RU2603722C1 - Minimally invasive method of treating hushed limited destructive forms of tuberculosis and nonspecific spondylitis in patients of senior age groups - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to spine orthopaedics. After X-ray determination of destruction center trocar is inserted in zone of damage along paravertebral line from the right at an angle of 35-45° to the vertebral body and then microirrigator is introduced through trocar. Extrafocal fixation of damaged spine section by spinous processes above and below the center of destruction is also made with the device. Postoperative period involves antibacterial therapy and after completion of the process of vertebral bodies' consolidation the device of external fixation is removed. Wherein necrotic tissue is destroyed with cutter and removed, then microirrigator is introduced through trocar into center of vertebrae destruction. After introduction of microirrigator through trocar it is used for introduction into the damaged area mixture of preparations of calcium sulphate, demineralized bone matrix with addition of patient's bone marrow aspirate taken from wing of ilium, after which trocar and microirrigator are removed.

EFFECT: method allows to considerably reduce length of staying in hospital, increase percentage of positive results of treatment and reduce the number of postoperative complications.

1 cl, 7 dwg, 3 ex

Description

The invention relates to medicine, namely to orthopedics of the spine, and can be used in the treatment of certain forms of spondylitis - inflammatory diseases of the spine, a characteristic feature of which is the primary destruction of the vertebral bodies with subsequent deformation of the spine.

There is a method of treating spondylitis in people of older age groups, which consists in conservative treatment using antibacterial drugs with strict bed rest for 4-6 months ["Orthopedics, traumatology and prosthetics". - 1983. - No. 12. - S. 1-5].

This method of treatment is associated with prolonged bed rest, leading to a number of complications in 35-40% of patients and the need for prolonged wearing of a corset, and is characterized by relatively low efficiency, in particular, it gives positive treatment results only in 30-40% of cases.

There is also known a method of anterior spinal fusion of the atlanto-axinal zone in destructive forms of spondylitis, consisting of a puncture of a retroferangal abscess through the mouth, antibiotic therapy followed by fixation of the cervical spine, while the defect in the destruction zone of C ₁ -C ₂ vertebrae is replaced by an autograft from the wing of the submarine a patient who is preformed so that its surfaces are in maximum tight contact with the adjacent surfaces of the defect C ₁ -C ₂ vertebrae, with the upper the edge of the autograft is formed in the form of a gutter, tightly covering the front edge of the large occipital foramen or the front arch of the atlas C _{1 of the} vertebra, and its lower edge is made in the form of the letter U in accordance with the bed of the defect in the body C _{2 of the} vertebra [RU 2177270, АВВ 17/56, 12/27/2001].

This method also has a relatively low efficiency.

The closest in essence to the proposed one is a method of treating the initial and limited destructive forms of spondylitis, which consists in exposing the affected area with antibacterial drugs, and after radiological determination of the lesion using a trocar along the paravertebral line to the right at an angle of 35-45 ° to the vertebral body enter the zone the foci, the purulent contents of the foci are sucked out with a syringe through the trocar, into which the irrigator is inserted through the trocar, and then the trocar is removed, and the left irrigator is closed and sewn to Auger, the patient is laid on his stomach and extrafocal fixation of the affected spine by the compression device for the spinous processes above and below the focus, and during further rehabilitation through the irrigator to the focus and intravenously administer antibiotics [RU 2195890, A61B 17/56, 01/10/2003] .

In the closest in technical essence to the proposed, there are signs that coincide with the features of the claimed invention, in particular, after the x-ray determination of the destruction site in the damage zone along the paravertebral line to the right at a angle of 35-45 ° to the vertebral body, a trocar is introduced, with a syringe through the purulent contents of the focus are aspirated by the trocar, the microirrigator is injected through the trocar, and the apparatus of the affected spine is extrafocally fixed for the spinous processes above and below the destruction focus, postoperative carried antibacterial therapy and after the completion of the consolidation process vertebral external fixation device is removed.

The problem to which the invention is directed, is to increase the effectiveness of treatment, providing a technical result, which consists in increasing the effectiveness of treatment by reducing the time spent by patients in the hospital, reducing the recovery time of patients, increasing the percentage of positive treatment results and reducing the number of complications.

The goal is realized, and the required technical result is achieved by the fact that after the x-ray determination of the destruction site, a trocar is inserted into the damage zone along the paravertebral line to the right at an angle of 35-45 ° to the vertebral body, purulent contents are aspirated through the trocar of the lesion, a microirrigator is introduced through the trocar, and extra-focal fixation by the apparatus of the affected spine for the spinous processes above and below the lesion is performed, in the postoperative period they are given antibacterial therapy and, after the process of consolidation of the vertebral bodies is completed, the external fixation apparatus is removed, according to the invention, necrotic tissues are destroyed with a milling cutter and then removed through the trocar of the microirrigator with the cutter, and after the microirrigator is introduced through the trocar, the mixture of drugs is injected into the damage zone calcium sulfate, demineralized bone matrix with the addition of a patient's bone marrow aspirate, taken from the iliac wing, followed by Dahl trocar and mikroirrigator.

The graphic materials presented:

in FIG. 1 - roentgenogram of patient M., 65 years old, before surgery, direct and lateral projection, limited destruction of the L1-L2 vertebral bodies is noted;

in FIG. 2 - radiograph of patient M., 65 years old, 1.5 months after surgery;

in FIG. 3 - radiograph of patient M., 65 years old, 2 months after the operation, direct and lateral projection, there is a clear bone fusion of the L1-L2 vertebral bodies;

in FIG. 4 - radiograph of patient C, 67 years old, before surgery, a direct and lateral projection, the destruction of the disk and contact surfaces of the vertebral bodies L1-L2;

in FIG. 5 - radiograph of patient C, 67 years old, after surgery (closed resection of the destruction zone of the L1-L2 vertebral bodies was performed with posterior extrafocal fixation of the damaged area of the spine by the apparatus);

in FIG. 6 - radiograph of patient C, 67 years old, 1.5 months after the operation, the formation of bone regenerate (callus) in the area of resection of the L1-L2 vertebral bodies is observed;

in FIG. 7 - radiograph of patient C, 67 years old, 2.5 months after the operation, complete bone fusion of the L1-L2 vertebral bodies was observed.

The proposed minimally invasive method for treating subsided limited destructive forms of tuberculosis and nonspecific spondylitis in patients of older age groups is as follows.

Using an X-ray electron-optical transducer, the localization zone of the destruction of vertebral bodies is determined. A trocar is introduced into the damage zone along the paravertebral line to the right at an angle of 35-45 ° to the vertebral body (Fig. 1). A special cutter is introduced through the tube of the trocar and the zone of necrosis is destroyed to a healthy bleeding tissue of the vertebrae. The cutter is removed and the suction tip is inserted and the resulting chips from the necrotic tissues are evacuated. Using a microirrigator, a mixture of calcium sulfate preparations, a demineralized bone matrix with the addition of bone marrow aspirate (stem autocells) of the patient, taken from the iliac wing, is introduced, and then the trocar and microirrigator are removed.

The next stage of the patient is laid on the stomach and extrafocal fixation of the affected spine by the apparatus for the spinous processes above and below the destruction site (Fig. 2).

With the expiration of three to five days after the operation, the patient is activated, during the rehabilitation process, antibacterial drugs are administered intravenously for two weeks through the irrigator.

One and a half to two months after the operation, when the radiograph shows clear signs of the formation of bone fusion of the vertebral bodies due to the resulting bone regenerate, the device is removed, and the patient is discharged for outpatient treatment with fixation of the spinal surgery area with a light corset for one to two months until the full bone restructuring of the body block of the affected vertebral bodies.

Clinical example 1.

Patient M., 65 years old, was admitted to the clinic 03/27/2001 with a diagnosis of subsided, limited nonspecific spondylitis of the lumbar spine with destruction of the L ₁ -L ₂ vertebral bodies with severe pain. Regarding this disease, the patient was treated in a hospital of the general treatment network, where the patient was given antibacterial therapy with broad-spectrum antibiotics.

During the examination: walks with the help of a support (cane), the lumbar spine is fixed with a corset. Palpation of the paravertebral zone in the region of L ₁ -L ₂ vertebrae is painful. Spinal function in the lumbar region is limited due to pain. On the roentgenogram, contact destruction of the L ₁ -L ₂ vertebral bodies with destruction of the disc and cortical plates of the L ₁ -L ₂ vertebral bodies is noted (Fig. 1).

04/05/2001, the patient underwent surgery. Under the control of the electron-optical transducer, the lesion area of the L ₁ -L ₂ vertebral bodies was determined. A trocar was introduced into the destruction zone along the paravertebral line to the right, at an angle of 35-45 ° to the vertebral body (the focus of destruction). A special milling cutter was introduced through the tube of the trocar, with the help of which they destroyed the necrosis zone in the contact surfaces of the vertebral bodies to healthy bleeding bone tissue. This created the conditions for the formation of bone block and fusion of damaged vertebral bodies. After the cutter was removed, a suction tube was introduced through the trocar tube and the resulting chips from the necrotic tissues were removed. The resulting cavity is washed with a solution of antiseptic and antibiotic and dioxidine. A microirrigator was introduced through the trocar tube, through which a mixture of drugs was introduced: calcium sulfate (20% of the volume) and demineralized bone matrix with the addition of bone marrow aspirate (patient’s stem cells taken from the iliac wing) (80% of the volume). Drainage and microirrigator removed. One suture is applied to the wound. The wound is covered with a sterile sticker.

Then the patient was laid on his stomach and extrafocal fixation of the affected spine by the apparatus for the spinous processes above and below the site of destruction. The needle of the device is covered with sterile wipes. On the fifth day after surgery, the patient was allowed to walk. A broad-spectrum antibiotic solution was administered intravenously to the patient for 2 weeks.

1.5 months after the operation, radiographs showed clear signs of bone marrow formation (fusion of vertebral bodies), the apparatus was removed (Fig. 2).

The patient was discharged for outpatient treatment with fixation of the lumbar spine with a corset for 1-2 months.

On the control x-ray 2 months after the operation, a clear bone fusion of the bodies L ₁ -L ₂ vertebrae is detected (Fig. 3).

Fixation of the lumbar spine with a corset is discontinued. Appointed: physical therapy, massage, orthopedic observation at the clinic at the place of residence.

Clinical example 2.

Patient C, 67 years old, was admitted to the clinic on May 22, 2004 with a diagnosis of subsided tuberculous spondylitis of the lumbar spine with contact destruction of the L ₁ -L ₂ vertebral bodies with secondary radicular syndrome.

During the examination: the patient walks with the help of a support (cane), experiencing pain in the lumbar spine, despite its fixation with a rigid corset. On the x-ray contact destruction of the bodies L ₁ -L ₂ vertebrae (Fig. 4).

After a clinical and laboratory examination, an operation was performed on 03.06.2004. Under the control of the electron-optical transducer, the destruction zone of the vertebral bodies L ₁ -L _{2 was} determined. A trocar is introduced along the paravertebral line to the right at an angle of 35-45 ° to the area of the focal point L ₁ -L _{2 of the} vertebrae. Through the tube of the trocar, a special cutter in the area of the lesion destroyed the necrosis zone to healthy bleeding bone tissue of the L ₁ -L ₂ vertebral bodies. This created the conditions for the formation of bone regenerate and bone fusion of the affected bodies of L ₁ -L ₂ vertebrae. The cutter has been deleted. Fragments of necrotic tissue were removed through the tube of the trocar using suction. The resulting cavity is washed with antiseptics and rifadin solution. A microirrigator was introduced through the tube of the trocar, through which a mixture of calcium sulfate (50% of the volume) and demineralized bone matrix with the addition of bone marrow aspirate (stem autocells taken from the patient's iliac wing (50% of the volume) was introduced. The trocar and the microirrigator were removed, the wound was covered with a sterile sticker.

The patient was laid on his stomach and extrafocal fixation of the affected spine by the apparatus for the spinous processes above and below the destruction site (Fig. 5). From the third day the patient is allowed to walk. In the process of rehabilitation, the patient received anti-tuberculosis therapy. One and a half months after the operation, the x-ray control shows clear signs of bone callus formation (clear signs of bone fusion of damaged bodies of L ₁ -L ₂ vertebrae) - FIG. 6. The device was removed and the patient was discharged for outpatient treatment with fixation of the lumbar spine with a corset.

On the control radiograph 2.5 months after the operation, clear signs of the formation of bone fusion of the bodies of L ₁ -L ₂ vertebrae are detected (Fig. 7).

The patient was prescribed exercise therapy, massage, moderate occupational therapy, observation by an orthopedist in the clinic at the place of residence.

Clinical example 3.

Patient Z., 66 years old, was admitted to the bone department on 10.27.2004 with a diagnosis of subsided spondylitis of the lumbar spine with destruction of L ₁ -L ₂ vertebral bodies with severe radicular pain, suffered focal pulmonary tuberculosis.

With regard to the disease, the patient was treated in the purulent department of the general treatment network, where the patient received antibiotic therapy with broad-spectrum antibiotics for 2.5 months.

On examination, the patient walks with the help of a support (cane). The lumbar spine is fixed with a corset. Function in the lumbar region is limited due to pain. On the roentgenogram of the lumbar spine, contact limited destruction of the L ₁ -L ₂ vertebral bodies is detected.

After a thorough clinical and laboratory examination of the patient, the operation was performed on November 12, 2004 - a closed minimally invasive resection of the destruction zone of L ₁ -L ₂ vertebral bodies in combination with posterior extrafocal fixation of the affected area of the spine by the apparatus.

Under the control of the electron-optical converter, a trocar was introduced into the destruction zone of the L ₁ -L ₂ vertebral bodies at an angle of 35-45 ° to the right along the paravertebral line. A special cutter was introduced through the tube of the trocar and the necrosis zone between the L ₁ -L ₂ vertebral bodies was destroyed to healthy bleeding bone tissue of the vertebral bodies. After the cutter was removed by suction, the formed small fragments of necrotic tissue were removed through the tube of the trocar. The resulting cavity is washed with a solution of an antiseptic, a broad-spectrum antibiotic and an anti-tuberculosis drug.

A microirrigator was introduced into the cavity, through which a mixture of calcium sulfate (30% of the volume) and demineralized bone matrix with the addition of bone marrow aspirate (70% of the volume) was introduced. The trocar and microirrigator were removed, the wound was covered with a sterile sticker.

The patient was placed on his stomach and extrafocal fixation of the affected spine by the apparatus for the spinous processes above and below the destruction site. From the third day after surgery, the patient is allowed to walk. In the process of rehabilitation of the patient, broad-spectrum antibiotics were intramuscularly injected and tablet anti-TB drugs were administered.

After 1.5 months, clear signs of the formation of bone fusion of the L ₁ -L ₂ vertebral bodies were found on the control radiograph. The device was removed. The patient was discharged for outpatient treatment. The lumbar spine is fixed with a corset. 2.5 months after the operation, the control radiograph showed clear signs of fusion of the L ₁ -L ₂ vertebral bodies.

The proposed method is intended for the treatment of patients of older age groups with subsided limited tuberculosis and nonspecific spondylitis. The method allows to reduce by 60-70% the length of hospital stay of patients, 40-50% to reduce the rehabilitation of patients, 2-3 times increase the number of patients with positive treatment results and reduces the number of postoperative complications. Thus, the proposed method can improve the effectiveness of treatment, which is manifested through a reduction in the length of stay of patients in the hospital, a decrease in the recovery time of patient activity, an increase in the percentage of positive treatment results and a decrease in the number of complications.

Claims (1)

A minimally invasive method for treating subsided limited destructive forms of tuberculosis and nonspecific spondylitis in patients of older age groups, which consists in the fact that after radiological determination of the destruction site, a trocar is introduced into the damage zone along the paravertebral line to the right at an angle of 35-45 ° to the vertebral body, followed by introduction through the trocar microirrigator, as well as extrafocal fixation by the apparatus of the affected spine for the spinous processes above and below the focus of destruction, in the postoperative During this period, antibiotic therapy is carried out, and after the process of consolidation of the vertebral bodies is completed, the external fixation apparatus is removed, characterized in that, before the microirrigator is introduced through the trocar into the lesion of the vertebrae, the necrotic tissue is destroyed by the cutter and then removed, and after the microirrigator is introduced through the trocar into the zone injuries are injected with a mixture of preparations of calcium sulfate, demineralized bone matrix with the addition of a bone marrow aspirate of the patient, taken from the iliac wing sti, after which the trocar and microirrigator are removed.

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