UA34754A - Method for surgical treatment of penetrating backbone fractures - Google Patents

Abstract

The invention relates to the medicine. The method for the surgical treatment of the penetrating backbone fractures provides for the formation of the internal canal in the bones and the use of the implants for the bone fusion in the vertebrae. The tunnel to the intervertebral disk is formed through the pedicle of vertebra. The disk and the adjacent hyaline plates are destroyed. The recess under the lower edge of the transverse process serves as the reference point for cutting the tunnel.

Description

The proposed invention relates to medicine, in particular to orthopedics and traumatology, can be used to treat instability of vertebral segments, uncomplicated and complicated spinal fractures.

The result of a severe injury to the spine is a wedge-shaped deformation of the vertebra, damage to the intervertebral disc, and a violation of the axis of the spine. The following degenerative changes of the fibrous ring and the nucleus pulposus in the injured disc always lead to a violation of the bearing capacity of the vertebral segment, the appearance of instability, which is characterized by its excessive deformity and leads to irritation of pain receptors: ligaments, capsules, arcuate joints. Weakening of the injured area of the intervertebral disc, subsequent degeneration causes protrusion and instability.

The goal of surgical treatment of such patients is to eliminate disc protrusion and stabilize the spinal segment.

Known methods of surgical treatment of penetrating fractures of the spine (A. s. USSR Mo 1042738. and s. USSR Mo 1568993), which include, as one of their elements, posterior surgical access to the spine, exposure of the vertebral arches, stabilization of the segment with a metal structure, introduction of chondrolytic enzyme into the intervertebral disc or crushed demineralized bone matrix (DBM) to form a fibrous or bone interbody block.

The disadvantages of these methods are as follows: 1. Danger of injury to segmental vessels with the formation of an extraperitoneal hematoma. 2. During percutaneous disc puncture, the thinned edges change the topographical and anatomical relationships of the tissue, which complicates the manipulation. 3. A low percentage of bone interbody block formation, and the formed interbody fibrous block does not provide stability. 4. The use of chondrolytic enzymes can cause severe allergic reactions, aseptic inflammation of the intervertebral disc and, as a result, nonspecific spondylitis. 5. Danger of damage to the root and accompanying vessels during puncture of the disc from the wound.

A known method of surgical treatment of penetrating fractures of the spine by means of anterior corporodesis through the base of the bracket (Atoii MU. (1985): Oregaime EpNrepapapu tii det Rihaieiig ehiette bei (gaitaiisnpeg

Opegesppiiviaaptypo. Wei. Opposition Ttashtay!. 32, 6-14).

The indicated method is the closest to the proposed one and we chose it as a prototype.

The prototype method is implemented as follows. Under anesthesia, posterior access to the spine is performed, the spinous processes, brackets are exposed, and the transverse process is cut off on one side. At the base of the bracket on the posterior-lateral surface of the body of the vertebra, a hand drill is used to form a channel directed upward and inward at an angle of 45". The channel passes through the body of the broken vertebra, through the injured intervertebral disc and ends in the body of the upper vertebra. Cortical spongy is introduced into the formed channel transplant. In this way, spinal cord decompression and anterior corporeodesis are performed. The transplant is taken from the pelvic wing. If necessary, internal fixation with metal plates is performed. The wound is sutured in layers.

The prototype method due to the tunneling (fenestration) of the intervertebral disc and the partial removal of the nucleus pulposus ensures its decompression, that is, it leads to the elimination of intradisc pressure and, accordingly, disc protrusion.

Thanks to this, the pain syndrome associated with the irritation of the receptors of the outer layers of the fibrous ring and the posterior longitudinal ligament is eliminated. The graft connecting the bodies ensures further formation of the interbody bone block, restores resistance and stabilizes the anterior support complex. All this provides a therapeutic effect.

The prototype method has clear advantages compared to methods of open surgical decompression and anterior corporodesis. The prototype method also has advantages over puncture methods of decompression and corporodesis. 1. The traumatic nature of the intervention is significantly reduced. operative blood loss and risk of surgical intervention. 2. The development of postoperative epidural fibrosis and cicatricial stenosis of the spinal canal is excluded. 3. Better conditions are created for the formation of a bone block, the graft comes into direct contact with the bone bed, partially capturing the disc as well.

However, the prototype method has significant drawbacks that reduce its effectiveness and narrow the scope of its application: 1. Due to the anatomical features of the spine (the location of the spinal nerve and large vessels along the back-side surface of the body of the vertebra and the disc), there is a great danger of their injury. 2. Graft removal causes additional trauma. 3. The great depth and sharp angle of the surgical wound do not always allow to follow the recommended direction of the instrument, as well as to use the method in obese patients. 4. Traumaticity and duration of surgery (posterior spondylodesis) significantly increases due to resection of the transverse process.

The purpose of the proposed invention is to restore the support function and eliminate the instability of the injured spinal segment, prevent damage to large vessels and spinal nerves, reduce the trauma of surgical intervention, increase its effectiveness, and prevent the development of traumatic osteochondrosis.

The goal is realized by creating a method of surgical treatment of penetrating injuries of the spine by forming an intra-osseous sofa during posterior access through the leg of the bracket in the direction 10-20" inside and 35-40" cranially through the zone of the nucleus pulposus of the intervertebral disc into the body of the upper vertebra (fig. 1, 2) with subsequent filling of the canal with one of the indicated implants (fig. 3, 4): - cortical-spongy autograft; - demineralized bone homograft; - puncture-crushed cancellous bone autograft; - puncture-PDKM.

The method differs in that the channel in the vertebra passes through the leg of the bracket in the direction of 10-20" inside and 35-40" cranially; the tool that forms the channel passes through the bone tissue of the body of the vertebra, the zone of the nucleus pulposus of the intervertebral disc and the body of the upper vertebra. After removing the drill, the canal is filled with puncture-chopped auto- or homo-bone graft using a screw-threaded syringe and a fixing rod made of cortical bone auto- or homo-graft is inserted.

The listed elements and their interrelation constitute the novelty and significant differences of the object that was declared, which together with the known elements ensure obtaining a new positive effect, which consists in safety during the operation, in creating conditions for the formation of an interbody bone block, in the restoration of support function and elimination of spine instability, in the prevention of traumatic osteochondrosis, in increasing the effectiveness of treatment.

The execution of the method is explained by diagrams.

In fig. 1 shows the spine in direct projection, the location of the fossa for transpedicular access.

In fig. 2 shows the lateral projection of the spine, the introduction of a drill with a screw thread 1 through the base of the root of the bracket into the body of the broken vertebra 2. ruptured disc 3, the superior body 4 at an angle of 35-40". The intraspinous path is indicated by a dotted line.

In fig. C shows the introduction of PDCM into the intervertebral disc with a syringe with a helical piston stroke.

In fig. 4 shows the introduction of the fixator graft 5 through the bone channel in the body of the lower and higher vertebrae, through the disc filled with PDCM 6.

The method is carried out as follows. Under endotracheal anesthesia with the patient in the prone position, after appropriate treatment of the operative field, posterior access is performed at the level of the fracture. Skeletal spinous processes and arches of vertebrae. Determine the level of damage. On the right or left, the base of the transverse process of the broken vertebra is exposed. Along the lower edge of the transverse process, near its base, soft tissues are separated with a rasp in the direction of the top of the lower articular process. In the corner between the base of the transverse process and the lower articular process, there is a pit 4x4 mm in size and 1 to 3 mm deep. The size of the fossa can vary, but it was present in all of our observations on lumbar spine blocks. The cortical layer of the bottom of the fossa is perforated with an awl, while the edges of the fossa do not allow the tool to slide along the arch and injure the main vessels adjacent to the vertebra (aorta, inferior vena cava, segmental vessels, spinal nerve exiting from the intervertebral foramen). Through the hole formed by the awl, a hand drill with a diameter of 5-6 mm with markings for the depth of insertion forms a channel in the direction of 10-20" internally and 35-40" cranially. The diameter of the drill and the depth of the channel are determined before the operation on direct and profile spondylograms, taking into account the diameter of the leg of the bracket and the size of the vertebra. The average drill diameter is 5-6 mm. After passing through the cortical layer of the bracket, the drill is easily advanced along the axis of the bracket and in the body of the broken vertebra. The natural angle of the bracket helps to hit the drill in the center or ventral third of the injured intervertebral disc. The strong cortical walls of the bracket leg keep the drill from deflecting out of the intravertebral canal that has been formed by the awl.

Intraosseous access excludes contact of the drill with large vessels and spinal nerves, which are contained in the intervertebral canal, therefore their damage is excluded, the traumatic nature of the operation is reduced.

The passage of the drill through the upper locking plate of the broken vertebra is easily determined due to the increase in resistance during the passage of the tool, the entry of the drill into the upper vertebra is also determined by the increase in resistance to the rotation of the tool. The use of a drill with a screw thread allows you to smoothly transfer rotational movements to translational movements, and the crumpling of the channel walls with a screw thread provides the necessary hemostasis.

Through the formed channel, a special tool can be brought to the disc cavity and destroy the remnants of the disc, the locking plate of the cranially located vertebra, aspirate the contents of the disc.

Through the formed channel, we inject PDKM in the amount of 3 to 5 cm using a syringe with a screw thread into the destroyed disk. depending on the degree of damage to the vertebra. In the case of penetrating shrapnel damage, up to 5 cm3 is injected, while part of the homogenate fills the cavities in the body of the vertebra. With a compression fracture, only the cavity in the disc is filled and about 3 cm3 is injected. The bone matrix has pronounced osteoinductive properties, including in heterotropic conditions, the remains of the destroyed disc are not an obstacle for its bone reconstruction. A rigid demineralized graft or bone chip can be inserted into the canal. Then they perform reclination of the spine, internal fixation with metal plates, posterior spondylodesis with allo- or allografts. The wound is sutured in layers, drained, and closed with an aseptic bandage.

With such a transpedicular tunneling of the disc, the fibrous ring remains intact, which helps preserve the fixing properties of the disc. The reconstructed transplants and the formed bone block of the vertebrae ensure the bearing capacity of the spinal segment and eliminate its instability. Thus, they not only restore the bearing capacity and eliminate the instability of the segment, but also reliably prevent the reduction of the supporting function of the spine in the inflamed postoperative period, prevent the development of traumatic osteochondrosis.

A concrete example of the implementation of the method is given in the extract from the medical history of patient Vasylkovskaya Mo 15188

I. L.

Thus, the proposed method has new elements that significantly differentiate it from the prototype method: 1. The tool is passed through the body of the broken vertebra and the leg of the bracket at an angle of 35-40" cranially and 10-20" inside the damaged disc and the lower locking plate of the superior vertebra 2. The landmark for introducing the tool is the fossa located under the lower edge of the base of the transverse process.

Z. The damaged disk and the locking plates of adjacent vertebrae are destroyed, PDKM is injected into the damaged disk through a puncture. a fixator made of allo- or auto-bone is introduced into the spinal canal during surgery on the back structures of the spine without widening the access. The first element allows you to use intraoperative intraosseous access to the damaged disc, avoid damage to spinal nerves and large vessels located on the back-lateral surface of the vertebral bodies and inside the spinal cord, ensures simplicity and low-traumatic intraoperative puncture of the disc and its manipulation.

The second new element provides a permanent anatomical reference that facilitates the insertion of the instrument into the bone.

The third new element ensures the restoration of bearing capacity and eliminates the instability of the damaged spinal segment, reliable fusion of the vertebral bodies, prevents the reduction of the supporting function of the spine and the development of traumatic osteochondrosis in the distant period.

Until now, the method has been used in the trauma department of the Luhansk Regional Clinical Hospital and the trauma department of the 9th city hospital in five patients. In all five patients who were operated on by the proposed method. the bearing capacity of the damaged spinal segment was restored, the height loss of the broken vertebra and the injured disc did not occur in the long term.

The given data sufficiently confirm the high clinical efficiency and safety of the proposed method in comparison with the prototype. ' 74 chu i, y"

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Claims (1)

The method of surgical treatment of penetrating fractures of the spine by forming an intra-bony canal and intra-discal introduction of implants to obtain bony fusion of the vertebrae, which is characterized by the fact that a tunnel is made through the leg of the bracket into the injured intervertebral disc, the disc and adjacent hyaline plates are destroyed, the guideline for forming the tunnel is deepening under the lower edge of the transverse process.