RU2621170C1 - Method of lumbar spine deformation correction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method comprises accessing a spine, facetectomy, discectomy, limited resection of acanthas adjacent sections, implaint insertion into interbody space and closure of formed bone defect edges. Access to the spine is carried out by cutting 3-4 cm of the skin in the projection of the joint pair and blunt muscle dissection in the intermuscular sulcus using tubular retractors. Facetectomy and resection of ligamentum flavum are carried out on the access side, and then ligamentum flavum and diapophysis of the lower spondyle are removed on the contralateral side. Total discectomy and implant insertion into the interbody space are carried out. Then, subcutaneous access is made from the existing skin cut and additional aponeurosis cut is made in close proximity to interspinous space. Resection of the interspinous ligament, caudal portion of upper acantha and cranial portion of lower acantha is carried out, preserving supraspinal ligament. Formed bone defect edges are closed, after which transpedicular systems are mounted on the access side and transcutaneously on the contralateral side.

EFFECT: method ensures the spine stability and prevents cicatricial degeneration of the paravertebral muscles.

1 ex, 19 dwg

Description

The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics, and is intended for the correction of deformations of the lumbar spine, manifested kyphotic, shear, rotational deformation and their combination.

A known method that allows for the correction of kyphotic, shear and rotational deformities in the thoracic, thoracolumbar, lumbar spine (RF patent 2573057, IPC АВВ 17/56, publ. 01.20.2016). In this method, resection of the posterior root structures of the arches and vertebral body is performed, followed by deformation correction until the edges of the resulting resection defect are closed with the help of a latch. At the same time, the cranial part of the broken vertebra, the degenerated disc and the caudal locking plate of the overlying vertebra are resected horizontally to the entire anteroposterior size to the anterior longitudinal ligament, providing the planned correction in all planes and tight contact of the bone of two adjacent vertebrae in the position of the achieved correction.

The disadvantages of this method are: trauma to a large array of soft tissues during an operation followed by cicatricial degeneration of paravertebral muscles, large intraoperative blood loss, a high percentage of intra- and postoperative complications, the limited use of this method in the presence of concomitant somatic pathology.

Closest to the claimed is the method adopted for the prototype, Smith-Petersen osteotomy (SPO) (Smith-Petersen MN, Larson CB, Aufranc OE: Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. J Bone Joint Surg 1945; 27 : 1-11.), Characterized by resection of the posterior structures of the spine (articular processes, part of the arches and spinous processes) at the disc level, with subsequent extension on the operating table, the edges of the formed bone defect are closed, thus achieving extension at the level of the intervertebral disc and correction deformation.

The disadvantages of this method are: trauma to a large array of soft tissues during surgery with subsequent cicatricial degeneration of the paravertebral muscles, large intraoperative blood loss, low bone fusion, the spine remains in an unstable position, the limited use of this method in the presence of concomitant somatic pathology.

The technical result of the invention is the creation of a method free from the above disadvantages.

The problem is solved in that the method of correction of deformations of the lumbar spine includes access to the spine, facetectomy, discectomy, partial resection of adjacent sections of the spinous processes, implantation into the interbody space of the implant, and closure of the edges of the formed bone defect. In this case, access to the spine is carried out by cutting the skin 3-4 cm in the projection of the articular pair and blunt muscle stratification in the intermuscular groove using tubular retractors. A retractor system provides visibility and then sets the pedicular screws. A facetectomy is performed from the access side, the yellow ligament is resected from the access side. The medial surface of the contralateral facet joint is visualized, after which the yellow ligament and the superior articular process of the lower vertebra are removed from the contralateral side. A total discectomy is performed, an implant is implanted in the interbody space closer to the ventral surface of the vertebral bodies, which allows you to set a greater wedge-shaped interbody space and, therefore, a larger angle of the lumbar lordosis. Then, from the existing skin incision, subcutaneous access to the aponeurosis is performed and an additional aponeurosis incision is performed in the immediate vicinity of the interspinous gap. Resect the interspinous ligament, the caudal part of the superior spinous process and the cranial part of the lower spinous process, with the preservation of the supraspinous ligament. With the subsequent gradual extension of extention on the operating table (including through the introduction of an angular interbody implant), the edges of the formed bone defect are closed, thus forming a wedge at the level of the intervertebral disc and correction of kyphotic deformation, after which the transpedicular systems are mounted on the access side and abutted from the contralateral side.

The invention is illustrated by the following graphic materials, where in FIG. 1 - multislice computed tomography (MSCT) of the spine before the implementation of the method of sagittal section; FIG. 2 - multislice computed tomography (MSCT) of the spine after the implementation of the method of sagittal section; FIG. 3 - multislice computed tomography (MSCT) of the spine after the implementation of the method of sagittal section; FIG. 4 - multislice computed tomography (MSCT) of the spine before the implementation of the method axial section; FIG. 5 - multislice computed tomography (MSCT) of the spine after the implementation of the method of axial section; FIG. 6 - multi-sectional computed tomography (MSCT) of the spine before the implementation of the method, frontal section; Fig.7 - multislice computed tomography (MSCT) of the spine after the implementation of the method, frontal slice; FIG. 8 - magnetic resonance imaging (MRI) of the spine before the implementation of the method of sagittal section; FIG. 9 - magnetic resonance imaging (MRI) of the spine before the implementation of the method axial section; FIG. 10 - radiography of the lumbar spine before the implementation of the method frontal projection; FIG. 11 is a radiography of the lumbar spine before the implementation of the method of lateral projection; FIG. 12 is a radiography of the lumbar spine after the implementation of the method frontal projection; FIG. 13 is a radiography of the lumbar spine after the implementation of the method of lateral projection; FIG. 14 is a schematic illustration of skin incisions and aponeurosis; FIG. 15 is a schematic illustration of a resection zone of a posterior support complex; FIG. 16 is a schematic illustration of a vertebral-motor segment after the implementation of the method; FIG. 17 is an intraoperative photograph of a system of retractors; FIG. 18 is a schematic depiction of decompression and resection of bone structures on the ipsilateral side; FIG. 19 - the same from the contralateral side.

The proposed method is as follows.

At the preoperative stage, multislice computed tomography (MSCT) is performed (Figs. 1, 4, 6), kyphotic, shear, and rotational deformations in the lumbar spine are determined. The size of the defect of the posterior structures to achieve a given correction is determined in advance during preoperative planning. The patient on the operating table is located on the rollers located under the chest and under the area of the hip joints. A skin incision (1) of about 3-4 cm (Fig. 14) is carried out in the projection of the articular pair, access to the spine is performed by blunt stratification of the muscles (2) and (3) in the intermuscular groove using tubular retractors. This ensures the preservation of the anatomical integrity of the musculo-ligamentous apparatus, stability and normal function of adjacent segments of the spine. After providing an overview of the system of retractors (Fig. 16) install pedicular screws. Perform total facetectomy, resection of the yellow ligament from the access side. Rotating the operating table around the sagittal axis and adjusting the angle of the microscope, provide conditions for visualizing the medial surface of the contralateral facet joint. The yellow ligament (4) is removed (Figs. 18 and 19) and the upper articular process of the lower vertebra from the contralateral side (if necessary, partial resection of the lower articular process of the upper vertebra is performed) using pistol nippers and a high-speed drill. The protection of the dural sac (5) and the radicular nerve (not shown in Fig.) Is carried out by a retractor. A total discectomy is performed, an implant is inserted into the interbody space closer to the ventral surface of the vertebral bodies (6) (Fig. 16), which allows you to set a greater wedge-shaped interbody space and, therefore, a larger angle of the lumbar lordosis. From the existing skin incision, an additional incision (7) (Fig. 14) of a 2 cm aponeurosis is performed in the immediate vicinity of the interspinous gap. In this case, soft tissues are minimally injured, by reducing the number of skin incisions, the risk of infection and necrotization of the skin flap between the incisions is reduced. From the spinous processes, muscle is exfoliated and laterally displaced with the help of retractors (3) (Fig. 14). Resection of the interspinous ligament (8), the caudal part (9) of the superior spinous process and the cranial part (10) of the lower spinous process with the preservation of the supraspinous ligament (11) is carried out (Fig. 15), with subsequent gradual extension of the extension on the operating table (including by introducing an angular interbody implant (6) (Fig. 16)), the edges of the formed bone defect are closed, thus forming a wedge at the level of the intervertebral disc and correction of kyphotic deformation (Fig. 16). After closing the edges of the resection wedge, the position of the dural sac (5) and the spinal roots are revised (Figs. 18 and 19). The transpedicular system is mounted on the access side, on the contralateral side, the transpedicular system is installed transcutaneously. Manipulations are carried out under radiological control. The wound is washed with saline, the wound is drained. Wounds are sutured in layers and an aseptic dressing is applied.

Clinical example.

Patient B., born in 1958. He entered the Federal State Budgetary Institution "Research Institute named after Y. L. Tsivyan" of the Ministry of Health of Russia in May 2015 with the following complaints: 1) pain in the lumbar spine aggravated by physical exertion, sitting position, 2) pain in the outer, back surface of the left thigh and lower legs, aggravated by walking, 3) numbness on the outer, back surface of the left thigh, lower leg and outer edge of the left foot, 4) weakness in the left foot.

After a comprehensive clinical and radiological examination, including examination by specialists, MSCT (Fig. 1, 4, 6), MRI (Fig. 8 and 9), an X-ray examination (Fig. 10, 11), a clinical diagnosis was made: Osteochondrosis of the lumbar spine with predominant lesion L4-L5, L5-S1, left-side lumbar degenerative scoliosis, degenerative antaterospondylolisthesis L4, degenerative spinal stenosis at the level of L4-L5, compression-ischemic radiculopathy L5, S1 on the left, lower distal monoplegia on the left.

A decompression-stabilizing intervention was performed with correction of kyphotic monosegmental deformity in the indicated manner, transpedicular fixation of L4-L5 vertebrae, transforaminal interbody fusion L4-L5. A linear incision was made of soft tissues in the projection of the articular pair L4-L5 to the left, departing from the spinous processes of 3 cm. The articular pair was highlighted. A tubular retractor is installed. The intersternal gap L4-L5 on the left is highlighted. Through the roots of the arcs, polyaxial screws are inserted into the bodies of the L4, L5 vertebrae. A total L4-L5 facetectomy was performed on the left. In the course of a facetectomy, compression of the dural sac by hypertrophic articular processes and the yellow ligament was noted. Resection of the yellow ligament from the access side was performed. By turning the operating table around the sagittal axis and adjusting the angle of the microscope, conditions are provided for visualizing the medial surface of the contralateral facet joint. The yellow ligament and the superior articular process of the lower vertebra were removed from the contralateral side, and the partial resection of the lower articular process of the upper vertebra was removed. A complete decompression of L4, L5 roots on both sides was achieved. The final revision of the spinal canal - root compression is eliminated, the roots easily move, a distinct pulsation of the dural sac appeared. Then L4-L5 total discectomy was performed, transforaminal interbody fusion was performed with a wedge-shaped implant made of PEEK (Polyether ether ketone) material with a cavity in the center filled with autobone. From an existing skin incision, a 1 cm aponeurosis incision was made in the immediate vicinity of the interspinous gap. The removal of the interspinous ligament with preservation of the supraspinatus, a partial resection of the adjacent surfaces of the spinous processes of L4, L5. Using hyperextension on the operating table, an angular correction is set at the level of the L4-L5 segment. A correction of 15 degrees has been achieved on the operated segment. A rod is laid in the heads of the transpedicular screws on the left, clamped by nuts. Under the control of the image intensifier tube, through the roots of the arches into the bodies of the L4, L5 vertebrae on the right with the help of Jamshidi needles, guide needles were installed, linear sections of soft tissues in the projection of the roots of the arches L4, L5 of the vertebrae to the right along the direction of the guide needles with a size of 1 cm. On the guide needles into the bodies L4, L5 The right vertebrae are equipped with transpedicular cannulated screws. A rod is laid in the screw heads using a rod extension, and a transpedicular system is mounted on the right. Seams in layers. Iodus Ac. Bandage. The patient is upright the next day after surgery.

On the control MSCT (Fig. 2, 3, 5, 7) in the postoperative period, it was noted that correction of kyphotic, anterior shear and rotational deformity was achieved.

The advantage of the proposed method over existing ones is the minimal soft tissue injury, significantly less blood loss, the best cosmetic result with the high corrective ability of this variant of osteotomy, with this method there is a high result of bone fusion. When using the method, kyphotic, shear and rotational deformities in the lumbar spine are corrected. The spine remains in a stable position.

The method of segmental vertebrotomy is implemented on modern equipment, using modern technologies and materials.

Claims (1)

A method for correction of deformities of the lumbar spine, including access to the spine, facetectomy, discectomy, partial resection of adjacent sections of the spinous processes, implantation into the interbody space and closure of the edges of the formed bone defect, characterized in that the spine is accessed by cutting the skin 3-4 see in the projection of the articular pair and blunt muscle stratification in the intermuscular groove using tubular retractors, a system of retractors provide an overview, then the mouth the pedicular screws are screwed, a facetectomy is performed on the access side, the yellow ligament is resected on the access side, the medial surface of the contralateral facet joint is visualized, after which the yellow ligament and the superior articular process of the lower vertebra are removed from the contralateral side, total discectomy is performed and the implant is inserted into the interbody space, then the implant from an existing skin incision, subcutaneous access to the aponeurosis is performed and an additional 2 cm aponeurosis incision is performed in the immediate b izosti from interspinous gap resect the interspinous ligament, the caudal portion of the upper spinous process and the lower cranial spinous process preserving nadostistoy bundles are brought together edges formed by the bone defect, whereupon the part mounted transpedicular access and traskutanno contralateral side.

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