RU2495633C1 - Method of spondilectomy via access through arch root - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopedics, namely to spinal surgery and is used in treatment of patients with a trauma, neoplasms and developmental anomalies of spine. Ablated are arches, articular processes together with joints and transverse processes to the base of arches. Spongy body tissue, its apophysary plates and contacting vertebra intervertebral disks with epiphyseal plates of adjacent vertebrae to anterior longitudinal ligament are ablated through bases of arches from two sides. After that, feeding vessels are coagulated, processed with wax and covered with hemostatic sponge. Formed space is filled with bone autochips from spongy bone tissue; spine is fixed with rod.

EFFECT: increased method efficiency.

1 ex, 10 dwg

Description

The invention relates to traumatology and orthopedics, namely spinal surgery, and is used in the treatment of patients with trauma, neoplasms and malformations of the spine.

Known methods for removing vertebrae from one posterior approach (RU 2390312 C1, Tomita K. et al. Total en Bloc Spondylectomy. SPINE, 1997, Vol.22, 3, p.324-333) involving sequential resection of the vertebra, where the first step is removed arc of the vertebra at the level of its base, together with the spinous, articular and transverse processes. The second stage consists of lateral access to the body, resection of adjacent intervertebral discs, and isolation of the body or vertebrotomy with a Jigley saw block at the level of the contact plates of the contact vertebral bodies.

A disadvantage of the known methods is: the removal of the body is performed from symmetric paravertebral accesses, by holding a Jigley saw and chisel after ligation of segmental vessels. At the same time, there is an extremely high risk of pneumothorax (when removing the thoracic vertebrae), blood loss up to 50% of the BCC.

The objective of the invention is to provide a method for extirpation of the vertebrae of the thoracic and lumbar regions, based on the use of favorable anatomical features of the vertebral structure, namely, spondylectomy through the arch root from standard posterior access under good visual control, reduce blood loss, shorten treatment time and improve functional outcome.

The specified technical result is achieved by the fact that in the method of spondyllectomy by access through the root of the arch, including fixing the segments of the spine with a monolateral rod installed in the screw heads, removing the arch, articular processes along with the joints and transverse processes to the base of the arches, directly at the back surface of the vertebral body with exposure of the dural sac, through the base of the arches on both sides, the spongy tissue of the body, its apophysial plates and the intervertebral discs contacting the vertebra are removed along with the epi fizar plates of adjacent vertebrae to the anterior longitudinal ligament, then the supply vessels are coagulated, waxed and covered with a hemostatic sponge, the resulting space is filled with autologous bone from spongy bone tissue.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

Figure 1 - Scheme of the posterior column of spinal segments in the operation zone: 1 - arc of the resected vertebra; 2 - projection of the base of the vertebral arch; 3 - yellow ligament.

Figure 2 - Scheme of setting transpedicular screws through the arches of contact vertebrae: 4 - screw heads.

Figure 3 - View of the body of the resected vertebra after removal of the arc: 5 - the body of the vertebra; 6 - bodies of adjacent vertebrae; 7 - a dural bag; 8 - the core of the structure.

Figure 4 - View after extirpation of the vertebral body through the root of the arc.

Figure 5 - Diagram of the operation after extirpation of the vertebral body, interbody fusion with autologous bone and fixation with instrumentation: 4 - heads of transpedicular screws, 8 - rod; 7 - corrugated dural bag; 8 - autobone in the interbody, the arrow shows the direction of movement of the screw heads along the rod.

6 (a, b) - CT scan of patient Z .: compression-comminuted fracture with wedge-shaped deformation of ThXII, spinal stenosis by 95%

Fig.7 - View of the wound after spondyllectomy and resection of the locking plates of adjacent vertebrae: 7 - dural sac, the arrow indicates the bed of the resected vertebra.

Fig. 8 is a view of the wound after compression maneuvering along the screws and closing the bodies of adjacent vertebrae: 7 — corrugated dural sac; 8 - autobone in the form of bone crumb in the interbody gap; the arrow shows the direction of movement along the rods.

Figure 9 - View of the wound at the time of the end of the operation; structural rigidity complemented by a transverse coupler. The dural sac is covered with a hemostatic sponge. Posterior spinal fusion with autobone fragments.

Figure 10 (a, b) - Radiographs (a) and CT (b) of the patient after surgical treatment: The axis of the spine and the standing structure are correct.

The method is as follows.

Dorsal access to the posterior column of the spine is carried out in accordance with preoperative planning. The extent of access is determined by the instrumentation zone (Figure 1). Preferred is the setting of transpedicular anchor points. bilaterally. Install the screws at 3 levels cranial to the resected vertebra and 2 pairs of screws in the caudal vertebrae (Figure 2).

Segments of the spine are fixed monolaterally with a rod installed in the screw heads. Remove the arc, articular processes along with joints and transverse processes to the base of the arches, directly at the back surface of the vertebral body with exposure of the dural sac (Figure 3).

Since the exposure of the base of the arc, the methodology used by us has significant differences. In the methodology used by us, the antero-lateral part of the vertebral body with adjacent intervertebral discs was not exposed. Through the base of the arches on both sides, spongy body tissue, its apophysial plates and intervertebral discs contacting the vertebra, together with the epiphyseal plates of adjacent vertebrae to the anterior longitudinal ligament, are removed with spoons. The feeding vessels are coagulated, waxed and covered with a hemostatic sponge.

The space formed after resection of the vertebral body is filled with autologous bone from spongy bone tissue and fixed with a metal structure (Figure 5). The corrugated dural sac is covered with a hemostatic sponge.

Clinical example.

Patient Z., 28 years old, was admitted to the department on 11/23/2011 with a diagnosis of TBSM, an early period. Explosive fracture ThXII with dislocation of ThXI. Mechanical and neurological instability according to Denis. SZ type according to ASIF. Lower paraplegia. Disorders of the pelvic organs.

Complaints of pain in the lumbar spine. Lack of movement in the lower limbs. Lack of sensitivity with dermatome L1 level.

Medical history: Injury 11/15/2011 - fell from the height of the 2nd floor. He was hospitalized in the neurosurgical department of the City Emergency Hospital, performed surgical treatment: Laminectomy L1 vertebra.

The patient was examined:

- On Rg-grams of the spine fracture ThXII vertebra.

- MSCT: Compression-comminuted fracture with wedge-shaped deformation of ThXII, spinal stenosis by 95% (Figa, b).

Indications for surgical treatment: the presence of mechanical and neurological instability.

Date and name of operation: Shortening ThXII spondyllectomy through the root of the arc. Enhanced laminectomy of ThXI-LI vertebrae. Decompression, revision of the dural sac and spinal cord. Rear instrumental fixation of ThIX-LII segments with the Legasy (Medtronic) pedicular immersion system. 360 ° spinal fusion.

Operation progress: After triple treatment of the surgical field with an alcohol solution of chlorhexidine, individual nodal sutures were removed, the wound edges were stupidly diluted with tuffers. The muscles are paravertebral on both sides separated by a raspator, the edges are partially excised. Determined by soft tissue imbibition in blood, meager cerebrospinal fluid outflow. Hemostasis by electrocoagulation. Instability of the LI vertebral arches, fractures of the transverse and articular processes of the ThXI-XII vertebrae are determined. After removal of free bone fragments, instability of ThXI-LI segments was revealed.

In the bodies of ThIX-XI, LI-II vertebrae in pairs through the legs of the arches under the control of the image intensifier are introduced transpedicular screws. Right anchor points are closed by a rod to the right in stabilization mode.

An extended laminectomy of ThXII-LI vertebrae was performed. The lumen of the spinal canal was made by fragments of the body of the ThXII vertebra with compression and linear rupture of the dural sac up to 4 cm. The dural sac is cyanotic in color, does not pulsate. Damaged elements of the spinal cord fall out through the defects of the dural sac.

Through the resected roots of the arches, fragments of the body with adjacent disks of the ThXII vertebra to the anterior longitudinal ligament and end plates of adjacent vertebrae were removed from 2 sides (Fig. 7).

Between the bodies of the ThXI-LI vertebrae, fragments of autobone in the form of "bone crumb" are laid. Installation of the structure on the left, compression 5 cm before the closure of the vertebral bodies (Fig. 8).

The dural bag is corrugated. The edges of the TMT defect are divorced. During the audit revealed a break in the spinal cord up to 95% with the preservation of conductors in the right side. Toilet of a dural bag with furatsillin solution. After matching fragments of the spinal cord, TMT is sutured tightly. Rg-control: kyphotic and scoliotic deformity is not determined.

The structural rigidity is complemented by a transverse coupler. The dural sac is covered with a hemostatic sponge. Posterior fusion with autobone fragments (Fig. 9). Control of hemostasis with blood pressure 110/70 mm. Hg The wound is sutured in layers tightly. Intradermal suture. Aseptic dressing. Blood loss 800 ml (11% bcc).

The postoperative period was uneventful. Received infusion therapy, anesthesia, a / b therapy, dressings, massage. He began to sit on the 9th day after surgery in a stiff lumbar corset.

In dynamics, the neurological status is the same.

On control Rg-grams: The axis of the spine is straight. The scoliotic and kyphotic components of the deformity are completely eliminated. The standing metalwork is satisfactory (Fig.10 a, b).

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

The application of the method in the FSBI "RRC" WTO "them. Acad. G.A. Ilizarova showed that his use allows spondyllectomy through the arch root from standard posterior access under good visual control, which allows to reduce the duration of the operation, the amount of blood loss, shorten the treatment time and improve the functional result.

Claims (1)

Method of spondyllectomy by access through the arch root, including fixing the segments of the spine with a monolateral rod installed in the screw heads, removing the arch, articular processes along with the joints and transverse processes to the base of the arches, directly at the back surface of the vertebral body with exposing the dural sac, characterized in that the base of the arches, the spongy tissue of the body, its apophysial plates and the intervertebral discs contacting with the vertebra along with the epiphyseal plates of adjacent poses are removed from both sides stitches to the anterior longitudinal ligament, then the feeding vessels are coagulated, waxed and covered with a hemostatic sponge, the resulting space is filled with autologous bone from spongy bone tissue.

Images