RU2804846C1 - Method for surgical correction of pelvic tilt in children with neuro-muscular and syndromal scoliose - Google Patents

Abstract

FIELD: traumatology; orthopedics; neurosurgery.

SUBSTANCE: used to correct the spatial orientation of the pelvis in children with neuromuscular and syndromic scoliosis. Access is made to the posterior elements of the spine up to the articular processes. Transpedicular screws are inserted into the vertebral bodies under the control of the Stealth Station navigation system, for which screws are installed transpedicularly on the right and left at the levels of the planned metal fixation. Polyaxial screws are passed through the posterior superior iliac spine into the iliac bones towards the greater sciatic notch on both sides. At L3-L4-L5-S1 levels, facetectomy is performed using an ultrasonic bone scalpel Misonix, for which a pre-curved rod is placed on the screws in the thoracolumbar spine on the right and left to match the spinal deformity and secured with nuts. Correction of scoliotic deformity is performed using a derotational maneuver, forming kyphosis and lordosis. Under the control of a visualization system to confirm the stability of the O-arm fixation in 2-D mode, the final fixation of the supporting elements to the rod with nuts is performed. At the level of the L4 vertebra, connectors are fixed to the rod laterally on each side, interconnected end to side, due to the presence of polyaxial heads at the ends, and the position of the pelvis in space is manipulated in all three planes. The distal ends of the connectors are fixed into the heads of polyaxial screws inserted into the iliac bones, segmental contraction and distraction are performed between the connectors, achieving correction of the pelvic tilt. The final tightening and fixation of the connectors is carried out. Decortication of the posterior elements of the spine is carried out; the auto-bone obtained during the formation of transpedicular canals is fragmented, supplemented with an allograft based on hydroxyapatite and laid along the elements of the metal structure, forming a posterior spinal fusion. A vacuum drainage system for the wound is installed through the counter-aperture, the wound is sutured in layers and an aseptic bandage is applied.

EFFECT: method provides multi-planar correction of pelvic tilt and allows for independent correction of deformation of the thoracolumbar spine and spatial orientation of the pelvis through the use of two pairs of open lateral connectors on each side, which makes it possible to achieve stability of the spinopelvic fixation, eliminating the need to stabilize the anterior column of the spine.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, neurosurgery, vertebrology, and can be used to correct the spatial orientation of the pelvis in children with neuromuscular and syndromic scoliosis.

Violation of the spatial orientation of the pelvis is a common consequence of neuromuscular diseases, including cerebral palsy and neuromuscular scoliosis that develops against its background. Syndromic scoliosis includes spinal deformities that occur due to spinal cord injury; motor neuron disorders, spinal muscular atrophy; muscle fiber disorders, Duchenne muscular dystrophy, spina bifida; and many other neuropathic and myopathic conditions. Treatment of patients with pelvic distortion due to neuromuscular scoliosis requires spinopelvic fixation. There are two technologies of spinopelvic fixation that can provide spondylosis in neuromuscular scoliosis: L-Rod or Unit Rod fixation with rods according to the Luque method in combination with the original method of pelvic fixation according to the Galveston method, and segmental fixation with screws and hooks according to Cotrel-Dubousset . A combination of these, including lumbar screws and iliac screws, is used as a method of pelvic fixation in the correction of neuromuscular deformity of the spine to increase strength. (Michael W. Peelle, MD, Lawrence G. Lenke, MD, Keith H. Bridwell, MD, and Brenda Sides, MA. Comparison of Pelvic Fixation Techniques in Neuromuscular Spinal Deformity Correction: Galveston Rod Versus Iliac and Lumbosacral Screws. SPINE Volume 31 , Number 20, pp. 2392-2398). The Luque - Galveston technique was the “gold standard” in the treatment of neuromuscular deformities of the spine accompanied by pelvic distortion. The rods were fixed to the lumbar and thoracic spine using a sublaminar wire loop. The introduction of the Galveston technique in the 80s of the last century significantly improved the results of surgical treatment for extended fixations with spinopelvic fixation. (The Galveston technique for L-rod instrumentation of the scoliotic spine. Spine (Phila Pa 1976). May-Jun 1982; 7(3): 276-84.) Inserting rods into the iliac bones and using them as an area of fixation and support became a breakthrough in the development of spinopelvic fixation methods. The main disadvantages of the spinopelvic fixation technique in patients with neuromuscular deformity of the spine using original Galveston rods installed in the wings of the iliac bones, according to radiological follow-up in the postoperative period, were: the formation of zones of bone tissue resorption, the formation of zones of bone tissue resorption of more than 2 mm at the locations of the fixing rod. The problem is a consequence of micromobility of the rods in the iliac bones at the implant-bone interface with subsequent destabilization of metal fixation. In addition, bending the rods correctly is a technical challenge. This problem was partially solved with the advent of the Unit Rod system (1983) for children with neuromuscular scoliosis, through the use of a pre-curved rod. (D F Bell, S F Moseley, J Koreska (1989). Unit Rod Segmental Spinal Instrumentation in the Management of Patients with Progressive Neuromuscular Spinal Deformity. Spine, 14(12), 1301-1307.). However, this did not solve the problem of the formation of bone resorption zones.

The technology of pelvic fixation was further developed later with the use of screws inserted into the sacrum and wings of the ilium. Techniques using screws for pelvic fixation have avoided complex lumbosacral three-dimensional bending of the rod and minimized implantation complications. Correction of neuromuscular deformities with severe pelvic obliquity, which uses fixation elements only up to the sacrum, does not provide adequate stabilization and sufficient leverage for effective corrective maneuvers. Further development of spinopelvic fixation using a T-shaped arrangement of metal structures made it possible to achieve adequate stability.

In known methods of pelvic fixation, only the tilt of the pelvis in the frontal plane was eliminated, in the absence of pelvic mobility in the sagittal plane, which, in turn, in patients with neuromuscular deformity of the spine reduces the stability of the vertical posture.

A device is known for fixing a part of the thoracic and/or lumbar spine of a person to the pelvis, which includes an assembly of a plurality of fixing elements located one above the other, and at least one rod or wire connecting these fixing elements, as well as a device for attaching assemblies to the pelvis. The device for attaching the assembly to the pelvis includes at least one supporting fixing element, which is an extended body having a recess extended along the length of the extended body, the supporting fixing elements are made on the basis of a previously made three-dimensional model of the pelvis and the lumbosacral spine on based on computed tomography. The contact surface of the recess is intended to contact at least part of the outer and inner surfaces of the iliac wing and at least part of the iliac crest. The device is intended for operations performed from the dorsal approach, mainly for performing spinopelvic fixation, subject to maximum safety and ensuring maximum stability of the spinopelvic fixation. Use is indicated for violations of spinopelvic stability, supporting function of the pelvis, including neurogenic scoliosis, deformities due to neurofibromatosis, congenital scoliosis, tumors and developmental anomalies of the spine and pelvis (RF Patent No. 2585733). We took this method as a prototype.

The objective of the invention is to develop a method for surgical correction of pelvic tilt in children with neuromuscular and syndromic scoliosis.

The technical solution to this problem is to restore the frontal and sagittal balance of the torso by performing multiplanar correction of the pelvic tilt and independent correction of the deformity of the thoracolumbar spine to increase the stability of the vertical posture.

The essence of the method is the use of two pairs of open polyaxial lateral connectors, which makes it possible to create a multiaxial system that combines the presence of a lever and degrees of freedom to carry out effective corrective maneuvers of the spatial orientation of the pelvis. The proposed method allows for maximum correction of the scoliotic curve of the thoracolumbar spine above the pelvic fixation, as it gives independence to the spinal and pelvic metal structures, allowing for correction of the spatial orientation of the pelvis due to a greater number of degrees of freedom. To obtain greater pelvic mobility, we proposed using extended facetectomy at the L3-L4-L5-S1 levels. Facetectomy is performed using high-tech equipment - the Misonix ultrasonic bone scalpel, which reduces intraoperative blood loss. Pelvic fixation is performed by inserting two pairs of screws on each side into the wings of the ilium. The use of two pairs of open polyaxial lateral connectors and two pelvic screws in all clinical examples avoids fixation of the anterior supporting column, reducing the duration of surgery. Correction of pelvic tilt is carried out by performing step-by-step contraction, distraction and rotation at the level of each connector. An additional advantage of the proposed method of pelvic fixation is its modularity. Open polyaxial lateral connectors made it possible to create two movable hinges on each side with the ability to manipulate the pelvis in three planes. Preliminary modeling of the connectors allows you to set the required amount of lumbar lordosis and correct the pelvic tilt.

Performing spinal and pelvic fixation using the traditional Cotrel-Dubousset technique in children by performing posterior spinal and pelvic fixation using two pairs of open polyaxial lateral connectors and using ilium screw fixation as a means of spinopelvic fixation, represents an alternative to the Galveston technique with comparable effectiveness and safety. The use of two screws in each iliac wing resulted in fewer implant-related complications than the use of one screw in each iliac wing, which we hypothesize is due to increased strength and stiffness of the overall construct. (Jonathan N Phillips, James P Gutheil, D Raymond Knapp Jr. Iliac screw fixation in neuromuscular scoliosis. Spine (Phila Pa 1976. 2007 Jun 15; 32(14): 1566-70.)

The method is carried out as follows. At the stage of preoperative preparation, computed tomography, MRI, radiography with functional tests are performed. The length of the metal structure to achieve a given correction is determined in advance during preoperative planning in such a way as to achieve an equilibrium state of the sum of all curves of the spine and improve spinopelvic parameters in the sagittal and frontal plane. The operation is performed with the patient in the prone position. After treating the surgical field three times, under anesthesia and under the control of intraoperative neuromonitoring, a linear skin incision is made along the line of the spinous processes of the thoracolumbar vertebrae. An electric knife is used to cut through the subcutaneous fat down to the fascia. Retractors are installed. The fascia is incised to the supraspinous ligament. Using a rasp on the right and left, access is made to the posterior elements of the spine to the articular processes. Having gained access to the posterior elements of the spine, transpedicular screws are inserted into the vertebral bodies under the control of the Stealth Station navigation system. Along with Stealth Station navigation, the O-arm system is used, which is a mobile computed tomograph. Allowing 2D fluoroscopy and 3D imaging for adults and children, providing 3D visualization of the patient's spine in the operating room. Screws are installed on the right and left transpedicularly at the levels of planned metal fixation, then the screws are passed through the posterior superior iliac spine into the iliac bones towards the greater sciatic notch on both sides. During the formation of all transpedicular canals, neuromonitoring is performed in the nerve proximity mode, in order to avoid dangerous proximity of transpedicular screws to neural structures. Instrumental palpation of transpedicular canals at all levels in order to exclude screw malposition. Next, at the L3-L4-L5-S1 levels, an extended facetectomy is performed using a Misonix ultrasonic bone scalpel. A pre-curved rod according to the spinal deformity is placed on the screws in the thoracolumbar spine on the right and left. The rod is partially fixed with nuts. Correction of scoliotic deformity is performed using a derotational maneuver to form kyphosis and lordosis close to physiological. After monitoring in 2-D mode using the O-arm visualization system, confirming the stability of fixation and satisfactory correction of the sagittal balance, the final fixation of the supporting elements to the rod with nuts is performed. After final fixation of the thoracolumbar spine deformity. At the level of the L4 vertebra, connectors are fixed to the rod laterally on each side, connected end to side due to the presence of polyaxial heads at the ends. It must be taken into account that fixation of the L5 vertebra in conditions of hyperlordosis reduces pelvic mobility due to the close location of the screw heads on the rod. The distal ends of the connectors are fixed into the polyaxial heads of the pelvic screws. Segmental contraction and distraction are performed between the connectors, thus achieving spatial correction of the pelvic tilt. After achieving correction of the pelvic tilt, the final tightening and fixation of the connectors is performed. After final fixation with nuts, the entire structure acquires rigidity and stability. Then the posterior elements of the spine are decorticated. The resulting autologous bone is supplemented with an allograft based on hydroxyapatite and laid along the elements of the metal structure to form a posterior spinal fusion. Carry out control of hemostasis, revision and toilet of the surgical wound. The wound is drained through the counter-aperture with the installation of a vacuum wound drainage system. The wound is sutured in layers and an aseptic bandage is applied.

The department performed 12 surgical interventions using this method of surgical correction of pelvic tilt.

Clinical example of the method.

Patient B., 16 years 6 months, ill since birth. Progressive deformity of the thoracolumbar spine. In February 2020, selective dorsal rhizotomy was performed at the National Medical Research Center of Neurosurgery named after. Burdenko. Regularly receives rehabilitation courses at his place of residence and in rehabilitation centers. To conduct a rehabilitation course, he was admitted to the department of diagnostics and rehabilitation treatment of children with psychoneurological pathology at the National Medical Research Center for Children's Health, where the child underwent a pre-examination. For antispastic purposes, the child received injections of botulinum toxin type A under ultrasound control into the target muscles of the limbs using the drug Dysport. Due to severe scoliotic deformity of the spine, the child underwent a CT scan of the thoracic cavity and spine, the results of which revealed a CT picture of left-sided scoliosis of the lumbar spine with compensatory deviation of the axis of the thoracic and cervical spine, disturbances in the static function of the thoracic and lumbar spine, the presence of pronounced pelvic distortion at an angle of 32°. The photographs show the appearance of the patient before surgical treatment (Fig. 1A, Fig. 1B, Fig. 2A, Fig. 2B, Fig. 3). In FIG. 2A and Fig. 2B, the arrows indicate a pointed rib deformity, which was eliminated after correction of the spinal deformity. Fig. 4A and FIG. 4B x-ray of the thoracolumbar spine in a direct projection before surgery: the main right-sided arch in the lumbar spine is over 130° and the pelvic obliquity is over 30°, which prevented sitting in a stable position. The diagnosis was made: “Neurogenic left-sided lumbar scoliosis, stage IV. Secondary deformation of the chest with dislocation of internal organs.” Surgical intervention was performed: dorsal correction and fixation of spinal and pelvic deformities using a multiaxial metal structure under the control of intraoperative monitoring and CT navigation. In the conditions of the neuro-orthopedic department with orthopedics of the National Medical Research Center of Health of the Ministry of Health of the Russian Federation, an operation was performed in the following volume: A linear skin incision was made along the line of the spinous processes of the Th2-L5 vertebrae. Hemostasis. An electric knife was used to dissect the subcutaneous fat down to the fascia. Hemostasis. Retractors installed. The fascia is incised to the supraspinous ligament. Using a rasp on the right and left, access was made to the posterior elements of the spine to the articular processes, and tight packing was done with napkins. Hemostasis. Through the roots of the arches into the vertebral bodies on the left Th4, Th 5, Th6, Th7, Th10, Th11, Th12 L1, L2, L3, L4, L4, under the control of CT navigation. transpedicular screws were inserted. On the right at the level of Th4, Th 5, Th6, Th7, Th10, Th11, Th12 L1, L2, L3, L4 under the control of CT navigation. transpedicular screws were inserted. During the formation of all transpedicular canals, neuromonitoring was performed in the nerve proximity mode. No dangerous proximity to neural structures was recorded. Instrumental palpation of transpedicular canals at all levels of formed transpedicular canals, bone walls. Image intensifier control, screw position is correct. A bed for screw implantation was made symmetrically in the wings of the iliac bones using Luer cutters. An extended facetectomy was performed at the L3-L4-L5-S1 levels. Facetectomy was performed using a Misonix ultrasonic bone scalpel. On the right, two screws were inserted through the crest of the iliac wing; on the left, two screws were inserted through the crest of the iliac bone. A rod is placed on the screws in the thoracic and lumbar spine on the left at the level Th3 - L4, pre-bent according to the deformation of the spine, pre-fixed with nuts. On the screws on the right in the thoracic and lumbar spine at the level of Th3-L4, a rod is placed, pre-bent according to the deformation of the spine, pre-fixed with nuts. After preliminary fixation of the fixing rods, a derotational maneuver was performed, the rod was rotated 30°. The scoliotic curve in the thoracic and lumbar spine was corrected, and a sagittal profile of the spine close to the physiological one was formed. Final fixation of the rods with nuts. Image intensifier control, a satisfactory degree of correction of spinal deformity was obtained, the position of the metal structure elements was satisfactory. Next, using two pairs of open lateral connectors, spinopelvic fixation was performed. Exposed connectors are pre-modeled using a rod bender. Preliminary fixation of open lateral connectors. Using levers, the pelvic version and pelvic tilt were corrected. Moderate contraction was given on the right, distraction on the left. The position of the pelvis is correct, the distortion has been eliminated. Final fixation of the exposed lateral connectors was performed. Additionally, transverse ties are installed. The resulting autologous bone was fragmented during the formation of transpedicular canals and placed on the decorticated posterior elements of the spine. Posterior spinal fusion is supplemented with an allograft. The soft tissues are sutured in layers with interrupted sutures. The skin is sutured with a continuous intradermal suture. The active wound drainage system is functioning. Aseptic dressings. Fig. 5A, Fig. 5B, Fig. 5B shows the patient's appearance after surgery. The red arrow marks the location of the rib deformity, which was completely eliminated after surgical treatment. According to X-ray data after surgery: frontal projection (Fig. 6A) and lateral projection (Fig. 6B), the position of the implants is satisfactory. A pronounced clinical and radiological effect was noted in the form of correction of spinal deformity and pelvic tilt. The angle of residual scoliotic deformity after surgical treatment was 28° according to Cobb. The correction was 75° or 72%. The residual pelvic tilt angle was 2° according to Cobb. The patient was verticalized on the 3rd day.

Using the method allows for multi-planar correction of pelvic tilt and independent correction of thoracolumbar spine deformity and spatial orientation of the pelvis through the use of two pairs of open lateral connectors on each side, which makes it possible to achieve stability of the spinopelvic fixation, eliminating the need to stabilize the anterior column of the spine.

Claims (1)

A method for surgical correction of pelvic tilt in children with neuromuscular and syndromic scoliosis, including pelvic fixation, correction of deformity and fixation of the vertebrae using a transpedicular system, characterized in that access is provided to the posterior elements of the spine to the articular processes, then transpedicular insertion of screws into the bodies is performed vertebrae under the control of the Stealth Station navigation system, for which screws are installed on the right and left transpedicularly at the levels of the planned metal fixation, then polyaxial screws are inserted through the posterior superior iliac spine into the iliac bones towards the greater sciatic notch on both sides, then at the levels L3-L4- L5-S1 facetectomy is performed using an ultrasonic bone scalpel “Misonix”, for which a pre-curved rod along the spinal deformity is placed on the right and left side of the screws in the thoracolumbar spine and fixed with nuts; the scoliotic deformity is corrected using a derotational maneuver, forming kyphosis and lordosis , then, under the control of the visualization system to confirm the stability of the O-arm fixation in 2-D mode, the final fixation of the supporting elements to the rod with nuts is performed, then at the level of the L4 vertebra, connectors are fixed to the rod laterally on each side, interconnected end to side, due to the presence at the ends of the polyaxial heads, the position of the pelvis in space is manipulated in all three planes, the distal ends of the connectors are fixed into the heads of the polyaxial screws inserted into the iliac bones, segmental contraction and distraction are performed between the connectors, achieving correction of the pelvic tilt, then the final tightening and fixation of the connectors is performed; Next, decortication of the posterior elements of the spine is performed, obtained during the formation of transpedicular canals, the autologous bone is fragmented, supplemented with an allograft based on hydroxyapatite and laid along the elements of the metal structure, forming a posterior spinal fusion, a vacuum drainage system for the wound is installed through the counter-aperture, the wound is sutured in layers and an aseptic bandage is applied.