RU2467716C1 - Method for spinal decompression in thoracic and lumbar vertebral fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely traumatology, orthopaedics and neurosurgery. A method represents a posterolateral surgical approach to anterolateral vertebral canal of a thoracic spine, and microsurgical extraction of a vertebral fragment compressing spinal cord at the front. An endoscopic technique and a minimum extent of osteoligamentous resection are used. The posterolateral surgical approach to the vertebral canal is performed by partial resection of an arch leg and vertebral articular processes with maintaining anatomic and functional integrity. The bone fragment compressing spinal cord is removed by resection of a posterior vertebral body and an edge of the vertebral canal within a middle vertebral post. The bone fragments are removed from the vertebral canal under endoscopic control. The approach is assisted by microsurgical instruments, magnifying and endoscopic equipment.

EFFECT: use of the method enables higher therapeutic effect of the surgery ensured by reduced number of injures and damages of paraspinal muscles, eliminated necessity of thoracotomy, minimum extent of osteoligamentous resection of vertebrae, their ligaments and joints.

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Description

The invention relates to medicine, namely to traumatology, orthopedics and neurosurgery, and can be used for anterior decompression of the spinal cord for fractures of the thoracic and lumbar vertebrae.

Complicated fractures of the thoracic and lumbar vertebrae are often accompanied by anterior compression of the spinal cord by bone fragments, which causes severe neurological deficiency and is difficult to treat due to the peculiarities of the anatomical structure of the thoracic and lumbar spine.

To date, the problem of choosing the optimal methods of surgical interventions on the thoracic and lumbar spine with this pathology is completely unresolved. At the same time, the surgeon has two tasks: neurosurgical - the implementation of full decompression of the spinal cord, and orthopedic - ensuring the maximum possible biomechanical stability of the operated vertebral segment by choosing the minimally invasive access.

The main risk during operations for complicated fractures of the thoracic and lumbar vertebrae:

- manipulations with the spinal cord and, therefore, its trauma;

- violation of the blood supply to the spinal cord due to damage to the radiculomedullary vessels;

- instability of the thoracic vertebral segment due to extensive osteo-ligamentous resection.

Most of the methods for anterior decompression of the spinal cord for fractures of the thoracic and lumbar vertebrae that are currently used are quite traumatic; access to the anterior parts of the spinal canal that they provide is not beneficial. Due to the extensive resection of the vertebral bodies and ligaments, there is a high risk of damage to the radiculomedullary arteries, spinal cord and postoperative instability of the thoracic vertebral segment.

There is a method of anterior decompression of the spinal cord for fractures of the thoracic and lumbar vertebrae, including posterior operative access to the thoracic spine, resection of the arch of the arch leg and intervertebral joint (Aebi M, Etter C, Kehl T, et al. Stabilization of the lower thoracic and lumbar spine with the internal spinal skeletal fixation system. Indications, techniques, and first results of treatment. // Spine. - 1987. - V.12. - P.544-551).

The disadvantage of this method is that the volume of the resection requires the removal of the arch, transverse processes, legs of the arches and intervertebral joints of the vertebra. To remove bone fragments of the vertebra from the anterior spinal canal, abduction and forced traction of the spinal cord are required. Such manipulations in conditions of decompensation of blood circulation in the compressed spinal cord lead to postoperative neurological complications.

The closest is the method of anterior decompression of the spinal cord after a laminectomy (RF Patent No. 2306887, IPC АВВ 17/56, publ. 2007), including resection of the vertebral arch root, resection of the articular processes and lateral wall of the spinal canal, formation of a canal in the posterior canal with a crown body part of the damaged vertebra, wedging of intracanal located fragments in the ventral direction into the formed defect.

The disadvantage of this method is that to perform decompression of the spinal cord, a laminectomy, removal of intervertebral joints and arches from two sides is necessary. During the anterior decompression, most of the vertebra is removed, which in the early and late postoperative periods will adversely affect the reparative regeneration of the damaged vertebra, while the fragments that compress the spinal cord are not removed, but are implanted (wedged) in the ventral direction with a special tool. Such manipulations, carried out not under the direct control of vision, can lead to damage to the neurovascular formations of the spinal cord. Also, removal and forced traction of the spinal cord is required to remove bone fragments of the vertebra from the anterior spinal canal. Such manipulations in conditions of decompensation of blood circulation in the compressed spinal cord lead to postoperative neurological complications.

The objective of the invention is to eliminate these drawbacks, reduce trauma, provide the possibility of use in somatically severe patients with concomitant pathologies who are contraindicated with transthoracic access, by using video endoscopic equipment to visualize hard-to-reach anatomical formations of the spinal canal during decompression, reduce the duration of surgery and anesthesia, minimizing the volume of osteo-ligamentous resection and blood loss. The method eliminates the need for direct manipulation of the neurovascular formations of the spinal cord during decompression.

The objectives are achieved in that in the method of anterior decompression of the spinal cord in case of fractures of the thoracic and lumbar vertebrae, including resection of the root of the vertebral arch, resection of the articular processes and the lateral wall of the spinal canal, the formation of a damaged vertebra with the help of a crown cutter, it is proposed to perform resection the root of the arc closest to the fragment of the vertebra, resect the posterior third of the body of the broken vertebra within the middle supporting column of the spine, while maintaining the front wall spinal canal, and then displace the preserved front wall of the spinal canal and bone fragment into the resection zone of the posterior third of the vertebral body, followed by removal of the fragment under endoscopic control.

The essence of the method is illustrated by the drawings: figure 1 - comminuted fracture of the vertebra with front compression of the spinal cord by a bone fragment and the formation of a stroke in the upper part of the leg of the vertebral arch using an awl; figure 2 - resection of the lateral wall of the spinal canal of a broken vertebra using a cutter; figure 3 - resection of the posterior third of the body of a broken vertebra while maintaining the anterior wall of the spinal canal using video endoscopic assistance, figure 4 - decompression of the spinal cord by moving the remnants of the anterior wall of the vertebral canal and fragments of the vertebra into the resection zone of the posterior third of the vertebral body, figure 5 - revision of the spinal cord and removal of vertebral fragments using video endoscopic assistant, Fig.6 - CT of the vertebra after decompression of the spinal cord (example).

The method is as follows.

Microsurgical instruments, video endoscopic equipment are required. Surgery is performed under endotracheal anesthesia in the patient’s position on the abdomen.

A typical posterior surgical access is made to the damaged vertebra 1, during which the transverse processes 2 and the arches 3 of the vertebra 1 are distinguished. The allocation is performed on one side, respectively, of the lateralization of a fragment of the 4 vertebra compressing the back of the brain 5.

After this, the formation of the stroke 6 in the leg of the arc 7 is carried out with the help of an awl 8. The awl 8 is circularly passed through the leg of the arc 7 and immersed to a depth of 4-5 cm, so as to reach the middle third of the vertebral body 9.

Next, the milling channel 10 is formed along the stroke 6 formed by the awl 8. For this, a milling cutter 11 with a diameter of 10-12 mm is used. During the passage of the cutter 11, the leg of the arc 7 of the vertebra 1 is resected, as well as the side wall of the vertebral canal 12. The cutter 11 is immersed to the depth of the posterior third of the vertebral body 9, respectively. Opening the lateral wall of the vertebral canal 12 allows visualization of the spinal cord 5 and its trauma in the subsequent stages operations.

After the formation of the milling channel 10 in the upper part of the leg of the arch 7 and the posterior third of the vertebral body 9, a resection of the posterior third of the vertebral body with the opening of the lateral wall of the spinal canal 12 is carried out.

With a conchotome 13, under the control of the endoscope 14, a resection cavity 15 is formed in the posterior third of the vertebral body 9 with preservation of the anterior wall of the vertebral canal 12. The safety of the anterior wall of the vertebral canal 12 ensures the safety of the resection of the posterior third of the vertebral 9, while the visual control of manipulations with the endoscope 14 remains adequate by visualizing the lateral surface of the spinal cord 5. After resection of the posterior third of the vertebral body 9, the spinal cord 5 remains compressed only by a fragment of the vertebra 4 adjacent to the anterior her wall of the spinal canal 12.

Next, direct decompression of the spinal cord 5 is performed by mixing with a conchotome 13 residues of the preserved anterior wall of the spinal canal 12 with the adjacent bone fragment 4 from the spinal cord 5 into the formed cavity 15 in the posterior third of the vertebral body 9. Thus, not a single operation was performed during the entire operation direct manipulation of the spinal cord 5.

After decompression, the spinal cord 5 is revised using an endoscope 14 inserted into the resection cavity 15 of the posterior third of the vertebral body 9, and corporodesis of the vertebral body is performed by auto- or heterografts 16.

At the end, a typical transpedicular osteosynthesis of the damaged segment of the spine is performed.

Hemostasis is performed. The wound is sutured in layers tightly. An aseptic dressing is applied to postoperative sutures.

Example.

Patient U, 42 years old. Diagnosis: Complicated spinal injury. Compression-comminuted fracture of the L1 vertebra with spinal cord pressure. Lower paraparesis with dysfunction of the pelvic organs.

Complaints on admission: Pain in the thoracolumbar spine, weakness in the limbs, numbness in the legs, impaired function of the pelvic organs.

Medical history. According to the patient: the night before he fell from the roof of a two-story house while intoxicated. Immediately after the fall, there was a sharp pain in the thoracolumbar spine, weakness and numbness in the legs. An ambulance was delivered to the Central Hospital in m / f. When examining in the admission department on the x-ray of the thoracolumbar spine revealed compression-comminuted fracture L1 vertebra. Computed tomography of the thoracolumbar spine revealed a compression-comminuted fracture of the L1 vertebra with a rough anterior compression of the spinal cord.

Objective examination: The state of moderate severity, conscious, adequate, the skin is clean, vesicular breathing, no wheezing. Heart sounds are rhythmic, no noise, R-76 per min, blood pressure 120/80 mm RT. Art. The tongue is moist, the abdomen is soft, painless, the liver, spleen are not enlarged. Violation of the functions of the pelvic organs.

Neurological examination: Neurological status reveals pathological symptoms in the form of revitalization of tendon reflexes from the legs, D = S, hyposthesia from the level of L1 segment, bilateral with Babinsky.

Strength in the legs is sharply reduced to 2 points. The tone in the limbs is reduced.

According to the proposed method, an operation was performed: posterolateral surgical access to the anterolateral spinal canal of the thoracic spine at the level of L1 vertebra and microsurgical decompression of the spinal cord with the removal of bone fragments of the L1 vertebral body using endoscopic technique according to the method described above (Fig.6).

Condition after surgery with pronounced positive dynamics. Discharged from the hospital on the 12th day.

At the follow-up examination 1 month after the operation: no health complaints.

By the proposed method, 28 operations were performed, in all cases a good clinical result was achieved. On control examinations, 1-2 years after the operation, consolidation of the body of the broken vertebra was observed.

The application of this method allows to increase the therapeutic effect of the operation by reducing trauma and damage to the paraspinal muscles, the absence of the need for thoracotomy, and the minimum amount of osteoligmentary resection of the vertebrae of their ligaments and joints. A more adequate decompression of the anterior spinal cord from posterolateral access is provided, and the possibility of spinal cord injury is minimized, the risk of damage to surrounding soft tissues, blood vessels, nerve structures is reduced, and the time of surgery is reduced. All this improves the living conditions of patients, reduces the number of bed days and general disability.

Claims (1)

The method of anterior decompression of the spinal cord in case of fractures of the thoracic and lumbar vertebrae, including resection of the root of the vertebral arch, resection of the articular processes and the lateral wall of the spinal canal, formation of a damaged vertebra using a crown cutter in the posterior part of the body, characterized in that the root of the arch of the proximal is resected fragment of the vertebra, the posterior third of the body of the broken vertebra is resected within the middle supporting column of the spine while maintaining the anterior wall of the spinal canal, hydrochloric front wall of the spinal canal and the bone fragment is in the posterior third of the vertebral body resection zone followed by removal of the fragment under endoscopic control.

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