RU2289350C2 - Method for treating acute vertebral-spinal trauma - Google Patents

Abstract

FIELD: medicine, traumatology, neurosurgery.

SUBSTANCE: the present innovation deals with treating vertebral and spinal lesions due to fulfilling posterior access to lesion area followed by disk curettage and introducing into lesion area an autotransplant out of the arch of traumatized vertebra developed at laminoectomy. The transplant could be made of porous titanium nickelide; as for fixation, it should be carried out with the help of transpedicular apparatus. The innovation enables to decrease traumatism and prevent the relapse of kyphotic deformation.

EFFECT: shortened terms of therapy.

2 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology and neurosurgery, in particular to the treatment of injuries of the spine and spinal cord, and is intended for use in the departments of neurosurgery and traumatology.

There is a method of closed removal of the wedge of the Urban of the lumbar vertebrae, including the fixation of interchangeable vertebrae in the external fixation apparatus, their distraction is carried out at an angle until the original height of the damaged vertebra is restored, while the top of the distraction angle is placed in the plane corresponding to the location line of the Urban wedge, which is offset to the ventral surface to restore the curvature of the lumbar (Pat. 2071287, RF. Publish. 10.01.97. Bull. 1).

A known method of anterior spinal fusion, which consists in removing the pathological focus, preserving the front and middle parts of the interlocking plates of the spondylated vertebrae, the spinal recline, the additional formation of grooves in the back of the spondylated vertebrae of an arcuate shape, the use of an endoprosthesis of the spine from an inert material blank, which is made in the form of a cylinder with an offset a longitudinal hole, modeling from an endoprosthesis preform by forming at the end ends of the preform UPOV, and forming in the front portion of the preform recess communicating with an offset longitudinal bore, filling the longitudinal hole and biased recess endoprosthesis remote damaged vertebral bone and the vertebral circuit spondiloziruemyh translational-rotational movement of the endoprosthesis (US Pat. 2,102,934, Russian Federation. Publ. 27.10.1998).

A known method of treating gross forms of axial spinal deformities by transposition of a non-free rib graft into the ventral defect zone and posterior fixation of the spine, in which the proximal end of the graft on the muscle leg is mobilized from access from the inner surface of the rib with dissection of the intercostal muscles along the lower edge of the overlying and upper underlying ribs to costal-transverse articulation, form an additional feeding leg and the corresponding portion of the anterior dentate muscle, after which exercise dosed distraction with a previously implanted endocorrector with many support points to the stop state of the endocorrector (Application No. 961041370, RF. Publish. 05.27.1998).

A known method of treating spinal injuries complicated by spinal disorders, including decompression of the spinal cord with the restoration of the shape of the spinal canal by eliminating the Urban wedge and stabilization of the spine, in which they perform closed decompression of the spinal cord at the same time and / or in a controlled manner and stabilize the spine using an extra focal device by applying compression and distraction efforts to adjacent parts of the spine and closed transposition of the Urban wedge with rigid fixation about extrafocal device, wherein after the closed spinal extrafocal via decompression device without stopping spinal fixation produce Front corporodesis damaged vertebrae kostnmi autografts (Claim №96116105, RF. Publ. 10.11.1998).

However, in the known method requires additional access to the area of damage, which is associated with increased trauma, and surgery is performed in two stages, which is associated with a repeated anesthetic aid.

The objective of the present invention is to develop a method for the treatment of acute spinal cord injury, which allows to reduce treatment time, reduce morbidity and prevent relapse of kyphotic deformity and repetition of anesthetics.

The problem is solved in that in a method for the treatment of acute spinal cord injury, including decompression of the spinal cord, the introduction of a graft and fixation of adjacent vertebrae with a pedicle apparatus, rear access is made to the compression zone and the damaged disc, after which curettage of the disc is performed and the graft is inserted into the anterior department of interbody space.

To prevent recurrence of kyphotic deformation, continued compression of the spinal cord and early formation of the bone block, an autograft is used, which is formed from fragments of the arc of the injured vertebra.

To eliminate extensive trauma to the bone structures of the vertebrae, it is advisable to use an implant made of porous tatane nickelide as a graft.

Patented method for the treatment of acute spinal cord injury is explained by a detailed description, an example of the method, scheme and radiographs, in which:

Figure 1 - diagram of extensive damage to the vertebrae;

Figure 2 - diagram of the fixation of damaged vertebrae and placed between them autograft;

Figure 3 - illustrates extensive damage to the vertebrae. Spondylograms of the lumbar spine of patient B., 56 years old, in 2 projections with a compression fracture L1 with a subluxation of D12 vertebra (before surgery);

Figure 4 - characterizes the correction of deformation, fixation of the vertebral bodies and anterior fusion. Spondylograms of the lumbar spine of patient B., 56 years old, in 2 projections after decompression, application of the apparatus and reduction of the subluxation of D12 vertebra;

5 is a copy of radiographs of the spine after surgical treatment. Spondylograms of the lumbar spine of patient B., 56 years old, in 2 projections after removal of the apparatus. The axis of the spine is correct. In D12-L _I segments, bone block is determined;

6 is a copy of x-rays of the spine characterizing the long-term result of treatment. Spondylograms of the lumbar spine of patient B., 56 years old, in 2 projections. Long-term result 1.5 years after discharge. The axis of the spine is correct. Bone block is retained in segments D12-L _I ;

The method is as follows.

By radiographs, the localization and degree of damage to the vertebrae is determined (Figure 1).

A linear skin incision is made under endotracheal anesthesia along the line of the spinous processes. The aponeurosis is dissected paravertebrally, the extensors of the back are separated by a raspator, hemostasis is made with hot saline. A laminectomy of the injured vertebra and partial resection of the plates of adjacent arches are performed. Anterior decompression of the spinal cord is performed. Curettage of the injured disc. Bone autografts are introduced into the anterior interbody space.

TMT is opened by a linear incision, the spinal cord is revised and sutured tightly.

Screw rods are introduced into the legs of the arcs above and below the damage area (Figure 2). Produce hemostasis. Antibiotics are introduced into the wound, passive drainage from the polyvinyl chloride tube is established. Sutured postoperative wound. Carry out the installation of the external fixation device and its stabilization after eliminating the deformation of the spine. Apply alcohol dressings to the wound and to the injection sites of the screw rods.

Clinical example.

Patient B., 56 years old, was treated from 06/15/99 to 04/04/99 with a diagnosis of Traumatic disease of the spinal cord, acute period. Compression-comminuted fracture of the L1 vertebral body with contusion and compression of the cauda equina roots. Lower flaccid paraplegia. Dysfunction of the pelvic organs.

Complaints of pain in the lumbar spine and lower extremities, delayed urination and defecation, lack of movement in the legs.

Household injury 10.06.99, the fall from the height of the 5th floor (Figure 3).

Neurological status: there are no active movements in the lower extremities. The middle and lower abdominal reflexes are sharply reduced. Tendon reflexes from the lower extremities are absent. Hyperesthesia of the skin in the L1-L2 dermatome, hypo-and anesthesia of the skin from the level of L3 root. Paresthesia in the lower extremities. There is no cremasteric reflex. Tactile sensitivity and joint-muscle feeling are sharply reduced. Pelvic dysfunction by type of delay.

The patient was examined: during myelography with omnipack spondylograms revealed a compression-comminuted fracture of the L1 vertebral body with a dislocation of its upper posterior edge into the lumen of the spinal canal by 2/3 with rotation. Compression-comminuted vertebral fracture L1, a double fracture of the left half of the L1 arch at the base and in the inter-articular region, rupture of the left intervertebral joint L1-2, a sharp narrowing of the lumen of the spinal canal due to the displacement of the posterior fragment of the vertebral body L1 were determined on CT.

June 24, 1999, the patient underwent surgery - laminectomy of the L1 vertebra, partial resection of the plates of the arches D12 and L2 of the vertebrae, anterior decompression, revision of the spinal cord (Figure 4). D12-L1 disk curettage was performed, bone autografts (in a quantity of 2 pcs.) Were introduced into the anterior interbody spaces. Then the wound is sutured. The apparatus of external transpedicular fixation of the spine was mounted.

The postoperative period without features, the sutures were removed on the 10th day. The patient was treated: antibiotics, painkillers, cerebrolysin, nitroxaline, biseptol, trental, piracetam, platifillin, vitamin therapy, massage, exercise therapy, electrical stimulation.

During the control tomography dated October 8, 1999, the formation of a bone block in the D12-L1 segments in the posterolateral sections (larger on the left), vertebrae due to consolidation of the vertebral bodies, fusion of the autograft with the bodies, confirmed by densitometry, was noted. October 16, 1999 - the device is removed (Figure 5).

On myelograms with omnipack dated 10.26.99, there is the presence of adhesive arachnoiditis in the region of L1, there is no kyphotic deformation. Patency of the subarachnoid space is reduced above the L1 level of the vertebra.

Neurologically, a positive dynamics was noted in the postoperative period - sluggish paraplegia gave way to praraparesis with a tendency to regress. The patient walks with crutches, the function of the pelvic organs has recovered. The muscle strength in the right n / limb is 4 points, on the left is 3-3.5 points. Rear flexion of the right foot - 5 points, plantar flexion - 4.5 points; left flexion - 0 points, plantar flexion - 3.5 points. Tendon reflexes are inhibited. Hypesthesia of the skin from the level of L3 root. There are no pathological stop signs. Physiological administration is normal. The course of treatment is completed, in satisfactory condition the patient was discharged. Control inspection and examinations were carried out after a year and a half. The achieved result is saved (Fig.6).

The proposed method allows to eliminate compression of the spinal cord, to restore the anatomical relationship of nerve and bone structures in the area of injury, to eliminate kyphotic deformation, to make stable fixation of the injured segments, to avoid repeated anesthesia and surgical intervention, which leads to a reduction in treatment time. Also, it allows reducing the formation time of the bone block in the injured segments by 1.5-2.0 times.

The proposed method is less traumatic and technically simple to perform, it is used in the neurosurgery department of the RTC "WTO" named after Academician G.A. Ilizarov.

Claims (3)

1. A method for the treatment of acute spinal cord injury, including decompression of the spinal cord, the introduction of a graft and fixation of adjacent vertebrae with a transpedicular apparatus, characterized in that they provide rear access to the compression zone and damaged disk by laminectomy, resection of plates of arches of adjacent vertebrae, and then curettage disk and introduce the graft into the anterior interbody space, and the apparatus is installed on the legs of the vertebral arches remaining after a laminectomy. 2. The method according to claim 1, characterized in that they use an autograft, which is formed from fragments of the arc of an injured vertebra. 3. The method according to claim 1, characterized in that an implant made of porous titanium nickelide is used as a graft.

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