RU2692580C1 - Method of transforaminal interbody fusion and rotated pusher - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: group of inventions refers to medicine, namely to vertebrology, and can be used for transforaminal interbody fusion. One-sided resection of hypertrophied articular processes of facet joint is performed. Carry out the entrance to the spinal canal and partial decompression of the roots of the spinal cord. Resected bone tissue is preserved and milled. Complemented root is shifted in medial direction. Disc herniation and osteochondral growths are resected. In opened after displacement of root of fibrous ring of intervertebral disc with scalpel, a window is cut, through which discectomy and curettage of disc is performed. Adjacent bone plates of adjacent vertebrae are cleaned until blood dew appears. Tongue of interbody spacing is performed. Cage is filled with autogenous crumbs and the obtained implant is inserted into an interbody space in a sagittal plane and shifted in the disk cavity on the opposite "healthy" side, keeping its position strictly in a sagittal plane. Rotary pusher (RP) is installed in the gap between the lateral edge of the implant and the lateral edge of the hole in the fibrous ring by orienting the RP blade in the sagittal plane. RP rotates through 90 degrees, the RP blade to translate into the horizontal plane, moving the implant towards the midline. RP is transferred into a sagittal plane. In the gap formed between the RP and the implant, a larger RP is installed. Rotating RP of larger size by 90 degrees to bring the blade into horizontal plane, moving the implant even further towards the midline. RP of larger size is transferred into sagittal plane and both RP are removed. To RP of smaller size RP of larger size is installed in horizontal plane with subsequent turn into sagittal one. In the gap between the RP of larger size and the implant in the sagittal plane, a RP of an even larger size is set and rotated by 90 degrees, moving the implant even further. Successively increasing size of RP, performing similar manipulations before implant installation into required position. RP is removed. Second cage is filled with autogenous crumbs and the obtained implant is inserted into an interbody space parallel to the first implant. RP for implementing the method of transforaminal interbody fusion comprises a guide and a pushing part, guide is made in form of rod and is equipped with L-shaped handle installed on end of rod, pushing part is located on rod opposite end from handle and is made in the form of flat blade with width of 8 mm, or 9 mm, or 10 mm, or 11 mm, or 12 mm , or 13 mm, or 14 mm with a rounded edge on side ends and with a rounded wedge-shaped face in front part.EFFECT: group of inventions enables to move the implant in a direction perpendicular to the axis of the pusher, enabling correction in the sagittal plane.2 cl, 15 dwg

Description

The group of inventions relates to medicine, namely to vertebrology, and can be used in neurosurgical and orthopedic interventions for degenerative lesions of the spine.

Spinal fusion is the most widely used method of treating diseases of the spinal column, which require stabilization of the damaged part of the spine. It is used for injuries, degenerative changes, developmental abnormalities, tumors. Today, there are many types and methods of spinal fusion, new methods are being intensively introduced using the most modern materials and techniques. Spinal fusion is one of the most intensively developing operations. Most often, anterior or posterior spinal fusion is performed.

With anterior spinal fusion, the vertebrae are accessed from the front and the vertebral bodies are attached. This method is more reliable, but also more traumatic.

In case of posterior spinal fusion, access is performed from the back and vertebrae are fastened in the area of the processes and arms. The method is simpler and more accessible, less traumatic for the patient.

There is a method of posterior spinal fusion, performed when installing the implant according to US patent No. 4834757 (IPC A61F 2/44, publ. 30.05.1989). In a position on the abdomen, a linear incision of soft tissues along the line of the spinous processes is performed. Poluduzhki and mezhduzhkovy gap on both sides. Perform interlaminectomy (i.e., resection of the yellow ligament and adjacent arcs) and resection of the articular processes of the arcuate girdle from the “diseased” side. The dural sac and spine from the “sore” side are shifted to the midline. The opened fibrous ring of the disk on the “diseased” side is dissected, and the disc is curried. The selection of the height of the implant is carried out by templates. The implant of the desired height is stuffed with bone chips, fixed in a pusher. The implant is hammered into the disk on the “diseased” side with a hammer blow on the pusher handle. After that, all the same actions are performed on the opposite "healthy" side.

This method provides the ability to install two interbody implants with a large total contact area of the implant-bone, reducing pressure at the border of the implant-bone, reducing the likelihood of implant subsidence, nonunion, pseudoarthrosis.

The disadvantages of the method include the need for resection of the posterior supporting (bone) structures of the spine from two sides, and the stability in the operated segment is greatly weakened.

In addition, bilateral resection of the yellow ligament (posterior wall of the spinal canal) leads to the formation of an extensive cicatricial adhesions both on the “diseased” and “healthy” side, because the dura mater and roots (the contents of the spinal canal) are in contact with the paravertebral muscles from two parties.

The traction of the roots and the dural sac is also carried out from two sides, as a result of which the roots can be traumatized and neurological symptoms appear on the “healthy” side.

Blocking the implant with a hammer blow on the impactor handle leads to the risk of uncontrolled damage to the bone beams.

The known method of the rear interbody fusion (RF patent No. 2555118, IPC A61F 2/44, publ. 10.07.2015), in which one-sided interlaminar access to the intervertebral space is produced. After decompression and medial displacement of the roots and the dural sac, a limiter is installed to protect them. Specify the direction and height of the interbody space with the help of the face milling cutter. An intervertebral implant is screwed into the prepared space in the oblique direction.

Unilateral interlaminar access reduces trauma and reduces the likelihood of postoperative complications.

The disadvantages of this method include the high probability of implant subsidence due to the small implant-bone contact area and injury to the vertebral body when the implant is screwed in.

The closest to the proposed is the method of transforminal interbody fusion described in the step-by-step guide of the AOSPINE osteosynthesis association “Step-by-Step Guide: Key Step in a MIS TLIF procedure” (https://aospine.aofoundation.org/Structure/education/online- education / mis-material / Documents / Step-by-Step% 20Guide% 20-% 20Key% 20Steps% 20in% 20a% 20MIS% 20TLIF% 20Procedure.pdf), which consists in performing access to the operated vertebral segment from the side compressed nerve secrete half-bows and the interstitial gap between them, unilateral resection of hypertrophied articular processes of the arcuate with the entry into the spinal canal and partial decompression of the roots of the spinal cord, the resected bone tissue is preserved and crushed, the compressed root is shifted in the medial direction, the hernia of the disk and bone and cartilage growths are resected in the fibrous ring of the intervertebral disc that opened with a spaloneeral segment of the spine of the spinal cord. through which disectomy and correction of the disc are performed, the endopaus bony plates of the adjacent vertebrae are cleaned until the appearance of “blood dew”, they are stretched out zhtelovogo gap cage packed autokostnoy grit and mounted in the implant obtained in the interbody space kosopoperechnom direction.

In this method, resection of the posterior support (bone) structures is carried out only on one “diseased” side, i.e. on the part of the compressed nerve, stability in the operated segment suffers to a lesser extent. The yellow ligament (posterior wall of the spinal canal) is also resected on the one hand, the dura mater and roots (contents of the spinal canal) are in contact with the paravertebral muscles only from the side of the compressed nerve, the scar-adhesive process only on the “diseased” side. Performing traction of the root and dural sac on the diseased side eliminates the risk of injury to the roots and the appearance of neurological symptoms on the “healthy” side.

The disadvantages of this method include the high probability of implant subsidence development due to the small implant-bone contact area due to the installation of one implant in the interbody space. In addition, this method does not provide the ability to install lordotic keys, providing the possibility of correction strictly in the sagittal plane.

Known pusher to install the implant according to US patent No. 8608804 (IPC A61F 2/44, publ. 17/12/2003). This pusher includes a longitudinal rod, at one end of which the grips for the implant are placed, and at the opposite end is a lock for controlling the gripping and releasing from the gripping of the implant.

The disadvantages of the pusher to install the implant on US patent No. 9608804 include the inability to move the implant in a direction perpendicular to the axis of the pusher.

Closest to the proposed tool is used to push the implant according to US patent No. 6443987 (IPC A61F 2/44, publ. 03.09.2002). This tool includes a flat end face guide and a pushing part, at the end of which spikes, corrugations or grooves for grabbing the implant are made.

The pusher, described in US patent No. 6443987, is designed to install the implant by striking the flat end of the handle. When this impact force is applied along the axis of the pusher. It is impossible to move the implant in a direction perpendicular to the axis of the pusher in the direction of the midline.

The task (technical result) of the present invention is to create a method of transforaminal interbody fusion and a rotatable pusher free from the disadvantages described above.

The task is solved by the fact that they perform access to the operated vertebral segment, from the side of the compressed nerve, they make half-arms and an interjoint gap between them. Perform one-sided resection of hypertrophied articular processes of the arculocephalic joint, enter the spinal canal and partially decompress the roots of the spinal cord. The resected bone tissue is preserved and crushed. The compressed root is shifted medially, the disc herniation and bone and cartilage growths are resected, and a window is opened with a scalpel after dislocation of the fibrous ring of the intervertebral disc after displacement of the disc. The locking bone plates of the adjacent vertebrae are cleaned until the appearance of “blood dew”, they stretch the interbody space. The cage is filled with crumb and is placed in the interbody space. According to the invention, the implant is placed in the sagittal plane and shifted in the frontal plane in the disk cavity to the opposite “healthy” side, while maintaining its position strictly in the sagittal plane. To do this, in the gap between the lateral edge of the implant and the lateral edge of the hole in the fibrous ring, a "rotatable pusher" (PT) is installed, orienting the RT blade in the sagittal plane. The rounded wedge-shaped end in the front of the scapula facilitates the installation of the scapula into the narrow gap between the lateral surface of the cage and the lateral edge of the opening in the fibrous ring.

By rotating the RT at 90 degrees, his scapula is transferred to the horizontal plane, moving the implant back toward the midline. The rounded edge of the blade in the lateral ends minimizes the force when the PT rotates and freely slides along the edge of the blade both along the lateral support and along the shifted cage. The RT is again transferred to the sagittal plane, the gap between the RT and the implant is set to a larger RT. The rounded wedge-shaped end in the front of the scapula allows you to install it in narrow gaps between the lateral surface of the cage and the medial surface of the lateral support. Rotate the RT of a larger size by 90 degrees to transfer the scapula to the horizontal plane, moving the implant even further towards the midline. The L-shaped handle, one end of which ends on the guide, and the other hangs freely, allows one PT to rotate the implant in a direction perpendicular to the axis of the pusher not to touch the handle of the other PT with its handle. Larger RTs are transferred to the sagittal plane and both RDs are removed. In place of a smaller RT, a larger RT is installed in the horizontal plane with subsequent reversal into the sagittal one. In the gap between the larger RT and the implant in the sagittal plane, the RT is set to an even larger size and rotated by 90 degrees, moving the implant even further away. Consistently increasing the size of the RT, similar manipulations are carried out before the implant is placed in the required position. After that, the RT is removed, the second cage is filled with an autocodial crumb and the resulting implant is placed in the interbody space parallel to the first implant. Remove the interstitial distractor, eliminate the stretching of the interbody space, layered seams on the wound.

The problem is solved in that the rotatable pusher includes a guide and a pushing part. According to the invention, the sender is made in the form of a rod and provided with an L-shaped handle mounted on the end of the rod, the pushing part is placed at the opposite end of the rod and made in the form of a flat blade with a rounded edge on the side ends and with a rounded wedge-shaped end in the front part.

This design of the rotated pusher provides the ability to move the implant in a direction perpendicular to the axis of the pusher in the direction of the center line and the correction strictly in the sagittal plane.

The proposed sequence of operations provides the ability to install two interbody lordotic keys, ensuring the possibility of correction strictly in the sagittal plane, with a large total contact area of the implant-bone, which leads to a decrease in pressure at the border of the implant-bone, reducing the likelihood of implant subsidence, nonunion, pseudoarthrosis, and thus contributing to improved clinical and radiological outcomes.

Installing a cage in the sagittal plane on both sides of the midline parallel to each other allows meticulously and predictably to perform angular correction in the segment in the sagittal plane, i.e. eliminate kyphotic deformity and create segmental lordosis. This is achieved by using lordotic cage with a well-known wedge shape or rectangular cage due to installation in the front sections of the disk. Cages are installed on both sides of the middle line symmetrically: in parallel, at the same depth, the wedge shape of both cages is the same, so there is no collateral "skew" or unexpected change in the relationship in the operated segment in the frontal plane and / or other planes.

In this case, resection of the posterior support (bone) structures is carried out only on one “diseased” side, i.e. from the side of the compressed nerve, therefore stability in the operated segment suffers to a lesser extent. Resection of the yellow ligament (posterior wall of the spinal canal) is also carried out only on one side (“diseased”), in this connection the dura mater and roots (contents of the spinal canal) are in contact with the paravertebral muscles only from the compressed nerve. Therefore, the development of scar adhesions is possible only on the "sick" side. The "healthy" side is not compromised. Traction of the root and dural sac is carried out only from the “sick” side, therefore the risk of trauma to the roots and the appearance of neurological symptoms on the “healthy” side is excluded.

The invention is illustrated by images, where in FIG. 1 shows the claimed rotated pusher, front view; in fig. 2 - side view; in fig. 3-8 - the sequence of moving the implant from the patient to the healthy side. FIG. 9 shows magnetic resonance imaging before surgery, explaining a clinical example. FIG. 10-15 - control multispiral computed tomography (MSCT) 3 months after surgery, and in FIG. 10-11 shows the sagittal sections through the first and second implants, respectively.

The proposed method is carried out, and the rotated pusher works as follows.

The patient is placed on the operating table on the abdomen. Perform a linear incision of soft tissue along the line of the spinous processes or parasagittal (according to Wiltse). The half-bows and the desired inter-spacing between them are separated from the side of the nerve compression, i.e. from the “sick” side. Perform one-sided facetectomy, i.e. unilateral resection of hypertrophied articular processes of the arc-grab joint. Due to this, they enter the spinal canal, as well as, partial decompression of the spinal cord roots. The resected bone is preserved and crushed. In the future, it is used to fill the cage, because is a good osteoinductive material.

Next, the compressed root and dural sac 1 are shifted in the medial direction, i.e. towards the middle line. Under hernia disk, osteochondral growths are resected. Thus, carry out the final decompression of the squeezed root. In the fibrous ring of the intervertebral disk that opens after displacement of the spine, a window is cut out with a scalpel through which disectomy and correction of the disk are performed. At the same time, the terminal bony plates of the adjacent vertebrae are cleaned until the appearance of “blood dew”, i.e. completely free from the remnants of intervertebral cartilage. In the surgical (advanced) stages of osteochondrosis, the height of the intervertebral disc is always reduced, and when performing spinal fusion, it is necessary to restore the height of the disc by setting the cage to the maximum possible height. Considering that the upper and lower limiting plates of the disk look like a concave lens, the upper-lower size of the entrance to the disk (in the region of the hole cut in the fibrous ring) is significantly smaller than the same size in the middle sections of the disk. Therefore, to install the implant of the maximum possible size (for the middle sections of the disk), the posterior parts of the interbody space are stretched, for example, by bending the patient in the sagittal plane using the operating table and additionally stretching the back sections of the spine with a special distractor. After the height of the disc in the posterior regions equals the height of the disc in the middle regions, implant placement becomes possible. Thanks to these techniques, it is possible to introduce a cage of the maximum possible height in the intervertebral space. The cage selected with the help of templates is filled with crumb, is screwed onto the impactor pin and the resulting implant 2 is inserted into the interbody space through a hole cut in the fibrous ring. A properly selected height implant 2 is set gently but firmly. Impactor retrieve. Methodically installed implant 2 at this stage is tightly wedged in the interbody space between the bodies of adjacent vertebrae. At the same time, it is located strictly in the sagittal plane on the “sick” side, i.e. on the access side.

Next, the implant 2 is moved by the pusher in the cavity of the disk to the opposite "healthy" side, while maintaining its position strictly in the sagittal plane. It is difficult to push implant 2, which is tightly inserted into the disc, towards the midline. Firstly, due to large friction, and secondly, due to the fact that the force must be applied not along the axis of the pusher, but perpendicularly to it. In addition, the movement of the pusher in a direction perpendicular to its axis towards the midline is limited by the limits of elastic deformation of the medial edge of the orifice cut out in the fibrous ring, i.e. fibrous ring tissue. It is no more than 1-2 mm.

The small size of the surgical corridor, bounded proximally by the walls of the wound, and distal by the edges of the hole cut in the fibrous ring, do not allow the implant to be moved using known hinge or lever-type instruments: 1) due to constraint; 2) due to the inability to maintain the sagittal position of the implant when it is moved.

In order to move the implant 2, in a gap between the lateral edge of the implant 2 and the lateral edge of the hole in the fibrous ring (not shown in fig.), A special rotatable pusher 3 (PT), shown in FIG. 1, 2, the width of the blade 4 of which is 8 mm, while the blade 4 of the PT 3 is oriented in the sagittal plane (Fig. 3). Handle 5 rotates the PT 3 by 90 degrees and translates the scapula 4 of the PT 3 into a horizontal plane, thereby moving the implant 2 towards the midline (Fig. 4). By turning the knob 5 in the opposite direction of the PT 3 after that, it is again transferred to the sagittal plane. A gap appears between PT 3 and implant 2. This gap is also set in the sagittal plane PT 6 (blade width 9 mm) (Fig. 5), rotated by 90 degrees to convert the blade 4 into a horizontal plane. At the same time, the lateral edge of the PT 6 abuts against the laterally installed PT 3, and the medial edge rests against the implant 2. Considering that the laterally installed PT 3 all over the plane rests on a durable fibrous ring, it is a non-shear support. Therefore, when a distracting force is applied between PT 3 and the implant 2, the implant 2 moves further away towards the midline (Fig. 6). Then, PT 6 is transferred to the sagittal plane and both RTs are easily removed. After that, in place of PT 3, PT 6 is installed in the horizontal plane with subsequent reversal into the sagittal one (not shown in Fig.). Now he is the lateral support. This is achieved by solving two problems.

First, due to the fact that the disk has the shape of a biconvex lens, its height is uneven, and decreases from the center to the lateral parts. Therefore, RT, which has a large width, when installed, will be closer to the center and, accordingly, to the sheared implant. This makes it possible to further move the implant at the turn of the RT even of the same size, since The “support” is closer to the shear implant.

Secondly, the use of the ever increasing size of the RT as a lateral support allows to gradually increase the height of the interbody space. This is important when the shifted implant 2 begins to approach the opposite “healthy” edge of the interbody space, where the height is lower than in the middle sections.

Next in the gap between the PT 6 and the implant 2 in the sagittal plane set PT (width of the blade which is 10 mm), rotate it 90 degrees. Implant 2 is further moved to the "healthy" side. As a rule, already at this stage, implant 2 is behind the middle line, i.e. on the "healthy side", and you can begin to install a second implant. However, if a specific anatomical relationship allows, it is necessary to push the implant 2 as far as possible, i.e. to the lateral edge on the “healthy” part of the disk (Fig. 7). To do this, consistently, repeat the distracting maneuver with a pair of PT with a blade width of 10 and 11 mm, 11 and 12 mm, 12 and 13 mm, 13 and 14 mm, respectively. At what stage to stop further advancement of the implant 2, the surgeon determines on the basis of his experience, tactile sensations and radiological control data. After giving the implant 2 the necessary position in the disk, both RTs are removed. A schematic representation of the movement of the implant 2 in the interbody space is shown in FIG. 7. The second cage is filled with crumb of an autocrescent, screwed onto the impactor pin and the resulting implant 7 is inserted into the interbody space in the previously formed hole in the fibrous ring, i.e. to the place of the shifted cage (Fig. 8).

The interstitial distractor is removed, the operating table is bent, the patient on the table is transferred to the neutral position. Both implants 2 and 7 are very tightly wedged in the intervertebral space. Considering the good primary stability of the performed spinal fusion, the main stage of the operation can be completed or, more often, can be supplemented by the routine transpedicular fixation of the adjacent vertebrae.

Conduct intraoperative x-ray control. Hemostasis. Impose layers of seams on the wound.

Clinical example.

Patient X., born in 1976. Entered the FGBU "NIITO them. YL Tsivyan" Ministry of health of Russia in August 2017 with the following complaints: 1) pain in the lumbar spine, 2) pain on the back of the right thigh and lower leg, 3) numbness in the perineum and impaired urination, 4) weakness in the feet.

After a comprehensive clinical and radiological examination, which included an examination by specialists and magnetic resonance imaging (MRI) (Fig. 9), a clinical diagnosis was made: osteochondrosis of the lumbar spine, L5-S1 disc hernia, degenerative stenosis of the spinal canal at the L5-S1 level, cauda - Syndrome, lower sluggish distal paraparesis, dysfunction of the pelvic organs (PTF).

Decompression-stabilizing intervention was performed: removal of a herniated disk L5-S1, decompression of the roots of the spinal cord, transpedicular fixation of the L5-S1 vertebrae, transforaminal interbody spinal fusion L5-S1.

The position of the patient on the operating table lying on his stomach on a special stand. Linear incision of the skin, subcutaneous tissue and aponeurosis in the midline in the projection of the spinous processes of L4-L5-S1. The bows and transverse processes of the L5-S1 were selected. Under the control of a surgical microscope, resection of the adjacent half-arches (interlaminectomy) L5-S1 was performed on the right. Performed resection of the hypertrophied lower articular process (facetectomy) of the L5 vertebra on the right and resection of the superior articular process (facetomy) of the S1 vertebra on the right. Thus, the L5-S1 foraminotomy is performed on the right. When performing interlaminectomy and facetectomy, compression of the dural sac with hypertrophied articular processes and a yellow ligament is noted. Produced resection of the yellow ligament from the access side. After that, a visual inspection is available dural bag and spine S1 on the right. They are compressed and strung. Palpation with a neurosurgical hook under the root determines a dense-elastic formation. The root of S1 is displaced medially on the right, and under it a transgamentary hernia of the disk is found. Hernia is removed in the form of several sequestered fragments. Achieved complete decompression of the spine and dural sac. In the fibrous annulus of the L5-S1 disk, a gap of 3 × 3 mm was revealed on the right. A scalpel of 7 × 7 mm square shape was cut out with a scalpel. Through the formed aperture, a curettage of the L5-S1 disk and its discectomy, i.e. maximum removal of the pulpal nucleus. In this case, the switching plates of the adjacent parts of the bodies L5 and S1 are cleaned from hyaline plates to blood dew. Produced bending of the operating table and, due to this, giving the patient a position of easy bending in the lower back. A special distractor is installed between the spinous processes L5 and S1. With its help, the distraction of the posterior parts of the L5 and S1 vertebrae has been carried out.

With the help of templates, the required size of the implant to be installed is determined - 9Х25 mm. The bone obtained during resection of the articular processes was crushed, it filled two cages of Fidji (from PEEK material - Polyether ether ketone) 9 × 25 ° in size. The cage is screwed onto the impactor pin and the implant is installed in the interbody space through a hole formed in the fibrous ring. Impactor removed.

In the gap between the lateral edge of the implant and the lateral edge of the hole in the fibrous ring, a rotating pusher is installed with a blade width of 8 mm, while the PT blade is oriented in the sagittal plane. By turning the RT 90 degrees, the scapula is translated into a horizontal plane and thus the implant is shifted towards the midline. PT 8 mm again transferred to the sagittal plane. A gap appeared between him and the implant. In this gap, too, in the sagittal plane, a PT with a blade width of 9 mm is set, after which it is rotated 90 degrees to convert the blade into a horizontal plane. Due to the arising distracting force between the 8 mm PT and the implant, the implant moved further away towards the midline. PT 9 mm transferred to the sagittal plane and both RT extracted. In place of PT 8 mm, PT 9 mm is installed in the horizontal plane with subsequent reversal into the sagittal one. In the gap between the PT 9 mm and the implant in the sagittal plane set PT 10 mm. When turning it 90 degrees, the implant is pushed beyond the middle line to the “healthy” side. Both RT extracted. The second cage is screwed onto the pin of the impactor and through the hole in the fibrous ring the implant is placed in the interbody space in place of the shifted implant. In the space left in the interbody space (the cavity of the disk), lateral to the second implant, pieces of the remaining auto-bone are laid.

The interstitial distractor was removed, the operating table flexion was removed, the patient on the table was moved to the neutral position. Both implants and loosely laid pieces of autobone were wedged in the interbody space. Screws 40 mm long and 6.5 mm in diameter are screwed into the vertebral bodies L5 and S1 through the lice. In the tuning forks screws laid rod. Mounted transpedicular system. X-ray control in two projections. The standing of the implants is correct. Hemostasis. The wound is washed with 1 liter of betadine. The wound is sutured in layers. Iodine. Aseptic dressing. The patient is verticalized on the following day after surgery.

On the control multispiral computed tomography (MSCT), 3 months after the operation, the presence of a bone block 8 at the level of L5-S1 (Fig. 10, 11, 12), the half-arms of 9 and the joint pair 10 at the level of L5-S1 on the left (Fig. 13 , 14, 15). FIG. 12 also clearly shows that the bone block 8 is formed by two bone bridges 11 and 12, which grow through two symmetrically installed implants.

The proposed method can be installed implants metal, polymer, hollow, compact having a rectangular cross-section and a length of not more than 25 mm.

Claims (2)

1. The method of transforaminal interbody spinal fusion, which consists in accessing the operated vertebral segment, from the side of the compressed nerve, isolate the half-arms and the interstitial gap between them, carry out a one-sided resection of hypertrophied articular processes of the arc-horny joint, enter the vertebral canal and partial decomposition of the decompressor artery. brain, resected bone tissue is preserved and crushed, compressed root is shifted in the medial direction, resect the disc herniation and bone and cartilage growths, in the fibrous ring of the intervertebral disk that opened after displacement of the root, cut out a window with a scalpel through the diskectomy and curettage of the disk, the interfacing bone plates of the adjacent vertebrae are cleaned before the “blood dew” appears, stretching the interstitial space crumb and install the resulting implant in the interbody space, characterized in that the implant is set in the sagittal plane and shifted in the dis and on the opposite “healthy” side, while maintaining its position strictly in the sagittal plane, for this purpose a rotary pusher according to claim 2 (PT) is installed in the gap between the lateral edge of the implant and the lateral edge of the hole in the fibrous ring , turning the RT by 90 degrees, the PTO blade is transferred to the horizontal plane, moving the implant towards the midline, the PT is again transferred to the sagittal plane, and the gap between the PT and the implant is set to a greater pitch PT zmera, rotate the larger RT by 90 degrees to transfer the scapula to the horizontal plane, pushing the implant even further towards the midline, the larger RT is transferred to the sagittal plane and both RTs are removed, the larger RT is replaced in the horizontal plane with the subsequent reversal into the sagittal, in the gap between the larger RT and the implant in the sagittal plane, the RT is set to an even larger size and rotated by 90 degrees, moving the implant even further, consistently increasing the size of the RT, similar manipulations are carried out before the implant is placed in the required position, then the RT is removed, the second cage is filled with autocrescent crumb and the resulting implant is placed in the interbody space parallel to the first implant, the interstate distractor is removed, the elongation of the interbody space is removed, the suture is layered over the wound. 2. A rotated pusher for carrying out the method of transforaminal interbody spinal fusion under item 1, comprising a guide and a pushing part, characterized in that the guide is made in the form of a rod and provided with an L-shaped handle installed at the end of the rod, the pushing part is located at the end of the rod opposite to the handle and is made in the form of a flat blade 8 mm wide, or 9 mm, or 10 mm, or 11 mm, or 12 mm, or 13 mm, or 14 mm with a rounded edge on the lateral ends and with a rounded wedge-shaped end in the front.

Images