RU2735897C1 - Method for restoration of local spinal balance in congenital deformity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopedics and can be used in treating patients with spinal deformities in congenital deformity of thoracic and lumbar spines, with vertebral formation and segmentation disturbed. Dorsal bilateral approach to the operated spine is performed in a scoliotic arch and non-segmented bone shaft. In the legs of the vertebrae adjacent to the non-segmented bone core, and in the non-segmented bone core symmetrically to the longitudinal axis of the spinal column, support transpedicular screws are installed. Spinal deformity is mobilized and corrected. That is ensured by corrective sectoral vertebrobotomy of deformed spine at deformation peak through non-segmented bone core using bone ultrasonic scalpel, transpedicular rods are inserted into heads of transpedicular screws, performing compression maneuver on convex side of scoliosis arc, spine is fixed in reached position by transpedicular system, tightening transpedicular rods in heads of transpedicular screws, creating spondylosyndesis using autobone.

EFFECT: method provides reduced traumatism, reduced blood loss and reduced risk of neurological complications in correcting spinal deformation in patients with congenital vertebral abnormalities by using an ultrasonic bone scalpel for vertebrotomy in a non-segmented bone shaft.

3 cl, 13 dwg, 1 ex

Description

Technology area

The invention relates to medicine, to spinal surgery, and can be used in the treatment of patients with deformities of the spine with congenital deformity of the thoracic and lumbar spine, against the background of violation of the formation and segmentation of the vertebrae. Suitable for children with multiple developmental anomalies of the thoracic and lumbar spine.

State of the art

Known methods of spinal deformity correction involve the use of modern versions of CDI (Cotrel-Dubousset instrumentation) instrumentation for transpedicular fixation (source [1]: New universal instrumentation in spinal surgery. Sotrel J. Dubousset I. Guillaumat M. Clinical orthopedics and related research: February 1988 - Volume 227 - Issue - pp. 10-23. New universal instrumentation in spinal surgery. Cotrel Y, Dubousset J, Guillaumat M. Clin Orthop. 1988; 227: 10-23); source [2]: History of spinal screw and pedicle screw fixation. Mark B. Cabins and James N. Weinstein. Iowa Ortop Jv. 1991; 11: 127-136 pp. PMC2328959. The History of Vertebral Screw and Pedicle Screw Fixation. Mark B. Kabins and James N. Weinstein. Iowa Orthop Jv. 11; 1991 PMC2328959) with the simultaneous execution of corrective vertebrotomy at the apex of the deformity. The key sign of such correction of the spinal deformity is a three-column vertebrotomy at the apex of the deformity arch.

A known method for correcting spinal deformities (rough forms of scoliosis) by corrective vertebrotomy using two accesses to the spine (source [3]: patent RU 2362503). The first surgical stage is transthoracic and transpleural access to the convex side of the arch. A mobilizing discectomy is performed at several levels in the area of the apex of the deformity and compression of the deformed vertebral bodies along the arc to eliminate their wedge shape and give them mobility for subsequent correction of the torsion component of the deformity (source [4]: patent RU 2159587 "Method for correcting spinal deformity") ... Then, if possible, skeletal traction is applied to the patient's skull and lower legs. After that, in the prone position, a median approach to the spine is performed with complete skeletonization of the posterior spine during the proposed installation of the corrective segmental instrumentation. The posterior spine is mobilized with excision of the intervertebral joints and ligaments. A posterior wedge-shaped vertebrotomy is performed at several levels, necessarily in the areas of intervention in the anterior spine. In accordance with the preoperative planning scheme, after revision of possible points of support, hooks of correcting segmental instrumentation are installed on both sides of the vertebrae in the region of the posterior spine. In the area of the apex of scoliosis at the level of vertebrotomy, the most deformed vertebrae are selected. These can be vertebrae located above and below the apical (apical), respectively. If the apex of the deformity is the intervertebral space, then the cranial vertebra will be the second one above the apex, the caudal vertebra will be the second vertebra below the apex. A pair of hooks is wound towards each other at the arches or at the roots of the arches of these vertebrae from the convex side. If possible, pedicle-pedicular hook grippers are used. If such an opportunity is not provided due to the shape of the spinal deformity, then it is possible to install both laminar-pedicular and laminar-laminar grips. In the hooks on the concave side of scoliosis, the first rod is installed, pre-bent in accordance with the deformation of the spine and physiological bends. A feasible correction of the spinal deformity is carried out both by installing the rod itself in the hooks and by tensioning the hooks on the rod between each other. The resulting correction is securely fixed with plugs on the hooks. The second rod is placed into hooks on the convex side of the scoliotic arch. Then, a feasible additional correction of scoliosis is performed on the second rod, while the main correction of the residual arch is carried out due to the compression of the grip, which consists of two hooks at the apex of the deformity on the convex side. The hooks are compressed gradually and smoothly in order not to damage the preserved posterior parts of the spine from the convex side. Compression is performed until the convex part of the arches closes together. Then the obtained additional correction from the convex side is securely fixed with plugs on the hooks, as well as by the formation of several transverse connections between the rods. After that, posterior bone grafting is performed using auto-crumb from resected and decorticated posterior vertebrae.

To implement this method [3], it is necessary to carry out two wide access to the spine, extensive skeleton of the vertebrae, which leads to significant tissue trauma and blood loss. The use of hooks for fixing a given position of the vertebrae does not provide a stable and reliable rigid fixation (for example, in comparison with fixation with screws, the hooks are less stable). In addition, the described surgical intervention, for the implementation of all the described manipulations, is time-consuming, the operation is lengthy and with a large volume of blood loss. The instrumentation used does not reduce blood loss.

A known method for correcting the spine with segmentation disorders in children (source [5]: RU 2462204) by wedge-shaped vertebrotomy of the spine at the apex of the deformity through one access. One posterior approach to the spine, wedge-shaped vertebrotomy of the spine at the apex of the deformity to achieve mobility, installation on both sides and fixation of metal structures at the ends of the deformity of the spine, distraction is carried out along the concave side of the spine, and contraction along the convex side of the spine. The use of this invention makes it possible to achieve the maximum correction of the spine in case of segmentation disorders in children with the prevention of the development of secondary signs of deformity during the growth of the child. However, the method also requires reducing tissue trauma and reducing the amount of blood loss.

A variant of subtraction pedicular osteotomy (PSO) is known, 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 arch, followed by deformity correction. In this way . correction of spinal deformity is achieved (source [6]: Buchowski JM, Kuhns CA, Bridwell KN, Lenke LG. Surgical management of posttraumatic thoracolumbar kyphosis. Spine J. 2008; 8: 666-677).

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

In case of rigid deformities, the two methods described above [5,6] can be combined to achieve optimal correction, however, this lengthens the duration of the operation and increases the invasiveness of the intervention, and increases blood loss. The risk of developing complications typical for both ventral and dorsal approaches increases.

Three-column mobilization performed from the dorsal approach, developed for these reasons, is represented by two main options: pedicle shortening vertebrotomy (Pedicle Subtraction Osteotomy PSO) and vertebral column resection (Vertebral Column Resection VCR) (source [7]: Mikhailovsky MV, FGBU "NNIITO named after Ya.L. Tsivyan" Ministry of Health of the Russian Federation. "Severe kyphotic and kyphoscoliotic deformities of the spine" Clinical guidelines. Novosibirsk 2013]. The described methods [7] allow to mobilize fixed or rigid spine deformity and correct it in the sagittal plane within 35 They can also be used to achieve significant correction in the frontal plane, with or without kyphosis, for which PSO is performed asymmetrically in the frontal plane, and the VCR in this situation provides for an asymmetric position of the ventral pivot point (graft or implant).

When using the methods described above, the following problems arise. They cannot be effectively and minimally traumatic applied in case of spinal deformity against the background of an unsegmented bone rod, in children with multiple developmental anomalies of the vertebrae, when anatomical landmarks are disturbed, the type of abnormal structure of the vertebrae. To achieve the necessary mobilization of the spine, according to analogs, vertebrotomy must be performed at the level of the apex of the deformity, where all anatomical landmarks are violated, the type of anatomical features, and the abnormal structure of the vertebrae, which complicates the operation and increases its duration. To achieve the necessary strength, stability, reliability of fixation of the spine against the background of an unsegmented bone rod, fixation is carried out in the vertebrae with a normal structure, fixation of a larger number of higher and lower vertebrae is required, volumetric instrumentation covers your segments and below the unsegmented bone rod, bypassing it. Vertebrotomy performed at the apex of the deformity (apically) reduces the number of fixed spinal motion segments, which is very important in a growing body. When vertebrotomy is performed at the apex of the deformity (apically) against the background of an unsegmented bone rod, when there is a total bone block (a bone rod without the usual anatomical landmarks) and fixation is carried out in normal (non-abnormal) vertebrae, during surgical manipulations on the spine, the volume of intraoperative blood loss significantly increases and the risk of neurological complications increases.

The essence of the technical solution.

The objective of the invention is to improve the local balance of the spine in the frontal and sagittal planes in the thoracic and lumbar spine in children with congenital malformations of the vertebrae using the minimum possible instrumentation, with a minimum risk of neurological complications and a small amount of blood loss.

The technical result consists in reducing the trauma, reducing the volume of blood loss and reducing the risk of neurological complications in the correction of spinal deformity in patients with congenital anomalies of vertebral development.

The technical result is achieved by the fact that in the method of restoring the local balance of the spine in congenital deformity, a dorsal (posterior) bilateral access to the operated spine in the area of the scoliotic arch and non-segmented bone rod of abnormal vertebrae is performed. Support transpedicular screws are installed in the legs of the vertebrae adjacent to the non-segmented bone rod and in the non-segmented bone rod itself symmetrically to the longitudinal axis of the spine. Mobilization and correction of the spinal deformity is performed; for this, a corrective sectoral vertebrotomy of the deformed spine is performed at the apex of the deformity (apically) through an unsegmented bone rod using a bone ultrasonic scalpel. Install transpedicular rods in the heads of transpedicular screws, carry out one-step correction of deformity, perform a compression maneuver on the convex side of the scoliotic arch, fix the spine in the achieved position with the transpedicular system, tightening the transpedicular rods in the heads of the pedicular screws. Spinal fusion is created using autologous bone. The transpedicular screws are inserted into the unsegmented bone shaft. This makes it possible to achieve sufficient correction of the spinal deformity, reduce blood loss and reduce the number of fixed spinal motion segments, which is very important in a growing body (in children). The use of an ultrasonic bone scalpel for vertebrotomy in the area of an unsegmented bone rod allows avoiding unnecessary damage to adjacent tissues, reducing the amount of tissue damage, and reducing blood loss.

The method is illustrated by illustrations, which show:

FIG. 1 - Radiographs of the spine of a child with congenital deformity in the thoracic region before surgical treatment. The lines indicate the volume of the planned spine resection through an unsegmented bone rod;

FIG. 2 - 3D-reconstruction of the spine before surgery;

FIG. 3 - Photos of the patient before surgery;

FIG. 4 - Radiographs of the spine of a child with congenital deformity in the thoracic region after surgery. The line shows the level after vertebrotomy;

FIG. 5 - 3D-reconstruction of the spine before surgical treatment. The arrow indicates the contact area of the vertebral bodies after sectoral vertebrotomy.

FIG. 6 - Photos of the patient after surgery;

Fig. 7 - exposure of posterior structures and installation of reference points, including in the region of an unsegmented bone rod;

Fig. 8 - excision of the posterior structures of an unsegmented bone (vertebral) nail using a bone ultrasonic scalpel;

Fig. 9 - removal of the posterior support column, excision of the posterior structures of an unsegmented bone rod at the apex of the deformity is performed in the form of a wedge (triangle), the boundaries are shown by lines facing the base towards the convex side of the deformity and having a predetermined apical angle, which is calculated depending on the magnitude of the deformity;

Fig.10 - visualization of the contents of the spinal canal;

11 - sectoral sawing of the anterior support column (vertebral bodies) under the protection of cerebral spatulas, fragments of the vertebral bodies are removed by lumping;

Fig. 12 - installation of a metal structure with deformity correction by a compression maneuver on the convex side of the scoliotic arch;

Fig. 13 - the resected part of the spine is closed before contact without diastasis.

The method is carried out as follows.

To restore the local balance of the spine in congenital deformities of the thoracic and lumbar spine, surgical intervention is performed, dorsal (posterior) bilateral access to the operated spine in the area of the scoliotic arch and non-segmented bone rod of abnormal vertebrae. All manipulations are performed under neurophysiological control. The posterior structures of the spine were exposed, supporting points were established, including in the region of the non-segmented rod. Support transpedicular screws are installed in the legs of the vertebrae adjacent to the non-segmented bone rod and in the non-segmented bone rod itself symmetrically to the longitudinal axis of the spine. EOP control is performed to control the position of the pedicle screws and determine the area of vertebrotomy according to preoperative planning.

Mobilization and correction of the spinal deformity is performed; for this, a corrective sectoral vertebrotomy of the deformed spine is performed at the apex of the deformity (apically) through an unsegmented bone rod using a bone ultrasonic scalpel.

An ultrasonic scalpel is used to cut the posterior support column at the apex of an unsegmented bone rod in the form of a wedge (resected triangular fragment), facing the base to the convex side of the deformity and having a given apical angle, according to preoperative planning. After removing the posterior supporting column and visualizing the contents of the spinal canal, sectoral sawing of the anterior supporting column (vertebral bodies) is performed under the protection of cerebral spatulas. Fragments of the vertebral bodies are removed by lumping.

Then the metal structure was mounted with deformity correction by a compression maneuver on the convex side of the scoliotic arch. Install transpedicular rods in the heads of transpedicular screws, carry out one-step correction of deformity, perform a compression maneuver on the convex side of the scoliotic arch, fix the spine in the achieved position with the transpedicular system, tightening the transpedicular rods in the heads of the pedicular screws. After the corrective maneuver, the segmentally resected part of the spine is closed until contact without diastasis. The operation is completed with a 360 ° fusion using autologous bone. The transpedicular screws are inserted into the unsegmented bone shaft. This makes it possible to achieve sufficient correction of the spinal deformity, reduce blood loss and reduce the number of fixed spinal motion segments, which is very important in a growing body (in children). The use of an ultrasonic bone scalpel for vertebrotomy in the area of an unsegmented bone rod allows avoiding unnecessary damage to adjacent tissues, reducing the amount of tissue damage, and reducing blood loss.

The technical result provided by the given set of features is the reconstruction of the local balance in the frontal and sagittal planes. The use of vertebrotomy of the apical zone in children with multiple developmental anomalies of the vertebrae makes it possible to perform adequate local correction of the deformity with restoration of the spine balance, as well as to minimize the risk of neurological complications due to the leading compression maneuver of correction. This makes it possible to reduce the area of instrumental fixation in comparison with the classical principles of fixation of scoliosis, which is important for maintaining axial growth. The use of a bone ultrasonic scalpel can reduce the volume of intraoperative blood loss.

Clinical example.

A 12-year-old patient was treated in a medical facility with a diagnosis of Q76.3 - VAR of the spine. Scoliotic deformity against the background of segmentation disorders and vertebral formation. The leading defect is the Th4 hemivertebra. Shrengel's disease. Concomitant diagnosis: J30.3 - allergic rhinitis, remission, K59.0 - chronic constipation, K82.8 - pancreatic biliary dysfunction, D62 - Acute post-hemorrhagic anemia, J98.8 - Respiratory disorders. Was admitted with complaints: progressive deformity of the spine, pain syndrome, reduced range of motion in the left shoulder joint. An.morbi: According to the patient, the deformity of the spine was noticed at the age of 4, the range of motion in the left shoulder joint decreased, and they were not treated. St.localis on admission: On examination, a right-sided C-shaped scoliosis in the upper thoracic spine is noted. Torticollis. Facial asymmetry. The asymmetry of the shoulder girdles and shoulder blades, the right one is 1 cm higher. High standing of the left shoulder blade. Decreased range of motion in the left shoulder joint. There is no clinical misalignment of the pelvis. St.nevralis on admission: General condition: satisfactory, clear consciousness, correctly oriented in time, correctly oriented in space, emotionally stable, adequate. Pupils: equal. Diplopia: no. Eyeball movement: in full. Reaction to light: alive. Sensitivity: not compromised. Reflexes: from the upper extremities, from the lower extremities, S = D, no pathological signs. Coordination: Performs tests confidently. Meningeal syndromes: no, Kernig's syndrome is negative. Aphasia: no. Apraxia: no. Asteriognosis: no. Paresis: not detected. No atrophies. Muscle strength 5 points, symmetrical. Tremor: no. Peripheral nervous system: Lassegh's symptom -, Neri's symptom - from 2 sides. Photo of the patient before treatment Fig. 3

On x-ray telemetry of the spine with the capture of the pelvis in 2 projections before surgery (figure 1): there are multiple anomalies of development and segmentation of the vertebrae. The leading arc Th2-Th4-Th6 31 dex against the background of segmentation disorders at this level and the Th4 hemivertebra, violation of L3-4 segmentation on the right. Computed tomography (figure 2) of the thoracic spine before surgery. According to the topogram, on tomograms, MPR and 3D, it is determined: congenital anomaly in the development of the spine: left lateral wedge-shaped hemivertebra between Th2 and Th3; right lateral wedge-shaped hemivertebra between Th3 and Th4; C-shaped scoliotic deformity of the thoracolumbar region, apex at Th3-4, angle 40 degrees, arch to the right; concrescence of the Th2-5 vertebrae; doubling of the anterior segments of the III, IV, VIIth ribs on the right, concrescence of the II-III, IV-VI-th ribs on the left;

All manipulations were performed under neurophysiological control. To restore the local balance of the spine, surgical intervention, dorsal (posterior) bilateral access to the operated spine in the area of the scoliotic arch and an unsegmented bone rod of abnormal vertebrae were performed. The posterior structures of the spine were exposed and pivot points were established, including in the region of the non-segmented rod. Figure 7 shows the exposure of the posterior structures and the installation of reference points, including in the region of the non-segmented bone nail. Pedicle screws were installed in the pedicle of the vertebrae adjacent to the non-segmented bone rod and in the non-segmented bone rod itself symmetrically to the longitudinal axis of the spine. An image intensifier was performed to control the position of the pedicle screws and determine the area of vertebrotomy in accordance with preoperative planning.

The spine was mobilized, a corrective sectoral vertebrotomy of the deformed spine was performed at the apex of the deformity (apically) through an unsegmented bone nail using a bone ultrasonic scalpel. Excision of the posterior structures of an unsegmented bone (vertebral) nail using a bone ultrasonic scalpel is shown in Fig. 8. An ultrasonic scalpel was used to cut the posterior support column at the apex of an unsegmented bone rod in the form of a wedge (resected triangular fragment) facing the base to the convex side of the deformity and having a predetermined apical angle, according to preoperative planning. Figure 9 shows the removal of the posterior support column, the excision of the posterior structures of an unsegmented bone rod at the apex of the deformity is performed in the form of a wedge (triangle), the boundaries are shown by lines facing the base to the convex side of the deformity and having a given apical angle, which is calculated depending on the value deformation. After removing the posterior support column and visualization of the contents of the spinal canal (Fig. 10), under the protection of cerebral spatulas, sectoral sawing of the anterior support column (vertebral bodies) was performed (Fig. 11). Fragments of the vertebral bodies were removed by chunking. Then carried out the installation of the metal structure with correction of the deformity by a compression maneuver on the convex side of the scoliotic arch (Fig. 12). We installed transpedicular rods in the heads of the pedicle screws, performed one-step correction of the deformity, performed a compression maneuver on the convex side of the scoliotic arch, fixing the spine in the achieved position with the transpedicular system, tightened the pedicle rods in the heads of the pedicle screws. After the corrective maneuver, the segmentally resected part of the spine is closed before contact, without diastasis (Fig. 13). The operation is completed with fusion using autologous bone.

Computed tomography of the thoracic spine after surgery in Fig. 5. According to the topogram, on tomograms, MPR and 3D it is determined: congenital anomaly of the spine development: the area of vertebrotomy at the Th4 level; screws are correct; intracanal formations are not defined; paravertebral soft tissues with moderate postoperative edema. On x-ray telemetry of the spine (see figure 4) with the capture of the pelvis in 2 projections (after surgery), there are multiple anomalies of development and segmentation of the vertebrae. Leading arch Th2-Th4-Th6 14 dex state after surgical treatment. Photo of the patient after treatment in Fig.6.

Claims (3)

1. A method of restoring the balance of the spine in congenital deformities of the thoracic and lumbar spine, against the background of a violation of the formation of segmentation of the vertebrae, characterized by the fact that a dorsal bilateral approach is performed to the operated spine in the area of the scoliotic arch and an unsegmented bone rod, to the pedicles of the vertebrae adjacent to the unsegmented bone support transpedicular screws are installed in the unsegmented bone rod itself symmetrically to the longitudinal axis of the spine, mobilization and correction of the spinal deformity are performed, for this, a corrective sectoral vertebrotomy of the deformed spine is performed at the apex of the deformity through an unsegmented bone rod using a bone ultrasound scalpel; the heads of the transpedicular screws, perform a compression maneuver on the convex side of the scoliotic arch, fix the spine in the achieved position and the transpedicular system, tightening the transpedicular rods in the heads of the transpedicular screws, create spinal fusion using autologous bone. 2. The method according to claim 1, characterized in that in sectoral vertebrotomy, the posterior support column is cut at the apex of an unsegmented bone rod in the form of a wedge, which faces the convex side of the deformation with its base. 3. The method according to claim 1, characterized in that in sectoral vertebrotomy after removal of the posterior support column and visualization of the contents of the spinal canal under the protection of cerebral spatulas, sectoral sawing of the anterior support column is performed, fragments of the vertebral bodies are removed.

Images