RU2262318C1 - Method for vertebroplasty - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: the present innovation deals with corporectomy in patients with pathological vertebral fractures. One should introduce an insertion into inter-body defect after pre-manufacturing it out of cement as a groove of 2-3 mm thickness to be placed into defect with its protuberance towards dural sac at 2-3 mm against it; in case of a great inter-body defect one should introduce drainages from the side of safe vertebrae with possibility for their removal. If additional fixation is necessary one should introduce metal rods into vertebrae being adjacent with inter-body defect which partially protrude into defect area that prevents neural structures against thermal and mechanic damage.

EFFECT: higher efficiency of vertebroplasty.

2 cl, 2 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and may find application in corporectomy in patients with spinal fractures.

Vertebral fractures often occur against the background of pathological changes in their bone structure, leading to a decrease in strength. The most common cause of them is osteoporosis and tumor damage. Often such fractures are accompanied by complete destruction of the vertebra with the formation of a large number of fragments, deformation of the spinal canal, compression of neural structures and the development of deep neurological disorders. If in osteoporosis, the process of fracture consolidation under conditions of stabilization of the spine proceeds without features, then in the tumor process, fusion is impossible without removal of the tumor tissue. A necessary condition for the surgical treatment of tumors is their complete removal of the complete block. Therefore, corporectomy is the treatment of choice for some benign and most malignant (both primary and metastatic) spinal tumors. The second objective of the operation is to replace the defect formed after removal of the vertebra and restore the spinal support. The main way to restore the support ability of the spine, including in case of tumors, is bone autoplasty of the vertebral defect and metal fixation. This method is also widely used in the treatment of malignant tumors. However, firstly, it requires an additional operation to collect the autograft and, secondly, during the period of its restructuring, there are limitations both in the regimen of activation of the patient, as well as in radiation and chemotherapy, which negatively affects the treatment of this patient.

Recently, to replace the interbody defect after corporectomy, in particular with tumor lesions of the spine, various kinds of fast-hardening biocompatible materials have increasingly been used. Among them, bone cement (methyl methacrylate) is most widely used. Methyl methacrylate (MMK) is used both in combination with metal structures and separately without additional fixation. The advantage of using bone cement is the possibility of optimal adaptation (contact) of the graft over the entire surface and in the shape of the end plate of the vertebral body, which creates maximum stability at the border of the implant and bone. In this case, there is no need to perform additional surgical intervention to collect the autograft. Thus, these operations significantly reduce the rehabilitation period and allow you to prescribe radiation and chemotherapy as soon as possible after surgery.

However, a significant problem in the use of MMC is that during polymerization in tissues, its temperature can reach 122 ° C. The effect of this temperature on adjacent biological tissues is accompanied by their necrosis. In view of this, the use of MMC in the immediate vicinity of nerve formations (spinal cord shell and roots) can be accompanied by serious complications associated with their burns. To avoid these complications, many different methods have been proposed for protecting the spinal cord from thermal damage.

Closest to the claimed is a method of vertebroplasty with isolation of the contents of the dural sac proposed by Sundaresan N. et al. (Sundaresan N., et al: Treatment of neoplastic epidural spinal cord compression by vertebral body resection and stabilization. J Neurosurg 63: 676-684, 1985), taken as a prototype. According to this method, before the introduction of bone cement (MMC) into the interbody defect, a foaming gel or free fatty tissue is placed on the posterior longitudinal ligament or dural sac in order to prevent thermal effects on the spinal cord and nerve roots. Then pour liquid cement on top until the defect is completely filled.

The disadvantages of this method is that the use of free fatty tissue and gel, as shown by the experience of their use, does not allow evenly covering the dural sac. As a result of this, cement may flow into the spinal canal with compression of the neural structures and thermal effects on them. Moreover, it is impossible to cool the spinal cord with saline solution during cement polymerization due to the possible displacement of free adipose tissue or gel flushing. Complications arising as a result of this can lead to burns and compression of neural structures, to deep neurological disorders, which requires additional therapy (including reoperation) and increases the duration of treatment for this pathology.

The technical result of the present invention is to reduce the number of intra- and postoperative complications due to the preliminary introduction of a cement insert into the interbody defect.

This result is achieved by the fact that in the known method of vertebroplasty, including corporectomy and the introduction of liquid bone cement into the interbody defect, according to the invention, an insert in the form of a gutter 2-3 mm thick, which after the corporectomy, is corresponding in width and height to the size of the interbody defect. placed in the defect bulge to the dural sac at a distance of 2-3 mm from it, and liquid cement is introduced into the resulting bed until the defect is filled.

It is advisable in the presence of a large interbody defect to introduce drainage from the side of the saved vertebrae with the possibility of their removal.

If additional fixation is necessary, it is advisable to introduce metal rods protruding 0.5-1 cm into the defect region into the vertebrae adjacent to the interbody defect.

Prefabrication of the gutter corresponding to the size of the defect allows, after being placed in the defect by the bulge to the dural sac, to completely block access to the dural sac and thus protect it from mechanical stress and burns when filling the defect with liquid bone cement, and, as we have shown experimentally, sufficient for this is a gutter thickness of 2-3 mm.

The installation of the gutter convex to the dural sac at a distance of 2-3 mm ensures the integrity of the structure and at the same time avoids damage to it.

Subsequent administration of liquid bone cement provides defect replacement and spinal stability without the risk of burns and mechanical damage to neural structures.

If it is necessary to fill a large defect with liquid bone cement, the additional introduction of drains to the dural sac allows it to be cooled using physiological saline during the polymerization of MMC and to prevent thermal injury to neural structures.

The additional introduction of metal rods into the vertebrae adjacent to the defect before the introduction of liquid cement can improve the fixation of the spine.

The essence of the method is illustrated by examples.

Example 1. Patient S., 41, and / b 8006

Received at the Department of Spinal Pathology RNIITO them. R.R.Vredena in connection with severe pain in the cervical and thoracic spine with radiation to the right arm and left leg.

From the anamnesis: In April 2000, a left-side mastectomy for breast cancer was performed in the oncology clinic. Subsequently, she received planned courses of combined treatment. For the first time, pain in the cervical spine appeared in August 2002, paresis of the right upper limb was noted. On radiographs of the cervical spine from 09.16.02, the destruction of the vertebral body CV was revealed with a decrease in its height. On scintigraphy - pathological hyperfixation of a radiopharmaceutical with an accumulation gradient of up to 100%. After a course of chemotherapy and Bonophos, the pain disappeared, and motor function in the arm was restored. Since January 2003, pains appeared in the thoracic spine, along the lateral surface of the chest.

On admission, radiographs showed a pathological fracture of the CIV-VI vertebrae with pathological kyphotic deformation of the CIV-VI, a pathological fracture of ThIX.

Diagnosis: Pathological fracture of CV-VI, ThIX vertebrae on the background of metastases of cancer of the left breast. Condition after mastectomy (2000). Vertebrogenic syndrome. Sop .: Osteochondrosis of the lumbar, disc herniation LV-SI.

On 13.11.03, at the Department of Spinal Pathology, RNIITO, under endotracheal anesthesia in the position of the patient on the back, Bailey CIII-CVII vertebral bodies were separated in layers by Bailey left-side access. X-ray control. During the audit, the body of the CV is practically not visualized; in its place, a retraction with the apex of kyphotic deformation is noted. Resected vertebral CV-CVI bodies along with adjacent discs. The end plates of the CIV and C VII vertebrae were distinguished. An insert in the form of a gutter with a thickness of 3 mm in height and width corresponding to the dimensions of the interbody defect was made of cement. After polymerization (hardening) of the cement, the prepared insert is tightly installed in the defect by the bulge to the dural sac, at a distance of 2-3 mm from it. Given the great mobility of the cervical spine for reliable fixation of the defect, metal rods 3 mm in diameter and 30 mm long are rigidly inserted into the end plates of adjacent bodies on the defect side so that their parts 10 mm protrude into the defect's lumen. Liquid bone cement is poured into the prepared bed around the rods until the defect is filled. Excess cement is removed with a sharp spoon. X-ray control. The wound is sutured. Aseptic dressing.

Blood loss - 200 ml. The duration of the operation is 2 hours 30 minutes.

The patient is raised to a vertical position 3 days after surgery. Sutures were removed after 10 days, and the patient was discharged without external immobilization. When examining 3 months after the operation, there are no complaints, the support ability of the spine is preserved, walks without external immobilization.

Example 2. Patient K., 47 l. and / b 482

I entered the Department of Spinal Pathology RNIITO for pain in the thoracic spine, aggravated by vertical loads with irradiation along the intercostal space.

From the anamnesis: Pain in the thoracic spine appeared in October 1999. It was treated in a community clinic with a diagnosis of osteochondrosis of the thoracic spine. In January 2000, the pain intensified sharply, was examined at the Department of Neurology, where, according to an X-ray examination, a pathological fracture of the ThVIII vertebra, metastasis of breast cancer was revealed. For examination, the patient was referred to the Oncology Center - diagnosis: Cancer of the right breast T3N × M1. Received planned chemistry - and radiation therapy. 06/03/00, a radical mastectomy according to Modden on the right and a bilateral ovariectomy were performed. On scintigraphy 06/14/00 - hyperfixation of radiopharmaceuticals ThVIII-IX. In September 2003, disease progression was noted: metastases in the neck of the left thigh and 5 ribs on the right were revealed. On computed tomography from 12.16.03. determined compression fracture of the body Th VIII vertebra. The patient was sent to RNIITO them. R.R. Vredena.

Upon admission to the magnetic resonance imaging from 01/21/04 - compression fracture ThVIII, destructive changes ThIX.

Diagnosis: Pathological fracture of Th VIII, against the background of metastasis of breast cancer ThVIII-Th IX vertebrae. Condition after mastectectomy T3N × M1 and bilateral ovariectomy (2000). Vertebrogenic syndrome.

At the Department of Spinal Pathology, RNIITO, on January 24, 04, under endotracheal anesthesia in the position of the patient on the left side, the VIII rib was isolated and resected subperiostally in layers on the left side, and VII-e was mobilized by crossing along the midclavicular and anterior axillary line. Thoracotomy. Under radiological control, the site of surgery is determined. Segmental vessels in the projection of ThVII-ThX bodies are coagulated and crossed. Mobilized lateral ThVII-ThIX vertebrae. During revision, the ThVIII vertebral body is roughly wedge-shaped. Under X-ray control in ThVII and ThX vertebrae, a metal structure was installed to fix the affected segment. ThVIII-ThIX vertebral bodies removed. In this case, the bone tissue of the vertebral bodies was degeneratively changed with pink inclusions. A cement in the form of a gutter with a thickness of about 2 mm was modeled from cement, corresponding in height and width to the dimensions of the interbody defect. After the cement has hardened, the insert is firmly installed in the defect by the bulge to the dural sac, at a distance of 2-3 mm from it. Given the large size of the defect between the gutter and the dura mater from the side of the vertebrae adjacent to the defect, 2 catheters were let down. Liquid bone cement is poured into the prepared bed around the rods until the defect is filled. During the entire period of cement polymerization, saline was supplied through the proximal catheter, and an electric pump was connected to the distal catheter, with the help of which the heated liquid was removed. Excess cement is removed with a sharp spoon. X-ray control. The wound is sutured. Aseptic dressing.

Mortar loss - 700 ml. The duration of the operation is 3 hours 20 minutes.

The patient is raised to a vertical position 3 days after surgery. Sutures were removed after 10 days, and the patient was discharged without external immobilization. When examining 1 month after the operation, there are no complaints, the support ability of the spine is preserved, walks without external immobilization.

To date, this method has operated on 6 people with metastatic lesions of the spine. All performed the replacement of the defect with bone cement.

The proposed method in comparison with the known has the advantage that it allows us to completely eliminate the possibility of mechanical and thermal effects on the spinal cord, nerve roots and surrounding soft tissues, as we have shown in the treatment of patients.

The method was developed at the Russian Research Institute of Traumatology and Orthopedics. RR Vredena and underwent clinical testing in the Department of Spinal Pathology in 6 patients with a positive result.

Claims (3)

1. A method of vertebroplasty, including corporectomy and the introduction of bone cement into the interbody defect, characterized in that an insert in the form of a gutter 2-3 mm thick, which is placed in the form of a groove, which is placed in the defect with a convexity to dural bag at a distance of 2-3 mm from it, and liquid cement is injected into the resulting bed until the defect is filled. 2. The method according to claim 1, characterized in that in the presence of a large interbody defect, drainages with the possibility of their removal are introduced into it from the side of the stored vertebrae. 3. The method according to claim 1, characterized in that, if necessary, additional fixation in the vertebra adjacent to the interbody defect is injected with metal rods protruding 0.5-1 cm into the defect area.