RU2325865C2 - Treatment method for spinal tuberculosis complicated by fistulous process - Google Patents

Abstract

FIELD: medicine; spinal surgery.

SUBSTANCE: invention can be used for treatment of the tubercular spondylitis that is attended by fistulous process. A resection of the osteal centres within a healthy bone is carried out, fistulous ducts on all extent are exsected and sealed, and the osteal cavity is filled with a muscularly-fastsialnym autograft on a vascular leg with its bracing that allows to reach of disconnection of vertebras from fistulous ducts and abscesses which drain.

EFFECT: reception of the treatment method for the complicated spinal tuberculosis surgically.

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Description

The invention relates to medicine, namely to spinal surgery and phthisioorthopedics, and can be used to treat tuberculous spondylitis accompanied by a fistulous process.

One of the complications of spinal tuberculosis (up to 10%) is the formation of fistulas of various localization. In most cases, the fistula process develops with tuberculosis of the lumbar and lumbosacral spine, less commonly with tuberculous spondylitis of the cervical and thoracic vertebrae.

Existing methods of treating these complicated forms of spinal tuberculosis include both local methods of treatment of the fistulous process and surgical methods to eliminate the source of inflammation. However, with all the variety of treatment methods, it is not always possible to achieve a quick and lasting cure. In this regard, the task of finding new methods remains relevant.

There is a method of surgical treatment of fistula with tuberculosis of the lumbosacral spine (Marakusha I.G. Surgical treatment of fistula with tuberculosis of the lumbosacral spine. // Vestn. Khir. - 1960. - No. 10. - P.76-80; I.G. Surgical treatment of tuberculosis of the lumbosacral spine complicated by fistulas. - In the book: Surgery of tuberculous spondylitis. - L., 1961. - P.68-74.). This treatment method is characterized only by abscessotomy and necrectomy in the area of bone foci without radical removal of the affected vertebrae by resection, as well as the use of vasole tampons. The duration of treatment of such patients was up to 2-3 years.

There is also a method of treating spinal tuberculosis, consisting in radical resection of the vertebrae and active short (up to 3 weeks) drainage of the cavities (Tikhodeev S.A. Surgical treatment of inflammatory diseases of the spine complicated by fistula // Vestn. Khir. I.I. Grekova. - 1994.- T.152. - No. 5-6. - S.120-123.). This method is effective only for small chronic suppurative processes without significant purulent sagging and with short fistulous passages.

The prototype of the proposed method is a method for treating fistula with spinal tuberculosis, called by the authors a shortening fistulotomy, including abscessotomy, necrectomy or resection of the affected vertebrae, fistulotomy, followed by bone tamponade with balsamic tampons brought out. Tampons changed every 2 weeks. The treatment process took 5-6 months or more. This technique was used with various modifications depending on the level of the lesion and the degree of suppuration process (Kornev P.G. Surgery of osteoarticular tuberculosis - M., Medicine, 1964. - P.497-505).

With this method, treatment was carried out in an almost open way, patients became for a long period (from 3 to 12 months) a source of excretion of both mycobacterium tuberculosis and other pyogenic flora (Proteus, Pseudomonas aeruginosa, Staphylococcus aureus, etc.). The prolonged presence of tampons led to the formation of fistulous passages with thick scar walls, which required repeated operations.

The objective of the proposed method is the abacillation of patients in the shortest possible time, preventing the development of amyloidosis of internal organs, reducing the time of inpatient treatment.

The problem is solved by radical resection of the affected vertebrae as a source of suppurative process, closing of the bone cavity with a fascial muscle autograft on the feeding leg, excision of fistulous passages throughout, separate drainage and intensive local postoperative treatment.

This method allows you to create optimal conditions for the rapid healing of the main focus of inflammation in the vertebrae by disabling bone changes from the fistulous passages that are secondarily infected and support the existence of suppurative process.

Summing up a muscle flap on the vascular pedicle provides sufficient blood supply, prevents the formation of a long non-healing bone cavity in the spine and prevents the penetration of secondary pyogenic flora into the bone, causing a non-specific inflammatory process.

The proposed method is represented by graphic material.

Figure 1. General view of the pathology: 1 - cavity destruction in the vertebrae; 2 - fistulous course.

Figure 2. The first stage of the operation: 3 - border resection of the vertebrae; 4 - fistulectomy zone.

Figure 3. The final stage of the operation: 5 - muscle-fascial flap; 6 - m. psoas major (psoas major muscle); 7 - flap formation zone.

The method is as follows.

The radical phase of the operation is performed (abscessotomy, resection of the affected vertebrae, excision of fistulous passages throughout). Then a muscle-fascial autograft is formed on the feeding leg from nearby muscles depending on the location of the lesion (intercostal, large lumbar or square muscle of the lower back, etc.), which is immersed in the formed bone cavity in the vertebrae and fixed with sutures. Long fistulous passages after excision are sutured tightly, and the cavities of the sagging or abscesses are drained along the shortest path. The operation ends with suturing the wound.

As an example of the effectiveness of using this method, we present the following observation: Patient R., and / b 491. Diagnosis: Tuberculosis of the thoracolumbar spine, fistulous form. Repeatedly operated on the spine using traditional techniques, however, the process recurred with the formation of fistulas. An examination revealed progression of the process at the level of L4-L5 vertebrae and the formation of fistulous passages, purulent sagging in the retroperitoneal space, which was clearly visible on the fistulograms when contrast was introduced into the fistula in the left lumbar region. The patient underwent surgery, including resection of the affected L4-L5 vertebrae with removal of all pathological tissues (granulations, caseous decay products, bone sequestration) from the destruction cavity, excision of fistulous passages throughout the entire range within healthy tissues. The bone cavity is filled with a tightly muscular-fascial flap on the feeding leg, formed from the large lumbar muscle (M. psoas major sinister) and fixed with sutures to the paravertebral tissues. The operation ended with drainage of the retroperitoneal space through the counter-hole and the wound suture until completely tight. In the postoperative period for drainage, serous discharge was removed after 7 days, the wound healed by first intention, there was no increase in temperature after removal of the drainage. The patient started walking on day 20, was discharged in satisfactory condition. Observation during the year showed no signs of recurrence of inflammation, a bone block of the remains of the destroyed vertebrae is formed.

Positive treatment results of the proposed method were obtained in all 6 patients with spinal tuberculosis complicated by the fistulous process of both the thoracic and lumbar regions. During operations on the thoracic vertebrae, the fascial muscle flap was formed from the intercostal muscles.

Claims (1)

A method for the treatment of spinal tuberculosis complicated by a fistulous process, including resection of the affected vertebral bodies and fistulotomy, characterized in that the bone cavity in the vertebrae is filled with a muscle-fascial autograft on a vascular pedicle and fixed, and fistulous passages are excised throughout for healthy tissues, long fistulous passages after excision are sutured tightly, cavities of sagging or abscesses are drained.

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