RU2147844C1 - Method for treating damages of the vertebral column aggravated with spinal disorders - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves treating fresh cases in making concurrently reposition of dislocated vertebrae and bone fragments, and Urban wedge transposition in early period beginning from the trauma moment. The inveterate cases are treated by removing vertebrae dislocations in postoperative period in applying gradual controlled correction. Anterior spondylodesis is carried out in the cases of splintered fractures of the vertebral column without interrupting vertebral column fixation in a device outside the focus. EFFECT: prevented development of the secondary cicatricial commissural process in the vertebral canal. 2 cl, 5 dwg

Description

 The invention relates to medicine, namely to vertebrology and neurotraumatology, and can be used in the treatment of spinal injuries complicated by spinal disorders.

 The main problem in the treatment of patients with spinal fractures complicated by spinal disorders is the full decompression of the spinal cord and its structures, on the one hand, and on the other, reposition of vertebral fragments with restoration of the anatomical structure of the damaged segment of the spine and stable fixation of this department for the period necessary for the formation full bone block.

 Due to the lack of perfect repair devices and reliable fixators, as well as operative reception in stale and especially old cases, often spinal cord decompression, usually performed from posterolateral access and including resection of the Urban wedge, ends with spinal fusion in the position of unrepaired displacement of damaged vertebrae. Therefore, despite the positive dynamics in the restoration of spinal cord function, the formation of orthopedic inferiority of the spine in the form of the development of secondary degenerative-dystrophic changes, functional insufficiency and, in connection with this, increase in neurological deficit is in parallel.

A known method of open decompression of the spinal cord in patients with spinal fractures with spinal disorders, which consists in the resection of the wedge of Urban, protruding into the spinal canal and compressing the spinal cord. For this, it is necessary to remove half or the entire arch of the broken vertebra and then resect for a considerable extent the entire back of the broken vertebra in order to restore the patency of the spinal canal. (Reference book - Neurotraumatology; under the editorship of Acad. Konovalova AN and others, Institute of Neurosurgery of the Russian Academy of Medical Sciences, - CPI, "VAZAR-FERRO", M., 1994- p. 243-244.)
The disadvantages of the method are the high morbidity of surgical admission, which consists in extensive resection of the bone tissue of the vertebrae to form a new bed for the spinal cord, which leads to a large loss of blood. In this case, all the tissues lining the spinal canal are destroyed, and the spongy bone is exposed for a large length, which subsequently leads to the development of scar-adhesive processes in the spinal canal. The surgeon performing a resection of the Urban wedge confirms this impossibility of eliminating kyphotic deformity of the spine at the level of damage and is forced to undergo spinal fusion in the position of unresolved vertebral displacement, which necessarily leads to the development of secondary degenerative-dystrophic changes in adjacent segments of the spine.

 For chronic vertebral fractures and dislocations for decompression of the spinal cord, the bodies of the vertebrae compressing the brain are resected, followed by their replacement with a bone graft (Handbook - Neurotraumatology; edited by Acad. Konovalova AN and others; Institute of Neurosurgery RAMS, - CPI, "VAZAR-FERRO", M., 1994- p. 243-244). At the same time, the invasiveness of the operation and its volume increase even more than in recent cases. Despite the increase in the volume of surgical intervention for chronic injuries, it is impossible to immediately eliminate compression of the spinal cord and achieve full recovery of the shape of the spinal canal and its functions. After the operation, patients for a long period (up to 3 months) are forced to observe bed rest.

 The task is to reduce trauma, reduce blood loss, prevent scarring and adhesions in the spinal canal and secondary degenerative-dystrophic changes in adjacent segments of the spine, as well as reduce the treatment time, is solved as follows.

 Decompression of the spinal cord with the restoration of the shape of the spinal canal and stabilization of the spine is carried out, according to the invention, in a closed manner using an extra focal device by displacing bone fragments and vertebrae at the same time and / or in a controlled manner, rigidly fixing them in the extra focal device, while simultaneously eliminating them with compression and distraction efforts spinal deformity, and a closed transposition of the Urban wedge is performed, and controlled correction is carried out with a distraction rate of 1-2 mm s per day. In comminuted vertebral fractures, both fresh and old, with significant destruction of the vertebral body after performing closed decompression of the spinal cord, without stopping fixation in the extrafocal device, anterior corporodesis of damaged vertebrae is performed with bone autografts.

 The use of extra focal devices due to their properties — low trauma, strong fixation and high reponizing properties, successfully proved on the basis of the Ilizarov principle in other sections of traumatology, allows for closed decompression of the spinal cord, eliminates all types of displacement of fragments and vertebrae in patients with different severity of the spinal column injuries. In stale and old cases, the removal of vertebral displacement is performed in the postoperative period by means of gradual controlled correction with the application of distraction and compression efforts with a distraction rate of 1-2 mm once a day, which allows achieving high efficiency and decompression of the spinal cord with restoration of the shape of the damaged spine and forms of the spinal canal. The use of closed decompression of the spinal cord significantly reduces operational blood loss.

 Repositional manipulations with the application of compression-distraction efforts to adjacent parts of the spine and the closed transposition of the Urban wedge allow you to change the position of the vertebrae (segments) until the shape of the damaged spine and the shape of the spinal canal is completely restored without the need for resection, which prevents the development of secondary degenerative-dystrophic changes, functional spinal insufficiency and in this regard, an increase in neurological deficit. The implementation of anterior corporodesis of damaged vertebrae with bone autografts with rigid fixation of the spine in an extra focal device eliminates the crushing of spongy autografts and contributes to their rapid increment to vertebral bodies and functional restructuring. All this leads to a reduction in the treatment of patients.

 Closed decompression of the spinal cord is indicated in patients with unstable spinal fractures with a clinic for damage to the spinal cord and ponytail according to the type of partial violation of spinal cord conductivity in the form of segmental motor and sensory disturbances and disorders of the function of the pelvic organs.

 Contraindications for surgical treatment is the presence of pyoderma at the site of the alleged imposition of the apparatus. The presence of pressure sores in the repair stage in remote places from the zone of application of the extrafocal osteosynthesis apparatus is a relative contraindication.

 The method is as follows.

 Surgery is performed in one or two stages. The first stage involves closed decompression of the spinal cord by eliminating the displacements of bone fragments and dislocations above and below the lying vertebrae. To do this, eliminate kyphotic deformation at the level of the damaged vertebral body or vertebrae, subluxation of the body of the overlying vertebra and displacement of the broken vertebra. The described spinal deformity resulting from a fracture essentially represents the so-called presence of a wedge of Urban (Reinberg S.A., Radiodiagnosis of diseases of bones and joints, p. 96).

 Repositional manipulations are carried out in an off-focal device, for example, the design of UNIITO (Fig. 1 - general view of the device). With its help, all types of displacement of fragments are closed in a closed way without direct open intervention on the elements of the spinal canal with fixation of the spine until the fracture is fused.

 The device for extra focal osteosynthesis of the spine consists of supporting elements in the form of arched plates 1 (the base of the device) with longitudinal slots 2, in which threaded rods 4 are attached through expansion washers 3 (4). The rods 4 are fixed so that one base plate fixes two adjacent vertebrae. The support plates 1 through the brackets 5 are interconnected by a long longitudinal rod 6, consisting of two parts connected by a hinge 7 and short side rods 8. The screw rods 6 and 8 are connected to the brackets 5 through expansion washers 9.

 To carry out manipulations on damaged structures of the spine, the rods are inserted into the vertebral bodies transpedicularly, using classical points or using the technology developed by the authors directly in the vertebral bodies and in the spinous process (Pat. N 2058757 publ. 04/27/96, bull. N 12).

 Compression-distraction efforts eliminate kyphotic deformation of damaged segments of the spine. Manipulating the bases 1 of the extrafocal device, the vertebrae are moved relative to each other in the sagittal and frontal planes (Fig. 2a, 2b). To do this, create distraction forces on the side rods 8 and compression forces on the middle link 6.

 Having achieved distraction efforts in the device at the first stage of reposition and eliminating kyphotic deformity and subluxation of the overlying vertebra anteriorly, they begin to reduce the posterior displacement of the body of the compressed vertebra into the lumen of the spinal canal. The body of the damaged vertebra is moved anteriorly, creating distraction forces on the rods 4 inserted into the vertebra, with respect to the support plate 1 (Fig. 3a, 3b). A different distraction force applied to the right and left rods, introduced transpedicularly, eliminates the rotational component of the displacement of the body of the broken vertebra. After achieving a reduction in the displacement of the vertebral body, the rods 4 are rigidly fixed to the support plate 1.

 The complete simultaneous elimination of all types of displacement of vertebral fragments is advisable in fresh cases, no later than ten days after the injury. During these periods, the reposition of the fracture is usually easy and allows you to immediately achieve the desired result. In later cases, simultaneous reposition of fractures is difficult due to the formation of primary cicatricial ties by this time. The displacement of a broken vertebra in the direction of the spinal canal due to damage to the underlying disc is always possible at the same time in the operating room. Correction efficiency is monitored by the monitor of an X-ray electron-optical converter.

 Fracture reposition and elimination of vertebral displacement in stale and old cases are performed in the postoperative period by means of gradual controlled correction. For this, distraction-compression efforts, similar to those described for simultaneous reposition, a fracture is applied to the base supports 1 of the device of extra focal osteosynthesis once a day with a distraction rate of 1-2 mm.

 The final effectiveness of the reposition and decompression of the spinal cord is monitored by x-ray examination in standard spinal placement and myelography with omnipack. The dynamics of the regression of neurological symptoms is monitored according to clinical examination and staged electroneuromyography. According to a clinical examination, the restoration of lost motor functions begins from the first hours after surgery to several days.

 In relation to patients with chronic spinal fractures with spinal disorders, Ilizarov’s law on the effect of compression-distraction efforts on the repair of bone, connective and nervous tissue is fully applicable. In these cases, distraction efforts and strong fixation of the vertebrae in the extrafocal device allows obtaining bone regenerate at the site of a broken vertebra and the formation of an induced bone block. The well-known beneficial effect of distraction on scar tissue in the form of their softening and plasticity and slow controlled distraction allow avoiding aggravation of the neurological picture, as is the case when applying methods of open simultaneous elimination of chronic displacement of the vertebrae. Fixation in the extra focal device is continued until a strong bone block is formed at the site of damage.

 All spinal fractures complicated by spinal disorders are unstable, especially in the cases of comminuted or so-called explosive fractures, therefore, in some cases, for firm fixation of the damaged segment of the spine and acceleration of the fusion period, it is necessary to perform anterior spinal fusion. Anterior spinal fusion is performed in the classical way with ongoing rigid fixation of the spine in an extra-focal device. When performing surgery during discectomy, additional scooping of hernial protrusions or removal of osteophytes of the posterior edges of the vertebral bodies with sharp spoons is possible. The need for this action is determined by previously conducted radiopaque studies. The spongy bone of the wing of the pelvis is used as an autograft. An autograft is taken from a section of the general operational access or from an additional section.

 The use of extra focal devices greatly facilitates patient care. The injured begin to walk under the guidance of an exercise therapy practitioner using crutches (stilts) and orthopedic devices (express tutor for the lower limbs made of polyvic or standard orthopedic tires) on the third day after the first stage of the operation and on the fifth and seventh days after anterior fusion. Active management of the patient in the postoperative period, such as early getting up and walking, dressings taking into account the course of the wound process, creates conditions for the rapid repair of pressure sores, if patients come with such trauma in stale cases, and prevent the appearance of new ones.

 Early activation of patients and training in walking with crutches or orthopedic devices favorably affects the psychoemotional background of the victims, creating an active motivation for the patient to recover, and also significantly prevents the development of complications associated with physical inactivity, such as pressure sores, hypostatic changes in the lungs, and passage disorders urine and bowel function.

 The active management of patients and the simplicity of caring for an extra focal device allows patients to be transferred within a period of more than two weeks from the moment of the second stage of the operation to outpatient treatment in the community.

 Dismantling of the apparatus and removal of the rods from the vertebrae is carried out under intravenous anesthesia in the presence of radiological signs of fusion between the vertebrae at the level of fusion. Usually this period is 2-3 months from the moment of the operation of the anterior fusion. Sanitize the skin at the places of removal of the rods and for 3-4 days make a removable corset from polyvic or use ready-made orthopedic products for walking.

 Thus, the proposed method for the treatment of spinal injuries complicated by spinal disorders is less traumatic, allows you to completely restore the anatomical structure of the damaged segment of the spine and the shape of the spinal canal, which significantly improves the quality and effectiveness of treatment for victims, allows early activation of patients and significantly reduces treatment time.

 Example. Patient I., and.b. N 87751, was admitted to the vertebrology department of UNIITO 13 days after the injury, falling from the height of the third floor, with complaints of pain in the lumbar spine, urinary retention and stool, weakness in the lower extremities, the inability to actively extend the right lower limb. When examining the patient revealed kyphotic spinal deformity at the level of the spinous process of the first lumbar vertebra, pain. Loss of function of the quadriceps muscle of the right thigh, hypesthesia in the innervation zone L3 on the right. The knee reflex on the right is absent, the knee reflex on the left and the achilles reflex on the right are reduced. The patient performed an MRI scan. Identified vertebro-medular conflict of the III century, post-traumatic spinal cord gleosis at the level of D11-D12.

 Diagnosis: comminuted unstable fracture of the L1 vertebral body, damage to the L1 - L2 disk, retrosthesis of the L1 vertebral body, partial violation of spinal cord conductivity, pelvic disorders. Vertebromedicular conflict of the III art.

 Due to somatic contraindications (otitis media), the patient underwent surgery within one month after the injury. Operation - extrafocal osteosynthesis of the spine by an external fixation apparatus, reposition of a vertebral fracture L1, closed decompression of the spinal cord. The shape of the spinal canal has been restored, the ratio of the height of the broken vertebral body to the height of the intervertebral discs. A slight displacement of the Th12 vertebral body anteriorly was eliminated by gradual controlled distraction in the postoperative period. The rate of distraction is 1 mm per day. A regression of neurological symptoms was achieved: the function of the pelvic organs was restored, a good restoration of the function of the quadriceps of the right thigh. Slight hyposthesia in zone L3 on the right.

 Given the nature of an unstable spinal fracture, in order to accelerate the time of fusion and stabilization of the damaged spine, anterior spinal fusion of Th12-L1, L1-L2 vertebrae was performed with an autograft from the ilium wing one month later.

 Fusion of the L1 fracture was achieved and the bone block Th12 - L1-L2 was formed. There is no loss of correction in the long term. The shape of the spine and spinal canal is fully restored. This is also confirmed by an MRI scan. There is a complete regression of neurological disorders. The function of the right lower limb is fully restored. The patient is able to work.

Claims (2)

 1. A method for the treatment of spinal injuries complicated by spinal disorders, including decompression of the spinal cord with restoration of the shape of the spinal canal by eliminating the Urban wedge and stabilization of the spine, characterized in that they produce closed decompression of the spinal cord at the same time or gradually with a dosed correction and stabilization of the spine using an extra focal device by applying compression-distraction efforts to adjacent parts of the spine and closed transposition of the Urban wedge with JCOMM extrafocal fixation of the device.  2. The method according to claim 1, characterized in that, with significant destruction of the body of the damaged vertebrae after performing closed decompression of the spinal cord using an extra focal device, without stopping the fixation of the spine, anterior corporodesis of the damaged vertebrae is made with bone autografts.

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