/96, the patient was discharged home. She currently feels well and works in her specialty.

 Example 2. Patient G ..., V.I., 38 years old, disabled person of 2 groups, medical history N 8378, was admitted 05.15.95, with complaints of pain in the lumbar spine, radiating along the back surface of both legs, more right , limited walking distance to 15-20 m. Moved leaning on a cane. Neurologically: Akhilov’s reflex decrease on the left and absence on the right, weakness in the extensors of both feet, more on the right, hypesthesia in zone S1, more on the right. A history of two operations of the anterior corporodesis according to Chaklin, which were unsuccessful. There was a deepening of listhes, an increase in pathological symptoms. Examination (spondylography, NMR) revealed the presence of L5 spondylolisthesis with compression of the neurovascular elements of the spinal canal. The situation was complicated by the presence of a severe coronary heart disease in a patient with a history of two myocardial infarction. After preparation, the patient was operated according to the claimed method. The operation lasted 45 minutes. After decompression of the neurovascular formations of the spinal canal, two devices with thermomechanical shape memory were installed, each of which was fixed with one hook for the transverse process of the fifth lumbar vertebra, and the other for the sacral bone, for which two holes were formed in the latter. Pain syndrome regressed, the patient walks without the help of a cane, the walking distance is unlimited. In the neurological status, only the absence of the Akhilov reflex to the right and a decrease in strength in the extensors of the right foot by 0.5 points remained.

Using the proposed method allows you to:
1. To minimize the amount of blood loss, to preserve such an important element of the biomechanics of the spine as paravertebral muscles due to the small operational access that captures the displaced and the underlying vertebrae.

 2. To achieve adequate decompression of the neurovascular formations of the spinal canal by resection of the arch, yellow ligament, foraminotomy, and, if necessary, resection of the posterior upper body of the underlying vertebra.

 3. To reduce violations of the biomechanics of the spine after surgery due to the preservation of the spinous process, supraspinatus and interosseous ligaments.

 4. The device used is easy to manufacture and install.

 5. The device is implanted into the human body for life, which eliminates the need for additional operations to extract it.

 6. Due to the shape memory effect, traction of the displaced vertebra continues in the postoperative period, spontaneously, until the device takes its original shape.

 7. The combination of these advantages allows more than six times in comparison with the methods of treatment used to reduce the time of inpatient treatment, contributes to the quick recovery of disability, eliminates the need for long-term rehabilitation and disability.

Claims (1)

 A method for the treatment of spondylolisthesis of the lumbar spine, including a linear incision of the skin, subcutaneous tissue, dissection of the thoracolumbar ligament, separation of the paravertebral muscles, resection of the yellow ligament and intervertebral disc, reposition and fixation of the displaced vertebra using a device, characterized in that the skin incision, separation of the paravertebral muscles at the level of the displaced and the underlying vertebrae, the arch of the displaced vertebra is resected, the spinous process, supraspinatus and interosseous ligaments are preserved, repo is performed positioning and fixation of the displaced vertebra using two devices installed in parallel, made of material with a thermomechanical shape memory, having hooks at the ends and two loops in the middle, made in one plane, with one hook securing the device to the transverse process of the displaced vertebra - for the bow of the subject, or for the transverse process of the displaced vertebra and the sacral bone in case of displacement of the last lumbar vertebra.

Images