RU2557707C1 - Method for surgical approach to upper and lower cervical spines - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: planned skin incision is first configured on an anteriolateral neck surface by projection zoning of a clavisternomastoid and a neck median line to be marked with colour graphic lines. A first line extends along a medial border of the clavisternomastoid. A second line extends from a suprasternal notch to the middle of a hyoid shaft. Both of the lines are then combined by drawing a perpendicular third line from a lower border of the middle of a hyoid shaft to the medial border of the clavisternomastoid, thereby forming a projection triangle. Cutaneofascial layers, platysma and subcutaneous fat are incised along the first and third lines to cut out a musculocutaneous flap, which is brought outwards. Underlying soft tissues are dissected to an anterior surface of cervical spinal bodies by splitting subcutaneous fat between a neurovascular bundle and a pharynx, detaching an intracervical fascia, splitting perioesophageal subcutaneous fat and displacing midline organs of the neck in the medial direction, and the neurovascular bundle - in the lateral direction.

EFFECT: method enables reducing a risk of treatment-induced traumatic injuries of the midline organs of the neck, an upper laryngeal nerve, upper and lower thyroid arteries, as well as a parenchyma and an excretory duct of a submandibular salivary gland with optimising topographo-anatomical relations of the incision wound structures, thus providing a surgical angle approaching 90 degrees.

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Description

The invention relates to medicine, namely to neurosurgery, vertebrology, traumatology and orthopedics. This technical solution can be used in the implementation of surgical interventions for tumor, inflammatory lesions and traumatic injuries, requiring skeletons of vertebral bodies C2-C7 to perform the main stage of surgical intervention.

The complexity of the topographic and anatomical relationships of the cervical spine with the surrounding vital organs of the neck significantly limits the possibilities of surgical intervention on the vertebral bodies. In this case, the most difficult task remains the implementation of rational surgical access to perform the main stages of radical interventions performed for inflammatory, tumorous diseases of the vertebrae and their traumatic injuries.

Individual topographic and anatomical conditions and a variety of forms of pathology of the cervical spine determine the differentiated choice of surgical approaches. For pathology of the cervical vertebral bodies, anterior and anterolateral approaches are used: upper-angular, lower-angular, lower-median angular, T-shaped, bracket-shaped combined polyzonal, anchor-shaped. Of the listed accesses, when performing extended volumes of surgical interventions, the lower-angle, T-shaped, staple-shaped and combined approaches are used, which allow performing surgical procedures not only on several pathologically altered vertebrae, but also on the adjacent parts of the neck [Ramikh E.A. Injury of the lower cervical spine: diagnosis, classification, treatment // Surgery of the spine. 2005. No3. S.8-24; Ramikh E.A. Damage to the upper cervical spine: diagnosis, classification, treatment features // Spinal Surgery. 2005. No1. S.25-44].

The closest analogue to the claimed invention is the antero-cervical staple-shaped access [Kushhabiev V.I. Surgery of the cervical vertebrae. Nalchik: Elbrus, 1976. P.62-65], during which an incision is made along the medial edge of the sternocleidomastoid muscle, then fascial and fascial layers are cut from the inside of the sternum in the transverse direction above - along the cervical-submandibular fold, below - to the sternal end of the opposite collarbone. At the same time, the superficial and intrinsic fascia of the neck are dissected along with platism, the third fascia of the neck, scapular-hyoid, sternum-thyroid and sternum-hyoid muscles, intracranial fascia. The awl-hyoid, awl-pharyngeal muscles and the posterior abdomen of the biceal muscle also cross in the upper wound.

However, this access, like all of the above, is characterized by the formation of an extensive zone of operational accessibility, which makes them, despite the convenience of performing operational techniques, very traumatic. Their trauma is determined by a significant number of crossed muscles, work on all fascia of the neck, extensive dissection of the deep cellular spaces, the possibility of intraoperative damage to the neurovascular bundle and submandibular salivary gland.

The objective of the invention is the development of anterior cervical surgical access to the bodies of C2-C7 vertebrae, which reduces the risk of iatrogenic traumatic injuries of the median organs of the neck, upper laryngeal nerve, upper and lower thyroid arteries, as well as the parenchyma and excretory duct of the submandibular salivary gland during optimization of the topographic- anatomical relationships of the structures of the surgical wound, providing an angle of surgical action approaching 90 °.

The essence of the claimed invention is characterized by the fact that in the method of surgical access to the upper and lower cervical spine, the configuration of the planned incision of the skin on the front-side surface of the neck is determined by establishing projection zones of the sternocleidomastoid muscle and the midline of the neck with the use of color marking in the form the first line, passing along the medial edge of the sternocleidomastoid muscle, and the second line - from the level of the jugular notch to the middle of the hyoid bone and which then connect by perpendicular to the third line from the lower edge of the middle of the hyoid bone body to the medial edge of the sternocleidomastoid muscle, forming a projection triangle, cut the skin-fascial layers, platysma and adipose tissue along the first and third lines with cutting out the skin -muscular flap, which is diverted outward, conduct dissection of the underlying soft tissues to the front surface of the cervical vertebrae by stratification of the fiber between the neurovascular bundle and the pharynx, separation of the intracervical fascia, stratification of the paesophageal tissue and displacement of the median organs of the neck medially, and the neurovascular bundle laterally.

The technical result of the claimed invention.

Such a technique as performing a cut of a certain configuration according to previously applied colorographic marking in accordance with the subcutaneously located anatomical landmarks, allows you to create a musculocutaneous flap without additional damage to the muscles, blood vessels, nerves, submandibular gland, as well as to ensure the convenience of mobilization of these structures, dissection of the cervical fascia, cellular spaces of the neck and skeletonization of bodies of C2-C7 vertebrae, including manipulations based on the dentoid process of the C2 vertebra. The implementation of the section in accordance with the third projection line, drawn in the form of a perpendicular from the lower edge of the middle of the hyoid bone to the medial edge of the sternocleidomastoid muscle, limits the possibility of iatrogenic traumatic injuries of the contents of the submandibular triangle, namely, the submandibular salivary gland parenchyma and due to the intactness of the soft tissues located above the short shoulder of the incision, forming a bed for the above gland and preventing it from being “dislocated” ju ”into the surgical wound (unlike analogues). This type of incision makes it possible to exclude the performance of unwanted instrumental manipulations, in particular excessive traction by the retractor of the capsule and submandibular parenchyma of the submandibular gland, ligation of the adducting and abducting blood vessels that feed this gland, as well as the common facial vein, superior thyroid arteries and veins, the intersection of the awl-hyoid, awl muscles and the posterior abdomen of the biceps muscle. In connection with the foregoing, the surgical access described in this application is less traumatic when maintaining a sufficient volume of the surgical wound, its index and the angle of surgical action approaching 90 °, which allows you to perform the main stage of surgical intervention not only on adjacent vertebrae, but also at the entire level upper and lower cervical spine.

The implementation of the claimed surgical access allows you to maintain the integrity of the sternocleidomastoid muscle, to avoid damage to the neurovascular bundle of the neck and its case, to exclude the impaction of the anatomical structures adjacent to the surgical wound, to achieve only a temporary violation of the integrity of the small muscles of the median organs of the neck when the wound channel passes through the fascial -cellular layers without subsequent restriction of the functions of the median organs of the neck during the formation of the postoperative scar.

The method of surgical access to the upper and lower cervical spine is as follows.

Indications for the use of the claimed surgical access are: multiple and combined tumor, inflammatory lesions and traumatic injuries of the upper and lower cervical spine, in which the skeleton of C2-C7 vertebrae is required to perform the main stage of surgical intervention.

Before performing the main stage of surgical intervention, the configuration of the planned incision of the skin on the front-side surface of the neck is determined. To do this, set the projection zone of the sternocleidomastoid muscle and the midline of the neck. Apply color marking in the form of lines. The first line is drawn along the medial edge of the sternocleidomastoid muscle. The second line is drawn from the level of the jugular notch to the middle of the hyoid bone. The first and second lines are connected by perpendicular to the third line from the lower edge of the middle of the hyoid bone to the medial edge of the sternocleidomastoid muscle, forming a projection triangle. An incision is made of the skin-fascial layers, platysma and adipose tissue along the first and third lines with the cutting out of the musculocutaneous flap, which is diverted outwards. The underlying soft tissues are dissected to the anterior surface of the cervical vertebrae by stratification of the fiber between the neurovascular bundle and the pharynx, separation of the intracervical fascia, stratification of the paesophageal tissue and displacement of the median organs of the neck medially, and the neurovascular bundle laterally. If necessary, due to individual anatomical variability, the upper laryngeal nerve, upper and lower thyroid arteries are mobilized. After performing the main stage of surgical intervention on the affected / damaged cervical vertebrae, the surgical wound is sutured in layers.

Example

Patient M., 43 years old, was admitted to the neurosurgical department with the diagnosis: “Closed complicated injury of the cervical spine. Compression-comminuted fracture of the bodies of C4-C5 vertebrae with a bruise and compression of the spinal cord at this level. Upper paraparesis, lower paraplegia. Violation of the functions of the pelvic organs. "

After clinical and introscopic examination, indications were established for decompression-stabilizing intervention in the cervical spine with surgical access using the method described above.

The implementation of this surgical access provided a good visualization of the bottom of the surgical wound due to the wide area of access to the vertebral bodies C2-C7 and the angle of surgical action of 90 ° in the absence of "dislocation" of the submandibular gland, which eliminated the need for additional unwanted instrumental manipulations.

The postoperative period is smooth, the wound healed by first intention, the cosmetic result is good.

Claims (1)

A method of surgical access to the upper and lower cervical spine, characterized in that the configuration of the planned incision of the skin on the anterior-lateral surface of the neck is determined by establishing projection zones of the sternocleidomastoid muscle and the midline of the neck with the use of colorographic marking in the form of the first line, passing along the medial edge of the sternocleidomastoid muscle, and the second line - from the level of the jugular notch to the middle of the hyoid bone, which are then connected by erecting perpendicular to the third line from the lower edge of the middle body of the hyoid bone to the medial edge of the sternocleidomastoid muscle, forming a projection triangle, cut the skin-fascial layers, platysma and adipose tissue along the first and third lines with cutting out a skin-muscle flap, which is removed outwardly, the underlying soft tissues are dissected to the front surface of the cervical vertebral bodies by stratification of the fiber between the neurovascular bundle and the pharynx, and separation of the intracranial fascia , stratification of the paesophageal tissue and displacement of the median organs of the neck medially, and the neurovascular bundle laterally.