RU2742593C1 - Method for stabilizing spinal motion segment with minimally invasive transpedicular tool in patients with spinal osteoporosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery and orthopedics and can be used for surgically treating degenerative diseases and traumatic spinal injuries in patients with spinal osteoporosis. The method consists in using percutaneous transpedicular screws and a bone-and-plastic material. After the percutaneous access is marked at the levels of the screw insertion on two sides through the legs of the vertebrae through the roots of the legs, trepans are introduced. Channels for access to the bodies of the vertebrae are formed. Screws are carried out through prepared channels in the bodies of the vertebrae and the heads of the screws are fixed to the rods. The trepans are embodied in the form of Jamshidi needles, which are used in the bodies of the vertebrae and are embodied in such a way that cannulated dilatators are introduced into the body of the vertebrae through the legs, forming channels for access to the bodies of the vertebrae. The spokes are removed, through the formed channels transpedicularly, using cannulated dilatators as a guide. Bone funnels are installed in the bodies of the vertebrae, cannulated dilatators are removed, bone crumbs are injected into the body of the vertebrae through bone funnels and are compacted, after which bone crumbs of the vertebrae are filled. Cannulated dilatators are installed repeatedly through bone funnels, through which the spokes are reintroduced. Cannulated dilatators are removed, screws are carried out on the spokes with a channel for the spoke to the point of entry of the spoke into the foot of the vertebrae. The spokes are removed and the screws are carried out in the bodies of the vertebrae, whereupon the rods are percutantly carried out and the heads of the screws are fixed to the rods.

EFFECT: method ensures that the risk of compression of the spinal cord and the spines is eliminated, prevents the risk of the development of a cement pulmonary embolism and preserves the possibility of correcting the position of the screws by means of the cement draining of the vertebrate channel.

1 cl, 1 ex, 11 dwg

Description

The invention relates to medicine, in particular to methods of surgical treatment of degenerative diseases and traumatic injuries of the spine in patients with spinal osteoporosis.

Currently, there is a significant increase in the population of elderly people, which is due to an increase in the frequency of degenerative diseases and osteoporosis of the spine. Osteoporosis of the spine is often the cause of pathological fractures of the spine, many of which are unstable. Transpedicular fixation with various types of fusion is often the only treatment that can achieve clinically significant results in patients with degenerative diseases of the spine, but the failure rate due to loosening of the fixator can be as high as 60% if osteoporosis is present. In order to increase the stability of the fixator, technologies have now been developed using bone augmentation using bone cement - methyl methacrylate (polymethyl methacrylate), see RU 2479274 C1. Augmentation with methyl methacrylate has disadvantages: the method involves the injection of liquid cement into the vertebral bodies. The spread of liquid cement is an uncontrolled process, as a result of which there is often drainage of cement into the spinal canal with the risk of compression of the roots and spinal cord and into the vascular bed with the risk of pulmonary embolism. The method does not prevent fatigue fracture of the fixator; when blocking the vascular bed of the vertebrae, it slows down fusion. With this method of augmentation, the time of screw insertion is limited by the time of cement polymerization - this process is uncontrolled, it can polymerize before the screws are inserted. Once the cement has polymerized, it becomes impossible to guide the screws. Also, after polymerization of the cement, it is impossible to correct the position of the screw with its non-optimal trajectory. The disadvantage of augmentation of the vertebrae with cement is the impossibility of augmentation of the vertebral pedicle, in this case the fulcrum is displaced ventrally and loosening of the screw occurs in the vertebral pedicle. In addition, during polymerization of polymethyl methacrylate, an exothermic reaction occurs and thermal damage to tissues, including the roots and spinal cord, occurs.

One of the current trends is also a decrease in the invasiveness of surgical interventions. The purpose of using minimally invasive interventions is to reduce the risk of infectious complications, reduce the time of surgery and preserve the paravertebral muscles, which is necessary to achieve good results in the long-term period. During percutaneous fixation, surgery is performed without direct visual control of the vertebral structures, and in this case, the use of methyl methacrylate-based augmentation is an even more risky surgical intervention. Thus, at present, it is necessary to develop a method of minimally invasive fixation, in which the disadvantages of previously developed methods are eliminated: the use of liquid substances should be excluded, there should be no time limit for the screw placement, effective augmentation of both the vertebral body and its pedicle should be achieved without chemical and thermal damage to the surrounding tissues, which does not interfere with the subsequent installation of screws, and a safe minimally invasive installation of screws is ensured.

Known minimally invasive bone-cement system for internal fixation of the spine (CN 202313683 U), containing a special set of instruments, screws and rods. The system implements a method based on the introduction of liquid cement (polymethyl methacrylate). The disadvantages of this method are the potential cytotoxicity of the cement, an exothermic reaction with heating to 70 ° with the risk of damage to the surrounding tissues, uncontrolled spread of cement, drainage into the spinal canal with possible compression of the roots and spinal cord, the vascular bed with the development of pulmonary embolism. In addition, cement has a limited working time that can vary depending on the room temperature. In addition to these disadvantages, when performing this method, it is impossible to perform augmentation of the vertebral pedicles. As a result, such augmentation changes the fulcrum and the screw loosens in the vertebral pedicle. The time of screw insertion is limited by the time of cement polymerization, after its polymerization, with complete polymerization, it is impossible to insert a screw and re-conduct it with a non-optimal installation trajectory. The system requires the manufacture of special tools that can only be used with this system.

Known analogue of the alleged invention, RU 2663940 C1, but when performing the method, it is necessary to skeletonize the posterior structures and perform under direct visual control. When performing the method, minimally invasive damage to the vertebral pedicle is possible with the release of the material used for augmentation into the spinal canal and compression of the roots. Augmentation leads to the fact that the densest tissue is on the trajectory of the screw, which can lead to deviation of the screw from the trajectory if the method is performed without a guide - a wire.

As a prototype, the selected method of percutaneous transpedicular fixation of the spine with puncture vertebroplasty in the treatment of patients with advanced osteoporosis and multiple metastatic lesions of the spine (RU 2479274 C1), which consists in the use of percutaneous transpedicular screws and bone cement, while in the pre-defined vertebrae above and below lying from a pathological fracture, puncture, through the roots of the legs, trepans are introduced to the middle of the vertebral body, stilettos are removed from the trepans and guide pins are inserted in their places, the trepans are removed, a puncher and a tap are inserted along the knitting needles, marking the progress of the screws only to the depth of passage of the leg of the vertebral arch , then trepans are again installed along the spokes, the guide pins are removed, bone cement is injected into the vertebrae through trepans, immediately after the injection of cement, guide pins are inserted along the trepans, the trepans are removed, along the guide pins, before the cement hardens completely, in earlier the prepared passages are inserted with pedicle screws, which are fixed with bars percutaneously.

The objective of the invention is to improve the prototype method.

EFFECT: eliminating the risk of compression of the spinal cord and roots due to drainage of cement into the spinal canal, eliminating the risk of cement pulmonary embolism, increasing the working time for introducing screws, eliminating the toxic effect of methyl methacrylate and maintaining the blood supply to the vertebrae, ensuring the safe application of the method when performing percutaneous stabilization, eliminating thermal tissue damage, making it possible to correct the position of the screws.

The stated technical result is achieved due to the fact that in the method of stabilization of the spinal motion segment with transpedicular instrumentation in patients with osteoporosis of the spine, including transpedicular bilateral formation of canals in the vertebrae at the levels of screw insertion, preliminary threading, insertion of Jamshidi biopsy needles through the formed canals, restoration of support ability bone tissue by injection of osteoplastic material at the levels of insertion of transpedicular screws, two-sided insertion of screws into the vertebral bodies through prepared canals and fixation of the screw heads to the rods, after marking the percutaneous access at the levels of screw insertion from both sides through the legs, Jamshidi needles are inserted into the vertebral bodies through which pins are passed into the vertebral bodies, along which cannulated dilators are inserted through the legs into the vertebral body, forming channels for access to the vertebral bodies, through the formed channels transpedicularly, using nulled dilators as a guide, bone funnels are inserted into the vertebral bodies, through which the bone crumb is inserted into the vertebral body with an impactor and compacted, after which the vertebral pedicles are filled with bone crumb, cannulated dilators are inserted through the bone funnels, through which the wires are re-inserted, the cannulated dilators are removed , screws with a channel for the spoke are passed along the spokes to the point of entry of the spokes into the vertebral pedicle, the spokes are removed and the screws are inserted into the vertebral bodies, after which the rods are passed percutaneously and the screw heads are fixed to the rods.

The invention is illustrated by illustrative material.

FIG. 1-11 show the stages of implementation of the method.

The following positions are indicated in the illustrative material.

1. Jamshidi's needles.

2. Knitting needles.

3. Cannulated dilators.

4. Bone funnels.

5. Impactors.

6. Screws.

The method of stabilizing the spinal motion segment with transpedicular instrumentation in patients with spinal osteoporosis is as follows.

In the position of the patient on the stomach under the control of fluoroscopy, the vertebral legs are identified at the levels of the planned introduction of screws 6 and the percutaneous access is marked. Jamshidi needles 1 (Fig. 1) are inserted through the vertebral legs into the vertebral bodies, through which the needles 2 are inserted transpedicularly into the vertebral bodies (Fig. 2), along which cannulated dilators 3 are inserted into the vertebral bodies (Fig. 3), forming channels in vertebral bodies; using dilators 3 as a guide, on each side at each level, the bone funnels 4 are inserted transpedicularly into the vertebral body (Fig. 4), their position is controlled using fluoroscopy (Fig. 5 lateral projection, Fig. 6 direct projection), the bone funnels should be located within the vertebral body. After the installation of the bone funnels into the vertebral bodies, the impactor 5 introduces bone chips, which are compacted in the area of the planned introduction of transpedicular screws (Fig. 7). After completion of the formation of compacted bone tissue in the vertebral bodies, the vertebral legs are filled with bone chips (Fig. 8), then dilators 3 are re-inserted through the bone funnels (Fig. 9), through which wires 2 6 are inserted into the vertebral bodies (Fig. 9). Along the spokes 2, screws 6 with a channel for the spoke are brought to the point of entry into the leg (Fig. 10), the spokes 2 are removed, screws 6 are passed through the vertebral pedicles into the body, rods are drawn percutaneously and the screw heads are fixed to the rods (not shown). The final position of the screws 6 is shown in FIG. eleven.

Clinical example

Patient K., 73 years old, was admitted to the neurosurgical department of the Federal State Budgetary Institution PFMITS MH RF 09.01.2018. Long history of low back pain, significant deterioration since November 2017, the patient denied spinal injury. Conducted repeated courses of conservative therapy at the place of residence - without effect. In connection with persistent lumbodynia, CT was performed, an unstable compression-comminuted fracture of the L4 vertebra was revealed, according to the results of CT, a decrease in bone density to 65 units was noted. Hounsfield. Systemic osteoporosis was verified by dual-energy absorptiometry (Tcr = -3.5).

Diagnosed with postmenopausal osteoporosis of the spine. An unstable compression-comminuted pathological fracture of the L4 vertebra, against the background of systemic osteoporosis of the spine.

On admission, the patient had a pronounced axial pain syndrome. There were no signs of radiculopathy or myelopathy.

On 10.01.2018, the operation was performed according to the proposed method. Minimally invasive transpedicular fixation is supplemented with anterior interbody fusion. In the long-term period, regression of the axial pain syndrome was achieved; control CT scans from January 21, 2020 did not reveal any signs of impaired stability of the transpedicular fixator and progression of deformity. According to CT, there were no signs of bone grafting material resorption. Anterior interbody fusion L3-L5 was formed.

The formation of canals through the legs of the vertebral body along the wire allows augmentation of the vertebrae and transpedicular fixation atraumatically without skeletonization of the posterior structures, which reduces the risk of infectious complications and improves functional results by preserving the innervation of the paravertebral muscles.

The use of cannulated dilators makes it possible to compact the bone tissue of the vertebral pedicles and form channels percutaneously for the introduction of bone funnels, as well as to ensure their accurate placement without the risk of vertebral pedicle fracture.

Restoration of the supporting ability of the vertebrae with bone chips excludes drainage of bone-plastic material into the spinal canal and vascular bed with the development of pulmonary embolism and neurocompression. Osteoplastic material has a biological nature and does not interfere with the formation of interbody fusion.

The restoration of the bone tissue support ability occurs both in the body and in the vertebral pedicles, which increases the strength of the minimally invasive fixation.

The use of bone chips as osteoplastic material does not limit the working time for the insertion of screws and allows, using cannulated dilators, the repeated drawing of the wires along the previously used trajectory and passing the screws percutaneously along the wire to the point of entry into the pedicle of the vertebra for their subsequent passage transpedicularly into the vertebral body.

The augmentation technique can be reused to restore the support ability of the vertebra when the screw is pulled out during the correction of the spinal deformity and allows the screw position to be corrected in a non-optimal trajectory.

Claims (1)

A method for stabilizing the spinal motion segment with transpedicular instrumentation in patients with osteoporosis of the spine, which consists in using percutaneous transpedicular screws and osteoplastic material, in which, after marking the percutaneous access at the levels of screw insertion from both sides through the legs into the vertebral bodies by puncture through the roots of the legs, trepans are introduced, channels are formed for access to the vertebral bodies, screws are inserted into the vertebral bodies through the prepared channels, the screw heads are fixed to the rods, characterized in that Jamshidi needles are used as trepans, through which the spokes are passed into the vertebral bodies, through which they are inserted through the legs cannulated dilators into the vertebral body, forming channels for access to the vertebral bodies, remove the needles, through the formed canals transpedicularly, using cannulated dilators as a guide, install bone funnels into the vertebral bodies, remove cannulated dilators, through the impact funnels rum is injected into the vertebral body and compacted, after which the pedicles of the vertebrae are filled with bone crumb, cannulated dilators are inserted through the bone funnels, through which the needles are re-inserted, the cannulated dilators are removed, screws with a channel for the needles are passed through the needles to the point of entry of the spoke into the leg of the vertebra, the needles are removed and the screws are inserted into the vertebral bodies, after which the rods are passed percutaneously and the screw heads are fixed to the rods.

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