RU2497472C1 - Method of forming posterior wall of vertebral canal in case of spinal dysraphia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopedics, namely to spinal surgery and is used in treatment of patient with congenital impairment of fusion or formation of posterior wall of vertebral canal. Osteochondrous septum, originating from anterior wall of vertebral canal is ablated through access to posterior elements of spine. Osteotomy is performed within the limits of external cortical layer and spongy layer of arc fragments. Osteoclasis of internal cortical plate is performed in medial direction from two sides until arc fragments join. Their fixation by transosseous suture is carried out.

EFFECT: method makes it possible to prevent postoperative complications.

1 ex, 5 dwg

Description

The invention relates to traumatology and orthopedics, namely to spinal surgery, and is used in the treatment of patients with congenital disorders of the fusion (or formation) of the posterior wall of the spinal canal.

A known method of forming the posterior wall of the spinal canal after a laminectomy, including access to the posterior elements of the spine, delimitation of the brain tissue from scar-modified tissue by laying the transplant in the groove of the arches of adjacent vertebrae with closure of the spinal canal. Next, a demineralized tibial allograft prepared in size and shape of the defect to be closed, pre-conditioned in physiological saline for 40-60 minutes, is laid. Then, the allograft placed on the laminectomy defect is fixed with a thread from a non-absorbable suture to metal structures or to the posterior elements of adjacent vertebrae. As an allograft placed on a laminectomy defect of the posterior wall of the spinal canal, Osteomatrix is used. An allograft is fixed with interrupted sutures of non-absorbable material to the metal rods of a polysegmented metal structure (RU 2010103887 A).

The disadvantage of this method is the need for the use of an allograft, its preparation and adaptation to the shape of the defect and fixation.

It should be noted that the patent search did not find methods for plastic surgery of the posterior wall of the spinal canal in cases of spinal dysography, such as miningomyelocele, diastematomyelia. In some patients with these defects, the posterior wall of the spinal canal may be completely absent.

The objective of the invention is a method for the formation of the posterior wall of the spinal canal in cases of spinal dysography, due to osteotomy of the external cortical layer and internal osteoclasia with medial deviation of the arc fragments until they close and close the defect.

This task is achieved by accessing the posterior elements of the spine, removing the osteo-cartilaginous septum originating from the anterior wall of the spinal canal, then performing osteotomy within the outer cortical layer and the spongy layer of the arc fragments, and performing osteoclasia of the inner cortical plate in the medial direction from two sides to the closure of the fragments of arcs that are fixed by a transossal seam.

The invention is illustrated by a detailed description, a clinical example and illustrations which depict:

Figure 1 - Ascal diagram of the pathology of the spinal canal with diastematomyelia: a - fragments of the vertebral arch; b - the bony septum of the spinal canal; in-cleaved dural sac and spinal cord.

Figure 2 - Diagram of the operation after plastic surgery of the dural sac: 1 - formed a single dural sac; 2 - osteotomy zone of the external cortical layer of arc fragments.

Figure 3 - Scheme of the final stage of plastic surgery of the posterior wall of the spinal canal: 1 - medial deviation of the fragments of the arches; 2 - transossal seam.

Figure 4 - CT scan of patient S. in axial projection: the bony septum (1) is visualized in the projection of the LIV vertebra and arc fragments (2).

Figure 5 - CT scan of patient S. after surgical treatment: 1 - hemicords in a single dural sac; 2 - the spinal canal is closed.

The method is as follows.

With spinal dysography, there is always a splitting of the posterior wall of the spinal canal due to aplasia of the spinous processes and hypoplasia of fragments of open arches. A private option for spinal dysography is diastematomyelia. More common is type I, in which a bone or bone-cartilaginous septum emanating from the anterior wall of the spinal canal divides the dural sac with the spinal cord into two parts (Figure 1). The proposed method for the formation of the posterior wall of the spinal canal is used by us precisely for this pathology.

After excision of the septum and plastic walls of the dural sac, the problem of closing a bone defect in the posterior wall of the spinal canal arises.

The plastic defect is performed using fragments of the vertebral arches throughout the cleavage zone. Perverse anatomy in spinal dysography is represented by sufficient height and sagittally oriented half-arches (Figa). An osteotomy is performed within the outer cortical layer and the spongy layer of arc fragments by Luer clippers (Figure 2). Next, osteoclasia of the inner cortical plate is carried out in the medial direction from two sides until the arcing fragments are closed, which are fixed by a transossal suture (Figure 3).

Clinical example.

Patient Sh., 11 years old, was in the department with a diagnosis of Congenital vertebral column defect against the background of segmentation disorders and LII-SI fusion (neutral form). Fixed spinal cord syndrome. Diastematomyelia at the level of LIV-V (SCM I). Flaccid lower paraparesis (S> D). Neurogenic bladder dysfunction according to the hyperreflex type. Imperative urinary incontinence. Enuresis.

Orthopedic status: Build disproportionate in age. Decompensated C-shaped left-sided thoracic scoliotic arch with hibbus on the right. Pronounced skew of the pelvis counterclockwise. Shortening the right lower limb by 1.5 cm, reducing the circumference of the right thigh by 0.5 cm. Flat valgus deformity of the feet, more on the right. On the right - it is displayed passively to the middle position, on the left - it is displayed actively to the middle position.

The child was examined:

- On Rg-grams of the spine: Congenital disturbance of segmentation and fusion of LIII-SI. Right lumbar arch 16 ° with apex LIII without torsion. The expansion of the intrapedicular distance at the level of LII-SII with the presence of pathological shadow in the projection LIV. Dysgenesis of the sacrum. Agenesis of the tailbone.

- MRI and CT of the spine: Bone septum of the spinal canal at the level of LIV (Figure 4). Segmental splitting of the spinal cord to the level of ThXII. Spinal cord cone at the level of LIV-LV.

- Neurologist examination: Lower mixed paraparesis, coarser on the right. Neurogenic bladder dysfunction.

- Urodynamic research: Neurogenic bladder dysfunction in hypermotor type.

Indications for surgical treatment: Progressive kyphoscoliotic deformity.

Appointed operation: Revision of the spinal canal, removal of the bone-fibrous septum at the level of LIV-V, revision and plastic of the dural sac and the posterior wall of the spinal canal.

Operation progress: A vertical incision was made in the projection of the spinous processes of LIV-SI 9 cm long. After excision of the septum, the left and right hemicord were connected. The dural bag is opened. The latter is significantly thickened, there are multiple thin adhesions in the subarachnoid space, more to the left. A pronounced adhesion process between the roots of the hemicord on the left. On the right, the roots are located more freely, soldered into a single conglomerate. The dural bag is closed tightly with a continuous seam. The split divisions of the LV-SI vertebral arches are osteotomized at the base to the depth of the outer cortical layer and the spongy layer and are dorsally inclined due to osteoclasia of the inner cortical layer. Fragments of the arcs are sewn together with a transossal seam with the formation of the back column.

The postoperative period was uneventful. Received infusion therapy, anesthesia, a / b therapy, dressings, laser therapy No. 10, lower limb massage No. 10, exercise therapy. The child is put on its feet on the 9th day after surgery in a stiff lumbar corset.

CT control: Bone septum eliminated. Gemicords are visualized in a single dural sac. The vertebral canal is closed, not narrowed (Fig 5).

Re-examination of a neurologist: neurological status is the same.

In satisfactory condition, the child was discharged under the supervision of a neurologist and orthopedist at the place of residence.

Using the proposed method in FSBI "RRC" WTO "them. Acad. G.A. Ilizarova showed that due to the formation of the posterior wall of the spinal canal with options for spinal dysography, osteotomy of the external cortical layer and internal osteoclasia with medial deviation of the arc fragments until they close and close the defect, the integrity of the spinal canal is restored without the use of grafts, the functional result is improved and the treatment time is reduced with this pathology.

Claims (1)

The method of forming the posterior wall of the spinal canal in case of diastematomyelia, including access to the posterior elements of the spine, removal of the osteocartilaginous septum originating from the anterior wall of the spinal canal, then osteotomy is performed within the outer cortical layer and the spongy layer of the arc fragments, osteoclasia of the inner cortical plate is performed medial direction from two sides to the closure of fragments of arcs that are fixed by a transossal suture.

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