RU2551226C1 - Method for osteosynthesis of injured odontoid process of second cervical vertebra - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: soft tissues and pre-vertebral fascia are hydraulically prepared with 0.5% novocaine in an amount to dislocate the trachea and oesophagus. Anterior surfaces of the second and third vertebral bodies are approached. A guide pin is inserted through the caudal portion of the second cervical vertebra, through the body and base of the odontoid process and its fragment. A groove is formed along the mid-line of the anterior surface of the vertebral bodies from an upper edge of the third vertebral body, through the intervertebral disk to the caudal portion of the second vertebra at its depth of 2-5 mm. A canal is drilled along the pin. A screw fixing the injured odontoid process is inserted into the canal.

EFFECT: method enables reducing injuries and accelerating consolidation.

1 ex, 7 dwg

Description

The invention relates to medicine, namely to traumatology, orthopedics and neurosurgery, and can be used for osteosynthesis of an unconsolidated fracture of the dentoid process of the second cervical vertebra of the II-III types.

Fracture of the dentate process of the second cervical vertebra refers to extremely unstable injuries of the craniovertebral region and accounts for 15-20% of all fractures of the cervical spine. The most common causes: road traffic injuries, sports injuries, a fall from a height. In Russia, 1 person per 1000 per year (according to Dvorak, 2009) receives a spine injury in a traffic accident annually, of which 6594 per year is a fracture of the dentate process. Fracture of the dentoid process is difficult to treat due to the complexity of the anatomical structure of the atlanto-axial complex. Until now, the problem of choosing the optimal method of surgical intervention for fractures of the dentoid process of the C2 vertebra is unresolved. The surgeon's main task is to perform reliable fixation of the affected spine and ensure its stability with maximum safe access, without expanding the scope of intervention, which will reduce the time limits for limiting physical activity and immobilization.

Currently, for the correction and fixation of traumatic fractures of the body of the second C2 vertebra, there are methods that are divided into: conservative, conditionally conservative, based on skeletal traction (behind the parietal tubercles, zygomatic arches, using halosystems), and surgical, including open correction and fixation of the vertebrae.

A known method of osteosynthesis of the tooth-like process of the second cervical vertebra (RF Patent No. 2197910, A61B 17/56, publ. 2003), including the channel in the fragments using an awl at an angle to the axis of the vertebra from the lower surface C2. A bone graft is introduced into the canal. The disadvantages of the method are high invasiveness, the duration of the operation, the insufficient strength of fixation with a bone graft. The rehabilitation period after surgery is up to 3-6 months, while the period of external fixation (cervical semi-rigid collar) is up to 6 months.

A known method of treating a fracture of the dentoid process of the second cervical vertebra (RF Patent No. 2393798, A61B 17/56, publ. 2010), including calculating the trajectory of fixation of the fracture, surgical access to the anterior surface of the second and third vertebrae, screw fixation of fragments of the dentoid process, different the fact that they carry out an incision with a length of 1.5 ± 0.5 cm in the skin fold on the front surface of the neck. The calculated trajectory provides access to the anterior surface of the bodies of the second and third cervical vertebrae, sets up a tubular retractor with a 45 ° cut tightly adjacent to the anterior surface of the bodies of the second and third cervical vertebrae, then repositions and screw fixation of fragments of the dentate process C2.

The disadvantages of the method:

- the use of a cannulated screw d 3.5 mm, which is not enough to consolidate the fragments;

- a high degree of damage to the esophagus, caudal groups of the cranial nerves;

- increase in diastasis with the introduction of a screw with effort, which leads to a slowdown in consolidation;

- a high degree of risk of damage to the spinal cord when a screw is inserted into the fragment of the dentoid process in a half-closed manner;

- lack of visualization of the stages of surgical intervention;

- fixation of the neck with a soft fixer of the “Shants collar” type for a period of up to 2-3 months.

The closest is a method for osteosynthesis of a damaged tooth process of the second cervical vertebra using the claimed screw (RF Patent No. 2352285, A61B 17/68, publ. 2009), including access under radiological control to the front surfaces of the bodies of the second and third vertebrae, the introduction of a guide needle through the caudal section of the second cervical vertebra, through the body and base of the tooth-like process and its fragment, the formation of a canal along the spoke, the insertion of a screw into the canal that fixes the damaged tooth-like process.

The disadvantage of this method is its high morbidity, since access is performed through a wide incision of 8-10 cm, the duration of the operation, the risk of damage to vital organs of the neck (trachea, esophagus, upper segments of the internal carotid arteries and their branches), a long postoperative period.

The objective of the present invention is to remedy these disadvantages, increase the therapeutic effect by reducing trauma, providing a more adequate fixation of the spine, eliminating the need for manipulation of the spinal cord.

This object is achieved by the fact that during osteosynthesis of a damaged tooth-like process of the second cervical vertebra of type II-III, including access under radiological control to the anterior surfaces of the bodies of the second and third vertebrae, the introduction of a guide needle through the caudal part of the second cervical vertebra, through the body and base of the dentate process and its fragmentation, formation of a canal along the spoke with a drill, insertion of a screw in the canal fixing the damaged tooth-like process into the canal, is proposed additionally before access to the front surfaces of the bodies of the second and third vertebrae, carry out hydrotreating of the soft tissues and the prevertebral fascia with a 0.5% solution of novocaine in volume until the trachea and esophagus are dislocated. In this case, before the formation of the channel in the body, base and fragment of the tooth-like process, a groove is formed in the midline of the anterior surface of the vertebral bodies from the upper edge of the body of the third vertebra, through the intervertebral disk to the caudal section of the second vertebra, to its depth of 2-5 mm, and after the formation of the channel in thread the screw under it.

Due to the application of the method, the stability of the atlanto-axial joint is achieved, the risk of damage to the trachea, esophagus, surrounding soft tissues, blood vessels, nerve structures is reduced, the operation time and the postoperative period are shortened. The access to the anterior surface of the C2-C3 vertebrae and the osteosynthesis of the tooth-like process of the second cervical vertebra provide minimal invasiveness.

The essence of the method is illustrated by drawings. Figure 1 - the location of the incision in the projection of the body C3 of the vertebra, figure 2 shows the direction of the knitting needles when accessing the front surfaces of the bodies C2-C3 of the vertebrae; figure 3 - channel formation in the body C2 and the dentate process using a drill; figure 4 - the introduction of a tap for threading; figure 5 - the introduction of a screw into the body C2 and the dentate, x-ray; Fig.6 is the same CT scan of the cervical spine with 3D reconstruction; 7 - formed groove and channel in the second cervical vertebra.

The method is as follows.

It is necessary to have microsurgical instruments, magnifying equipment (an operating microscope or a head magnifier), a rigid endoscope, and an x-ray apparatus. Surgery is performed under endotracheal anesthesia. The patient is lying on his back. The head is thrown back to the maximum.

The surgeon is located to the right of the patient. After hydrotreating the soft tissues and the prevertebral fascia with a 0.5% novocaine solution in a volume of 50-70 ml to ensure the dislocation of the trachea and esophagus, a transverse skin incision 1 is made, 1.0-1.5 cm long, in the projection of the upper edge of the C3 vertebral body on the right. Subcutaneous tissue, platism, and fascia are dissected in layers, access to the anterior surfaces of the bodies of C2-C3 vertebrae with a tube expander 2. In the caudal region of the second vertebra 3, a spoke 4 is inserted under X-ray control. The needle is drawn through the body of the vertebra C2 in the direction of the dentoid process 5 along the midline at an angle of about 20 degrees from the axis of the spine.

Next, a cannulated drill 6 is passed through the spoke 4, a groove 7 is formed along the midline of the front surface of the vertebral bodies from the upper edge of the third vertebral body 8, through the intervertebral disc 9 to the caudal part of the second vertebra 3. In this case, the groove width is 5-8 mm, and its depth as it moves toward the caudal part of C2 smoothly changes from 1.0-1.5 mm to 5-8 mm. The width of the groove and its greatest depth are determined by the diameter of the screw used.

Then, a canal 10 is made by a cannulated drill, while the drill is placed in a groove 7 and directed along the spoke 4 into the body of the second cervical vertebra 3 and the broken tooth-like process 5 under X-ray control. Then the cannulated drill is removed, and a thread is cut using a tap 11, and a cannulated screw 12 with a diameter of mainly 6-7 mm is drawn along the spoke under X-ray control. The cannulated screw is screwed into the body of C2 and the dentate process, fastening the dentoid process to the body C2 of the vertebra.

At the end, hemostasis is performed. The wound is sutured in layers. An aseptic dressing is applied to postoperative sutures.

Activation of the patient in bed 1 hour after surgery, verticalization with external immobilization of the cervical spine in a semi-rigid head holder on the next day. Wearing a cervical orthosis in the postoperative period from 1 to 1.5 months.

Example.

Patient T., born in 1980, was admitted to the clinic on April 23, 2013, with a diagnosis of Unconsolidated fracture of the dentoid process of type II vertebra C2. Upon receipt of a complaint of pain in the cervical spine, limitation of mobility in the cervical spine.

Sick since April 3, 2013, when, after the car accident, the above complaints appeared. A radiography of the cervical spine was performed at the place of residence: no pathology was detected. However, in the subsequent complaints intensified, an MRI of the cervical spine was performed: fracture of the dentoid process of the C2 vertebra. Hospitalized in a hospital for further examination and surgical treatment.

Survey data at admission: general condition is relatively satisfactory. The skin of normal color, clean. Pulse 72 in 1 min, rhythmic. Vesicular breathing, NPV 16 per minute, no wheezing. In the musculoskeletal system: fracture of the dentoid process of the C2 vertebra. Palpation in the paravertebral zones is painful in the area of the craniovertebral transition. The abdomen is soft, painless. Urination is independent.

In neurological status: in a clear mind, contact, adequate, oriented in place and in time. Cerebral symptoms in the form of a headache. FMN - N. Swallowing and phonation are not disturbed. Tendon reflexes on the arms S = D, animated, tendon reflexes on the legs S = D, strength D = S-5 points. There are no meningeal signs. There are no pathological stop signs.

CT of the cervical spine from 05/16/2013: Fracture of the base of the dentoid process of C2 vertebra.

The operation was performed on 05/17/2013: Osteosynthesis of a fragment of the tooth-like process of the second cervical vertebra with a titanium cannulated screw cage according to the method described above.

In conclusion, hemostasis is performed. The wound is sutured in layers tightly. An aseptic dressing is applied to postoperative sutures.

The postoperative course is smooth. Antibacterial, vascular, analgesic and vitamin therapy, exercise therapy were carried out. Pain syndrome completely regressed. The patient is activated on the 2nd day, independently gets up and walks in the cervical orthosis. The postoperative wound healed by first intention, the sutures were removed on the 8th day.

Postoperative MSCT and X-ray control - satisfactory state of the screw cage. Condition at discharge is satisfactory.

To continue treatment, it is prescribed under the supervision of a neurologist and therapist for m / f. Wearing a cervical orthosis up to 1 month.

In the control radiograph of the cervical spine after 1 month after the operation, the condition after osteosynthesis of a fragment of the tooth-like process of the second cervical vertebra with a titanium cannulated screw cage, signs of consolidation at the fracture level.

When viewed after 3, 6 months - the patient's condition is satisfactory.

According to the proposed method, a successful treatment of 20 patients.

The use of this method of surgical treatment of fracture of the dentoid process of the C2 vertebra allows to increase the therapeutic effect of the operation due to minimal trauma. Significantly reduced operation time and postoperative period. The proposed method allows to accelerate the activation of victims, prevent secondary displacement of fragments, reduce the length of hospital stay of patients, reduces disability of patients.

Claims (1)

A method for osteosynthesis of a damaged dentoid process of the second cervical vertebra of type II-III, including access under radiological control to the anterior surfaces of the bodies of the second and third vertebrae, introduction of a guide needle through the caudal section of the second cervical vertebra, through the body and base of the tooth process and its fragment, formation along the spoke channel drill, insertion into the channel of a screw fixing a damaged tooth-like process, characterized in that, in addition to accessing the front surfaces of the bodies of the second and third vertebrae, the soft tissues and the prevertebral fascia are hydrotreated with a 0.5% novocaine solution in the volume until the trachea and esophagus are dislocated, and a groove is formed in the body, base and fragment of the dentoid process along the midline of the anterior surface of the vertebral bodies from the upper edge the body of the third vertebra, through the intervertebral disk to the caudal section of the second vertebra, to its depth of 2-5 mm, and after the formation of the channel, a thread for the screw is cut in it.

Images