RU2484783C1 - Method of resecting hemivertebrae of thoracic and lumbar localisation with access through arc root - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to spinal surgery. Spongy tissue of body, its apophisary plates and contacting with hemivertebra intervertebral discs together with epiphysary plates of adjacent vertebrae to contralateral side surface of spine are ablated through arc base with spoons. Correction and fixation with contractor and spinal fusion are performed.

EFFECT: method makes it possible to ablate all structures of abnormally developed hemivertebra completely without detachment and displacement of dural sac and creates conditions for complete correction of all elements of deformation.

1 ex, 15 dwg

Description

The invention relates to medicine, namely to spinal surgery, and is used in the treatment of patients with congenital spinal deformities caused by half-vertebrae.

A known method for removing a half-vertebra from one rear access involves resection of the posterior sections of the half-vertebra, i.e. half-arc, transverse and articular processes, arch and root of the arch, then the arc and its base are resected to access the body of the semi-vertebra, the dural sac is displaced at the apex of the deformity, and the body of the half-vertebra is removed through the gap between the burs and spoons (Ruf M., Harms J., Hemivertebra resection in congenital scoliosis. Operator. Orthop.TraumatoL, - 2/2004. P.205-219], [Vissarionov S.V. et al. Surgical treatment of children with congenital deformity of the upper thoracic spine. Spine surgery, - 2/2011 , p. 35-40).

However, the proposed method has a major drawback: when accessing the body, it is necessary to push back the dural sac, which can lead to spinal cord injury and increases the risk of neurological complications.

A known method for correcting congenital spinal deformity in children caused by the presence of a half-vertebra, including removing a half-vertebra and installing a contractor on intact vertebrae, additionally mobilizes the spine in the area of the remote half-vertebra, for which, on the side opposite to the remote half-vertebra, partial resection of two adjacent arcs from the spinous line is performed processes laterally to the edge of the arc, and on the side of the remote semi-vertebra perform an osteotomy of the arc, deviated from the normal axis of the vertebra nick along the line of spinous processes (RU 2301041 C2).

The disadvantage of this method is the need for resection to 1/3 of the arches of adjacent vertebrae, i.e. damage to the cortical layer and narrowing of the arch, which reduces the support of the arch and eliminates the hook fixation of adjacent segments.

The task of the invention is to provide a method for extirpating the semi-vertebrae of the thoracic and lumbar regions by removing all the elements of an abnormally developed semi-vertebra, correcting all the elements of the deformity and creating osteoplastic fusion.

This problem is achieved by the fact that in the method of resection of the semi-vertebrae of the thoracic and lumbar localization by access through the root of the arch, including the installation of contractors for intact vertebrae, removal of the half-arches, articular processes along with the articular and transverse processes, the spongy tissue of the vertebral body and its apophysial are removed with spoons through the base of the arc plates and intervertebral discs contacting with the semi-vertebra along with the epiphyseal plates of adjacent vertebrae to the contralateral lateral surface of the spine, correction and fixation by the contractor and spinal fusion.

The method is illustrated by a detailed description, an example of its practical use and illustrative materials, which depict:

Figure 1 - diagram of the posterior column of the semi-vertebra and adjacent vertebrae: 1 - half-arc of the semi-vertebra; 2 - the base of the semi-arc of the vertebra;

Figure 2 - diagram of the production of transpedicular screws through the arches of the contact vertebrae: 1 - screw heads;

Figure 3 - view of the body of the half-vertebra after removal of the half-arc: 1 - the body of the half-vertebra; 2 - bodies of adjacent vertebrae;

Figure 4 - view after extirpation of the body of the half-vertebra through the root of the arc;

Figure 5 - diagram of the operation after extirpation of the body of the semi-vertebra, interbody fusion with autologous bone and fixation with instrumentation: 1 - heads of transpedicular screws, 2 - rod; 3 - autobone in the interbody; arrows indicate the direction of movement of the screw heads along the rod;

6 - radiographs of the spine (a) and CT (b, c, d, e) of patient A. A kyphoscoliotic deformation is determined due to the supercomplete posterolateral L2 semi-vertebra (right);

7 is a surgical field. The arrow marks the spinous process of the L2 semi-vertebra;

Fig - intraoperative photographs (a) and x-ray (b) defines a half-arc (1), not segmented with an arc L3 of the vertebra;

Fig.9 is a variant of setting transpedicular anchor points through a segment with an unsegmented half-vertebra. The oval delineates the resection area of the posterior sections of the half-vertebra;

Figure 10 - view of the half-vertebra through the root of the arc (indicated by an arrow);

11 is a view of a wound after extirpation of a half-vertebra;

Fig - view of the wound after compression maneuver on the screws. Complete correction of the axis of the spine is noted;

Fig - intraoperative fluorography: sagittal and frontal axis of the spine restored;

Fig - posterior fusion of bone crumb;

Fig - radiographs of patient A. after surgical treatment: the axis of the spine and the standing structure is correct.

The method is as follows.

Rear access to the posterior column of the spine is in accordance with preoperative planning. The extent of access is determined by the instrumentation zone. Set transpedicular or hook anchor points on the collateral side with a semi-vertebral side in adjacent segments. If there is an unsegmented half-vertebra, during extirpation of which partial resection of an adjacent body is possible, instrumentation is performed through a segment - a contractor is installed, consisting of transpedicular screws or hooks placed on contact vertebrae (Figs. 1, 2).

The half-arc, articular processes together with the joints and transverse processes to the base of the arch, directly at the posterior surface of the vertebral body is removed (Figure 3).

From the moment of exposure of the base of the arc, the proposed method has significant differences, namely: the back of the body of the semi-vertebra with adjacent intervertebral discs is not exposed and does not push back the dural sac.

Then, through the base of the arc, which is represented in Figure 4 by an oval cortical layer and spongy tissue in the center, spongy tissue of the body, its apophysial plates and intervertebral discs contacted with the semi-vertebra with the epiphyseal plates of adjacent vertebrae are removed with spoons. The confluence of contact disks is also removed by spoons and conchotomes up to the contralateral lateral surface of the spine.

The operation is carried out without exfoliation of the dural sac and its displacement. Bleeding is stopped with wax and a hemostatic sponge. The space formed after resection of the half-vertebra is filled with autobone in the form of "bone gravel." After that, the anchor points (screws or hooks) of the structure, standing in adjacent vertebrae, are fixed with a rod until they contact (compression along the collateral rod) (Figure 5).

Clinical example

Patient A., 1 year 4 months old (born May 4, 2011), was admitted to the department with a diagnosis of Congenital progressive kyphoscoliosis on the background of an extracomplex posterolateral L2 right vertebra, not segmented with L3. Dysography of arcs L6, L7, S1-3.

Inspection performed:

- On the Rg-grams of the spine with the capture of the pelvis: Kyphoscoliotic deformation: the main right-sided lumbar arch with an apex at the level of the LIII vertebra - 32 °, kyphosis - 7 ° (Figure 6, a).

- MSCT of the spine: congenital anomaly of development: additional semi-vertebra L2 on the right, transitional L6, L7 vertebrae, dysplastic dysraphy of the arches L6, L7, S1, S2, S3 (Fig.6, b, c, d, e).

Indications for surgical treatment: Progressive kyphoscoliotic deformity.

Operation performed: Extirpation of the posterolateral unsegmented supernumerary LII half-vertebra on the right. Correction and stabilization of the monolateral transpedicular system. 360 ° spinal fusion.

Operation progress

Marked skin in the projection of the semi-vertebra L2 (Fig.7).

Performed back access to the arches of the vertebrae L1-L3. The L2 half-arc and the L1-L3 vertebral arches on the right are skeletonized. The half-arc L2 on the right was revealed (Fig. 8). The reference points are installed: screws 3.5 / 24 in L1 and L3 on the right (Fig. 9). Made a wedge-shaped removal on the left of the half-arc, the root of the half-arc L2 within the end plates (Figure 10). Fiber in the epidural space is exposed. The ripple of the dural sac is preserved.

Through the base of the arc, without pushing back the dural sac, the half-body L2 was removed within the framework of the connecting plates by the type of “egg shell” (Fig. 11). Hemostasis.

Control points were closed by a rod. Created structural stress in contraction mode 2.5 cm under the protective introduction of methylprednisolone (Fig).

On fluorography, kyphotic and scoliotic deformity is not determined. Standing construction correct (Fig.13).

Performed corporodez and posterior spinal fusion with bone fragments of the body of the semi-arc along the structure in the form of "bone gravel" (Fig.14). After that, the wound was sutured in layers and an aseptic dressing was applied.

The postoperative period is smooth. On the control radiographs: residual scoliotic deformation of 12 °, no kyphotic component, the position of the metal structure is correct (Fig. 15).

In satisfactory condition, the child was discharged under the supervision of an orthopedist at the place of residence.

Using the proposed method in the clinic FSBI "RRC" WTO "them. Acad. G.A. Ilizarova ”showed that its use allows you to completely remove all the structures of an abnormally developed half-vertebra without peeling or displacing the dural sac. This method creates the conditions for the complete correction of all elements of the deformation and the creation of osteoplastic fusion.

Claims (1)

The method of resection of the thoracic and lumbar localization of vertebrae by access through the root of the arch, including the installation of contractors on intact vertebrae, removal of half arcs, articular processes along with the articular and transverse processes, removes the spongy tissue of the vertebral body, its apophysial plates and intervertebral discs contacted with the semi-vertebra by spoons through the base of the arc together with the epiphyseal plates of neighboring vertebrae to the contralateral lateral surface of the spine, correction and fixation by the contractor and spon Dilodez.

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