RU2629328C1 - Method for surgical correction of spine sagittal disbalance - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in interbody spaces up to and below the vertebra, determined on the basis of preoperative planning, autoregally filled cages are introduced transforaminally from the rear access. Then, vertebra osteotomy is performed: its arch, processes and legs are removed, angular osteotomy is performed to the anterior quarter of its body and the ends of the formed wedge-shaped defect are brought together. After that, a modeled rod is laid in the previously installed transpedicular screws in the vertebral bodies above and below the osteotomous, final fixation of the achieved imbalance correction is performed.

EFFECT: method allows to form a bone block between adjacent vertebrae, to provide reliable fixation, to prevent development of pathology of adjacent vertebral-motor segments.

6 dwg

Description

The invention relates to medicine, in particular to neurosurgery and orthopedics, can be used to perform corrective surgery for sagittal imbalance of the spine in the treatment of rigid deformities caused by degenerative scoliosis in adults, the consequences of idiopathic scoliosis, post-traumatic deformities.

A known method for correcting sagittal imbalance by wedge-shaped osteotomy of the vertebral body together with legs (PSO) on both sides, performed from the rear access. Its essence lies in classical posterior access to the spine, performing a laminectomy with resection of the spinous, transverse, articular processes, wedge-shaped resection of the vertebral body together with the legs of the vertebra to the front quarter of its body, with subsequent correction of spinal deformity in the sagittal plane. The method allows you to correct the sagittal balance of the spine during rigid deformities from the posterior approach to 40 degrees. This method is selected as a prototype (1, 2, 3, 7, 8).

The disadvantages of this method include the fact that the spine undergoing osteotomy becomes absolutely unstable due to the removal of the rear two supporting columns of the spinal column (4). To stabilize the spine, various fixation systems are used (5). At the moment of the development of spinal surgery, transpedicular fixation systems are most often used. However, this method does not provide sufficient stability of the spine due to the presence of two free intervertebral discs. The bone block does not form between adjacent vertebrae, the system remains mobile. All support load falls on the metal structure, which in turn leads to a high risk of fracture of the implants. Instability of metal structures requires repeated operations associated with an increased risk of damage to neural structures, infectious complications (1, 2, 6, 9).

The technical result of the present invention is the correction of the sagittal balance, the formation of a bone block between adjacent vertebrae and reliable fixation of the spinal column in a given position, which allows to solve the problem of instability and fractures of the fixing system in the postoperative period, to prevent the development of pathology of adjacent vertebral motor segments.

The result of the invention is achieved due to the fact that set-ups filled with autobone (removed facet joints) are installed, which are inserted into the interbody spaces a level higher and lower than that defined for osteotomy of the vertebra, after which osteotomy of this vertebra is performed with removal of its arch, processes and legs, followed by angular vertebrotomy to the front quarter of his body and reducing the ends of the formed wedge-shaped defect, then into the previously installed transpedicular screws in the vertebral bodies above and below the osteoto th e laid otmodelirovannuyu post produce the final fixation achieved unbalance correction.

The additional use of interbody cages contributes both to an increase in the degree of deformation correction due to wedging of the vertebral bodies at the support point, and to facilitating the delivery of osteoplastic autologous material into the space between the vertebral bodies, which contributes to the formation of a reliable bone block, maintaining the height of the interbody space at a given level and stabilization of the spinal column 360 degrees.

The drawings show:

FIG. 1. MRI of the patient before surgery

FIG. 2. X-rays in direct projection before surgery

FIG. 3. X-rays in a lateral projection before surgery

FIG. 4. X-rays in direct projection after surgery

FIG. 5. X-rays in lateral projection after surgery

FIG. 6. Correction scheme for sagittal imbalance with isolated application of PSO and the described method.

The method is as follows: in x-ray, under endotracheal anesthesia, in the position of the patient on the stomach, after triple processing of the surgical field, skin incision and access to the posterior vertebral structures, the transpedicular system screws are installed along the entire length of the deformation. Using bone nippers, conchotomes, osteotomes, pistol nippers, facet joints are removed at the level of the vertebra, which will be subjected to osteotomy. Standard transforaminal access produces curettage of the intervertebral discs above and below the osteotomized vertebral body. Into the body cavity are inserted interstitial cages filled with autobone obtained from parts of removed facet joints. Cages are oriented in the frontal plane relative to the center of the vertebral body. The process is controlled using an electron-optical converter (EOC). The vertebra selected for osteotomy based on preoperative planning is isolated. At the vertebra, the arc with the spinous process, the legs of the vertebral body are removed. Next, using the osteotome, an angular osteotomy of the vertebra is carried out to the front quarter of his body under image intensifier control. After completion of the osteotomy using the operating table under the image intensifier tube, the ends of the wedge-shaped defect of the vertebral body are brought together. The screws of the transpedicular system previously installed in the above and underlying vertebrae, relative to the osteotomy, are fixed with a nut pre-bent to the required angle of correction of the rod. The resulting correction of imbalance is fixed in the achieved position.

The method of correction of sagittal imbalance promotes the formation of a bone block between the osteotomized vertebra and adjacent segments, increases the degree of correction of sagittal imbalance, due to the additional use of interbody cages, which allows to solve the problem of instability of the metal structure after surgery and prevent the disease of adjacent vertebral motor segments.

Complications in the postoperative period were not observed in any patient.

Clinical example. Patient K., 35 years old. Suffered from idiopathic scoliosis of the spine since childhood. Attempts at conservative treatment did not lead to correction of the deformity. Since 2010, after the last pregnancy and childbirth, a sharp deterioration, tear to the left. The pain syndrome has become permanent. In 2013, fixation with a transpedicular structure from Th2 to L5 with correction of frontal deformation was performed. After 2 months, due to the instability of the metal structure, the fixation was extended to the S1 vertebra. Due to improper fixation biomechanics, repeated instability of the metal structure developed. 1 month after the second operation, pain appeared in the lumbosacral spine, deformity increased. In this connection, she was hospitalized in the 18th department of RNIITO for surgical treatment according to the quota of the Ministry of Health of the Russian Federation. Surveyed. On the roentgenogram revealed sagittal imbalance of the spine, the migration of screws from the S1 vertebra (Fig. 1, 2, 3).

Anamnesis of life without features. The patient did not suffer from somatic diseases. She had no neurological deficit. Soreness on palpation and percussion of the spinous processes and paravertebral points in the projection L5, S1 on both sides. No decrease in sensitivity was detected. Physiological reflexes from the legs are reduced, Achilles reflexes are not caused. No pelvic abnormalities. No other pathology of neurological status has been identified.

The diagnosis was made: Idiopathic scoliosis of the spine. Condition after surgical treatment from 2011. Instability of metal construction. Decompensation of statics and biomechanics of the spine. Vertebrogenic pain syndrome.

Considering the presence of vertebrogenic pain syndrome caused by sagittal imbalance, instability of the metal structure, surgical treatment in the amount of posterior responsonosynthesis Th11-12-L1-L2-L5-S1-SIPS, PSO at level L4, correction of kyphoscoliotic deformity is recommended.

The operation was performed using rear access, removing the old metal structure proximally to the level of Th11 vertebra, reinstalling new screws in Th11-12-L1-L2-L5-S1-SIPS. At levels L3-4, L4-5, interbody cages were transformed with transforaminal access, followed by an angular osteotomy of the L4 vertebra (PSO) under image intensifier control. Correction of sagittal imbalance, fixation of metal. Introoperative blood loss amounted to 2100 ml, the operation time is 7 hours 30 minutes. In the postoperative period, a significant decrease in pain in the lumbosacral spine, correction of posture was noted. On the control radiographs, the standing of the structure is correct, stable. On the teleentgenogram, the sagittal imbalance is corrected (Fig. 4, 5, 6). The patient at the department received an injection course of antibiotic prophylaxis, complex drug therapy. The condition has improved significantly. The patient was in hospital treatment from the moment of admission 24 days. Discharged in satisfactory condition. During outpatient examinations after 3 months, 6 months, 12 months, it was noted that the positive effect of the intervention remains. There is no pain. The design is stable. Neurological status - without pathology. Does not need treatment.

Thus, in this observation, despite the previous surgical intervention, the presence of unstable metal structures, sagittal imbalance of the spine, we managed to perform the required surgical treatment, obtain a stable clinical effect in the short and long postoperative periods with normalization of neurological status, restoration of statics and biomechanics of the spine.

Bibliography

1. Bridwell K.N. et al. Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance // Spine. - 2003. - Vol. 28. - No. 18. - P. 2093-2101.ku

2. Bridwell K.H. et al. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance // The Journal of Bone & Joint Surgery. - 2003. - Vol. 85. - No. 3. - P. 454-463.

3. Cho K. J. et al. Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance // Spine. - 2005. - Vol. 30. - No. 18. - P. 2030-2037.

4. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries // Spine. - 1983. - Vol. 8. - No. 8. - P. 817-831.

5. Gaines R.W. The use of pedicle-screw internal fixation for the operative treatment of spinal disorders // J Bone Joint Surg Am. - 2000. - Vol. 82. - No. 10 .-- P. 1458-1458.

6. Lafage V. et al. Sagittal spino-pelvic alignment failures following three column thoracic osteotomy for adult spinal deformity // European Spine Journal. - 2012. - Vol. 21. - No. 4. - P. 698-704.

7. Mummaneni P.V. et al. Pedicle subtraction osteotomy // Neurosurgery. - 2008. - Vol. 63. - No. 3. - P. A171-A176.

8. Rose P.S. et al. Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy // Spine. - 2009. - Vol. 34. - No. 8. - P. 785-791.

9. Schwab F.J. et al. Sagittal realignment failures following pedicle subtraction osteotomy surgery: are we doing enough? Clinical article // Journal of Neurosurgery: Spine. - 2012. - Vol. 16. - No. 6. - P. 539-546.

Claims (1)

A method of surgical correction of sagittal imbalance of the spine, including wedge-shaped osteotomy of the vertebra, correction of deformation and fixation of the vertebrae using a transpedicular system, characterized in that autobone-filled autobone is introduced into the interbody spaces to a level above and below the vertebra determined on the basis of preoperative planning from the posterior approach cages, then an osteotomy of the specified vertebra is performed with removal of its arch, processes and legs, followed by angular osteotomy until ne the middle quarter of his body and reducing the ends of the formed wedge-shaped defect, after which the modeled rod is placed into the vertebral bodies of the vertebrae above and below the osteotomy in the previously installed transpedicular screws, and the final fixation of the achieved imbalance correction is made.

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