RU2195220C2 - Method of vertebral column stabilization in cerebrospinal trauma - Google Patents

Abstract

FIELD: medicine, particularly, traumatology, orthopedics and neurosurgery. SUBSTANCE: method includes anterior-lateral spondylosyndesis by bone autograft with transthoracic, extraperitoneal, parapharyngeal approach to injured vertebras. In this case, transthoracic approach is effected by incision of soft tissues above rib with an angle of operative wound inclination relative to vertebral column of 60-70 deg. After surgical intervention, vertebral column is subjected to reclination with the help of cylinder, and graft is prepared to meet shape and sizes of defect space and provided with acute trihedrone at ends. After reclination of vertebral column, graft is introduced with its acute ends into holes of 0.1-0.5 cm deep of adjacent vertebra. Claimed method is used for stabilization of vertebral column with its various diseases at any level in acute period of cerebrospinal trauma. EFFECT: reduced injury to tissues and prevented displacement of vertebras.

Description

 The invention relates to medicine, namely to traumatology, orthopedics and neurosurgery, and can be used to stabilize the spine with its various diseases, injuries at any level, including in the acute period of spinal cord injury.

 A prerequisite for the restoration of reversibly impaired functions of the spinal cord in the acute period of spinal cord injury is the restoration of the normal anatomical shape of the spine and spinal canal with subsequent reliable fixation.

 The generally accepted access to the contents of the spinal canal at the thoracic level is a laminectomy, the essence of which is to remove the posterior wall of the spinal canal, the vertebral arch to the articular processes. At the same time, the angle of inclination of the axis of the operational action to the posterior surface of the spinal cord is 90 degrees. With this access, simultaneous open reduction, revision of the spinal cord, followed by interspinous spinal fusion, are performed. The disadvantage of a laminectomy is the inability to remove the anterior compressing substrate from the posterior approach at the level of the thoracic vertebrae.

 Despite the variety of stabilization methods, fixation of the spine by the type of interspinous spinal fusion does not always allow to maintain damaged vertebrae, especially after a laminectomy of two or more vertebrae (V.V. Kryuchkov, A.A. Lutsik. Surgical treatment of acute spinal cord injury in the chest level. - Novokuznetsk, 1985).

 Another fairly common access to the spine is anterolateral spinal fusion (transpleural). It is carried out by cutting along the 8th intercostal space with an angle of inclination of the axis of the surgical field to the front and side surfaces of the spinal cord 45 degrees. With this access, integrity is not violated and the anatomical structure of the posterior spine is maintained.

 However, transpleural decompression of the spinal cord is limited only by correction of deformation of the spinal column and stabilization without revision of the contents of the spinal canal, since a narrow incision of the bony part of the wound and its great depth do not allow a good examination of the contents of the spinal canal and neurosurgical procedures (V.V. Kryuchkov, A. A. Lutsik. Surgical treatment of acute spinal cord injury at the thoracic level. - Novokuznetsk, 1985).

 Currently, in clinical practice, bone grafts of various configurations (rectangular, oval, combined, etc.) are widely used for anterior fixation of vertebral bodies (I. A. Movshovich. Surgical orthopedics. - M .: Medicine, 1983, p. 315-345 )

The disadvantage of using the above grafts is the need to prepare special grooves for the introduction of the graft, while violating the integrity of the anterior spine, which requires external immobilization (gypsum bed, hammocks, etc.)
In acute injuries of the vertebral bodies, when neurosurgical procedures are necessary, the formation of grooves for the transplant is almost impossible.

 When using a rectangular graft in 15-20% of cases, its resorption and displacement are noted, which contributes to the progression of compression of the vertebral bodies with the formation of angular deformation. The patient needs a long bed rest (up to 6 months), which causes a violation of phosphorus-calcium metabolism, deterioration of the cardiovascular system and the progression of cardiovascular failure, atrophy of the muscular system and after lifting requires prolonged immobilization of the spine with a plaster or leather corset.

 A known method of anterior spinal fusion in the treatment of axial deformities of the spine (ed. Certificate. USSR 1426563, A 61 B 17/56, 09/30/08, BI 36).

 The method is carried out by excising rectangular fragments of bone substance and alternately moving the resulting grafts in the cranial or caudal direction 1/2 of the height of the vertebral body with additional fixation of each graft with a ventral ligament of a nylon filament.

 In order to maintain the autograft in accordance with the anatomical norm of the spine, immobilization with a plaster corset is necessary for three months after surgery. This increases the reliability of fixation due to the tight contact of the graft with the bed and additional fixation.

 The disadvantage of this method is the need to prepare longitudinal grooves and the duration of postoperative immobilization, as well as the inapplicability of the method in the acute period of spinal cord injury.

 The method for anterolateral spinal fusion with a bone autograft in case of a spinal cord injury, including parapharyngeal, transthoracic, extraperitoneal accesses to damaged vertebrae, is adopted according to the prototype, the damaged vertebra is resected and the spine is removed, then the vertebral body is filled with an autograft, inserting it into the instrument. The approach to the vertebrae is carried out through pleural access by simultaneous hemilaminectomy (transthoracic or extraperitoneal approach) in order to increase the angle of surgical action.

 Then fill the groove in the vertebral bodies in order to fix the graft, which is formed from the iliac wing. An autograft is made in the form of a cylinder (A. Livshits. Spinal cord surgery. - M., 1990, p. 150-163).

The reasons that impede the desired result in the prototype are as follows:
- the need to form a groove for the introduction of an autograft to the area of the affected vertebrae;
- additional transosseous fixation;
- inapplicability of the method for acute injuries.

 In addition, a soft tissue incision according to the prototype is carried out under the corresponding rib at an angle of inclination of the surgical wound with respect to the base of the vertebra of 45 degrees, which does not provide sufficient access to the spinal cord and examination of the spinal cord.

 The manufacture of an autograft in the form of a cylinder (A.V. Livshits. Spinal cord surgery, p. 142-143) and the formation of grooves in the vertebral bodies using an instrumental method makes it unreliable to fix an autograft with a possible dislocation (an autograft in the form of a cylinder is not fixed firmly in the vertebra, but the instrumental method of forming grooves is unreliable).

 The introduction of the autograft into the vertebral body according to the prototype is carried out “by eye”, which does not ensure its reliable fixation and entails the loss of the autograft.

 The problem to which the invention is directed, is to eliminate these disadvantages and create a method of stabilization of the spine in case of spinal cord injury, which reduces trauma to the vertebrae and transplantation, accelerates the stabilization process while providing optimal conditions for spinal cord function during neurosurgical operations in the acute period of spinal cord injury, simplification of immobilization.

 The essence of the claimed invention is expressed in the fact that the proposed method of stabilization of the spine in spinal cord injury by anterolateral spinal fusion with a bone autograft, including transthoracic, extraperitoneal parapharengial access to damaged vertebrae, spinal embossing, preparation of autograft and autograft filling. In this case, the transthoracic approach is carried out by cutting soft tissues above the rib with an angle of inclination of the surgical wound of 60-70 degrees with respect to the spine, followed by surgical removal of the spine using a roller, preparation of a graft in the form of a float with defective space dimensions and pointed triggers at the ends, introduction graft after re-implantation of the spine with pointed ends in the holes with a depth of 0.1-0.5 cm of the adjacent vertebrae.

Features distinguishing from the prototype:
- the transthoracic approach is carried out by incision of soft tissues above the corresponding rib with an angle of inclination relative to the axis of the spine 60-70 degrees;
- spinal embossing is carried out using a roller at the time of removal of the damaged vertebra;
- the autograft is made from the crest of the metaphysical part of the tibia in the form of a parallelepiped, the distal and proximal parts of the autograft are pyramids, there is a crest on the front surface of the pyramids;
- an autograft is inserted into the holes 0.1-0.5 cm deep of the adjacent vertebrae.

 The implementation of the approach to the spine by cutting a soft tissue over the rib with an inclination angle of the operative wound with respect to the spine of 60-70 degrees reduces the invasiveness of the operation, allows the removal of autograft material from the crest of the metaphysical part of the tibia during the operation with the optimal opening for the neurosurgical stage of the operation. The interval of the angle of inclination of the surgical wound 60-70 degrees with respect to the axis of the spine is selected as optimal. The use of a tilt angle of less than 60 degrees makes it difficult to examine the spinal cord, making it impossible to use an operating microscope. The use of the angle of inclination of the surgical wound with respect to the axis of the spine of more than 70 degrees is impossible due to the anatomical structure of the skeleton, since an angle of inclination of more than 70 degrees may damage the main vessels of the spinal cord and the spinal cord itself.

 The fact that spinal embossing is carried out using the roller of the operating table allows you to not squeeze the roots of the spinal cord and improves its inspection.

 The use of an autograft allows you to do without external immobilization, support is not lost when the autograft is rebuilt into bone marrow. The choice of a transplant graft allows you to securely fix it, while eliminating the possibility of dislocation and rotational displacements, which accelerates bone repair processes, there is no need to make grooves instrumental for an autograft, due to intactness to the spinal canal, conditions are created to accelerate the regression of neurological deficit.

 The introduction of the autograft with a pointed end into the holes of the adjacent vertebrae prevents the spine from shifting along the axis in the frontal, sagittal plane and rotational displacements, eliminating the need for additional fixation.

 An autograft is safely implanted in the vertebral body, which ensures a quick recovery of the patient. The duration of bed rest is 5-6 days. As the neurological disturbances in the limbs regress, if this occurs up to two months, patients are allowed to get up, sit down, walk with crutches and a semi-rigid corset.

 The prepared autograft is inserted into the vertebral holes 0.1-0.5 cm deep. This hole size provides reliable fixation of the autograft. In this case, only one affected segment of the spine is turned off. If the hole depth is less than 0.1 cm, rigid fixation of the autograft is not ensured, dislocation and non-healing of the autograft is possible. With a hole depth of more than 0.5 cm, the destruction of the vertebral bodies occurs, the introduction of the autograft into adjacent segments and their trauma.

 The possibility of practical application of the proposed method is confirmed by examples of its specific use in the treatment of patients of the Stavropol city hospital 4.

 Example 1

 Patient B., male gender, 18 years old, was admitted with a diagnosis of L4 compression-comminuted fracture, left L1 arch with a transition to the articular process, spinal cord compression at the L4 level, lower paraplegia, pelvic organ dysfunction, secondary displacement of body fragments with compression spinal cord at L1 level.

 Neurological indicator: there is no movement in the lower extremities, abdominal reflexes are moderately inhibited, knee, Achilles, plantar reflexes are absent. Severe hyposthesia with anesthesia from the level of D12-L1. There is no self urination. Stool retention on the peripheral type. On radiographs D12-L1, a fracture dislocation of L1 with a dislocation into the spinal canal of up to 2 mm is determined. A spinal puncture was performed on the gap L4-L5, a complete cerebrospinal fluid block was determined.

 An emergency laminectomy D12-L3 was performed. Squeezing of the spinal cord by the arches and articular processes of L1-L2 was detected. TMT of the spinal cord is cyanotic, there is no brain pulsation, the brain prolapses in an arcuate shape into the surgical wound. An audit of the anterior chamber of the subarachnoid space and the anterior surface of the spinal canal revealed damage to the TMT, and a change in cerebrospinal fluid at the level of L1. The cerebrospinal fluid is removed, an additional TMT of up to 4 cm is dissected. The spinal cord and the cauda equina are pink in color with bluish pinpoint hemorrhages. The dura mater is sutured tightly. Satisfactory pulsation of the spinal cord appeared. An autograft up to 8 cm long was taken from the crest of the right tibia.

 Before performing back stabilization, a control audit of the distal and proximal patency of the channel was performed. A typical Bosefort posterior H-shaped fusion D12-L3 was performed.

 7 days after the operation, a secondary displacement of L1 fragments with re-dislocation into the spinal canal to a depth of 0.5 cm was detected on the radiograph, and subsequently, the displacement increased to 1 cm.

 23 days after the first operation, a second operation was performed. During the second operation, a transthoracic approach was taken to the damaged vertebrae with a soft tissue incision above the 8th rib with an angle of inclination of the surgical wound relative to the vertebra of 65 degrees.

 After transthoracic access to the injured vertebral body, L1 fragments were removed, a nearby vertebrae were wedged out according to the size of the defect, an autograft was made from the metaphyseal part of the tibia with the shape of a defect with pointed trigrants at the ends.

 The ends of the autograft are inserted into the openings of the adjacent vertebrae with a depth of 0.3 cm. The location of the autograft corresponds to the axis of the spine.

 13 days after the operation, the patient could do breathing exercises, a week later he could do exercise therapy, and 25 days after the operation, he could move independently on crutches. 2.5 months after the second operation, the patient was discharged with a regression of neurological symptoms.

 The x-ray indices corresponded to the normalization of the anatomical structure of the spine, movement in the lower extremities was restored, and pelvic disorders were not observed.

 Example 2

 Patient E., male, 29 years old, was admitted with a diagnosis of sliding, mating fracture dislocation of C5-C6 vertebrae, Urban wedge at C5 level with spinal cord compression at C5 level, lower paraplegia, upper paraparesis, pelvic organ dysfunction.

 Neurological indicators: there are no abdominal reflexes, hypersthesia in the innervation zone C5-C6 on both sides, hyposthesia from the level of D2-D3, strength in the hands up to 1 point, in the lower extremities of the plegium, there is no independent urination.

 Radiographs C1-C7 determine C5 spondylolisthesis anteriorly by 1.5 cm and the introduction of C7 into the spinal canal.

 A lumbar puncture was performed; during cerebrospinal fluid tests, a complete cerebrospinal fluid block is determined.

 The patient underwent a conventional procedure in neurosurgical hospitals with a C4-C7 laminectomy operation, in which damage to the articular processes of C5-C6 was detected, the spinal cord was compressed at the C5 level by bone fragments. After their removal during the audit of the dura mater there is no pulsation, the color is purple, pronounced edema. Toothed ligaments, dura mater are dissected. Hydroma was evacuated up to 40 ml under pressure. The substance of the spinal cord is saturated with blood. Local hypothermia was produced with solutions cooled to 8 degrees Celsius. Layer-by-layer suturing of the wound with a three-story suture. Performed posterior fusion according to Novak (8-shaped wire suture for the spinous processes C2-C5-C7 and quick-hardening plastic). An additional fixation was made for the parietal tubercles with skeletal traction with a load of up to 2 kg. On X-ray control, the Urban wedge at the C5 level was not determined. 2 months after the regression of neurological disorders of the lower extremities, the patient was given a transthoracic dressing, after the application of which standing was satisfactory on the X-ray control. 3 months after the control x-ray was performed, a second displacement and an Urban wedge at C5 level were detected with the development of the above neurological picture. In this regard, the patient underwent an operation of anterior spinal fusion C5-C6 by means of left-side parapharyngeal access to the anterior surfaces of the bodies C4-C5-C6-C7, in which damage to the C5-C6-C7 discs with pathological mobility in the C5-C6 region, multiple comminuted fractures was detected C5-C6 vertebral bodies without signs of bone callus formation.

 The C5-C6 bodies were removed along with the C4-C7 discs with an angle of inclination of the surgical wound with respect to the spine of 60 degrees, anterior spinal fusion was performed with an autograft made in the form described in Example 1, its ends were processed and placed in the openings of the adjacent vertebrae to a depth of 0.1 cm. On radiographs after surgery: the axis of the spine and the shape of the spinal canal are restored. From the 5th day the patient was engaged in breathing exercises, exercise therapy, after 20 days the patient was able to move independently, the spine was immobilized by a soft collar of Shants. A complete regression of neurological disorders occurred after 1.5 months. By the end of the 2nd month, the radiograph indices corresponded to the norms of the anatomical structure of the spine, movements in the extremities fully recovered with regression of disorders of the pelvic organs. Shant's collar immobilization was stopped 3 months after surgery. On radiographs, full bone marrow is determined.

 Example 3

 Patient K., male, 31 years old, was admitted with a diagnosis of compression-comminuted fracture of the body D12, arches D12, compression of the spinal cord at the level of D12, impaired function of the pelvic organs, secondary displacement of fragments of the body with compression of the spinal cord at the level of D12. Neurological indicators: there are no movements in the lower extremities, abdominal reflexes are inhibited, knee, Achilles, plantar reflexes are absent. Severe hyposthesia with anesthesia from the level of D11-L1. There is no self urination. Stool retention on the peripheral type. On X-ray diffraction patterns D12-L5, a fracture dislocation of D12 with a dislocation into the spinal canal of up to 2-3 cm is determined. Spinal function was performed in the interval L5-L5, during cerebrospinal fluid tests the complete cerebrospinal fluid block is determined.

 During the second operation, a transthoracic approach was performed by incision of soft tissues above the 8th rib and an angle of inclination of 70 degrees with respect to the spine. After thoracotomy, fragments of the D12 body were removed, a wedge was used to wedge the nearby vertebrae, an autograft was made from the tibia of its metaphysical part according to the size of the defect, as described in example 1, the pointed ends were inserted into the holes of the so-called tearing depth of 0.1 mm to give the correct direction to the autograft, the depth of immersion in the bodies of adjacent vertebrae by 0.5 cm.

 The location of the autograft corresponds to the axis of the spine.

 5 days after the operation, the patient could do gymnastics, another 5 days after exercise, and 18 days after the operation he could move with crutches. 2 months after the second operation, the patient was discharged with a regression of neurological symptoms. Radiography indices corresponded to normal automatic structure, movements in the lower extremities recovered, pelvic organ disorders regressed.

 Thus, the claimed method is practicable, its use in traumatology, neurosurgery reduces trauma to the approach to the vertebrae and transplantation, accelerates the stabilization process while providing optimal conditions for spinal cord function during neurosurgical operations in the acute period of spinal cord injury, simplifies immobilization, increases the effectiveness of cure in the acute period of spinal cord injuries.

Claims (1)

A method of stabilization of the spine in spinal cord injury by anterolateral spinal fusion with a bone autograft, including transthoracic, extraperitoneal, parapharyngeal access to damaged vertebrae, spinal embossing, and autograft filling and filling of the defective space with an autograft are performed with an appropriate incision of the trans the angle of inclination of the surgical wound with respect to the axis of the spine 60-70 ^o , reclinir The spine is examined using a roller at the time of removal of the damaged vertebra, the autograft is made in size and shape of the defective space, with pointed trigrids at its ends, the autograft is inserted into the openings of adjacent vertebrae with a depth of 0.1-0.5 cm.