RU2271165C2 - Method for instrumental fixation of lumbosacral department at vertebral inflammatory diseases - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: after radical reconstruction of anterior column it is necessary to fix lumbosacral vertebral department from behind with compression CD-construction supplied with hooked supporting elements, moreover, the upper supporting hooks should be installed upon the arches of inferior lumbar vertebrae L4 or L5, the lower hooks should be put into channels artificially created at posterior sacral surface between median and intermediate sacral crests that enables to prevent the development of inflammatory process from the side of vertebrae's bodies backwards, create the best conditions to form spondylodesis, rehabilitate patients earlier and shorten in-patient therapeutic period.

EFFECT: higher efficiency.

3 dwg, 1 ex

Description

The invention relates to medicine and can be used to fix the lumbosacral spine with tuberculous spondylitis and hematogenous osteomyelitis.

For specific (tuberculous) and nonspecific (hematogenous) osteomyelitis of the spine, the development of inflammatory purulent and / or granulomatous changes in the vertebral bodies and the formation of paravertebral abscesses are characteristic. The basis of modern surgical treatment of tuberculous spondylitis is radical reconstruction of the spine, including the complete removal of damaged vertebral bodies, abscesses, anterior decompression of the spinal cord and anterior spinal fusion (Hodgson AR, Stock FE et al., 1956, 1960, Kovalenko D.G., Garbuz A. E., 1983, Kovalenko K.N. 1990). One of the conditions for the formation of stable anterior spinal fusion is the immobilization of the operated spine, which is achieved by bed rest and external fixation of the spine in a plaster bed or corset. However, even long-term, many-month limitation of the motor regimen and inpatient treatment of the patient do not provide complete immobility of the operated spine, which often leads to instability of the spine due to non-fusion of the graft or the formation of pseudoarthrosis [1].

These shortcomings can be compensated by submersible posterior instrumental fixation of the operated spine.

There is a method of instrumental fixation of the spine in tuberculous spondylitis with the rear rod structures of Harrington [2]. The disadvantage of this method is the non-rigid fixation of the spine, as well as the possibility of using the design only on the thoracic and lumbar spine.

A known method of rigid fixation of the spine by structures such as CD or TSRH [4]. However, these methods can also be used only for operations on the thoracic and lumbar spine, as the support hooks are fixed either on the transverse processes of the thoracic vertebrae, or on the arches of the vertebrae.

There is a method of fixing the lumbosacral region according to Galveston, when the lower supporting structural member (rod or screw) is inserted into the posterior portion of the iliac wing [5]. The disadvantages of the method are 1) the possibility of resorption of the bone around the support screw at high voltage, because the screw is inserted into the spongy bone between the cortical layers of the ilium, 2) fixation is not so much of the lumbosacral vertebrae with each other as the lumbar vertebrae with the ilium, while the vertebral segment L5-S1 is below the instrumental fixation zone and movements in the sacroiliac bone are not excluded articulation.

The prototype of the present invention is a method of transpedicular fixation of the lumbosacral spine, in which the structural support screws are carried out from back to front through the roots of the arches into the bodies of the lumbar vertebrae (upper supporting screws) and through the posterior sacrum masses into the bodies of the sacral vertebrae (lower supporting screws) [3]. Currently, this method in various modifications is used for injuries, tumors and degenerative diseases of the lumbar and sacral vertebrae. However, a fundamental disadvantage of the method is the inevitable connection of the anterior and posterior vertebral columns with a support screw, which in the inflammatory process in the vertebral bodies can be accompanied by its spread to the posterior structures and makes the use of transpedicular fixation impossible.

In the literature, there is no description of the methods of instrumental fixation of the lumbosacral spine with spondylitis.

The objective of the invention is to provide a method for posterior instrumental fixation of the lumbosacral spine, ensuring its immobility after radical reconstruction of the anterior column of the spine and not violating the anatomical fragmentation of the bone structures of the anterior and posterior columns of the spine.

The task is achieved due to the fact that the lumbosacral spine is fixed at the back with a compression CD design with hook support elements, while the upper support hooks are installed supralaminar (on the arches of the lower lumbar vertebrae L4 or L5), and the lower hooks are immersed in artificially created boxes on the posterior surface of the sacrum between the median and intermediate sacral ridges (crista sacralis mediana and crista sacralis intermedia).

The proposed method is presented in Figure 1:

1 - upper hook of the structure; 2 - an arc of the body L4; 3 - newly formed arches on the posterior surface of the sacrum at the level of the spinous process S1; 4 - the back surface of the sacrum; 5 - lower hook of the structure; 6 - metal rods; 7 - crista sacralis mediana; 8 - crista sacralis intermedia.

The method is as follows.

Posterior instrumental fixation of the lumbosacral can be carried out simultaneously (under one anesthesia) with a radical reconstruction of the anterior spine, or as an independent operation. The position of the patient is on the stomach. Rear median access with exposure of the arches of the lower lumbar vertebrae and the posterior surface of the sacrum. In adolescents from 14-16 years of age and adults, the arches of the sacral vertebrae are synostosed, and the posterior surface of the sacrum is a single bone. The posterior surface of the sacrum is exposed on both sides of the crista sacralis mediana to a width of 1-1.5 cm, while the posterior sacral openings do not open, and the anatomical formations passing through them are not injured.

The upper supporting hooks are installed on both sides of the spinous process on the arc L4 or L5 of the vertebra (depending on the length of fixation). On the back surface of the sacrum from two sides between the median and intermediate sacral ridges in the transverse direction using high-speed drill (frequency - 30-40 thousand revolutions / min), through grooves of 5 × 3 mm in size penetrate the spinal canal. In contrast to the sacral foramen, at the level of the spinal canal, the caudal part of the dural sac loosely fused to the bone, which avoids damage to it and the occurrence of cerebrospinal fluid. The lower supporting hooks with cranially directed tips are inserted into the created beds. The design rods are modeled according to the curvature of the lumbosacral region and set into supporting hooks. The tension of the structure is carried out by moderate compression and rigid fixation of the rod with lock nuts. The wound is sutured tightly with the provision of drainage.

The established design ensures the immobility of the operated spine, which ensures its stability, creates the best conditions for the formation of anterior spinal fusion and at the same time allows you to expand the motor mode, verticalize the patient and significantly reduce the time of inpatient treatment as early as possible, within the next few days after the operation.

Clinical observation:

Patient S., 44 years old, medical history No. 829, was admitted to the Department of Spinal Surgery 10.10.2001 with complaints of pain in the lower lumbar spine with irradiation during movements in the right leg. Neurologically detected radicular L5 syndrome on the right. X-ray contact destruction of the L4-5-S1 vertebral bodies with extensive destruction of the L5 body by 1 \ 2 is detected. Foci of destruction can be traced in adjacent sections of L4, mainly along the posterior surface. Prevertebral, paravertebral, presacral abscesses with the presence of small sequestration-like fragments, interspersed with lime (Figure 2). Diagnosis: Tuberculous spondylitis of the bodies of L4-S4 vertebrae. Paravertebral, prevertebral, epidural, presacral abscesses. Radicular syndrome L5 on the right. October 1, 2001, the operation was performed: Abscessotomy of a presacral abscess. Necrectomy S1-4. The wound healed by primary intention. November 1, 2001: Necrectomy, resection of L4-5 vertebral bodies, dural sac decompression, epidural abscess removal, anterior spinal fusion with an autograft from the iliac wing. During anterior fusion, a fracture of the distal cortical plate of the L5 body occurred. Due to adverse conditions for transplant fusion and the presence of instability in the operated segment of the spine, the patient underwent posterior instrumental fixation of the spine by hook structures. The rear stabilizing operation was carried out according to the described method. In the patient’s position on the abdomen, posterior longitudinal accesses above the spinous processes of L2-S1 reveal the posterior surfaces of the arches and sacrum. CDI support hooks are installed with fixation: on the left - supralaminar L4; on the right - supralaminar L3, into an artificially created groove on both sides - at level S2. The rods modeled along the lumbosacral curvature are installed and stressed. The design is stressed in the caudocranial direction. Layered suture of the wound leaving a drainage graduate. The duration of the entire operation is 45 minutes. Blood loss 100 ml. When conducting an x-ray tomographic examination of the spine 3 days after the operation, a metal structure is visible, installed by the supralaminar hooks L4 on the left and L3 on the right in the artificially created grooves at the level S2 of the vertebra (Figure 3). In the postoperative period, a complete regression of neurological symptoms was noted. The patient was raised in a corset 3 days after surgery. After lifting the pain in the spine is not noted. The wound healed by primary intention. Discharged 3 weeks after surgery.

Literature

1. Garbuz A.E., Tikhodeev S.A., Oleinik V.V. Bone grafting with limited forms of tuberculous spondylitis // Probl. tube -1991. - No. 4. - S. 38.

2. Bakin M.N. The value of additional fixation of the spine by the Harrington distractor in the surgical treatment of spondylitis in children // Traumatologist Orthopedist of Russia. - 1995. - No. 6. - S.20-24.

3. Dulaev AK, Shapovalov VM, Gaidar BV Closed spinal injuries of the thoracic and lumbar localization. - St. Petersburg: "MONSAR AV", 2000. - P.79.

4. Moon M.S. et al. Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines // Spine. - 1995. - No. 17. - P.1910-1916; Moon M.S. Tuberculosis of the spine: controversies and a new challenge // Spine. - 1997. - No. 15. - R.1791-1797.

5. Rothman Simeon at al. The Spine, 3 ^rd edition. - Copiright 1992, 1982, 1975 by WBSaunders Compane. - P. 475-478.

Claims (1)

The method of posterior instrumental fixation of the lumbosacral spine in inflammatory diseases of the spine by using CD structures with hook support elements, the upper support hooks being installed on both sides of the spinous process on the arches of the lower lumbar vertebrae L4 or L5, and the lower hooks are immersed in the box, artificially created on the posterior surface of the sacrum from two sides between the median and intermediate sacral crests.

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