RU2479274C1 - Method for percutaneous transpedicular spinal fixation after puncture vertebroplastic repair in treating patients suffering extensive osteoporosis and multiple metastatic spinal injuries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine. A method consists in the use of screws and systems for transcutaneous transpedicular spondylosynthesis and systems for percutaneous vertebroplastic repair. Trepans are introduced in the pre-specified vertebrae (including those involved in the metastatic process) to the middle of the vertebral bodies above and below a pathological fracture. The process is EOC aided. A stiletto is removed from the trepans, and guide pins are introduced. The trepans are removed as guided by the pins. Screw seats are marked transcutaneously as shown by the guide pins with the use of a perforator and a marker. The marker shows the screw path only at a depth of a vertebral pedicle to the vertebral body Further, the trepans guided by the pins are mounted again. The guide pins are removed. Bone cement is introduced into the vertebrae through the trepans under the EOC control. Immediately after the cement introduction, the guide pins are introduced through the trepans. The trepans are removed; before the cement is completely hardened, transpedicular screws are inserted percutaneously through the guide pins and the prepared screw path into the vertebral bodies. The screw are finally fixed with a bar.

EFFECT: method is used to ensure the maximum stabilising effect of transpedicular spondylosynthesis and the minimum tissue injuries.

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Description

The invention relates to medicine, in particular to neurosurgery, oncology and orthopedics, and can be used to perform minimally invasive percutaneous stabilizing operations in the treatment of pathological vertebral fractures due to systemic osteoporosis and metastatic lesions.

A known method of transpedicular fixation of the spine in combination with vertebroplasty with bone cement against a background of reduced mineral density of bone tissue and metastatic lesions of the vertebrae, as well as their pathological fractures. Its essence is the use of special cannulated screws for the transpedicular fixation system, equipped with one or more cavities that extend on one side to the screw head and the other through at least one additional channel to the outer surface of the screw shaft, and an adapter (RF Patent No. 2285483, published October 20, 2006). This method is selected by us as a prototype [4].

The disadvantages of the known device include the fact that surgical interventions with its use are performed with a wide skin incision, massive detachment of soft tissues for the best visualization of the anatomical landmarks of the spinal motion segment, significant blood loss, due to wide access. Another disadvantage is the use of expensive cannulated screws and adapters for introducing bone cement into the screw. The use of adapters significantly delays the total operation time. At the same time, given the improvement in the quality of life of elderly patients and the success in the treatment of cancer, surgical stabilizing interventions in patients with pathological vertebral fractures are becoming increasingly important. Open surgical interventions in this category of patients are associated with a high risk of complications due to the presence of concomitant severe chronic somatic pathology or the activity of the oncological process [1, 2]. For this reason, there is a tendency throughout the world to minimize surgical aggression during surgical interventions, in particular in spinal surgery [3].

The technical result of the present invention is a significant reduction in time, introoperative blood loss, the degree of invasion and trauma of transpedicular stabilization of the spine using percutaneous systems in conjunction with puncture vertebroplasty for pathological vertebral fractures due to osteoporosis and metastatic lesions. This allows the use of transpedicular fixation in weakened, elderly patients with severe concomitant diseases with a low percentage of postoperative complications.

The result is achieved through the use of transpedicular polyaxial screws with an internal stroke, and systems for percutaneous vertebroplasty, which differ from the prototype both by the screws themselves - the screws are not designed to introduce cement through them, the stroke inside the screw is designed to guide the spokes, and the method of spondylosynthesis in which cement is inserted into the vertebral bodies before the installation of the screws, and the screws themselves are inserted into the bodies of the previously marked vertebrae percutaneously.

The figures depict:

figure 1. - MRI of the patient before surgery;

figure 2. - X-rays in direct projection before surgery;

figure 3. - X-rays in a lateral projection before surgery;

figure 4. - X-rays in direct projection after surgery;

figure 5. - X-rays in lateral projection after surgery;

6. - installation of a system for introducing a percutaneous transpedicular screw into the vertebral body and a tubular retractor.

The method is as follows: in an X-ray room under general endotracheal anesthesia, in the patient’s position on the back, after triple treatment of the surgical field with antiseptic solutions, into pre-defined vertebrae (including those affected by the metastatic process) above and below the pathological fracture, puncture, through the roots of the legs, Trepans are introduced to the middle of the vertebral body. The process is monitored under the image intensifier tube. Stilettos are removed from trepans and guide needles are inserted in their place. Trepan on the knitting needles are removed from the vertebral bodies, while the spokes themselves remain in the vertebral bodies. By guiding knitting needles, having previously cut the skin 1-1.5 cm long, using specialized perforator and tap, transcutaneously, which allows not to separate soft tissues from the spine, thereby reducing the level of blood loss, invasion, trauma and time of surgery, marking of screw placement sites is carried out . In this case, the marking of the screw stroke by the tap is carried out only to the depth of the vertebral leg passage to the border with the vertebral body. This prevents the exit of cement from the vertebral body into the leg and into the soft tissues with its further introduction. Next, trepans for vertebroplasty are reinstalled on the guide needles. The guide needles are removed. Bone cement is injected into the vertebrae through trepan under the image intensifier tube control. On the trepans, immediately after the introduction of cement, guide knitting needles are inserted for installing the screws. Trepans are removed along the guide needles and previously prepared passages for the screws in the legs of the vertebra, before the cement hardens completely, transpedicular screws are installed percutaneously using specialized tools. The image intensifier tube is being monitored and the correct position of the screws is checked. Then the screws are finally fixed with a bar, which is also screwed percutaneously. Thereby, the maximum possible stabilizing effect of transpedicular spondylosynthesis is achieved with minimal blood loss, tissue trauma and reduction of the operation time.

The method is more effective compared to the prototype, as it is much faster in time, as a result of the rapid introduction of bone cement and transpedicular screws percutaneously, as a result of which the patient is in endotracheal anesthesia for less time. There are no large incisions and massive detachment of soft tissues, no skeletonization of the spine, which ensures earlier activation of the patient and early recovery after surgery due to small invasion. It is possible to carry out this operation using any of the existing systems for percutaneous transpedicular spondylosynthesis, which makes it significantly cheaper than using expensive cannulated screws.

Complications in the postoperative period were not observed in any patient.

Clinical example 1: Patient N-on V.N., born in 1953 She turned in May 2010 with complaints of sharp pains in the chest and lumbar spine, radiating to both legs, more to the left, aggravated by movements and at rest. Restriction of movement as a result of severe pain. From the anamnesis it is known that periodic pains in the thoracic and lumbar regions have been troubling for the past 10 years. Appealed to the clinic at the place of residence, received conservative treatment for osteochondrosis of the spine. The condition worsened in May 2010, when the pain syndrome intensified after exercise. Treated conservatively. Conducted therapy had no effect. Surveyed. On radiographs revealed pronounced osteochondrosis of the thoracic and lumbar spondylarthrosis, scoliotic deformity of the lumbar spine, according to MRI, pronounced stenosis of the spinal canal in the lumbar spine. In this connection, she was hospitalized at the 18th department of RNIITO for surgical treatment according to the quota of the Ministry of Health and Social Development.

Anamnesis of life without features. Somatically, the patient suffers from ischemic heart disease, hypertension, chronic gastritis, pancreatitis. In neurological status, there is a restriction of mobility in the lumbar spine, smoothness of lumbar lordosis, scoliosis, protective muscle tension of the lumbar region on the left. Soreness on palpation and percussion of the spinous processes and paravertebral points from L1 to L5 on both sides. Positive symptoms of tension: Neri, Wasserman, Lasega (left to 10-20 °, right - 25-30 °). Hypesthesia is noted on superficial types of sensitivity in the zone L4, L5, S1 on the left, L3, L4 on the right, weakness in the legs up to 3.5-4 points, more on the left. Physiological reflexes from the legs are reduced, Achilles reflexes are not caused. No pelvic abnormalities. No other pathology of neurological status has been identified.

Magnetic resonance imaging data (2010): S-shaped scoliotic deformity of the lumbar spine with bending to the right at the level of L2, L3 and to the left at the level of Th11, L1 is determined on the MRI series. Left-side foraminal protrusion of the L5-S1 disk up to 5 mm with compression of the left root, diffuse protrusion of the L1-L5 disks with the foraminal component at the L2-L4 level on the right on the concave side and at the L4-L5 level on the left with compression of the corresponding foraminal holes. Spinal stenosis at these levels. According to x-ray studies, there is a pronounced osteochondrosis of the thoracic and lumbar spondylarthrosis, scoliotic deformity of the lumbar spine (figures 1, 2, 3). According to densitometry, osteoporosis of the lumbar spine. The diagnosis was made: degenerative-dystrophic lesion of the spine, complicated by hernia formation, spondylosis, spondylarthrosis and spinal stenosis at the level of L2-S1, scoliotic deformity at the level of Th11-S1.

Systemic osteoporosis. Lower paraparesis. Vertebrogenic pain syndrome.

Given the severity of the pathological process, the presence of neurological deficiency, porosity of the vertebral bodies due to osteoporosis, the lack of effect from conservative therapy, the patient’s old age, the presence of concomitant pathology, the risk of postoperative complications, surgical treatment is recommended in the amount of decompressive foraminotomy at the level of L4-S1 on both sides, decompressive foraminectomy, discectomy at the level of Th12-L1-L2-L3-L4, transpedicular spondylosynthesis at the level of Th12-L1-L2-L3-L4 with a percutaneous stabilization system natsii Viper 2 with simultaneous percutaneous vertebroplasty of Th12, L4 vertebrae, correction of scoliotic deformation.

The operation went through mini-accesses using a tubular retractor for foraminotomy and discotomy and systems for setting transpedicular screws (Fig.6). Introoperative blood loss amounted to 150 ml, operation time 2 hours 30 minutes. In the postoperative period, the patient was activated (put on her legs) on the second day, a significant decrease in pain and a significant regression of neurological symptoms were noted: the severity of tension symptoms decreased (75-85 ° on the left and right), leg strength increased to 5 points, sensitivity increased legs. On the control radiographs, the standing of the structure is correct, stable, the deformation is corrected (Figs. 4, 5). A patient at the department received an injection course of antibiotic prophylaxis, vascular therapy. The condition has improved significantly. The patient was in hospital treatment from the moment of admission 12 days. Discharged in satisfactory condition. During outpatient examinations after 3 months, 6 months, 12 months, it was noted that the positive effect of the intervention remains. There is no pain. The design is stable. Neurological status - without pathology. Does not need treatment.

Thus, in this observation, despite significant pathological changes in the spinal column, systemic osteoprosis, concomitant pathology, it was possible to perform the required surgical treatment, to obtain a pronounced persistent clinical effect in the near and remote postoperative period with the normalization of neurological status, restoration of statics and biomechanics of the spine.

Bibliography

1. Vetril S.T., Kuleshov A.A., Vetril M.S. - Surgical treatment of lumbar and lumbar scoliosis using dorsal and ventral instruments // Actual issues of pediatric traumatology and orthopedics: Thes. doc. scientific and practical conf. children's traumatologists orthopedists of Russia. SPb., 2005, p. 87.

2. Mikhailovsky M.V., Fomichev N.G. - Surgery of spinal deformities. Novosibirsk, 2002

3. Schwab F., Lafage V., Farcy J.-P. - Surgical rates and operative outcome analysis in thoracolumbar and lumbar major adult scoliosis: application of the new adult deformity classification // Spine. 2007. Vol. 32. N.24. P.2723-2730.

4. RF patent 2285483, IPC A61B 17/56, A61B 17/70. A device for performing a stabilizing operation on the spine (its variants) and a method for performing a stabilizing operation on the spine / Dzukaev D.N., Semchenko V.I., Krasheninnikov L.A .; applicant and patent holders - Limited liability company “CONMET” (LLC “CONMET”), Dzukaev D.N. - No. 2004134385/14, declared 11/25/04; publ. 10/20/2006, Bull. No. 29.

Claims (1)

A method of percutaneous transpedicular fixation of the spine with puncture vertebroplasty in the treatment of patients with widespread osteoporosis and multiple metastatic lesions of the spine, which consists in the use of percutaneous transpedicular screws and bone cement, characterized in that in the predetermined vertebrae above and below lying from the pathological fracture, puncture, through the roots legs, trepans are introduced to the middle of the vertebral body, stiletto is removed from trepans and introduced into their places guiding They remove the needles, trepans, insert a puncher and a tap on the knitting needles, mark the screw travel only to the depth of the vertebra arc leg, then install trepans on the knitting needles, remove the guide knitting needles, bone cement is inserted into the vertebrae through the trepots, immediately after cement is introduced, guiding needles are inserted along the trepans, trepans are removed, along the guide needles, before the cement hardens completely, transpedicular screws are inserted into the previously prepared passages, which are fixed percutaneously with the rods.

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