RU2306887C2 - Method for anterior decompression of spinal cord after laminectomy - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: it is necessary to carry out laminectomy at resecting the vertebral arch including the roots of arches, at resecting inferior articular processes and caudal part of spinous process of the above-lying vertebra. Moreover, one should carry out median retraction of spinal cord, form the defect in posterior department of affected vertebra's body with the help of a hollow crown cutting, replace intracanally located fragments in ventral direction into the defect formed. Then one should perform impaction of fragments into the formed defect. The innovation enables to decrease the risk of spinal cord's lesion, prevent migration of fragments out of the formed defect.

EFFECT: higher efficiency of decompression.

2 cl, 7 dwg, 1 ex

Description

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

A known method of conservative decompression of the spinal cord, including correction of the threshold of pain sensitivity of the central nervous system, local spinal distraction, lateral rotation of the spine in both directions and the introduction of lidase, and then actovegin subdurally into the area of damage to the spinal cord (RF Application No. 95101149. Publ. 03/27/1997. )

However, the known method relates to therapeutic methods for the treatment of diseases of the spine and does not provide surgical intervention for its implementation.

A known method of anterior transposition of the spinal cord by decompression of the spinal cord, followed by correction and fixation of the deformed spine, which retains the posterior intercostal arteries and veins. The posterior-medial part of the vertebral bodies is resected by 1/2 anteroposterior size to the width of the interroot distance in the arch zone and one segment higher and lower after the appearance of the anterior epidural space, 1/2 of the anterior semicircle of the defect is filled with non-free muscle gloss, and it is fixed to the anterior the wall of the formed tunnel, after which the deformation is corrected using a distraction element (Application No. 9711463 of the Russian Federation. Publish. June 27, 1999).

However, the known method characterizes only the general medical level of development of the problem.

There is a method of surgical treatment of neurological complications in patients with osteochondrosis, which consists in the surgical removal of bone-cartilage structures of the spinal-motor segment in which electrical stimulation is performed by installing two pairs of electrodes above and below the lesion level (RF Application No. 2003122105. Publish. 10.02.2004 g .).

However, the known method is intended only for the treatment of osteochondrosis of the spine, it does not provide for the treatment of complicated spinal injuries.

A known method of surgical treatment of the consequences of complicated fractures of the spine, including decompression of the spinal cord, dosed restoration of the axis of the spine, anterior spinal fusion and fixation of the spine in the reached position, in which decompression of the spinal cord is performed by resection of the Urban wedge from the posterior approach, after decompression of the spinal cord, the axis of the spine is restored, then 1/2 part of the body of the damaged vertebra with adjacent discs is resected, after which anterior abdominal fusion is performed with a tallograft implant, the spine is fixed in the position reached by the external fixation device (RF Application No. 2002100579. Publish. September 20, 2003).

However, the known method is quite time-consuming to implement and requires complex tools and a special device for external transosseous fixation.

There is a method of eliminating anterior compression from posterior access after an extended laminectomy by “biting” intracanal fragments that compress the spinal cord (Shevtsov V.I., Khudyaev A.T., Kovalenko P.I., Samylov V.V. Features of surgical treatment of patients with acute spinal cord injury // III Congress of Russian Neurosurgeons: Abstracts - St. Petersburg, June 4-8, 2002. P.225).

However, the known method is performed under visual control of the surgeon, but due to the fact that the mechanical effect is directly on the substrate of compression, which is closely adjacent to the spinal cord and the epidural venous plexus, there is a chance of damage.

A known method of eliminating stenosis of the channel, which involves not resection of the intracanal formations, but their impact (wedging) in the posterior parts of the vertebral body. Simulation of the spinal canal by this method is relatively non-traumatic, reduces the risk of damage to neurovascular formations, requires simple tools (set of impactors) (Sim E. Reposition of dislocated dorsal vertebral wall fragments in fractures of the thoracolumbar transition & the lumbar spine. Experience with 35 cases . // Unfallchirurg. - 1991. - Vol. 94. - No. II. - P.554-559).

However, in some cases (late period of trauma, the special nature and localization of the fracture), the reception of the impact of bone fragments can be doomed to failure.

There is a method of eliminating anterior compression of the spinal cord, when intracanally located bone and cartilage fragments were removed using special cutters on the formed channels in the roots of the arches of the damaged vertebra, and the operation was completed by osteosynthesis due to Harrington back access rods without laminectomy (William T. Hardaker, Jr., MD , Wesly A. Cooc, Jr., MD, Allan H. Friedman et al. Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures // Spine. - 1992. - Vol.17. - No. 2. - R.162-171).

The main disadvantage of this method of decompression should be considered the problem of the inability to control the action of the instrument and, therefore, the threat of mechanical damage to the spinal cord and its elements. In addition, this technique requires a set of special sophisticated tools and equipment for its implementation.

The objective of the invention is to develop an effective method of anterior decompression of the spinal cord from a technically simple posterior approach with the exception of rough mechanical contact with the spinal cord and performed using simple tools.

The problem is solved in that in the method of anterior decompression of the spinal cord, including violation of the integrity of the injured vertebra, removal of intracanally located bone and cartilage fragments and subsequent osteosynthesis, a laminectomy and resection of the medial parts of the lateral arches and roots of the arches are performed, insignificant medial retraction of the spinal cord is performed using a hollow castellated mill of small diameter, form a defect in the posterior part of the body of the damaged vertebra, the dimensions of which correspond to the dimensions ntrakanalnyh structures carried reconstitution lumen spinal canal due to displacement intrakanalnyh fragments in the ventral direction formed in the defect.

It is advisable to prevent the migration of intracanal fragments from the formed defect, to carry out the implantation of the intracanal fragments in the ventral direction into the formed defect using the impactor-reponator.

It is advisable to reduce the time of inpatient treatment to carry out internal transpedicular osteosynthesis of the injured segment of the spine.

The invention is illustrated by a detailed description, a clinical example, the attached schemes and radiographs, on which:

figure 1 illustrates a diagram of normal anatomical relationships between the structures of the spine and the dural sac;

figure 2 illustrates a diagram of the anatomical relationship of the structures of the spine and dural sac in a comminuted fracture with an intracanal bone fragment;

figure 3 - arrangement of the cutter when drilling the posterior parts of the vertebral body;

figure 4 - arrangement of impactor during reposition of intracanal fragments;

5 is a diagram of the location of the spinal cord and vertebra after decompression;

6 is a photo of spondylograms of patient I. with a diagnosis of Complicated comminuted unstable fracture of L _I vertebra. Injury, compression of the spinal cord before treatment:

BUT). CT scan spondylogram,

B) CT reconstructive spondylogram in the median sagittal plane;

7 is a photo of the spondylograms of patient I. after surgery: Extended laminectomy L _I , total decompression of the spinal cord at the level of Th _XII , L _I vertebrae (according to the method described above). Revision of the spinal cord. Transpedicular fixation of Th _XII- L _II ,

BUT). Overview spondylogram in a lateral projection,

B) CT reconstructive spondylogram in the median sagittal plane after surgery.

The method is as follows.

Performing back median access is traditional.

The skeletonization of the spinous processes, arches and the area of the intervertebral joints must be performed carefully enough for accurate visualization of the anatomical structures. Before performing a laminectomy of the interested vertebra, it is necessary to resect the lower articular processes and the caudal part of the spinous process of the overlying vertebra. This will provide a sufficient angle of operational action during decompression. Having performed a laminectomy in the inter-articular part of the vertebra (with straight pistol-type nippers from the working part of small sizes), you can remove the arch, lower articular processes and the spinous process of the compressed vertebra in a single block. In this case, it is necessary to excise the yellow ligaments and joint capsules connecting the damaged vertebra to the underlying one. When conducting a laminectomy in this way, the posterior surface of the dural sac is widely exposed. In this case, the lateral parts of the arc remain in the wound. Chisels or nippers resect the medial parts of the lateral arches and the roots of the arches of the damaged vertebra. Using a brain spatula, delicately, the dural sac is displaced inwards and the medial parts of the lateral arches up to the posterior parts of the vertebral body are resected (Figs. 1, 2, 3). The above manipulations are carried out from two sides.

Elimination of the front compression is carried out by removal (drilling) of the posterior parts of the vertebral body with crown cutters. In this case, the direction of the cutter is changed, which allows creating a defect of sufficient volume (approximately equal to the volume of the intracanal structures) in the posterior part of the vertebral body (Fig. 4). In this case, medial retraction of the spinal cord is performed delicately, in order to avoid excessive stretching or tearing of the roots or other elements of the spinal cord. Removing fragments that compress the spinal cord is performed using biting machines or conchotomes. At the same time, it is taken into account that the dural sac is already stretched due to the fragment (s) prolapsed into the channel. The bleeding from the epidural veins that occurs during this stage is eliminated through the use of turundum soaked in a solution of hydrogen peroxide and bipolar thermocoagulation. In the presence of a defect formed by the cutters under the intracanal fragment, it is possible by impactor-reponators to eliminate stenosis due to its displacement in the ventral direction and indentation (impact) of the fragments into the body of the damaged vertebra (Fig. 5). In the case of applying stabilization methods involving the tension of the posterior longitudinal ligament, an additional moment of reposition will also be realized. It is preferable to apply transpedicular osteosynthesis, which allows for three-plane reposition, interbody primary fixation and compensates for iatrogenic loss of elements of the posterior support complex.

A clinical example of the method.

Patient I, 40 years old, was admitted to the neurosurgery clinic of the 2nd Design Bureau in Tyumen with a diagnosis of Closed complicated comminuted unstable fracture of the L _I vertebra. Contusion, compression of the spinal cord. Spinal shock.

The patient underwent surgery in a delayed order: Extended laminectomy L _I , total decompression of the spinal cord at the level of Th _XII , L _I vertebrae (according to the method described above).

Revision of the spinal cord.

Transpedicular fixation of Th _XII- L _II vertebrae with titanium nickelide elements. The wound healed by primary intention. In the immediate postoperative period, there was a pronounced regression of neurological symptoms (transition from group B to D) (Fig.6 and 7).

The proposed method allows for technically simple rear access with the exception of gross mechanical contact with the spinal cord and performed using simple tools to perform a laminectomy with subsequent anterior decompression of the spinal cord.

In addition, he proposes to prevent the migration of intracanal fragments from the formed defect and to shorten the treatment time.

Using the proposed method allows in the near postoperative period to observe a pronounced regression of neurological symptoms.

The proposed method is used in the clinic of neurosurgery 2 design bureau of Tyumen.

Figure 1

1. Spinous process

2. The articular process

3. Arc of the vertebra

4. The transverse process

5. Projection of the spinal cord and dural sac

6. The body of the vertebra

Figure 2

1. Spinous process

2. The articular process

3. Arc of the vertebra

4. The transverse process

5. Projection of the spinal cord and dural sac

6. The body of the vertebra

7. Intrachannel fragments

Figure 3.

5. Projection of the spinal cord and brain spatula

7. Intrachannel fragment

8. Mill

9. Iatrogenic defect in the vertebral body

Figure 4

5. Projection of the spinal cord and dural sac

7. Intrachannel fragment

9. Iatrogenic defect in the vertebral body

10. Impactor

Figure 5

5. Projection of the spinal cord and dural sac

6. The body of the vertebra

7. Intrachannel fragment

9. Iatrogenic defect in the vertebral body

Claims (3)

1. The method of anterior decompression of the spinal cord, including violation of the integrity of the injured vertebra, osteosynthesis, characterized in that a laminectomy is performed with resection of the vertebral arch, including the roots of the arches, resection of the lower articular processes and the caudal part of the spinous process of the overlying vertebra, medial retraction of the spinal cord is carried out, form with the help of a hollow castellated cutter, a defect in the posterior part of the body of the damaged vertebra displaces intracanally located fragments in the ventral direction in the This defect, make the impact of fragments into the formed defect. 2. The method according to claim 1, characterized in that the intracanal fragments are implanted in the ventral direction into the defect formed using the impactor-reponator. 3. The method according to claim 1, characterized in that the internal transpedicular osteosynthesis of the injured segment of the spine is performed.

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