RU2234876C2 - Method of frontal spondylosyndesis in cases of kyphosises in children - Google Patents

Abstract

FIELD: children diseases.

SUBSTANCE: method, which can be used in surgical treatment of backbone diseases in children, comprises incorporating a profiled cortical allotransplant with ventral protuberance between bodies of vertebra to be blocked. Ventral protuberance has saddle-shaped recesses on its cranial and caudal surfaces, which serve, during reclination of kyphosis, for the incorporation of transplant between anteroinferior surface of the superior and anterosuperior surface of the inferior vertebras to be blocked and is centered maximally precisely.

EFFECT: prevented dislocation of transplant.

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Description

The invention relates to medicine and can be used in the surgical treatment of kyphosis in children.

One of the elements of surgical interventions performed for various diseases and injuries of the spine is the osteoplastic stabilization of its anterior column - anterior or anterolateral fusion. To this end, cortical transplants are used, which have high strength properties, the ability of plastic assimilation with recipient beds during the adjustment process.

In the surgical treatment of tuberculous spondylitis, anterolateral spinal fusion is performed by introducing a bone graft in the form of a direct parallelepiped into nicks formed in the vertebral bodies (P. Kornev, Surgery of osteoarticular tuberculosis. L., 1964, 549 pp.). The use of this method in children, especially young children, cannot provide good fixation. This is due to the characteristics of childhood spondylitis - the small size of the vertebral bodies, the significant mobility of the affected and adjacent vertebral segments. Of great importance is also the excessive pressure of the ends of the graft on the bone beds in the bodies, which causes early resorption of the bone tissue of the receiving bed around the allograft and can contribute to the dislocation of the graft.

Known methods of anterior spinal fusion, in which the graft is attached by forming at the cranial and caudal ends of the graft pyramidal protrusions (ed. Certificate. No. 833226 “Method of anterior spinal fusion”, N.I. Khvysyuk et al.) Or bayonet-like narrowed ends (ed. certificate No. 862933 “Method of anterior spinal fusion”, Y. L. Tsivyan et al.). These methods are unacceptable for children, since such protrusions predispose to protrusion of the vertebral plate, death of the disc, loss of correction of deformation.

A known method of anterior fusion, in which the transplant is modeled from two components with ventral protrusions in the middle part, which are connected by friction along vertical grooves and are embedded in the coaxial grooves of the fixed vertebral bodies; when assembled, the transplant has a T-shaped cross section (patent No. 2065731 “Method of anterior spinal fusion”, Evseev V.A.).

The prototype of the invention is a method of anterior fusion, taking into account the features of the children's spine, in which the allograft is formed so that there is a protrusion on its ventral surface (author certificate. No. 1202569 “Method of anterior fusion”, K.N. Kovalenko, N.Yu. Ukhanov ) After resection of the vertebral bodies, the graft is inserted into the coaxial grooves so that its ventral protrusion is located between the front sections of the perceptive vertebrae, ensuring the stability of the anterior column of the spine in a correction state. Such a graft cannot provide adequate replacement of the interbody diastasis, since it only makes up for 1 / 4-1 / 3 of the vertebral area, and, in addition, the ventral protrusion is eccentric with respect to the axis of the spine.

The above methods of anterior spinal fusion do not take into account the features of gross angular kyphosis in children, the most common in tuberculous spondylitis and congenital malformations of vertebral bodies. These features are 1) the minimum size of the bodies of blocked vertebrae, their insufficient resistance to manipulations, accompanied by excessive trauma and a decrease in bone mass (excessive pressure, the creation of coaxial grooves, resection of fragments of vertebral bodies); 2) rotation of the vertebrae in the sagittal plane, accompanied by the convergence of the anterior sections of the blocked bodies.

Thus, the use of figured grafts with a rectangular ventral protrusion in children with anterior spinal fusion has the following disadvantages: 1) the creation of coaxial grooves for implantation in the bodies of blocked vertebrae is inevitably accompanied by their trauma and bone loss, which is extremely important in young children who initially have minimum size of the vertebrae; 2) the rectangular shape of the ventral protrusion of the graft is incongruent in the anterior sections of the blocked bodies with gross kyphosis, which requires additional resection of the latter; 3) the maximum possible ventral position of the graft in the blocked area is not ensured, which is necessary for kyphosis from the point of view of biomechanics [Mikhailovsky MV 1994, Bradford D.S. et al., 1977, White A. A., Panjabi M. 1978].

The objective of the invention is to develop a method of anterior spinal fusion, providing the greatest stability of an allograft in the area of reconstruction of the spine with kyphosis in children.

The scheme of the method is presented in figure 1. 1.5 - the anterior divisions of the vertebral bodies; 3 - ventral protrusion of the graft; 2, 4 - saddle grooves.

The task is carried out due to the fact that anterior fusion between the bodies of the blocked vertebrae is performed by a figured cortical allograft with a ventral protrusion, on which saddle-shaped recesses are made on the cranial and caudal surfaces, with which the graft is introduced during kyphosis reclamation between the anteroposterior surface of the upper and anterior upper surface of the lower blocked vertebrae as much as possible ventrally.

The differences of the proposed method of anterior fusion from the prototype are as follows: 1) the ventral protrusion has a saddle notch on the cranial and caudal surfaces, with which the graft is introduced between the anteroposterior surface of the upper and anterior upper surface of the lower blocked vertebrae during kyphosis reclamation; protruding anterior and posterior bone fragments of the transplant prevent its displacement in the anteroposterior direction; 2) with gross kyphosis, accompanied by the tilt of the bodies of the blocked vertebrae, it is not necessary to create coaxial grooves in their bodies; 3) the graft in the area of blocked vertebrae is located as ventrally as possible, which is more biomechanically justified in case of kyphosis.

The saddle-shaped notches on the ventral protrusion of the graft prevent its dislocation, since the ventrally located adjacent surfaces of the cranial and caudal blocked vertebrae are located in the congruent saddle-shaped notches of the graft.

The proposed method is as follows.

During surgery, access (transpleural, extrapleural, thoracodiaphragmatic, extraperitoneal) to the vertebral bodies is performed, the affected vertebrae are resected as a single unit within the healthy bone tissue of the bodies. From the allogeneic cortical bone (tibia), a shaped saddle-shaped cortical graft is formed. The graft during manual spinal reclination is introduced between the anteroposterior body of the cranial vertebra and the anteroposterior body of the caudal vertebra entering the fusion zone.

The total number of patients operated using this method of anterior spinal fusion is 7 children with tuberculous spondylitis. In all cases, a complete consolidation of the transplant and vertebral bodies was obtained. The observation period is from 1 year to 3 years.

Clinical example 1 (figure 2)

Z.R., 4 years 11 months, was in the clinic from 06/15 to 08/15/2001 with a diagnosis of

Primary: primary generalized tuberculosis: tuberculosis of the intrathoracic lymph nodes on the right (?), Tuberculous spondylitis Th 6-9.

Complications: pre-, paravertebral, epidural abscesses, mechanical instability of the spine, kyphotic deformation of the thoracic spine (kybosis value according to Сbb 70 °).

06/26/01 surgical intervention was performed (extended reconstruction of the spine Th5-9. Posterior osteoplastic and instrumental fixation by multisupported contractors with Luque modification) with anterior fusion according to this technique:

transthoracic, extrapleural access on the 6th intercostal space on the right; the anterior sections of the T5 and T9 bodies are sharply brought together, the space between them is occupied by the remains of scar tissue, discs and a fragment of the T6 body. Resected T6-8 block with contact disks, anterior decompression of the spinal canal. In the posterior part of the T9 body, a lesion was found containing caseous masses - processed. In the spinal canal on the scar-modified posterior longitudinal ligament there are inclusions of granulation tissue - removed. The lateral walls of the spinal canal were resected, and the left-sided paravertebral abscess containing caseous masses was opened and processed during resection of the left.

During the trial manual reclamation of kyphosis, pronounced rigidity of the scar-modified anterior longitudinal ligament was revealed - it was crossed in the transverse direction. The interbody diastasis T5-9 is filled with a figured saddle-shaped cortical allograft implanted between the anterior divisions of the vertebral bodies. Additionally, a fragment of the autorebre has been introduced. A ligament and pleura are sutured over the fusion zone.

The second stage of surgical intervention is posterior instrumental fixation.

The postoperative period was uneventful, the sutures healed by primary intention. Put on its feet in a recovery corset 3 weeks after surgery. On control radiographs of the spine after 8, 20, 50, and 120 days after surgery: a significant (about 50 °) correction of kyphotic deformation (Cobb kyphosis value of 22 °) was achieved, the grafts were tightly embedded into Th5-Th9 bodies; metal structures are stable.

Clinical example 2

MS, 2 years 5 months, was in the clinic from 05.19 to 08.15.2001 with a diagnosis of

Primary: primary generalized tuberculosis: primary tuberculosis complex in S1 on the right, calcination phase (?); tuberculous spondylitis T3-6.

Complications: prevertebral, bilateral paravertebral abscesses with calcifications, epidural abscess; mechanical instability of the spine, kyphotic deformity of the thoracic spine (Cobb kyphosis value 73 °).

07/10/01 an operative measure was performed (extended radical reconstruction of Th2-7. Rear polysegmental fixation by two contractors in Luque modification) with anterior fusion according to this technique:

transthoracic, tranpleural access to the right through a bed of 4 ribs the spine in the upper middle chest is deformed at an angle of 90 °, the bodies T2 and T7 are close, the diastasis between them is filled with remnants of scar tissue, discs and body fragments. Resected adjacent surfaces with anterior and lateral decompression of the spinal canal, in which an abscess containing granulation-necrotic masses was found, were resected.

Manual recycle of kyphosis is minimally effective, while it is not possible to recreate the support of the spine - the graft leans forward. Anterior fusion was performed with a figured saddle-shaped cortical allograft implanted between the front sections of the T2-7 vertebral bodies. In addition, a fragment of the auto-rib was laid. Layered seam of the wound.

The second stage of surgical intervention is posterior instrumental fixation.

The postoperative course is smooth, the sutures healed by primary intention. On the control radiographs of the spine, the achieved correction (about 27 °) of kyphotic deformation (kyphosis value according to Cobb 46 °) is preserved, the grafts are tightly embedded in Th2-Th7 bodies; metal structures are stable.

Claims (1)

The method of anterior fusion for kyphosis in children, including the introduction of a figured cortical allograft with a ventral protrusion between the bodies of the blocked vertebrae, characterized in that on the ventral protrusion of the graft perform saddle grooves on the cranial and caudal surfaces, with which the graft is introduced at the front of the upper anterior surface during kyphosis reclamation surface of the lower blocked vertebrae and positioned as ventrally as possible.

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