RU2506919C1 - Method for spinal deformation correction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to spinal surgery. A layered approach to a posterior spine is followed by inserting long pin supports into the vertebrae from both sides and then fixed after the deformation correction. Screws are inserted transpedicularly bilaterally into fixed screw points from the side of a concave portion of a primary curve of the deformation. Proximal and distal pins pre-curved along the deformation track are laid longitudinally and coupled with a connector within a junction between primary and secondary arches. Screw heads are brought to the pins and fixed by nuts with mobility retention. That is followed by an independent de-rotation manoeuvre along the proximal and distal pins in the opposite directions towards the reverse spinal torsion. To preserve a correction degree, the screw nuts first, and then the connector nuts are tightened.

EFFECT: after the longitudinal pin has been laid from the opposite side, a structure rigidity is aided by cross beams.

1 ex, 9 dwg

Description

The invention relates to medicine, namely to spinal surgery, and is used in the treatment of patients with spinal deformities of any etiology.

Known methods for the correction of spinal deformity include the use of modern versions of the CDI (Cotrel-Dubousset instrumentation) instrumentation, where the key point in the correction is the use of a rotational maneuver with the rod along the inner side of the main deformation arch.

There is a well-known technique involving the correction of deformation due to rotation of the rod by 90 ° with the translation of frontal deformation into the bends of the sagittal profile by the so-called “derot maneuver” (Y. Cotrel and J. Dubousset / CD instrumentation in spine surgery. Principles, technicals, mistakes and traps. Souramps Medical, 11 boulevard Henry IY - 34000 Montpellier. 1992. 159 p).

There is also a known method in which screws are introduced transpedicularly along the scoliotic arc (on the concave side - at each level, on the convex side - through one or two vertebrae). On the concave side of the arc, a rod is inserted into the heads of the screws, which rotates counterclockwise without the use of compression or distraction. Screw derotators (4-8) are attached to the paraapical vertebrae. With the help of derotators, correction is made in the clockwise direction. The screw heads are fixed to two rods. The operation ends with dorsal fusion (Sang-Min Lee et al. / Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis // Spine. 2004. Vol.29. N3. P.343 -349).

Closest to the claimed is a method for correcting scoliotic deformity of the spine by derotation, including the formation of fulcrum in the zone of transition of the base of the transverse process to the root of the arch on both sides of each vertebra entering the scoliotic arch. Derotation of individual segments alternately in the area of the cranial and caudal sections of the arc in the direction from the end vertebra to the apex of deformation is performed. The vertebrae are turned in the direction of correction of the pathological rotation of the spine and the achieved correction is fixed by attaching the grip installed on each vertebra to the rods curved in accordance with the normal sagittal contour of the corrected spine, which prevents complications associated with progression of deformation (RU 2307616 C2).

However, this method is applicable only for typical (with torsion of the vertebrae towards the convex part of the main arch) S-shaped deformities, for example, with idiopathic scoliosis. The prototype has the following disadvantages:

with atypical (with the torsion of the vertebrae towards the concave part of the main arch) three-plane deformations IV (Figure 1), the application of this method is limited by the localization, magnitude and rigidity of the arcs;

limitation of multi-support fixation systems in connection with the subsequent growth of the child.

The objective of the invention is to provide a method of derotation, correction of atypical deformity of the spine, to achieve simultaneous correction of the frontal, sagittal and torsion components of the deformity with the possibility of staged extension of the structure in children with incomplete growth.

This problem is solved by the fact that after layer-by-layer access to the posterior parts of the spine, supports for longitudinal rods are installed in the vertebrae on both sides of the vertebrae, followed by their fixation after deformation correction, then screws are installed transpedicularly bilaterally, and they are placed in support screw fixation points from the side of the concave part of the main arch of deformation longitudinally proximal and distal rods, previously bent along the deformation path, which are connected by a connector in the transition region between the main second and secondary arc, the screw heads are led to the rods and fixed with nuts while maintaining their mobility, then an independent deerational maneuver is performed along the proximal and distal rods in opposite directions in the opposite direction to the torsion of the vertebrae, in order to maintain the degree of correction, tighten the nuts on the screws, then the nuts on the connector, after laying the longitudinal rod on the opposite side, the structural rigidity is supplemented by transverse beams.

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

Figure 1 - diagram of the deformation of the spine IV degree: 1 - the direction of the torsion of the vertebrae.

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

Figure 3 - diagram of the instrumentation of the spine before performing a double independent derotational maneuver: 1 - proximal rod; 2 - connector; 3 - distal rod; 4 - vector of rotation of the deformation arc; 5 - frontal reduction of the vertebrae to the core; 6 - vector of rod rotation.

Figure 4 - diagram of the instrumentation of the spine after performing a double independent derotational maneuver.

Figure 5 - diagram of the final instrumentation: 1 - proximal rod; 2-connector; 3 - distal rod; 4 - contralateral rod; 5 - transverse beams.

6 - a, b) the external picture of the deformation in a standing position and the Adams test.

7 - spondylograms of the patient (explanation in the text).

Fig - CT scan of the spine: a) a picture of the deformation during 3D reconstruction;

b) neurofibroma 0.5 * 6.0 cm in the spinal canal at the level of the apex of deformation;

c) the vertex vertebra torsion is 42 °.

Fig.9 - radiographs (a) and CT (b) of the patient after surgical treatment. Degree of correction of deformation by a connector type system with double independent deeroting maneuver (explanation in the text).

The method is as follows.

Carry out dorsal access to the posterior column of the spine. The extent of access is determined by the instrumentation zone. Install transpedicular screws bilaterally (Figure 2).

Two pre-curved longitudinal rods that are connected with a telescopic or parallel connector in the transition region between the primary and secondary arcs fit into the support screw fixing points from the side of the concave part of the main deformation arc. The screw heads are brought to the rods and fixed with nuts while maintaining their mobility. Next, a double independent derotational maneuver is performed along two rods simultaneously in opposite directions in the direction opposite to the direction of vertebral torsion (Figure 3). This achieves a simultaneous, adequate correction of the frontal, sagittal and torsion components of the deformation (Figure 4). To maintain the degree of correction, the nuts on the screws are tightened first, then the nuts on the telescopic or parallel connector.

Further, by known methods, a longitudinal rod is laid on the opposite side. After fixing on the nuts, if necessary, perform the final mechanical maneuvers: distraction along the concave sides of the arcs, segmental reposition and compression along the convex sides of the arcs. The structural rigidity is supplemented by transverse beams (Figure 5).

An example of the practical use of the method.

A 13-year-old patient was admitted to the Department of Neurosurgery and Vertebrology of the Ilizarov Center with a diagnosis of Progressive kyphoscoliosis of the spine of a very severe degree against the background of type I neurofibromatosis.

When examining a complaint upon admission to spinal deformity in the thoracic and lumbar region, periodic pain, restriction of movement due to deformation.

Anamnesis of the disease: Deformation detected at 4 years, actively progressing for 2 years (+ 30 °). Conservative treatment (exercise therapy, massage, corsetting) is not effective. The child was consulted by a vertebrologist at the Ilizarov Center in January 2012, and surgical correction is recommended.

Orthopedic status: Decompensated S-shaped scoliotic deformity with main right-sided thoracic arch and genital gibbus on the right up to 11 cm high. Frontal imbalance with 2 cm deviation of CSVL line. Moderate deformation mobility during traction test. (Fig.6).

Neurological status is not impaired.

When examining on radiographs of the spine: the angle Cobb of the right-sided main arch in the thoracic with the apex at the level of Th _IX - 120 °, the angle of kyphosis at the apex -56 ° (Fig.7).

CT of the spine: Torsion of the vertebrae - 42 °. At the level of D10 - L1 in the spinal canal on the right, a dense strand of 0.5 * 6.0 cm at the level of the deformation apex (Fig. 8).

The indication for surgical treatment was the presence of severely progressive deformity of the spine.

Surgical treatment was performed in 2 stages:

1. Thoracotomy on the right along the IX rib, dyspiphysectomy on three levels: Th _8-9 , Th _9-10 , Th _10-11 .

2. Correction and stabilization of the deformity of the thoracolumbar spine (Th ₃ -L ₃ ) of the spine with a pedicular CD-type connector system. Posterior fusion.

Operation progress:

Stage 1: Under endotracheal anesthesia in the patient’s position on the operating table lying on the left side after three times the treatment of the surgical field with an alcohol solution of chlorhexidine, a skin incision of 4 cm was made in the projection of the IX rib, with a resection of the latter for 4 cm. The pleural cavity was opened in the wound the anterolateral divisions of the vertebrae entering the deformity arc are visualized. The pleural cavity is sharply narrowed. The intervertebral discs were removed on the segments Th _8-9 , Th _9-10 , Th _10-11 . A crumb from a resected rib was placed in the interbody space, covered with a tachocomb. A drainage tube is installed in the pleural cavity, the pleural cavity is sutured in layers, aseptic dressing is sutured to the skin. Active drainage is connected.

Stage 2: After a 3-fold treatment of the surgical field with an alcohol solution of chlorhexidine, a skin incision in the projection of the spinous processes of Th ₃ -L ₄ . Layered access to the posterior spine throughout the thoracic and lumbar. Hemostasis. In the area of the transitional section between the main and secondary arcs, the transpedicular-intracorporeal screws in Th _{3, 4, 6, 8} , L _{1, 2} and on the left in Th ₁₂ are installed in pairs on both sides. Hemostasis. Image intensifier control: the position of the screws is correct. The screws have 2 rods with a parallel connector of the domino type on the concave side of the deformation. A double independent derotational maneuver was made. The rods are fixed with nuts on the screws. Distraction of the rods at the level of the connector 4 cm. The rods are fixed with nuts in the connector. Visual correction of deformation of 70%. A rod was installed on the convex side of thoracic deformity in the contraction mode. For contraction, the screw cut in L3 is on the right. Hemostasis, screw removed. The nuts on the rods are extended. Image intensifier control: the position of the screws is correct. All maneuvers were carried out under the protective administration of methylprednisolone. The structural rigidity is complemented by two transverse ties. Posterior spinal fusion with autologous fragments and Chronos biomaterial. Layer-by-layer suturing of a postoperative wound. A seam on the skin, aseptic dressing. Aseptic dressings. Blood loss during surgery was 700 ml.

After the treatment, a decrease in the size of the hibus to 6 cm, the restoration of the axis of the “shoulder girdle - pelvis” is noted. The child is upright 5 days after surgery in the lumbar corset.

On postoperative radiographs: The angle of scoliotic deformation of the thoracic spine - 35 °, kyphosis - 6 °, torsion - 38 °. The standing metalwork is correct (Fig.9).

The application of the proposed method in the FSBI "RRC" WTO "them. Acad. G.A. Ilizarova showed that due to the force and direction of the vectors created on the rods, an instantaneous, adequate correction of the frontal, sagittal and torsion components of the deformation is achieved while maintaining the possibility of a staged extension of the structure in children with incomplete growth.

Claims (1)

A method of correction of spinal deformity, according to which, after layer-by-layer access to the posterior parts of the spine, the supports for longitudinal rods are installed in the vertebrae on both sides with their subsequent fixation after deformation correction, characterized in that the screws are installed transpedicularly bilaterally in the support screw fixation points from the side of the concave part of the main deformation arcs, lay longitudinally proximal and distal rods, previously bent along the deformation path, which are connected by a connector in the area of the transitional section between the main and secondary arches, the screw heads are brought to the rods and fixed with nuts while maintaining their mobility, then an independent derotational maneuver is performed along the proximal and distal rods in opposite directions in the direction opposite to the vertebra torsion, to tighten the degree of correction, first tighten nuts on the screws, then nuts on the connector, after laying the longitudinal rod on the opposite side, the structural rigidity is supplemented by transverse beams.

Images