RU2592779C2 - Method of minimally invasive circular decompression of spinal canal in complicated explosive fractures of lower and lumbar spine from modified intermuscular paraspinal access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology, vertebrology and can be applied for minimally invasive circular decompression of spinal canal in complicated explosive fractures of lower thoracic and lumbar spines from intermuscular paraspinal access. Superficial fascia is incised, shifted in lateral direction. One performs novocaine infiltration m. multifidus to more accurately determined slotted intramuscular space (spatium intermusculare) between m. longissimus and m. multifidus. Displacement and retention of m. multifidus is performed with rubber loop-holder.

EFFECT: method enables reducing injuries, improving rehabilitation period process.

1 cl, 18 dwg

Description

The invention relates to medicine, namely to traumatology, vertebrology, and can be used for minimally invasive surgical treatment of explosive, including complicated fractures of the lower thoracic and lumbar vertebrae.

Paraspinal intermuscular access is used for the surgical treatment of degenerative spinal diseases (Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg Am. 1968; 50 (5): 919 -926.), As well as uncomplicated thoracic and lumbar fractures (Wei Pang, Gui-lin Zhang, Wei Tian, Du Sun, Nan Li, Qiang Yuan, Bo Zhang, Yong-qing Wang, Wei Liu. Surgical treatment of thoracolumbar fracture through an approach via the paravertebral muscle. Orthopedic Surgery (2009), Volume 1, No. 3, 184-188.). Paraspinal intermuscular access has been modified to treat uncomplicated spinal fractures.

The well-known "Method for quick access to the arch processes of the lower thoracic and lumbar vertebrae" RF Patent No. 2308236, IPC АВВ 17/00, publ. 10.20.2007, which allows access to the arch processes of the lower thoracic and lumbar vertebrae, including a skin incision, subcutaneous tissue, dissection of the superficial fascia, exfoliation m. longissimus and m. multifidus to the arched joints, and the incision of the surface leaf of the thoracolumbar fascia is made along the edge of the supraspinatus ligament from the top of the spinous process.

The disadvantage of this method is that the obtained access does not allow performing operations in complicated injuries requiring decompression of the spinal canal, and also does not provide an accurate determination of the location of the intermuscular slit-like space to separate muscle groups.

The closest is the "Method of decompression of the spinal cord for fractures of the thoracic and lumbar vertebrae" (RF Patent No. 2467716, IPC АВВ 17/56, publ. 11/27/2012), including an incision in the skin, subcutaneous tissue, dissection of the superficial fascia, displacement of the ligament in the lateral direction , delamination m. longissimus and m. multifidus to the arched joints, performing similar manipulations on both sides of the spinous process. With this method, the osteoligamentous complex of the damaged vertebra is preserved.

The disadvantages of the method are that for its implementation is used not intermuscular paraspinal, but a typical posterior surgical approach involving skeletonization of muscle tissue. The method is used only in those cases if the fragment deployed in the spinal canal is strictly lateralized. This explains its one-sided application. With the most common central position of the bone fragment, the use of decompression on both sides of the proposed method destabilizes the damaged vertebral segment and requires mandatory transpedicular fixation, which, if a typical posterior surgical approach is used, requires more extensive traumatic exposure of the necessary bone structures.

To date, with complicated spinal fractures, paraspinal access has not been used. Performing decompression manipulations from paraspinal access is impeded by muscle fibers located on the front surface of the vertebrae of the vertebrae m. multifidus (segmented vertebral muscle) and m. longissimus (the longest muscle). In this regard, the aforementioned muscles are widely peeled off from the vertebral arches on both sides of the spinous processes and held by conservatives using a typical posterior median access. However, its morbidity, prolonged compression of the muscles by the branches of the retractors, as well as damage to the periarticular vessels suitable for the arched joints from the spinous processes (1. A.I. Shvets, A.A. Samoilenko. G.V. Samoilenko. Use of intramuscular access for installation pedicle structures in the lumbar spine. Lugansk State medical University, Lugansk. Ukraine, Trauma. Tom 12, №1, 2011 © ND≤travmatolog≥ ^{∨ ∨} she ortoped≥ of Donetsk nats≥onalnogo medichnogo un≥versitetu ≥m. M. Gorkog O. UDC 616. 711.6-089.84) ultimately lead to ischemia and cicatricial degeneration of paravertebral muscle fibers, which is clinically expressed by persistent vertebral syndrome in the postoperative period (2. Kawaguchi Y, Yabuki S, Styf J, Olmarker K, Rydevik B, Matsui H , et al. Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine 1996; 21: 26838.

Kawaguchi Y, Matsui H, Tsuji H. Back muscle injury after posterior lumbar spine surgery. Part 2. Histologic and histochemical analyses in humans. Spine 1994; 19: 2598-602.Taylor H, McGregor AH, Medhi-Zadeh S. The impact of self-retaining retractors on the paraspinal muscles during posterior spinal surgery. Spine 2002; 27: 2758-62.

Taylor H, McGregor AH, Medhi-Zadeh S. The impact of self-retaining retractors on the paraspinal muscles during posterior spinal surgery Spine 2002; 27: 2758-62.).

In addition, the difficulty in performing paraspinal access is the difficulty in accurately determining the location of the intermuscular slit space between muscle groups m. multifidus (segmented vertebral muscle) and m. longissimus (the longest muscle), which allows a non-traumatic and bloodless approach to the arched joints, transverse processes and insertion points of transpedicular screws. To determine the natural boundary between m. multifidus and m. longissimus uses MPT ³ data (3 Palmer, Daniel Kyle BS; Allen, et al. Multilevel Magnetic Resonance Imaging Analysis of Multifidus-Longissimus Cleavage Planes in the Lumbar Spine and Potential Clinical Applications to Wiltse's Paraspinal Approach. Spine: July 15, 2011 - Volume 36 - Issue 16 - p 1263-1267.) And tabular values based on anatomical studies ⁴ (4 Vialle R. Wicart P, Drain O. Dubousset J, Court C. The Wiltse paraspinal approach to the lumbar spine revisited: an anatomic study. Clin Orlhop Relat Res. 2006 Apr; 445: 175-80.). However, these data, according to the authors, are characterized by significant variability.

The objective of the invention is to perform circular decompression of the spinal canal under conditions of minimally invasive (modified intramuscular paraspinal) access, accurate determination of the intramuscular slit-like space between muscle groups: m. multifidus and m. longissimus, performing the technical technique of temporary atraumatic dislocation and fixation m. multifidus.

Brief Description of the Drawings

FIG. 1 is a schematic representation of a vertebra with a bone fragment in the spinal canal;

FIG. 2 is a schematic illustration of the administration of novocaine in m. multifidus (segmented vertebral muscle);

FIG. 3 - a schematic representation of a vertebra with a bone fragment in the spinal canal with the formed slit-like intermuscular space (spatium intermusculare);

FIG. 4 is a schematic representation of a vertebra with a bone fragment in the spinal canal with a held rubber loop-holder and the resulting slit-like intramuscular space (spatium intermusculare);

FIG. 5 is a schematic representation of a vertebra with a bone fragment in the spinal canal with the removed part of the arched joint;

FIG. 6 is a schematic representation of a vertebra with a bone fragment in the spinal canal with the removed portion of the vertebral arch;

FIG. 7 is a schematic representation of a vertebra with the removal of a bone fragment from the spinal canal;

FIG. 8 is a schematic representation of a vertebra with a removed bone fragment from the spinal canal.

FIG. 9 is a photographic image of an X-ray contrast study m. multifidus (segmented vertebral muscle);

FIG. 10 is a photographic image of a held rubber loop-holder and the formed slit-like intermuscular space (spatium intermusculare);

FIG. 11 is a photographic image of the removal of part of the arched joint;

FIG. 12 is a photographic image of the removal of part of the arch of the vertebra and legs of the vertebra;

FIG. 13 is a photographic image of the removal of bone fragments;

FIG. 14 is an image of a computed tomography of the lumbar spine with a revealed compression-comminuted fracture of the L3 vertebra with absolute stenosis of the spinal canal;

FIG. 15 is a computed tomography image of the lumbar spine with a revealed compression-comminuted fracture of the L3 vertebra with absolute stenosis of the spinal canal;

FIG. 16 is a computed tomography image of the lumbar spine after reposition and transpedicular stabilization of L2-L4 vertebrae with the Charnspine system;

FIG. 17 is an image of computed tomography of the lumbar spine after reposition and transpedicular stabilization of L2-L4 vertebrae with the Chamspine system;

FIG. 18 is a computed tomography image of the lumbar spine after ventral spinal fusion with a titanium mesh implant.

Designation of structural elements:

1 - m. multifidus (segmented vertebral muscle);

2 - m. longissimus (the longest muscle);

3 - m. iliocostals (Iliac-rib muscle);

4 - spatium intermusculare (slit-like intermuscular space);

5 - syringe with novocaine;

6 - rubber loop holder;

7 - bone fragment;

8 - spinal canal;

9 - a vertebra;

10 - an arch of a vertebra;

11 - leg of the vertebra;

12 - arched joint;

13 - spinous process.

The essence of the method

A method of minimally invasive circular decompression of the spinal canal with explosive complicated fractures of the lower thoracic and lumbar spine from the modified intramuscular paraspinal access is as follows.

After displacement in the lateral direction of the surface leaf of the thoracolumbar fascia, to more accurately determine the location of the intermuscular slit-like space, in m. multifidus (1) (segmented vertebral muscle), 5 mm indent from the spinous process (13) of the damaged vertebra, is administered up to 5 ml of a 0.5% solution of novocaine (5) (Fig. 1, Fig. 2).

The novocaine solution is distributed strictly along the muscle fibers m. multifidus (1) (segmented vertebral muscle) and does not penetrate the neighboring m. longissimus (2) (the longest muscle). This observation is confirmed by an X-ray contrast study m. multifidus. (Fig. 9) Thus, procaine infiltration noticeably (both visually and by palpation) delimits the necessary muscle groups (Fig. 3 (1), (2)), between which subsequently intermuscular access to the underlying bone structures of the spine (Fig. . 3).

After the introduction of transpedicular screws, depending on the location of the compressing fragments and the degree of stenosis of the spinal canal, unilateral or bilateral transpedicular access provides minimally invasive circular decompression of the elements of the spinal canal.

Minimally invasive circular decompression of the spinal canal means the removal of the following elements of the posterior and middle supporting complex: the arch of the damaged vertebra (9), the arched joints (12), the legs of the vertebra (11), the intervertebral disc, and the posterior dislocated fragment of the body of the damaged vertebra, preserving m. multifidus (1) (segmented vertebral muscle), spinous process (13) and interspinous ligament.

To prevent ischimization m. multifidus (1) (segmented vertebral muscle) and m. longissimus (2) (the longest muscle) and providing visual control of the technical actions of the surgeon, after removing the arched joint and leg (11) of the damaged vertebra (9), under m. multifidus (1) (segmented vertebral muscle) from the spinous process (13) above the arch of the vertebra (10) with a surgical needle carry out a rubber loop-holder (6), with which m. multifidus (1) (segmented vertebral muscle) is temporarily diverted to the spinous process (13) (Fig. 4, Fig. 10). This opens up sufficient space for biting part of the arch of the vertebra (10) with Kerrison's nippers from the side of the spinal canal. At the same time, the soft cushioning effect of the rubber retainer loop (6) on m. multifidus (1) (segmented vertebral muscle) in the process of abduction does not exert significant pressure on it, unlike the retractor branches. The operating table is given a lateral tilt up to 15 degrees in the opposite direction from the surgeon, increasing the viewing angle of the surgical field. Then, using Kerrison's nippers, bone spoons, conchotomes and a crown milling cutter, the arched joint (12) (Fig. 5, Fig. 11), part of the vertebral arch (10), vertebra leg (11) are sequentially removed (Fig. 6, Fig. 12), the intervertebral disc and bone fragments (7) of the damaged vertebra (9) located in the spinal canal (Fig. 7, Fig. 13). Similar manipulations are carried out on the counterlateral side of the spinous process (13), (Fig. 8.)

The method of circular decompression of the spinal canal for explosive fractures of the lower thoracic and lumbar spine from the modified intramuscular paraspinal access is illustrated by the following practical example: Patient S., 28 years old. Diagnosis: ZPSMT (closed spinal cord injury). Contusion, compression of the cauda equina at the L3 level of the vertebra. Lower paraparesis. Compression-comminuted (explosive) fracture of the L3 vertebra with spinal stenosis (type A3 according to AO / ASIF, class “C” according to Francel). Complaints at admission: severe pain in the lumbar spine, weakness in the limbs, numbness in the legs, impaired function of the pelvic organs. Medical history: Fall from a tree. 2 hours after the injury, the patient was taken by a team of the ambulance station to a specialized medical institution. When examining spondylograms of the lumbar spine, a compression-comminuted (explosive) fracture of the L3 vertebra was determined. Computed tomography of the lumbar spine revealed a compression-comminuted fracture of the L3 vertebra with absolute stenosis of the spinal canal (Fig. 14, Fig. 15) Objectively: Moderate severity. Consciousness is clear. The skin is clean, normal color. Breath is heard on both sides, vesicular, no wheezing. Heart sounds are clear, rhythmic. Pulse-80 in 1 min, blood pressure 120/80 mm Hg The tongue is clean, moist. The abdomen is soft, painless. Percussion-free fluid in the sloping places of the abdominal cavity is not determined. Violation of the functions of the pelvic organs as an acute delay in urination.

Vertebroneurological status: edema of the lumbar region, severe pain during palpation of the spinous process of the L3 vertebra. Hyposthesia from the L3 segment level. Lower paraparesis. Muscle strength reduced to 2 points. According to the claimed method, the operation was performed in the following volume: Circular decompression of the spinal canal from the modified paraspinal intermuscular access. Resection of the posterior-upper edge of the vertebral body L3. Reposition, transpedicular stabilization of L2-L4 vertebrae with the Charnspine system (Fig. 16, Fig 17.). There were no complications. Significant positive dynamics. Discharged 10 days after surgery. When viewed after 2 months, a complete regression of neurological symptoms is noted. The patient in a planned manner performed the second stage of surgical treatment: ventral spinal fusion with a titanium mesh implant (Fig. 18). At the control examination after 3 months: no complaints. The patient leads an active lifestyle.

The proposed method operated on 10 patients. In all cases, adequate decompression of the spinal canal, significant regression of neurological symptoms and early verticalization of the patients were achieved.

Using the proposed method of minimally invasive circular decompression of the spinal canal with complicated explosive fractures of the lower thoracic and lumbar spine from the modified intramuscular paraspinal access provides decompression manipulations in full, while minimizing the trauma of muscle tissue and preserves their potential, necessary in the early recovery period.

Claims (1)

A method of minimally invasive circular decompression of the spinal canal in case of complicated explosive fractures of the lower thoracic and lumbar vertebrae from the intramuscular paraspinal access, including a skin incision, subcutaneous tissue, dissection of the superficial fascia, its displacement in the lateral direction, separation m. longissimus from m. multifidus, performing similar manipulations on both sides of the spinous process, characterized in that they perform novocaine infiltration m. multifidus, due to which more precisely determine the slit-like intermuscular space (spatium intermusculare) between m. longissimus and m. multifidus, displacement and retention of m. multifidus is carried out with a rubber loop holder.

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