RU2752338C1 - Method for lumbo-pelvic fixation in surgical treatment of diseases of lumbar spine - Google Patents

Abstract

FIELD: medicine, neurosurgery in particular.

SUBSTANCE: invention relates to medicine, namely to neurosurgery and traumatology-orthopedics, and can be used in the treatment of patients with diseases of the lumbar spine. Perpendicular to the spinal column, transpedicular screws are implanted into the wings of the iliac bones, autonomously relative to the main transpedicular structure. A rod made of bioinert material is installed in the heads of the transpedicular screws implanted in the wings of the iliac bones and transverse compression is performed.

EFFECT: method provides a reduction in the intensity of the pain syndrome, the course of the postoperative period without complications, minimizing the risks of fractures of metalwork elements and reducing costs by stabilizing and transverse compression of the sacroiliac joint (SJ), eliminating the mobility of the SJ, as well as eliminating parts of the components of the system: iliac screws and remote connectors.

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Description

The alleged invention relates to medicine, in particular to neurosurgery and traumatology, and can be used in the treatment of patients with degenerative-dystrophic diseases, including malignant neoplasms, trauma of the lumbar spine.

For each of the pathologies considered, a variant of a multilevel lesion is possible, requiring the implantation of an extended metal structure.

Such a stabilizing system leads to blocking of a large number of spinal motion segments (VMS), while altering the biomechanics of the entire lumbar spine. Typically, the distal fixation point is the S1 vertebra, in some cases the iliac wings.

In both cases, the mobility of the sacroiliac joint (SIJ) is preserved, in addition, the load on the distal pair of screws increases, which is the cause of fractures of the elements of the metal structure (screw, rod) or the development of the osteolysis zone around the screws.

Pain in the SIJ after multilevel fusion occurs in 32-61% of patients. (Katz V, Schofferman J, Reynolds J. The Sacroiliac Joint: A Potential Cause of Pain After Lumbar Fusion to the Sacrum. // Journal of Spinal Disorders & Techniques. 2003. Vol. 16 (1). P. 96-99. doi: 10.1097 / 00024720-200302000-00015). In addition, pathological mobility and arthrosis of the SIJ can cause persistent lumbodynia, sometimes with pseudo-radicular symptoms, in more than 20% of cases. (Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH, The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J. Anat 2012 Dec; 221 (6): 537-567. ).

Underestimation of this fact can be the reason for making erroneous decisions when choosing treatment tactics. Traditionally, multilevel spinal lesions are treated surgically without a detailed study of the SIJ state, as well as without taking into account the prospects for further changes in them against the background of fusion.

One of the methods of surgical treatment is the method of reconstruction of the lumbar spinal motion segment. (Basankin I.V., Afaunov A.A., Shapovalov V.K., Kuzmenko A.V., Takhmazyan K.K., patent for invention RU 2527150 C1, 27.08.2014. Application No. 2013123961/14 dated 24.05. 2013.)

The operation is carried out in the following way: the patient is on the operating table lying on his stomach, the rollers are placed under the chest and under the pelvis. After treatment of the skin with an antiseptic solution, a median surgical access to the operated PDS L1-S1 is performed. Skeleton is performed from the spinous processes to the tops of the transverse processes. Under X-ray control, two pedicle screws are inserted into the bodies of L2, L3, L4, L5, S1 vertebrae through the roots of the arches. At the next stage, a transforamenal access to the spinal canal is performed on one side of each operated PDS. For this, the lower articular process of the overlying vertebra and the upper articular process of the underlying vertebra are resected, which form the intervertebral joints of the operated PDS. To expand the access to the spinal canal, the lower part of the inter-articular arch of the cranial vertebra and the upper part of the arch of the caudal vertebra of the operated PDS are removed. A lateral pocket is opened at the level of the underlying vertebra for decompression of the root extending downward. The lateral sections of the ligamentum flavum and capsules of the resected intervertebral joints are removed. The spinal roots passing below and medial to the roots of the arches of the cranial vertebra of the operated VMS are identified. After performing the transforamenal access to the spinal canal, additional mobilization of the operated spinal motion segment is performed by removing the interspinous ligament, the adjacent supraspinous ligament and the central part of the ligamentum flavum, as well as economical resection of the adjacent spinous processes. Alternately, on each side, the dural sac is displaced medially. Stop bleeding from the epidural veins. The posterior longitudinal ligament and the annulus fibrosus are dissected in its posterolateral part. After that, holes are formed in the annulus fibrosus through which the central part of the disc, the inner portions of the annulus fibrosus and the hyaline cartilage of the adjacent vertebral body endplates are removed. The next stage is the introduction of an interbody implant (cage with autobone) into the formed interbody defect of the operated PDS. Before implantation of the cage, using the repositioning instrumentation of the transpedicular system, segmental distraction is performed in the operated PDS. At the same time, due to the removal of the interspinous, yellow and supraspinous ligaments of the operated PDS, the amplitude of possible distraction significantly increases, and the necessary distraction and repositioning forces applied to the screws implanted into the PDS are decreasing. A cage with autologous bone is implanted. After the screws are connected with beams, segmental compression is performed, and final stabilization is achieved. The wound is drained and sutured in layers. Disadvantages of this method:

1) An extended metal structure, blocking several SMS and having as its end point the fixation of the sacrum, overloads the SIJ area, accelerates the development of degenerative processes in them, and also causes increased pathological mobility, which in a delayed period leads to the development of severe pain in patients.

2) The absence of blockage of the SIJ causes an increased load on the lower pair of screws, which in most cases leads to the development of osteolysis around them.

As the closest analogue adopted a method of surgical treatment: lumbar - pelvic fixation. (Rhee WT, You SH, Jang YG, Lee SY. Lumbo-sacro-pelvic Fixation Using Iliac Screws for the Complex Lumbo-sacral Fractures. J Korean Neurosurg Soc. 2007; 42 (6): 495-498.)

The indications for this operation are: spondylolisthesis, multilevel combined stenosis, trauma, malignant neoplasms of the lumbar spine.

Method of operation for lumbar-pelvic fixation: the patient is on the operating table lying on his stomach, the rollers are placed under the chest and pelvis. After treatment of the skin with an antiseptic solution, a median surgical access to the operated spinal motion segments L1-S2 is performed. Skeletonization is performed from spinous processes to the tops of transverse processes, skeletonization of the wings of the iliac bones. Under X-ray control, two pedicle screws are implanted into the vertebral bodies through the roots of the arches L2, L3, L4, L5, S1. Under X-ray control, one iliac screw is carried out into the wings of the iliac bones. Further, on each operated PDS, the upper and lower articular processes are resected, the lower part of the inter-articular arch of the cranial vertebra and the upper part of the arch of the caudal vertebra are removed. The spinal roots passing below and medial to the roots of the arches of the cranial vertebra of the operated VMS are identified. The lateral part of the ligamentum flavum is resected. Stop bleeding from the epidural veins. The dural sac is displaced medially. The posterior longitudinal ligament and the annulus fibrosus are dissected. Discectomy is performed, after which an interbody cage with autologous bone is implanted into the interbody defect. Then, outboard connectors are fixed in the heads of the iliac screws. The length of the bar is measured, bent. The rods are fixed in the heads of screws, connectors, and final stabilization is achieved. The wound is drained and sutured in layers.

Disadvantages of this method:

1) Technical difficulty in the formation of the required profile of the rod and its connection into a single system.

2) In the delayed period, patients often have barbell fractures due to their strong bending, which forces patients to undergo repeated operations, which in turn increase the risk of postoperative complications.

3) The high cost of this metal structure, including iliac screws, outboard connectors.

Tasks:

1) Improve the patient's quality of life by eliminating pain in the SIJ, by stabilizing and compressing them.

2) Reduce the risk of delayed complications: fracture of the rod, connector, reoperation, the threat of postoperative wound suppuration due to reoperation.

3) Reduce the consumption of material used for the operation and their cost.

The technical result of the developed method of lumbar-pelvic fixation in the surgical treatment of diseases of the lumbar spine is as follows:

1) The intensity of the pain syndrome generated by the SIJ is significantly reduced due to their stabilization and transverse compression.

2) The risks of fractures of the elements of the metal structure are minimized by eliminating the provoking factor in the form of mobility of the SIJ.

3) Reducing the cost of metal structures by eliminating the components of the system (iliac screws, external connectors) from part of the system.

The essence of the invention when using the developed surgical technique is an additional perpendicular to the spinal column in the wings of the iliac bones, autonomously relative to the main transpedicular structure implantation of transpedicular screws, in the heads of the transpedicular screws implanted in the wings of the iliac bones, a bar made of bioinert material is installed and transverse compression is performed.

The method has been tested for 5 years on 30 patients. None of the patients subsequently showed pain in the SIJ or fracture of the metal structure.

For a better understanding, the method is shown in Figures 1-2, where Figure 1 is the lumbosacral spine and SIJ before surgery, Figure 2 is the lumbosacral spine and SIJ after surgery, as well as positions 1-6, where position 1 is SIJ, position 2 - intervertebral disc, position 3 - pedicle screw, position 4 - cage, position 5 - longitudinal bar, position 6 - transverse bar.

The method includes:

- Implantation of transpedicular screws in the wings of the iliac bones, not associated with the lumbosacral hardware.

- Rotation of the screw heads implanted in the iliac wings in the transverse direction, installation on the last straight bar, with transverse compression of the SIJ.

- Stabilization of the KPS.

The method is carried out as follows. The patient is placed on the operating table in the prone position. Rollers are placed under the chest and pelvis. With the help of X-ray, the operated PDS is identified. After three times treatment of the skin with an antiseptic solution, surgical access to the operated PDS is performed, skeletonization is performed from the spinous processes to the tops of the transverse processes. Then, skeletonization of the iliac wings is performed. Under X-ray control, two pedicle screws (3) are implanted into the L2, L3, L4, L5, S1 vertebral bodies through the roots of the arches, then one traspedicular screw is implanted into the wings of the iliac bones (3). Further, on one of the sides of each operated PDS, the lower articular process of the overlying vertebra, the upper articular process of the underlying vertebra are resected. The lower part of the inter-articular part of the cranial vertebra arch, the upper part of the caudal vertebra arch are resected. The spinal roots passing below and medial to the roots of the arches of the cranial vertebra of the operated VMS are identified. The lateral part of the ligamentum flavum is resected. The dural sac is displaced medially. Coagulation of epidural veins is performed. The intervertebral disc is identified (2). The posterior longitudinal ligament and the annulus fibrosus are dissected. Discectomy is performed. A cage (4) with autologous bone obtained as a result of joint resection is implanted into each interbody defect. Measure the length of the rod, bend it. The transpedicular screws (3) implanted in the lumbar and sacral spine are connected with a longitudinal curved bar (5). Segmental compression is performed on each operated PDS. After that, the final stabilization of the transpedicular system is performed. The heads of the transpedicular screws (3) implanted into the wings of the iliac bones are turned in the transverse direction, and a straight bar is installed in them. Transverse compression of the SIJ is performed (1). Final stabilization of the transpedicular system is performed. The wound is inspected for foreign bodies. The wound is repeatedly washed with an antiseptic solution. A drain is placed in the wound, then sutured in layers.

Example

Patient K., 67 years old, was admitted to the department of the clinic on September 26, 2019, with a diagnosis of Degenerative-dystrophic diseases of the spine. Osteochondrosis of the lumbar spine. Combined spinal stenosis at the LI-SI level. Caudal compression syndrome. Arthrosis, instability of the SIJ.

During hospitalization, she complained of severe pain in the lumbar spine, SIJ, which intensified with physical activity. From the anamnesis, it was revealed that the pains bother for 7 years, was repeatedly treated conservatively at the place of residence without significant effect. From September 2, 2019, numbness in the lower extremities began to increase, pain in the SIJ began to increase. On September 20, 2019, he performed an MRI scan - a multilevel stenosis of the spinal canal at the L1-S1 level was revealed. Osteoarthritis of the sacroiliac joints. She was hospitalized for surgical treatment in a planned manner, due to the threat of an increase in neurological deficit, severe pain in the SIJ.

At the time of hospitalization, the patient's condition was assessed as moderate. General condition of moderate severity. Skin and visible mucous membranes of normal color. Normosthenic constitution. The muscular system is moderately developed. Auscultatory vesicular breathing is carried out in all departments. The number of breaths is 18 per minute, no wheezing. Pulse 78 in 1 minute, rhythmic, satisfactory qualities. BP 130/80 mm Hg heart tones are clear, rhythmic. The abdomen is soft, painless on palpation, peristalsis is heard. Diuresis controls. Neurological status: clear consciousness. It is oriented in time and space. Eye slits D = S. Pupils D = S, vivid photoreactions. The movement of the eyeballs in full. Swallowing and phonation are not disturbed. Tongue in the midline. Muscle strength in the lower extremities - 5 points, in the flexors of the feet - 2 points, in the extensors of the feet - 4 points. Achilles, plantar reflexes abs. Segmental hypesthesia from the LII level. There are no meningeal symptoms. Diuresis controls. The skin of the lumbar region was unchanged. Palpation of the spinous processes and paravertebral region at the LI-SI level is painful.

On September 27, 2019, an operation was performed in the amount of: lumbar-pelvic fixation LII-S1, SIJ.

The patient was on the operating table in the prone position. Rollers are placed under the chest and pelvis. With the help of X-ray, the operated PDS was identified. After three times treatment of the skin with an antiseptic solution, surgical access to the operated PDS was performed, skeletonization was performed from the spinous processes to the apexes of the transverse processes. Skeletonization of the iliac wings was then performed. Under X-ray control, two pedicle screws were implanted into the L2, L3, L4, L5, S1 vertebral bodies through the roots of the arches, then one traspedicular screw was implanted into the wings of the iliac bones. Further, on the left side, on each operated PDS, the inferior articular process of the overlying vertebra and the superior articular process of the underlying vertebra were resected. The lower part of the inter-articular part of the cranial vertebral arch and the upper part of the caudal vertebral arch were resected. The lateral part of the ligamentum flavum was resected. The dural sac was displaced medially. The epidural veins were coagulated. The intervertebral disc was identified. The posterior longitudinal ligament and the annulus fibrosus were dissected. Discectomy was performed. A cage with autologous bone obtained as a result of joint resection was implanted into each interbody defect. They measured the length of the rod, fired it. The transpedicular screws implanted in the lumbar and sacral spine were connected with a longitudinal curved bar. Segmental compression was performed on each operated PDS. Afterwards, the final stabilization of the transpedicular system was performed. The heads of the pedicle screws implanted in the wings of the iliac bones were turned in the transverse direction, and a straight bar was installed in them. Transverse compression of the SIJ was performed. The final stabilization of the transpedicular system was performed. The wound was revised for foreign bodies. The wound was repeatedly washed with an antiseptic solution. A drain was placed in the wound and sutured in layers.

In the postoperative period, the patient notes a decrease in pain in the extremities. The next day after the operation, the patient was upright, noted the absence of pain in the SIJ when walking. At discharge, the patient's condition was satisfactory, she could move independently without pain in the SIJ. After discharge, the patient underwent rehabilitation on an outpatient basis at the place of residence according to the recommendations of the attending physician outlined in the discharge crisis, during the year the patient was called for control images on a computed tomography and magnetic resonance imaging machine. The examination was carried out at 3 months after the operation, 6 and 12 months. The patient makes no complaints. Performs any physical work.

Claims (1)

The method of lumbar-pelvic fixation in the surgical treatment of diseases of the lumbar spine, including the implantation of the transpedicular system, characterized in that, in addition, perpendicular to the spinal column in the wings of the iliac bones, autonomously relative to the main transpedicular structure, the transpedicular screws are implanted, in the heads of the transpedicular screws in the wings, implanted cephalic , install a barbell made of bioinert material and perform transverse compression.

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