RU2382616C1 - Method of surgical treatment of patients with traumatic injury of vertebra and device for its realisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: fastening elements are connected to each other with transversal bars provided with two couplings which have screwed holes for locking elements. Coupling are located near spinous processes. Transversal bars are connected via couplings with longitudinal bars and distraction is carried out. Longitudinal bars are fixed by means of locking elements in couplings. Fixation of fastening elements is weakened and reclination is performed by converging central rods, introduced into central screwed holes of heads of fastening elements. Transpedicularly screwed into adjacent vertebra locking elements are finally fixed, central rods are removed. Intraosteal reposition-fixing device for spine contains fastening elements with heads which have side slots, located at acute angle to axis of fastening elements and whose bases are made in form of hollows and projections, external thread, central screwed holes and edge cuts, longitudinal bars, fixing nuts with wide bases, central rods, introduced into central screwed holes of heads of fastening elements. In device additionally included are transversal bars with installed on them two couplings, which have holes for locking screws. Transversal bars are located in side slots of heads of fastening elements and are fixed with nuts, longitudinal bars being installed in couplings of transversal bar and rigidly fixed with locking screws.

EFFECT: increase of reposition and reclination possibilities of system with distribution of even loading on screws and on the whole system in general.

2 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of comminuted fractures of the vertebral bodies of the thoracic and lumbar spine, both without the introduction of bone fragments into the spinal canal, and in the presence of stenosis of the spinal canal due to significant displacements of bone fragments.

A known method of surgical treatment of spinal canal stenosis by a posterolateral laminectomy, in which the screws are inserted into the roots of the arches adjacent to the pathological vertebra in pairs, is connected pedally to the rods along the lateral sides of the spine with their subsequent fixation. And with laminectomy, the roots of the arches, transverse processes and posterior sections of the damaged vertebral bodies and adjacent discs are also resected from both sides (RF patent No. 2197913, class A61B 17/56. Publish. February 10, 2003).

The disadvantages of this method are the limited repositioning capabilities of the system. In addition, the possibility of secondary compression of the dural sac and its contents due to the formation of shell-muscle scars and pressure of the muscles themselves in the area of the performed laminectomy is not ruled out.

There is also known a method of spinal osteosynthesis, including the use of a ventral spinal system, the fixing elements of which are inserted into the bodies of the vertebrae adjacent to the damaged one and connected using fastening elements with a longitudinal rod, which is the main bearing element. The main supporting element of the spinal system is located in the center of the fixing elements inserted into the vertebral bodies and in the center of the vertebral bodies, on the border of the anterior and middle osteo-ligamentous columns, along the vertical biomechanical force axis of the spine (RF patent No. 2228724, class A61B 17/56. Publ. May 20, 2004).

However, the disadvantages of this method are the high morbidity of surgical intervention and a high risk of serious complications associated with the need to penetrate the pleural cavity in the thoracic region, and with the likelihood of damage to the peritoneum, blood vessels and organs of the retroperitoneal space.

The closest solution in its technical essence to the first invention is a method for surgical treatment of patients with traumatic vertebral injury, including installing on two sides of the spinous processes of the stop-hooks under the vertebral arches 2-3 higher and 2-3 lower than the damaged one, connecting the stop-hooks with distractor rods and spinal distraction. Previously, grippers and nuts are installed on the distractor rods on both sides of them. Then, screws are screwed through adjacent grips into adjacent vertebrae and the damaged vertebra is reclaimed by moving the gripper along the shaft in the direction one to the other by rotating the nuts (RF patent No. 2127560, class A61B 17/56. Publish. March 20, 1999).

The disadvantage of this method of surgical treatment using grips and hooks-stops is the significant length of the stabilizing system, requiring multi-segment fixation of more than three segments of the spine.

Known fixer intended for the surgical treatment of injuries and diseases of the spine, containing bone threaded rods installed in fixation nodes connected in pairs by longitudinal screw ties and two transverse screw ties. Each of the fixation nodes is made in the form of a fork with transverse holes for a bone threaded rod and a shank with a threaded thread at the end and a neck at the base of the fork. In this case, the shank of each fork is threaded threaded to the end of the longitudinal screw tie, and the end of each transverse screw tie is fixed to the neck of the fork (USSR author's certificate No. 1532015, class A61B 17/60. Publ. 30.12.89 Bull. No. 48) .

The disadvantages of the known device include the lack of reliable stabilization of the system and the technical complexity of its layout.

A device for percutaneous spinal osteosynthesis is also known, comprising screws with heads having lateral grooves, an external thread, central threaded holes and edge slots, rods, fixing nuts and central rods inserted into central threaded holes of screw heads. It has transverse and longitudinal rods, couplings with holes, which together with the central rods form a reponitive system of the spine. The lateral grooves in the screw heads are located at an acute angle to the axis of the screws, and their bases and the surface of the rods are made in the form of circular recesses and protrusions, and the fixing nuts with wide bases (RF patent No. 2108763, class A61B 17/70. Publ. 20.04 .1998).

The disadvantages of this device are significant limitations of the repositioning capabilities of the system due to the direct connection of transpedicular screws with longitudinal rods. In addition, the frame system is not reliable enough, because screws with longitudinal rods carry an uneven load, which creates conditions that can lead to breakage of the structure.

Closest to the second invention in its technical essence is a transosseous reposition and fixing device for the spine, containing screws with heads having lateral grooves located at an acute angle to the axis of the screws, and the bases of which are made in the form of recesses and protrusions, an external thread, and central threaded holes and edge slots, longitudinal rods with a surface in the form of recesses and protrusions, locking nuts with wide bases, central rods inserted into central threaded holes screw heads. The device has threaded ends of screws with a core turning into threaded tips, central rods with threads on one end for screwing them into the central threaded holes of the screw heads, a thickening and a turnkey hexagon on the other end (RF patent No. 2171650, class A61B 17/60 Publish. August 10, 2001).

The disadvantages of this device, as well as the previous one, are significant limitations of the repositioning capabilities of the system due to the direct connection of transpedicular screws with longitudinal rods. In addition, the frame system is not reliable enough, because screws with longitudinal rods bear (especially with lateral movements) an uneven load, which does not exclude the possibility of breaking the structure.

The task to which the claimed inventions are directed is to increase the reposition and re-establishment capabilities of the system with the distribution of a uniform load on the screws and the entire system as a whole.

The problem is solved in that in the method of surgical treatment of patients with traumatic damage to the vertebrae, including screwing pediculary fasteners into adjacent vertebrae and reclination of the damaged vertebra, the fasteners are connected by transverse rods equipped with two couplings having threaded holes for retaining elements. The couplings are located next to the spinous processes, the transverse rods are connected through the couplings with the longitudinal rods, and distraction is performed. The locking rods are fixed with locking elements in the couplings, then the fixation of the fastening elements is loosened and the reclinations are carried out by bringing the central rods closer together. After that, the fasteners screwed into the adjacent vertebrae are finally fixed, and the central rods are removed.

Into a transosseous reposition and fixing device for the spine, containing fasteners with heads having lateral grooves located at an acute angle to the axis of the screws and the bases of which are made in the form of recesses and protrusions, an external thread, central threaded holes and edge slots, longitudinal rods with a surface in the form of recesses and protrusions, fixing nuts with wide bases, central rods inserted into the central threaded holes of the heads of the fasteners, additionally transverse Tanguy mounted with two couplings with holes for locking screws. In this case, the transverse rods are placed in the side grooves of the heads of the fasteners and are fixed with nuts. And the longitudinal rods are installed in the couplings of the transverse rod and are rigidly fixed with locking screws. The reponing system of the spine is formed by four central rods. As fasteners, for example, screws or screws can be selected.

The claimed method of surgical treatment of patients with traumatic damage to the vertebrae and transosseous reposition-fixing device for the spine are different from the known analogues. Those. the claimed solutions satisfy the condition of patentability of the invention of "novelty."

The analysis of the prior art showed that the claimed solutions meet the condition of patentability of the invention "inventive step".

The claimed method and device are so interconnected that they form a single inventive concept. Indeed, when creating a method of surgical treatment of patients with traumatic damage to the vertebrae, an transosseous reposition-fixing device for the spine was created.

Using this device in the proposed method allows to solve the problem with obtaining the desired technical result: improving the therapeutic effect.

Therefore, the claimed invention satisfy the requirement of unity of invention.

The invention is illustrated by drawings: in Fig.1 shows a screw, a nut with a wide base, a central rod, a transverse rod with two couplings, a longitudinal rod; figure 2 - diagram of transosseous transpedicular osteosynthesis of the spine by the device in reposition mode, side view; figure 3 is a diagram of transosseous transpedicular osteosynthesis of the spine by the device after reposition and reclination in fixation mode, side view; figure 4 is a view of figure 3; figure 5 is a section bB in figure 4.

The transosseous reposition and fixing device for the spine contains screws 1 with heads 2 having side grooves 3 located at an acute angle to the axis 4 of the screws 1 and the bases 5 of which are made in the form of recesses and protrusions, an external thread 6, central threaded holes 7 and edge slots 8, longitudinal rods 9, fixing nuts 10 with wide bases 11, central rods 12 with thread 13 at one end and hexagon 14 at the other, inserted into the central threaded holes 7 of the heads 2 of the screws 1, the transverse rods 15 with two couplings 16 with threaded holes 17 for the locking elements 18. The transverse rods 15 are placed in the lateral grooves 3 of the heads 2 of the screws 1 and are fixed with nuts 10. The longitudinal rods 9 are installed in the couplings 16 of the transverse rod 15 and are rigidly fixed by the locking elements 18. And the spinal reponition system consists of 4 removable central rods 12.

The method and device are implemented as follows.

The patient is placed on the operating table in a position on the abdomen with rollers under the chest and pelvis. After processing the surgical field, soft tissues are cut over the spinous processes of the damaged and adjacent vertebrae. Skeletonization of the spinous processes and vertebral arches is performed. If it is necessary to revise the spinal canal, using a vibration saw, a laminotomy is made of the damaged and, if necessary, overlying vertebrae with preservation of the supraspinatus ligaments. The spinous processes with arches of the vertebrae recline in the cranial or caudal direction. After revision of the spinal canal and decompression by impaction of bone fragments into the vertebral body and elimination of compression of the dural sac, deformation correction and fixation of the spine are performed. To do this, under x-ray control, screws 1 are installed pediculously in the vertebral bodies adjacent to the damaged vertebra. After returning to the former place, the spinous processes and arches of the vertebrae connect and fix the pedicular screws 1 with each other by transverse rods 15 with couplings 16, which are located along the spinous processes. Then, longitudinal rods 9 are installed in the couplings 16 of the transverse rods 15 and fixed at the level of the lower vertebra by the locking screws 18. Then, under the control of the X-ray diffraction, distraction is also performed to restore the height of the interbody gap at the level of the damaged segment. In this case, partial reclination of the height of the body of the damaged vertebra is obtained. The longitudinal rods 9 are fixed in the couplings 16 of the transverse rods 15 by the locking elements 18. They weaken the fixation of the transpedicular screws 1 and, bringing the central rods 12 closer to each other, create additional reclination of the body of the damaged vertebra. Perform control x-ray: and with the full restoration of the height of the body of the damaged vertebra, the transpedicular screws 1 are fixed, and the central rods 12 are removed. The entire transpedicular system is stabilized and the surgical wound is sutured in layers. Apply an aseptic dressing. In the vertical position of the patient is transferred the next day after surgery.

Example

Patient K., 33 years old, was admitted to the neurosurgery clinic 12 hours after receiving an injury with a diagnosis of Vertebral Spinal Injury (PSMT), comminuted-fractured fracture of the LII vertebra with contusion and compression of the spinal cord with bone fragments. The wedge index of the LII body is 0.45. The angle of kyphosis at a fracture level of 23 °. Lower mild paraparesis. Partial dysfunction of the pelvic organs. "

From the anamnesis it is known that when repairing a car it was crushed by a trailer in the flexion position in the lumbar spine. Immediately I felt a sharp pain in the indicated section of the spine with radiation to the lower extremities. After being released from under the trailer, he could not move independently due to pain in the lumbar spine and weakness in the legs, which gradually began to increase. From the scene, he was taken to the Central Republican Hospital (NRB), where, after a clinical and neurological examination and X-ray examination, a spinal cord injury with a comminuted fracture of the LII vertebra was revealed. By air ambulance the patient was taken to a specialized medical institution where computed tomography (CT) and magnetic resonance imaging (MRI) were performed. A CT study revealed a compression-comminuted fracture of the LII vertebral body with displacement of bone fragments into the spinal canal and compression of the dural sac with a spinal lumen deficiency of up to 60%. An MRI scan revealed that there is compression of the cone of the spinal cord and its roots. No foci of gross damage to the spinal cord were detected. Surgical treatment was performed in urgent order: a bone-plastic laminectomy of LI-LII vertebrae with impaction of bone fragments, revision of subarachnoid spaces and spinal cord, correction of the declared transosseous reposition-fixing deformity device and fixation of the lumbar spine at the level of LI-LIII vertebrae.

Surgical treatment was carried out under endotracheal anesthesia as follows.

The patient was placed on the operating table in a position on his stomach with rollers under the chest and pelvis. After processing the surgical field, soft tissues were cut over the spinous processes of the LI-LIII vertebrae. Skeletonization of the spinous processes and vertebral arches was performed. It was found that there is a rupture of the supraspinatus and interspinous ligaments of the LI-LII vertebrae, a fracture of the LII vertebral arch on the right along the medial edge of the articular processes. Using a vibropile, a laminotomy of the LI-LII vertebrae was performed with preservation of the supraspinous ligaments of the ThXII-LI and LII-LIII segments. The spinous processes with arches of the vertebrae reclined caudally and cranially. During the audit of the spinal canal, it was revealed that there is a bulging of the dural sac of cyanotic color at the level of the upper edge of the LII vertebra, and during the audit of the anterior epidural spaces, a bone fragment of 1.5 × 1.0 cm deforming the dural sac was revealed. The dural sac was pushed out medially, an impactor was inserted under it over the fragment, and then the bone fragment was implanted into the vertebral body. As a result, spinal canal deformity and dural sac compression were eliminated. After this, the dural sac was opened for 1.5 cm. Free flow of clear cerebrospinal fluid from the upper and lower floors of the dural sac was noted. We took 3.0 ml of cerebrospinal fluid for the study. The cone of the spinal cord pulsates, whitish in color, with single small-point hemorrhages. The dura mater was hermetically sutured with a twisted suture without its deformation. After that, it was decided to proceed to the stage of correction of deformity and fixation of the spine. Under the control of X-ray, screws were placed transpedicularly into the bodies of LI and LIII vertebrae. After returning to the former place of the spinous processes and arches of the LI-LII vertebrae, they were connected and fixed between each other by transverse rods with couplings, which were located along the spinous processes. Then, longitudinal rods were installed in the couplings of the transverse rods, which were fixed with locking screws at the level of the LIII vertebra. After that, under the control of an X-ray study, distraction was performed until the height of the interbody gap was restored at the level of LI-LIII segments. At the same time, partial reclination of the height of the body of the damaged vertebra was obtained. The longitudinal rods were fixed in the couplings by locking elements. Weakened the fixation of the transpedicular screws and, with the help of the central rods, brought them closer to each other by additional recline of the vertebral body. On the control radiograph, almost complete restoration of the body of the damaged vertebra was noted. After this, transpedicular screws were fixed, and the central rods were removed. They stabilized the entire transpedicular system. On the control radiographs, its correct position is noted. Kyphotic deformity is eliminated. The height of the body of the damaged vertebra is almost completely restored. The wedge index is 0.9. Made control of hemostasis. Layered stitches on the wound and stitches on the skin. The sutures were treated with a solution of antiseptics, an aseptic dressing was applied. During surgery, the patient was infused with 4000 mg of solomedrol. In the postoperative period, the drug was continued for 24 hours at the rate of 5 mg per 1 kg of patient weight. A CT scan performed on the second day after surgery revealed that spinal canal deformity was completely eliminated.

The patient in the postoperative period noted a positive neurological dynamics in the form of the restoration of self-urination and the full range of movements in the lower extremities. Hypesthesia along the outer surface of the thighs and the anteroposterior surface of the legs remained. On the second day, the patient was moved upright on crutches. A week later, the patient began to move without external support. After 1 month, the patient was discharged for outpatient treatment.

At the follow-up examination after 6 months, and then after one year, a complete regression of neurological symptoms was noted. A fracture of the LII vertebral body was consolidated. The position of the metal structure is stable. Loss of correction is not revealed. A CT scan did not reveal spinal canal deformity.

Claims (2)

1. A method of surgical treatment of patients with traumatic injury to the vertebrae, including screwing into adjacent vertebrae of transpedicular fasteners and reclining of the damaged vertebra, characterized in that the fastening elements are interconnected by transverse rods provided with two couplings having threaded holes for retaining elements; with spinous processes, connect the transverse rods through couplings with longitudinal rods and perform distraction, fix the longitudinal rods lock elements in the couplings, then weaken the fixation of the fasteners and carry out the reclining by bringing the central rods inserted into the central threaded holes of the heads of the fasteners closer, after which the fasteners finally screwed into adjacent vertebrae are finally fixed, and the central rods are removed. 2. Transosseous reposition and fixing device for the spine, containing fasteners with heads having lateral grooves located at an acute angle to the axis of the fasteners and the bases of which are made in the form of recesses and protrusions, an external thread, central threaded holes and edge slots, longitudinal rods , fixing nuts with wide bases, central rods inserted into the central threaded holes of the heads of fasteners, characterized in that the transverse bolts are additionally inserted into it ngi with two couplings installed on them, having holes for the locking screws, while the transverse rods are placed in the side grooves of the heads of the fasteners and are fixed with nuts, and the longitudinal rods are installed in the couplings of the transverse rod and are rigidly fixed with the locking screws.

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