RU2698618C1 - Method of three-column vertebrobotomy with diastematomielia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and spinal surgery, and is used in treating patients with spinal deformations accompanying diastematomielia. Three-column vertebrotomy is performed in diastematomielia from one dorsal approach to one surgical session. Median incision is used to access the spinous processes and arcs of the vertebra by two or three segments above and below the level of involvement. Paravertebral muscles are separated and displaced laterally on both sides. Screws of transpedicular fixation system are installed. Laminectomy is performed, a spinous process and a vertebral arch at the diastema level are resected. Diacemal-segregated dura mater is visualized. Laminectomy is continued up and down along the entire dura mater splitting. Dura mater at the splitting point is separated from the diastema. Thereafter, the diastema is resected by wire cutters to the base located on the anterior wall of the spinal canal. Correcting wedge-shaped vertebrosis is performed through a base of the diastema and opposite through the vertebral root. Longitudinal rods of the transpedicular fixation system are laid in the screw heads; a corrective maneuver is performed and the achieved deformation correction is recorded by tightening the rods in the screw heads. Dura mater is opened with a longitudinal incision higher and lower than the level of splitting; intradural adhesions are eliminated; dura mater sheath is closed and closed without bifurcation. Wound is layer-by-layer closed without drains and tube drainage.

EFFECT: method provides correcting spinal deformity with spinal cord defect ensured by eliminating spinal deformations and diastema in one operation.

1 cl, 9 dwg, 1 ex

Description

The field of technology.

The invention relates to medicine, traumatology and orthopedics, namely spinal surgery, and is used in the treatment of patients with spinal deformities with diastematomyelia.

The level of technology.

Known methods for removing bone spike from the spinal canal (type 1 diastematomyelia), correction options for spinal deformity with or without vertebrotomy. A known method for the correction of gross forms of scoliosis (source [1]: patent RU 2362503). Corrective vertebrotomy is carried out from two approaches. In a patient with severe scoliotic spinal deformity, the first surgical stage provides transthoracic and transpleural access to the convex side of the arch, mobilizing discectomy at several levels in the area of the apex of deformation and compression of the deformed vertebral bodies throughout the arch to eliminate their wedge shape and give them mobility for subsequent correction of the torsion component of deformation (source [2]: patent RU 2159587 "Method for the correction of spinal deformity"). Then, if possible, a skeletal traction is applied for the skull and lower legs of the patient. After that, in the position on the abdomen, median access to the spine is performed with full skeletonization of the posterior spine during the proposed installation of corrective segmental instrumentation. The mobilization of the posterior spine with excision of the intervertebral joints and ligaments is carried out. A back wedge-shaped vertebrotomy is performed at several levels, necessarily in the intervention zones on the front of the spine. In accordance with the preoperative planning scheme, after revision of possible points of support, hooks of corrective segmental instrumentation are installed on both sides of the vertebrae in the region of the posterior spine. In the region of the apex of scoliosis at the level of vertebrotomy, the most deformed vertebrae are selected. These may be vertebrae located respectively above and below the apical (apical). If the vertex of deformation is the intervertebral space, then the cranial vertebra will be second above the vertex, the second vertebra below caudal will be caudal. A pair of hooks starts in towards each other for the arches or for the roots of the arches of these vertebrae from the convex side. If possible, pedicular-pedicular hooks are used. If this possibility is not provided due to the form of spinal deformity, then it is possible to install both laminar-pedicular and laminar-laminar grips. In the hooks on the concave side of scoliosis, a first rod is installed, previously bent in accordance with the deformation of the spine and physiological bends. A feasible correction of the deformation of the spine is made both by installing the rod itself in the hooks, and due to the tension of the hooks on the rod between themselves. The received correction is reliably fixed by traffic jams on hooks. The second rod is mounted in hooks on the convex side of the scoliotic arc. Then, feasible additional correction of scoliosis on the second rod is performed, while the main correction of the residual arc is carried out by compression gripping, consisting of two hooks on the top of the deformation from the convex side. The hooks are compressed gradually and smoothly so as not to damage the surviving posterior spine from the convex side. Compression is performed until the convex part of the arches closes together. Then, the additional correction obtained from the convex side is securely fixed by stoppers on the hooks, as well as by the formation of several transverse joints between the rods. After this, posterior bone grafting is performed using autocracks from resected and decorticated posterior vertebrae.

The disadvantage of this method [1] is the invasiveness, as they perform two accesses, insufficient rigidity of fixation by the hook construction used and the duration of the stages of the operation.

A known method of correction of the spine for violations of segmentation in children (source [3]: patent RU 2462204) in which a wedge-shaped vertebrotomy of the spine is performed at the top of the deformation. The essence of the method consists in the implementation of rear access to the spine, sphenoid vertebrotomy of the spine at the top of the deformation to achieve mobility. At the same time, metal structures are installed on both sides of the spine and fixed at the ends of the deformation. Moreover, distraction is performed along the concave side of the spine, and contraction along the convex side. The use of this invention allows to achieve maximum correction of the spine with violations of segmentation in children with the prevention of the development of secondary signs of deformation in the process of growth of the child. This method does not include reconstruction of the spinal canal.

A known method of treating diastematomyelia (source [4]: Meacham W.F. Surgical treatment of diastematomyelia (Surgical treatment of diastematomyelia) // J. Neurosurg. 1967. Vol 27. P. 78-85). A midline section provides access to the spinous processes and arches of the vertebrae one or two segments above and below the level of damage. Paravertebral muscles are separated and displaced laterally on both sides. The spinous process and the arc of the vertebra at the level of the location of the bone spine are resected, the dura mater divided by the bone spike is visualized. Laminectomy continues up and down throughout the splitting of the dura mater. The dura mater at the cleavage site is separated from the bone spine, after which the bone spike is resected with nippers to the base located on the front wall of the spinal canal. The dura mater is opened with a longitudinal incision above and below the level of cleavage, intradural fusion is removed, and if necessary, the remaining fragments of the bone spike base are resected. Suturing of the dura mater, layer-by-layer suturing of the surgical wound is performed.

The method [4] leads to destabilization of the spine, the development of spinal deformity, the syndrome of the operated spine due to a violation of the integrity of the structures of the back support complex at the intervention level. The risk of developing liquorrhea in the early postoperative period, as well as repeated fixation of the spinal cord at the level of diastematomyelia in the late postoperative period due to a violation of the anatomical relationship of tissues in the intervention area with a violation of the integrity of the posterior wall of the spinal canal, is increased. The invasiveness of the intervention is high due to the wide mobilization of soft tissues with dissection of the elements of the ligamentous apparatus of the spinal column, wide skeletonization of bone structures.

A known method of treating diastematomyelia (source [5]: patent RU 2522916), which is as follows. After cutting the skin and soft tissues, the skeletons of the arches and spinous processes at a distance of 1-1.5 cm from the midline, Liston's pliers and high-speed boron resect the arches at the same level above and below the diastematomyelia, dissect the supraspinous and interspinous ligaments at the same level as caudal to diastematomyelia, and raise 1.5-2.0 cm the caudal edge of the fragment of the arches and spinous processes, Liston's pliers and a scalpel dissect the bone spine along the front edge of the arch, thus separating the bone spike from the fragment of the arches and spinous processes. The resected fragment of arches and spinous processes is raised by 80-90 ° and retracted. Then boron and nippers remove the diastema (bone or bone-fibrous septum) of the spinal canal. Next, the dura mater of the spinal cord is dissected, adhesions are excised, the front and back walls of the dural sac are successively sutured, restoring its tightness. Palpation revise the front surface of the vertebral arch at the level of elimination of diastematomyelia, and process it with high-speed boron. This eliminates the possible compression of the dural sac by the deformed structures of the posterior supporting complex while restoring the integrity of the spinal canal. A fragment of the arches and spinous processes is fixed to the spinous process of the underlying vertebra and paravertebral muscles with ligature sutures, and layer-by-layer suturing of the surgical wound is performed.

The disadvantage of this method [5] is the lack of correction of spinal deformity that accompanies diastematomyelia and the lack of reliable fixation of vertebral structures after the intervention, which can lead to postoperative vertebral displacements and the development and progression of spinal deformity.

A known method is subtractive pedicular osteotomy (PSO) (source [6]: Buchowski JM, Kuhns CA, Bridwell KN, Lenke LG. Surgical management of posttraumatic thoracolumbar kyphosis (Surgical treatment of post-traumatic thoracolumbar kyphosis). Spine J. 2008; 8: 666- 677), which consists in resection of the posterior support column at the level of the planned vertebrotomy, resection of a part of the vertebral body through the root of the arc with subsequent correction of deformation, which is achieved by correction of deformation of the spine.

The disadvantages of this method [6] are that it is impossible to correct kyphotic, shear and rotational deformity in the thoracic, thoracolumbar, lumbar spine, the spine remains in an unstable position.

The technical problem is that the described methods [1 to 6] do not allow high-quality one-stage treatment for severe malformations of the spine and spinal cord, when a combination of splitting (doubling) of the spinal cord of the connective tissue (less often bone) septum into two halves and curvature spine (kyphotic, scaliotic, shear, rotational deformity). Simple removal of the diastema (connective tissue or bone septum) leads to local instability of the vertebral motor segment and subsequently to the occurrence and progression of spinal deformity. Spinal cord fixation should include the correction of other concomitant, acquired or congenital, abnormalities in the anatomy of the spine and it is necessary to ensure fixation of the spine after surgery.

The essence of the technical solution.

The objective of the present invention is to provide quality treatment for severe malformations of the spine and spinal cord, when there is a combination of splitting of the spinal cord with a bone septum (type 1 diastema, bone spike) into two halves and curvature of the spine.

The technical result is to achieve correction of spinal deformity with spinal cord fixation.

The technical result is achieved by the fact that in the method of a three-column vertebrotomy with diastematomyelia from one dorsal access to one surgical session, a midline section provides access to the spinous processes and arches of the vertebrae two or three segments above and below the lesion level. Paravertebral muscles are separated and displaced laterally on both sides. Install the transpedicular fixation system screws. A laminectomy is performed, the spinous process and the arc of the vertebra at the level of the location of the diastema (bone spike) are resected, the dura mater divided by the diastema is visualized. Laminectomy continues up and down throughout the splitting of the dura mater. The dura mater at the cleavage site is separated from the diastema. After that, the diastema is resected with nippers to the base located on the front wall of the spinal canal. Corrective wedge-shaped vertebrotomy is performed through the base of the diastema and counter-through the root of the vertebral arch. Place the longitudinal rods of the transpedicular fixation system in the screw heads, perform a corrective maneuver and fix the achieved deformation correction by tightening the rods in the screw heads. The dura mater is opened with a longitudinal incision above and below the level of cleavage, the intradural fusion is removed, the dura mater is plasticized and sutured without bifurcation. Carry out layer-by-layer suturing of the surgical wound without drains and graduates.

The method allows to achieve the fixation of the spinal cord, correction of spinal deformity, fixation of the corrected spine in the required position from one surgical approach in the process of performing one surgical intervention. This reduces the operational load on the patient, who has a combination of diastema and curvature of the spine, and allows for quick and high-quality treatment.

The method is illustrated by a description, an example of practical use and illustrations, which depict:

FIG. 1 - 3D reconstruction of the spine by computed tomography (CT) scan, before surgery, rear view;

FIG. 2 - 3D CT reconstruction of the spine, before surgery, front view;

FIG. 3 - sagittal section at the level of diastematomyelia, before surgery;

FIG. 4 - frontal section at the level of diastematomyelia, before surgery;

FIG. 5 - 3D reconstruction of the spine according to CT, before the operation, front view, the dashed line shows the volume of the planned resection;

FIG. 6 - 3D reconstruction of the spine according to CT, after the operation, front view, the dashed line shows the level of vertebrotomy;

FIG. 7 is a frontal section at the level of diastematomyelia, a schematic representation of the direction of the “attack” during vertebrotomy through the root of the leg of the vertebra and through the base of the diastema;

FIG. 8 - 3D reconstruction of the spine by CT, after surgery, front view;

FIG. 9 - 3D reconstruction of the spine by computed tomography (CT), after surgery, rear view.

The method is as follows.

The method is carried out with a combination of diastema and curvature of the spine (Fig. 1; 2; 3; 4). Before the operation, 3d reconstruction of the spine is performed. Plan the volume of resection and the amount of correction (Fig. 5). The method is carried out from one dorsal access to one surgical session. The patient is laid back up. A midline section provides access to the spinous processes and arches of the vertebrae two or three segments above and below the level of damage (level of diastema and deformation). Paravertebral muscles are separated and displaced laterally on both sides. The spinal canal is reconstructed, diastema is removed, in combination with correction of the spinal deformity by corrective three-column vertebrotomy and fixation by the TPF system. To do this, establish a system of transpedicular fixation 2 or 3 segments above and below the affected area. Transpedicular intracorporeally under control through an electron-optical transducer (EOP) establish reference points (insert bone screws through the arches of the vertebrae) of the transpedicular fixation system (TPF). They carry out the removal of diastema and reconstruction of the spinal canal, and the fixation of the spinal cord. To do this, a laminectomy is performed, the spinous process and the arc of the vertebra at the level of the location of the diastema (bone spike) are resected, the dura mater divided by the diastema is visualized. Laminectomy continues up and down throughout the splitting of the dura mater. The dura mater at the cleavage site is separated from the diastema, after which the diastema is resected with nippers to the base located on the front wall of the spinal canal. A corrective wedge-shaped vertebrotomy is performed through the base of the diastema, with correction of the spinal deformity and fixation of the spine by the transpedicular fixation system. Corrective wedge-shaped vertebrotomy is performed through the root of the bone spike (base of the diastema) and counter-through the root of the arc of the vertebra (Fig. 6, 7). The base of the removed triangular fragment is directed towards the convex side of the deformation. Perform back instrumental fixation of the spine with a transpedicular fixation system. To do this, lay the longitudinal rods in the screw heads (reference points of the TPF system), perform a corrective maneuver and fix the achieved deformation correction by tightening the rods in the screw heads. After this, the dura mater is opened with a longitudinal incision above and below the splitting level, intradural fusion is removed, plasticization and suturing of the dura mater without bifurcation are performed. Carry out layer-by-layer suturing of the surgical wound without drains and graduates.

The practical application of the method is illustrated by the following clinical observation. Patient S.L. (1 year 5 months) was treated at the Clinic with a diagnosis (Fig. 1; 2; 3; 4): Q76.3 - Congenital scoliosis due to dysregulation in the lower thoracic spine. Diastematomyelia type 1 at the level of Th11-L1. Lower paraparesis. Condition after surgical treatment of lumbar myelocele. Concomitant diagnosis: D62 - Acute posthemorrhagic anemia, J04.0 - Acute laryngitis. Complaints: weakness in the legs, progression of spinal deformity. An. morbi: According to the mother, the deformity was noticed from birth, in infancy she was operated on for thoracic myelomeningocele. St. localis upon admission: On examination, C-shaped scoliosis in the upper thoracic spine, postoperative scar in the interscapular region, with Equinovarus deformity of the feet. St. nevralis upon admission: general condition: satisfactory, clear consciousness, correctly oriented in time and space, emotionally unstable, inadequate. Pupils: equal. Diplopia: no. Eyeball movement: in full. Light response: lively. Sensitivity: decreased sensitivity in the legs. Reflexes: from the upper extremities, from the lower extremities, S = D. Paresis: lower flaccid paraparesis. Atrophy of the muscles of the legs. The strength of the muscles of the lower extremities is 3-4 points, symmetrical. Tremor: no. Peripheral nervous system: Lassieg symptom -, Neri symptom - from 2 sides. mJOA 13. FIM 42.

Instrumental examinations before surgery. SKT of the pelvis, hip joints: hip dysplasia (more on the right), pelvic distortion (due to scoliosis). SCT of the thoracic and lumbar spine: VAR of the spine, butterfly Th2 vertebra, Th3-4, 6-7 concrescence, segmentation disturbances, Th8-L1 concrescence. The vertebra Th12 is not detected, 11 pairs of ribs. Bone septum in the spinal canal at the TI9-11 level, diplomiel, spina bifida Th4-8, L1-S1-5 post, scoliosis Th1-Th10-S1 68 degrees Cobb. (Fig. 1; 2; 3). MPT of the thoracic and lumbar spine: VAR, impaired formation, segmentation of the vertebrae in the thoracic spine, type 1 diastematomyelia, scoliosis. Indication for surgical treatment: the presence of a bone septum in the spinal canal, fixed spinal cord syndrome, progressive spinal deformity.

Surgical treatment was performed in stage 1 from one dorsal access to one surgical session: Removal of the bony septum of the spinal canal (diastema) at the level of Th11-L1 with corrective vertebrotomy at the level of Th12 with the removal of a portion of the asymmetric butterfly vertebra on the left. Correction and posterior instrumental fixation of the spine by the TPF system. Posterior fusion. Intraoperative neuromonitoring. The progress of the operation. Under endotracheal anesthesia in the patient’s position on the abdomen, an incision was made in the skin and soft tissues in the projection of the Th5-L1 vertebrae. A mid-section allowed access to the spinous processes and arches of the vertebrae two segments above and below the level of damage. The back support column is skeletonized. Paravertebral muscles are separated and laterally displaced on both sides. A local C-shaped deformation of the spine with a violation of the formation and segmentation of the vertebrae was determined. Transpedicularly bilaterally, the reference points of the Medtronic Pediatric system (screws of the transpedicular fixation system) are installed in the Th5-6, Th12-L1 bodies. The image intensifier tube was checked: the position of the metal structure was correct. The removal of the elements of the rear support complex. A laminectomy was performed, the spinous process and the arc of the vertebra at the level of the location of the diastema (bone spike) were resected, the dura mater separated by the diastema was visualized. Laminectomy continued up and down throughout the splitting of TMT. A bone septum (diastema) and two "sleeves" of the dural sac are highlighted. The TMT at the cleavage site is separated from the diastema, the bone septum is removed to the base with a set of tools and an electroboron. The diastema is resected by nippers to the base located on the front wall of the spinal canal. Through the base of the diastema and counter-through the root of the Th12 arc, a corrective asymmetric wedge-shaped vertebrotomy was performed on the left (Fig. 6, 7). Hemostasis during the operation. The longitudinal rods of the transpedicular fixation system are laid in the screw heads. A corrective maneuver was made and the achieved correction of deformation was fixed by tightening the rods in the screw heads. The final broach nuts. Plastic TMO. The TMT was opened with a longitudinal section above and below the level of cleavage, the intradural fusion was eliminated, plastic surgery and suturing of the TMT without bifurcation were performed. Control of hemostasis and liquorrhea is dry. A hemostatic sponge is placed on the TMT. Along the structure is autobone. The wound is sutured in layers by interrupted sutures. Ace. dressings. Blood loss during surgery was 200 ml. After treatment, there is a significant improvement in the frontal balance. The child is upright 3 days after surgery in a semi-rigid lumbar corset. On the control SKT of the thoracic and lumbar spine: the position of the screws is correct (transpedicular), residual deformation - scoliosis Th1-Th10-S1 10 degrees Cobb. (Fig. 8; 9). Neurological status without negative dynamics. The proposed method is used by the authors in the Ilizarov Center of Kurgan.

Claims (1)

A three-column vertebrotomy method for diastematomyelia, characterized in that from one dorsal access to one surgical session, a midline section provides access to the spinous processes and vertebral arches two or three segments above and below the lesion level, paravertebral muscles are separated and displaced laterally from both sides, set screws of the transpedicular fixation system, perform a laminectomy, the spinous process and the vertebral arch at the level of the diastema location are resected, visualize the divided di the dura mater, laminectomy continues up and down throughout the dura mater splitting, the dura mater at the cleavage site is separated from the diastema, after which the diastema is resected with slices to the base located on the anterior wall of the spinal canal, through the base of the diastema and counter-through the root the vertebral arches perform a corrective wedge-shaped vertebrotomy, lay the longitudinal rods of the transpedicular fixation system in the screw heads, and make corrective maneuver and fixed correction achieved deformation tightening the rods in the heads of the screws, the dura mater is opened, longitudinal sectional above and below the splitting level, intradural eliminate seam produce plastic and suturing the dura mater without bifurcation carried layerwise without suturing the surgical wound drains and graduates.

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