RU2649826C2 - Method of the spinal channel endoscopic decompression and minor-invasive transpedicular stabilization in the thoracolumbar spine explosive fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology, neurosurgery, vertebrology and can be used for the spinal canal endoscopic decompression and minimally invasive transpedicular stabilization in the thoracolumbar spine explosive fractures. Performing the mid-paraspinal mini-access with length of 37-42 mm and two punctures. Through the punctures, forming the channels for the transpedicular screws rostral (upper) pair transcutaneous installation at an angle of 0 to 10 degrees of their insertion into the above located vertebra body. Caudal (lower) pair of transpedicular screws in the sagittal plane is installed openly into the below located vertebra body. Installing longitudinal bars in the heads of transpedicular screws.

EFFECT: method allows to reduce the back muscular tissues trauma, reduce blood loss, reduce the radiation load on the patient and medical personnel.

1 cl, 18 dwg

Description

The scope of the invention

The invention relates to medicine, namely to traumatology, neurosurgery, vertebrology, and can be used for minimally invasive surgical treatment of explosive, including complicated fractures of the thoracolumbar spine.

Explosive fractures of the thoracolumbar spine are accompanied by a decrease in the sagittal size of the spinal canal due to displacement of fragments of the vertebral body ¹ (1 (Magerl F., Aebi M., Gertzbein SD et al. A comprehensive classification of thoracic and lumbar injuries // Eur. Spine J. - 1994. - Vol. 3. - P. 184-201)). The neurological deficit present in such patients or the threat of its appearance requires urgent surgical intervention ² . (2 (Tsivyan. Ya. L. Some reasons in favor of surgical treatment of spinal fractures // Surgery. - 1986. - No. 11. - C. 3-8)). Given the high percentage of concomitant injuries associated with explosive fractures of the spine, as well as the serious condition of the victims, it is necessary to minimize the stress impact of operations performed in the treatment of this category of patients ³ . (3 (Perlmutter O.A. Injury of the spine and spinal cord combined with extravertebral injuries: (clinic, diagnosis, and surgical tactics): abstract of thesis ... candidate of medical sciences. - M .. 1988, 24 pp .; Mlyavykh, S.G. Surgical tactics for unstable isolated and combined injuries of the thoracic and lumbar spine: Abstract of thesis of Candidate of Medical Sciences / S.G. Mlyavykh. Moscow. 2009. - 27 p.)).

In order to decompress the spinal canal, essentially from a minimally invasive paraspinal intermuscular access, an endoscopic technique is used. The stabilizing stage of the operation is the partially transdermal and partially open installation of transpedicular screws.

Analogs of the invention

The well-known "Method of decompression of the spinal cord for fractures of the thoracic and lumbar vertebrae", RF patent No. 2467716, IPC A61B 17/56, publ. 11/27/2012. The method is a posterolateral surgical access to the anterolateral spinal canal of the thoracic spine and microsurgical removal of a fragment of the vertebra compressing the back of the brain in front. Use endoscopic technique with a minimum volume of osteoligmented resection. Posterolateral surgical access to the spinal canal is carried out by partial resection of the arch leg and articular processes of the vertebra while maintaining their anatomical and functional integrity. The removal of a bone fragment compressing the spinal cord is carried out by resection of the back of the vertebral body and the edge of the spinal canal within the middle supporting column of the spine. Remove bone fragments from the spinal canal under endoscopic control. For access, microsurgical instruments, magnifying equipment, endoscopic equipment (www1.fips.ru/) are required.

The disadvantage of this solution is the use of classical median access, in which soft tissue is detached from the underlying bone structures of the spine with a violation of local blood circulation. This method is characterized by a significant traumatic effect on the muscle tissue of the back, which does not fully comply with the principles of minimally invasive surgery. The stabilizing stage of the operation using a transpedicular fixation system is performed in the traditional way.

Also known is the Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures, authors Xi-Yan Xu, Zheng-Jian Yan, Qing Ma, Liang Chen, Zhen-Yong Ke, Fu Chen, Yun Chen, Lei Chu , Zhong-Liang Deng publ. in Journal of Orthopedic Surgery and Research 2014, (http://www.josr-online.com/contene/9/1/105).

The authors combine percutaneous transpedicular stabilization with mini-access to perform decompression of the spinal canal. However, mini-access, in contrast to the claimed one, is performed more laterally between m. iliocostalis and m. longissimus. Removing the vertebral arch when it is damaged and displaced into the spinal canal from this access is not possible. A rigid retractor, compressing the surrounding tissues, is used to abduct and retain muscles, which increases the traumatic effect on the muscle tissue of the back and increases blood loss. The method does not include the use of endoscopic technology.

Also known is the Posterior keyhole corpectomy method with percutaneous pedicle screw stabilization in the surgical management of lumbar burst fractures. Authors Maciejczak A, Barnas P, Dudziak P, Jagiello-Bajer B, Litwora B, Sumara M. Neurosurgery. 2007 Apr; 60

(4 Suppl 2): 232-41; discussion 241-2. (http://www.pubfacts.com/)

This operation is performed using a microscope, which makes it difficult to change the viewing angle in the process of removing fragments of the body of the damaged vertebra located in the spinal canal. Also, the authors of this method use four transpedicular accesses (each up to 3 centimeters in size) on both sides of the spinous processes in the projection of the arched joints, which increases the traumatic effect on the muscle tissue of the back. In addition, the use of additional instruments (Sextant; Medtronic, Inc., Minneapolis) is required to fix the longitudinal rods with the heads of the transpedicular screws. For abduction and fixation of paravertebral muscles, the authors use rigid branches of the retractor, compressing the surrounding soft tissues with the threat of the development of ischemic disorders in them.

Disclosure of the invention.

The objectives of the claimed invention is to reduce the morbidity during surgical access, reduce the morbidity of manipulations of the stage of decompression of the spinal canal and the stage of stabilization of the spinal segment, as well as reducing the amount of blood loss and time of surgery.

The claimed method differs from the already known ones in that it characterizes transcutaneous open (hybrid) stabilization of explosive fractures of the thoracolumbar spine, in which one mid-paraspinal mini-access is used between m.multifidius (segmented vertebral muscle) and m.longissimus (longest muscle) and 2 punctures, while the average length of the mid-paraspinal mini-access is 40 mm, the minimum is 37 mm, and the maximum is 42 mm, which is two to three times less than with classical median access (Fig. 7, Fig. 8 )

In the claimed method, the formation of channels for installing transpedicular screws is carried out for the caudal (lower) pair through the mid-paraspinal mini-access, and for the growthal (upper) pair through 2 punctures.

In contrast to the well-known transcutaneous installation technique, when transpedicular cannulated screws are inserted into the vertebral bodies through spokes into the formed channels with preliminary skin dissection from 1.0 to 2.0 cm ⁴ (4 (Folley KT, Gupta SK Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results // J. Neurosurg. - 2002. - No. 97. - pp. 7-12)), in the claimed method, a growth (upper) pair of transpedicular screws is inserted into the body above the located vertebra from the side of the surgical wound through previously formed transcutaneous channels that allows the use of non-cannulas nnye pedicle screws. In this case, the metal spoke located in the transcutaneous-bone canal is removed at the time of the initial insertion of the screw.

In contrast to the already known methods in the claimed, when introducing the lower (caudal) pair of transpedicular screws through the mid-paraspinal mini-access, the use of any retractors with the aim of preventing ischemic disorders from the paravertebral muscles is fundamentally excluded.

Separated from the mini-access, the transcutaneous formation of intrapedicular bone canals in the body above the located vertebra with the subsequent insertion of transpedicular screws through the surgical wound eliminates the need for additional skin incisions used for the transcutaneous immersion of the heads of the transpedicular screws used in the transcutaneous stabilization method.

The correctness of the formation of the intrapedicular canals and the installation of transpedicular screws is carried out not only by intraoperative fluoroscopy, but also visually-palpation from the mini-access side, focusing on the needles preliminarily percutaneously drawn on the Jamshidi needles and on palpator-defined anatomical landmarks (processus accessorius, processus transversus, superior, etc.) with the index finger of the left hand of the right-handed surgeon.

Given the biomechanical preference for introducing transpedicular screws into the body above the vertebra located at an angle of 0 to 10 degrees in the sagittal plane ⁵ (5 (Makarevich S.V. Internal transpedicular fixation of the thoracic and lumbar spine in case of damage: Author's abstract: dis ... Dr. med sciences. - Minsk. 2002. - S. 4)), their introduction, from the upper corner of the mid-paraspinal mini-access in a given direction is carried out without technical difficulties.

In contrast to the classical transcutaneous stabilization technique, the transcutaneous open (hybrid) technique for stabilization of explosive fractures from the above access under visual palpation and fluoroscopic control ensures the exact location of the transpedicular screws with less radiation exposure to the patient and the operating room medical personnel. The use of integral non-cannulated screws reduces the likelihood of their failure in the long term. The installation of longitudinal rods in the heads of the transpedicular screws is carried out without the use of additional transdermal conductors due to the possibility of directly changing the angle of inclination in the wound, which reduces the time of the operation.

Result

The claimed method allows to improve treatment results by reducing the traumatic effect on the muscle tissue of the back, reducing the amount of blood loss, reducing the time of surgery. Detailed visual control of the stage, endoscopic decompression and the visual-palpation stabilization stage in combination with fluoroscopy are more likely to prevent possible intraoperative complications and reduce radiation exposure to the patient and the operating room medical staff.

Brief Description of the Drawings

FIG. 1 is a schematic illustration of a part of the spine with a deformed vertebra and metal knitting needles;

FIG. 2 is a schematic illustration of a portion of the spine with a deformed vertebra, showing the installation of integral, non-cannulated transpedicular screws;

FIG. 3 is a schematic illustration of a part of the spine with a deformed vertebra, showing the installation of longitudinal rods in the heads of integral uncanulated cannulated pedicle screws;

FIG. 4 is a schematic representation of a deformed vertebra with a held rubber loop-holder and the resulting slit-like intermuscular space;

FIG. 5 is a schematic representation of a vertebra with a bone fragment in the spinal canal with the removed part of the arched joint and an installed endoscopic tube;

FIG. 6 is a schematic representation of a portion of the spine with a deformed vertebra with an installed endoscopic tube and holistic, non-cannulated transpedicular screws;

FIG. 7 - an X-ray image of a part of the spine with a deformed vertebra and marked with conditional lines for marking the claimed mid-paraspinal mini-access and 2 punctures;

FIG. 8 - an X-ray image of a part of the spine with a deformed vertebra and marked with standard access marking lines;

FIG. 9 is a photograph of the mid-paraspinal mini-access with the ability to determine its size using, see markings;

FIG. 10 is a photograph of the mid-paraspinal mini-access appearance of the postoperative wound;

FIG. 11 is a photograph of the process of forming channels for holding the upper pair of transpedicular screws,

FIG. 12 is a photographic snapshot of the channel formation process for holding the upper pair of transpedicular screws;

FIG. 13 is a fluoroscopic image of the process of channel formation for holding the upper pair of transpedicular screws;

FIG. 14 is a photographic picture of the process of introducing the upper pair of non-cannulated transpedicular screws into the body of the growth-bearing vertebra through the mid-paraspinal mini-access;

FIG. 15 is a photograph of the installation process of longitudinal rods in the heads of transpedicular screws through the mid-paraspinal mini-access;

FIG. 16 is a photographic snapshot of a rubber loop holding process;

FIG. 17 is a photograph of an installed endoscopic tube;

FIG. 18 is a photograph of the process of removing fragments of the vertebral body deployed in the spinal canal.

Designation of elements:

1 - skin;

2 - damaged vertebra;

3 - higher located vertebra;

4 - lower located vertebra;

5 - mid-paraspinal mini-access;

6 - a metal spoke drawn through the mid-paraspinal mini-access;

7 - a metal spoke held transcutantly;

8 - caudal (lower) non-cannulated transpedicular screw;

9 - growth (upper) non-cannulated transpedicular screw;

10 - m.multifidius (segmented vertebral muscle);

11 - m.longissimus (the longest muscle);

12 - intermuscular space;

13 - rubber loop holder;

14 - a fragment of the vertebral body;

15 - spinal canal;

16 - vertebral arch;

17 - leg of the vertebra;

18 - arched joint;

19 - spinous process.

20 - endoscopic tube;

21 - a conditional line of the lower locking plate above the located vertebra;

22 - conditional midline of the spinous process of the damaged vertebra and the line along which produce the mid-paraspinal mini-access;

23 - puncture site;

24 - formed channel in the superior vertebra;

25 - conditional line of intersection of the middle of the transverse processes of the inferior vertebra;

26 - formed channel in the lower vertebra;

The implementation of the invention

The claimed invention is carried out as follows: after endotracheal intubation and induction of anesthesia, the patient is placed in a standard position on the abdomen using reposition rollers under the chest and pelvis. An intraoperative fluoroscopic labeling of the upcoming access is performed (Fig. 7).

In the frontal projection (Fig. 1), the damaged (2) and adjacent vertebrae (3), (4) are determined, the line of the lower contact plate of the superior vertebra (21), which is the beginning of the soft tissue incision, is marked.

Next, the incision is continued along the midline (22) of the spinous process of the damaged vertebra and ends in the projection of the conditional line of intersection of the middle of the transverse processes of the lower vertebra (25) (Fig. 7).

From the mid-paraspinal mini-access (5) (Fig. 1) between m.multifidius and m.longissimus to the body of the lower vertebra in a standard way at an angle of 10 degrees to previously formed channels (26) using Jamshidi needles, metal knitting needles (6 ) (Fig. 1) and cannulated taps introduce a caudal (lower) pair of non-cannulated transpedicular screws (8) (Fig. 2). At this stage of the operation, in order to prevent ischemic disorders from the paravertebral muscles, the use of any retractors is fundamentally excluded.

Transcutantly and intrapedicularly in the superior vertebra (3), using Jamshidi needles, metal knitting needles (7) (Fig. 1) and cannulated taps, form channels at an angle from 0 to 10 degrees for introducing a growth (upper) pair of non-cannulated transpedicular screws (9 ) (Fig. 1, Fig. 11, Fig. 12, Fig. 13).

The growthal (upper pair) of non-cannulated transpedicular screws (9) (Fig. 2) is inserted into the body above the located vertebra (3) through the formed channels (24) from the mid-paraspinal mini-access (5). In this case, the metal spoke (7) located in the formed channel (24) is removed at the time of the initial insertion of the growth (upper) uncanulated cannulated screw (9) (Fig. 2, Fig. 14).

At the same time, the correctness of the formation of the intrapedicular canals and the installation of transpedicular non-cannulated screws is carried out by intraoperative fluoroscopy and visually-palpation from the mid-paraspinal mini-access, focusing on pre-transdermally made needles, Jamshidi spokes, and palpation-determined anatomical landmarks (processus processus articularis superior, etc.) with the index finger of the left hand of the right-handed surgeon.

After the introduction of transpedicular screws, depending on the location of the compressing fragments and the degree of stenosis of the spinal canal, unilateral or bilateral paraspinal access provides minimally invasive circular decompression of the elements of the spinal canal, which means the removal of the following elements of the posterior and middle supporting complex: arches of the damaged vertebra (16), arcuate joints (18), legs of the vertebra (17), intervertebral disc and posterior fragment of the body of the damaged vertebra, Niemi m.multifidius, spinous process (19) and the interspinous ligament (FIG. 4, FIG. 5).

To prevent ischimization, FIG. 4 m.multifidius (10) (segmented vertebral muscle) and m.longissimus (11) (the longest muscle), and providing visual control of the surgeon's technical actions by the previously stated method (patent application for the invention No. 2014149395/20 (079420) dated 08.12 .2014), under m.multifidius (10) (segmented vertebral muscle), from the spinous process (19), a rubber loop-holder (13) is held over the vertebral arch (16) with a round surgical needle, with which the muscle is temporarily retracted towards the spinous process (19) (Fig. 4). The soft cushioning effect of the rubber loop-holder (13) on m.multifidius (10) (segmented vertebral muscle) does not exert significant pressure during abduction, while opening sufficient intermuscular space (12) for resection of the arch of the damaged vertebra by Kerrison nippers from the side of the vertebral canal (15), with preservation of the spinous process (19), supraspinatus and interspinous ligaments (Fig. 4, Fig. 5, Fig. 16).

Between m.multifidius (10) (segmented vertebral muscle) and m.longissimus (11) (the longest muscle) (Fig. 5, Fig. 6) in the projection of finding the pedicles sequentially, on both sides, an endoscopic tube (20) is installed and fixed to the operating table using an L-shaped holder, an endoscopic tube is used, the inner diameter of which is 25 mm, the length is 80 mm (Fig. 5, Fig. 6, Fig. 17).

Through the channel of the tube under endoscopic control, the final removal of the arch of the vertebra is carried out, a resection of the yellow ligament is performed, the contents of the spinal canal are revised. A vertebral pedicle is removed with a high-speed boron, followed by removal of fragments of the vertebral body (14) deployed in the spinal canal with bone spoons and conchotomes (Fig. 4, Fig. 5, Fig. 18). In some cases, the decompression stage of the presented method is carried out only on one side of the spinous processes, reducing the total time of surgical intervention, as well as creating more favorable conditions for subsequent ventral fusion.

The installation of longitudinal rods in the heads of the transpedicular screws is carried out without the use of additional percutaneous conductors due to the possibility of directly varying their angle of inclination directly in the mid-paraspinal mini-access (Fig. 3, Fig. 15).

Claims (2)

1. A method for endoscopic decompression of the spinal canal and minimally invasive transpedicular stabilization during explosive fractures of the thoracolumbar spine, including mid-paraspinal mini-access, insertion of transpedicular screws, minimally invasive circular decompression of the elements of the spinal canal and installation of longitudinal rods into the head of the transpedicular, - paraspinal mini-access has a length of 37-42 mm and is complemented by two punctures through which the channels for the transcutaneous installation of the rostral (upper) pair of transpedicular screws at an angle from 0 to 10 degrees of their introduction into the body above the located vertebra, the caudal (lower) pair of transpedicular screws in the sagittal plane is installed openly in the body below the vertebra under visual, palpation and fluoroscopic control, the use of endoscopic monitoring at the stage of decompression of the spinal canal. 2. The method according to p. 1, characterized in that they install non-cannulated transpedicular screws.

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