RU2791410C1 - Method for posterior decompression of the spinal cord with stenose of the spinal canal - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to spinal surgery and neurosurgery, and can be used to treat congenital hip dislocation and spinal canal stenosis and spinal cord compression at the level of the cervical and thoracic spine. Surgical intervention is performed from the dorsal bilateral access. After exposure of the posterior structures of the spine, the vertebrae are stabilized by passing screws through the pedicles into the vertebral body, and a transpedicular fixation system is installed in the vertebrae according to preoperative planning. Control is carried out to assess the position of the screws. The length of the cutting part of the ultrasonic scalpel is selected taking into account the thickness of the vertebral arch in the access area according to the data of computed tomography performed at the planning stage of the operation. The vertebral arches are sawn through, at the level of spinal canal stenosis, with the help of an ultrasonic bone scalpel, irrigation fluid is supplied to the cutting area of the supply. An incision is made with a scalpel in the lateral part of the vertebral arches in the projection of the lateral pockets of the spinal canal, without touching the membranes and tissues of the spinal cord with the cutting part. The depth of penetration of the cutting part of the scalpel into the tissue is visually and tactilely controlled. The vertebral arch is pulled upward from the spinal cord behind the spinous process and the arch is separated from the dura mater together with the yellow ligament. The arc and yellow ligament are removed in one conglomerate. The spinal deformity is corrected and the transpedicular fixation system is installed. Spinal fusion is performed with an autorib, mounting two autorib fragments to the rods of the transpedicular fixation system bilaterally.

EFFECT: method provides decompression of the spinal cord without any additional intraoperative trauma due to the exclusion of accidental contact of the instrument with the soft tissues of the spinal cord.

1 cl, 7 dwg

Description

The field of technology.

The invention relates to medicine, neurosurgery, namely to spinal surgery and is used in the treatment of patients with spinal canal stenosis and spinal cord compression at the level of the cervical and thoracic spine.

The level of technology.

Thus, there is a problem of performing decompression of the spinal cord at the level of the cervical and thoracic spine with minimal intraoperative trauma.

The essence of the technical solution.

There is a known method of access to the spinal cord, which performs decompression of the spinal cord (patent RU 2142748). Essence: a longitudinal incision of the skin-fascial layers approaches the tops of the spinous processes of the vertebrae, the attachments of the back muscles are cut off from them, which are peeled subperiosteally with a wide chisel and taken to the sides, exposing the posterior wall of the spinal canal. It is dissected by longitudinal parallel incisions along the line of the articular processes, while maintaining the integrity of these joints. In this case, the arches are dissected in an oblique frontal plane. The posterior wall of the spinal canal mobilized in this way is crossed transversely at the bottom or at the top to form a U-shaped pedicled flap. According to the indication, they are crossed in the middle with cutting out two U-shaped flaps. C-shaped dissection of the posterior wall of the spinal canal is accompanied by the formation of a flap on one wide pedicle. The flaps are removed and an operation is performed on the organs of the spinal canal, then the flaps are put in place and sutured. The arches are fixed with transosseous sutures or bone nails, restoring the posterior wall of the spinal canal without osteoplastic fixation and immobilization, which prevents immobilization of the spinal segment.

This method is not applicable at the level of the cervical and thoracic spine in conditions of spinal canal stenosis, since the flaps are first retracted, and then the flaps are placed in place. The return of the bone flap into place leads to a narrowing of the lumen of the spinal canal.

A known method of osteoplastic laminectomy used in the surgical treatment of traumatic and degenerative-dystrophic injuries of the spine and spinal cord (patent: RU 2336041). During laminectomy, the arches are dissected transarticularly from the lower arcuate joint of the vertebra to its upper end, sawing through only the lower articular process of the overlying vertebra and leaving intact the upper articular process of the underlying vertebra that articulates with it, the yellow ligament is dissected transversely from two sides, and along only one side of the bone-ligamentous the blocks are turned sideways on the intact side of the yellow ligament, intracanal manipulations are performed, the blocks are put in place and fixed with the restoration of the posterior supporting structure of the spine. The method improves the postoperative stability of the spine.

This method is not applicable at the level of the cervical and thoracic spine in conditions of spinal canal stenosis, since the bone-ligamentous blocks put the blocks in place and fix them with the restoration of the posterior supporting structure of the spine. The return of the bone-ligamentous blocks into place leads to a narrowing of the lumen of the spinal canal.

A known method of laminectomy according to B.M. Tserlyuk (Author St. SU No. 787010, A61 B 17/00 dated 01.29.79, Bull. No. 46 of 1980), including dissection of soft tissues over the spinous processes, excision of the thoracolumbar fascia, blunt exfoliation of the paravertebral muscles, dissection of the supraspinous ligament , sequential excision of the spinous processes, arches, interspinous and yellow ligaments of each vertebra, intracanal manipulations, closure of the formed bone defect with a flap from the fascia of the paravertebral muscles on a feeding leg, laying a bone-fascial flap on it.

The disadvantage of this method, with stenosis at the level of the cervical and thoracic spine, is the return of the bone-fascial flap in place with the threat of stenosis of the spinal canal and compression of the spinal cord.

A known method of osteoplastic laminectomy according to N.I. Khvisyuk [ed.St. SU No. 1223900, s. SU No. 3844074/28-14, dated 11/26/84, publ. in Bull. No. 14 dated April 15, 1986], including a longitudinal incision of soft tissues in the region of the compromised, superior and underlying vertebrae, skeletonization of the spinous processes and arches, excision of the supraspinous ligament, resection of the interarticular part of the arches, excision of the interspinous and yellow ligaments, excavation of each laminotomized bone fragment, removal of osteophytes and installation in their original place, rigid fixation by wedging with bone grafts and fixation with a plate fixator, and, if necessary, posterior stabilization with allografts placed with overlapping of the plasty zone, followed by layer-by-layer suturing of the wound tightly.

The disadvantages of this method are traumatization, as there is an elongation of the surgical wound by 1-2 vertebrae above and below the level of intervention.

A known method for the treatment of circular stenosis of the spinal canal at the thoracic level in patients with compression myeloischemia (patent RU 2739670), where laminectomy is performed using a high-speed burr and Kerisson nippers no more than 3 mm. When performing laminectomy, a fragment of the vertebral arch and hypertrophied yellow ligament are resected, creating posterior compression of the spinal cord and corresponding areas of anterior compression to the border of the pedicles of the corresponding vertebral arch, while medial facetectomy and removal of the yellow ligament from the area of the foraminal opening also occur. Thus, when performing a laminectomy, do not touch the dura mater (dura mater), do not displace or squeeze it with instruments.

The disadvantage of this method of decompression of the spinal cord in conditions of stenosis of the spinal canal at the level of the cervical and thoracic spine is its inevitable traumatization by the instruments with which decompression is performed (Kerrison Nippers). The use of a high-speed bur leads to unintentional mechanical damage to soft tissue structures and the spinal cord, due to vibrations, vibration, bone fragments, sticking, high cutting forces. The selective effect on the dense bone tissue of the vertebrae is not provided.

The instrumentation used in the known methods does not minimize surgical trauma to the spinal cord in conditions of spinal canal stenosis during spinal cord decompression at the level of the cervical and thoracic spine; the instrument can cause significant injury in case of accidental contact with the soft tissues of the spinal cord.

The technical result consists in performing decompression of the spinal cord at the level of the cervical and thoracic spine with a decrease in the volume of intraoperative trauma.

The technical result is achieved by the fact that in the method of posterior decompression of the spinal cord with stenosis of the spinal canal at the level of the cervical or thoracic spine, surgery is performed from the dorsal bilateral access, after exposure of the posterior structures of the spine, the vertebrae are stabilized by passing screws through the legs into the vertebral body, a transpedicular fixation system in the vertebrae according to preoperative planning, control is carried out to assess the position of the screws, the length of the cutting part of the ultrasonic scalpel is selected taking into account the thickness of the vertebral arch in the access area according to computed tomography performed at the planning stage of the operation, the vertebral arches are sawn, at the level of spinal canal stenosis using an ultrasonic bone scalpel, supplying an irrigation fluid to the cutting area of the supply, with a scalpel, make an incision in the lateral part of the vertebral arches in the projection of the lateral pockets of the vertebral canal, without touching the membranes and tissues of the spinal cord with the cutting part, visually and tactilely control the depth of penetration of the cutting part of the scalpel into the tissues, traction of the vertebral arch upwards from the spinal cord behind the spinous process and separate the arch from the dura mater together with the yellow ligament, the arch and yellow the ligament is removed with one conglomerate, the spinal deformity is corrected and the transpedicular fixation system is mounted, spinal fusion is performed with an autorib, two autorib fragments are mounted bilaterally to the rods of the transpedicular fixation system.

Decompression of the spinal cord is achieved without additional intraoperative trauma (reduction of surgical spinal cord injury).

The invention is illustrated by images:

fig. 1 - radiographs of the patient's spine in two projections;

Fig. 2 - CT scan of the patient's cervical spine before surgery;

Fig. 3 - MRI of the patient's cervical spine before surgery;

Fig. 4 - CT scan of the patient's cervical spine after surgery;

Fig. 5 - cutting part of the ultrasonic bone scalpel;

Fig. 6 - intraoperative photo, the lines show the cut area of the vertebral arch, the section of the vertebral arches in the lateral part (in the region of the vertebral pedicle in the projection of the lateral pocket of the spinal canal);

Fig. 7 - intraoperative photo, installation of the transpedicular fixation system and spinal fusion with an autorib.

The implementation of the invention is shown in the clinical example of a patient with stenosis of the spinal canal of the cervical spine (Fig. 1; 2; 3; 4). At the level of the thoracic region, the method is carried out similarly.

A method for posterior decompression of the spinal cord in case of spinal canal stenosis at the level of the cervical and thoracic spine, which makes it possible to eliminate stenosis and compression of the spinal cord while preserving the spinal cord, to avoid additional trauma to the spinal cord, is performed using an ultrasonic bone scalpel. When decompressing the spinal cord under conditions of stenosis of the spinal canal (Fig. 1; 2; 3), in particular, an ultrasonic scalpel with a cutting part as in Fig. 1 can be used. 5.

Surgical intervention is performed at the level of the cervical and thoracic spine from the dorsal bilateral approach. After exposing the posterior structures of the spine, the vertebrae are stabilized by passing screws 1 (Fig. 7) through the pedicles (pedicles) into the body of vertebra 2 (Fig. 7), and the anchor points (screws) of the transpedicular fixation system are installed in the vertebrae according to preoperative planning. Conduct image intensifier control to assess the position of the screws. The length of the cutting part (blade) of the scalpel is selected taking into account the data of computed tomography (CT) performed at the planning stage of the operation, taking into account the thickness of the vertebral arch in the access area.

Sawing of the vertebral arches (Fig. 6) is performed in the lateral part, in the region of the vertebral pedicle in the projection of the lateral pocket of the spinal canal, at the level of spinal canal stenosis using an ultrasonic bone scalpel (Fig. 5) by supplying irrigation fluid to the cutting area. The scalpel settings are selected individually depending on the density of the bone tissue and the degree of irrigation fluid supply varies.

An ultrasonic bone scalpel, with low cutting force, with a blunt blade movement frequency of 22,500 times per second, makes a thin incision, saws through the vertebral arches (Fig. 6) in their lateral part in the projection of the side pockets of the spinal canal, without touching the cutting part of the shells and tissues of the spinal cord, excluding the impact of high-energy vibrations and vibrations on the spinal cord, the effects on the spinal cord of fragments of bone tissue that stick, fly off and can damage it. After passing through the bone tissue of the vertebra, a slight dip is felt. Visually and tactilely control the depth of penetration of the cutting part of the scalpel into the tissue. Provides a highly precise, thin incision with reduced bleeding and exceptional tissue selectivity between bone and soft tissue. Additionally, a protector is installed on the ultrasonic scalpel, which allows the eye to control the depth of penetration of the cutting part of the scalpel into the tissue.

Next, the vertebral arch is pulled upwards from the spinal cord behind the spinous process and it is separated (bluntly-sharply) from the dura mater together with the yellow ligament. The arch and yellow ligament are removed in one conglomerate, excluding spinal canal stenosis and trauma to the spinal cord with an instrument. Rods 3 (Fig. 7) of the transpedicular fixation system are mounted into the vertebrae with deformity correction according to preoperative planning. Spinal fusion is performed with an autorib 4 (Fig. 7), mounting two fragments of an autorib to the rods 3 of the transpedicular fixation system bilaterally (Fig. 7).

All manipulations are carried out under neurophysiological control.

In the method of posterior decompression of the spinal cord in spinal canal stenosis, the loss of viable bone tissue is minimized, and bleeding during surgery is significantly reduced, so that the surgical field remains free of blood. All this leads to a significant reduction in the time of operation and minimization of surgical trauma.

The technical result provided by the given combination of features is the reconstruction of the spinal canal with decompression of the spinal cord from the posterior approach while reducing the operating injury, excluding mechanical damage to the dura by the cutting part.

Claims (1)

A method for posterior decompression of the spinal cord in stenosis of the spinal canal at the level of the cervical or thoracic spine, characterized in that surgery is performed from a dorsal bilateral approach, after exposure of the posterior structures of the spine, the vertebrae are stabilized by passing screws through the pedicles into the vertebral body, and a transpedicular fixation system is installed into the vertebrae according to preoperative planning, control is carried out to assess the position of the screws, the length of the cutting part of the ultrasonic scalpel is selected taking into account the thickness of the vertebral arch in the access area according to computed tomography performed at the stage of planning the operation, the vertebral arches are sawn through at the level of spinal canal stenosis using using an ultrasonic bone scalpel, supplying irrigation fluid to the cutting area of the supply, with a scalpel, make an incision in the lateral part of the vertebral arches in the projection of the lateral pockets of the spinal canal, without touching using the cutting part of the membranes and tissues of the spinal cord, visually and tactilely control the depth of penetration of the cutting part of the scalpel into the tissues, traction of the vertebral arch upwards from the spinal cord behind the spinous process and separate the arch from the dura mater together with the yellow ligament, the arch and the yellow ligament are removed with one conglomerate, correction of the spinal deformity and installation of the transpedicular fixation system, spinal fusion with an autorib, mounting two autorib fragments to the rods of the transpedicular fixation system bilaterally.

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