RU2785030C1 - Method for installing an intervertebral disc prosthesis using a neuronavigation device - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to orthopedics and neurosurgery, and can be used to install an M6-C intervertebral disc prosthesis using a Brainlab neuronavigation device. An incision is made along the skin fold along the anterolateral surface of the neck in the projection of the desired level using fluoroscopy, dissection of the subcutaneous muscle of the neck, abduction of the esophagus and trachea medially, sternocleidomastoid muscle and neurovascular bundle of the neck leterally. The correctness of the choice of access level is monitored using an intraoperative X-ray machine. The installation of the cervical retractor Kaspar, skeletonization of the anterior surface of adjacent vertebral bodies, the installation of pins for the cervical distractor and the actual distraction of the vertebral bodies, removal of the cervical intervertebral disc, osteophytes using Kerrison pistol cutters, curettes are carried out. The selection of the required size of the implant is carried out using probes of various calibers, followed by X-ray control. The grooves are cut for the final implant placement using the fin-cutter tool, previously registered in the neuronavigation system, and the actual installation of the intervertebral disc prosthesis under the control of the Brainlab neuronavigation station with the inserter tool, also registered in the neuronavigation system. Hemostasis followed by closure of the wound after confirmation of the correct position of the implant by means of CT control.

EFFECT: method provides installation of a cervical intervertebral disc prosthesis, which allows minimizing damage to neurovascular structures and the risk of improper implant installation, as well as reducing radiation exposure to the operator and patient due to a single intraoperative CT scan, followed by combining DICOM data with neuronavigation equipment and controlling the orientation of surgical instruments simultaneously in several planes.

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Description

The invention relates to medicine, namely to orthopedics and neurosurgery, and can be used in the surgical treatment of patients with herniated intervertebral disc of the cervical spine, as well as stenosis of the spinal canal at the same level with compression of the spinal cord or its roots.

Intervertebral disc herniation and spinal canal stenosis among the causes of compression of the spinal cord and roots occupies a leading position and is a difficult problem in terms of developing an optimal treatment method.

A known method of installing an intervertebral disc prosthesis under intraoperative x-ray control [Dante Leven, Joshua Meaike, Kris Radcliff, and Sheeraz Qureshi: Cervical disc replacement surgery: indications, technique, and technical pearls. Curr Rev Musculoskelet Med. Jun 2017; 10(2): 160-169].

The advantages of this method include the relatively low cost of the necessary equipment, which makes it affordable for most medical institutions.

The disadvantages of the method of installing an intervertebral disc prosthesis under intraoperative X-ray control mainly include an increase in the duration of the surgical intervention due to the need to orient the C-arm alternately in different projections, which also increases the radiation load on the patient and operator.

The objective of the invention is to develop a method for installing a prosthesis of the cervical intervertebral disc, which allows minimizing the risks of damage to neurovascular structures, improper installation of the implant.

The specified technical result is achieved by the fact that the method for installing the M6-C intervertebral disc prosthesis using the Brainlab neuronavigation device includes a standard incision along the skin fold along the anterolateral surface of the neck in the projection of the desired level using fluoroscopy, dissection of the subcutaneous muscle of the neck, retraction of the esophagus and trachea medially, sternocleidomastoid muscle and neurovascular bundle of the neck lethally, control of the correct choice of the access level using an intraoperative X-ray machine, installation of the Caspar cervical retractor, skeletonization of the anterior surface of adjacent vertebral bodies, installation of pins for the cervical distractor and proper distraction of the vertebral bodies, removal cervical intervertebral disc, osteophytes using Kerrison pistol nippers, curettes, selection of the required implant size using probes of various calibers with subsequent X-ray control, cutting grooves for the final installation of the implant, using the “fin-cutter” tool, previously registered in the neuronavigation system, and the actual installation of the intervertebral disc prosthesis under the control of the Brainlab neuronavigation station with the “inserter” tool, also registered in the neuronavigation system, hemostasis, followed by wound closure after confirming the correct position of the implant by means of CT- control.

The invention is aimed at reducing the radiation exposure to the operator and the patient, which is achieved by a single intraoperative CT scan followed by a combination of DICOM data with neuronavigation equipment. The ability to control the orientation of surgical instruments simultaneously in several planes also allows minimizing the time of implant installation.

The invention is illustrated by illustrative materials, where:

figure 1 shows the laying of the patient on the operating table, marked the place of the future incision;

in fig. 2 shows the laying of the patient on the operating table, the arms are fixed along the body with underwear;

in fig. 3 shows the location of the incision;

in fig. 4 naked subcutaneous muscle of the neck;

in fig. 5 shows the neck retractor Caspar: 1 - depth gauge; 2 - handle for installing the retractor blade; 3 - fenestrated blades for the cervical Caspar retractor; 4 - cervical retractor with ratchet; 5 - cervical retractor frame design;

in fig. 6 shows the vertebral body distractor: 6, 7 - vertebral body distractor (right and left); 8 - distraction screws (pins); 9 - screwdriver for distraction screws; 10 - drill for installing a distraction screw;

in fig. 7 shows Kerrison's pistol cutters, which are used to bite off bone elements (vertebral arches, parts of facet joints);

in fig. 8 shows a set of curettes of various designs for removing remnants of intervertebral discs and endplates;

Fig. 9 shows the installation of a frame with reflectors for instrument navigation;

in fig. 10 shows the installation of an implant of a given size under the control of neuronavigation.

The patient is placed on a simulated spinal table in the supine position in a neutral position, with the head turned to the contralateral side, with a silicone cushion placed under the shoulder girdle, avoiding excessive extension (Fig. 1). Silicone rollers are placed under the places of bone protrusions. Hands are fixed along the body with the help of disposable underwear. The head is placed on a soft headrest or silicone donut pillow. Electrodes for neuromonitoring are placed until the patient is completely fixed on the operating table (Fig. 2).

Under x-ray control, the level of access is determined and the incision site is marked, the lining is made with sterile surgical linen. (Fig. 3). An anterior horizontal longitudinal incision is made along the skin fold, then the fibers of the subcutaneous muscle of the neck are separated in the perpendicular direction (Fig. 4), the superficial fascia of the neck is longitudinally dissected, the sternocleidomastoid muscle is retracted laterally, in the medial direction - the muscles of the hyoid bone. After blunt dissection of the middle fascia of the neck with simultaneous coagulation of the transversely passing vessels, the neurovascular bundle is retracted laterally, and the visceral structures (esophagus, larynx, thyroid gland) are retracted medially.

With the help of an intraoperative X-ray machine, by installing an X-ray contrast instrument in the projection of the desired intervertebral disc, the correctness of the choice of the access level is controlled. The installation of the cervical retractor Kaspar (Fig. 5), skeletonization of the anterior surface of adjacent vertebral bodies, the installation of pins for the cervical distractor and the actual distraction of the vertebral bodies (Fig. 6) are carried out using Kerrison pistol cutters (Fig. 7.), curettes (Fig. 8 .) is the removal of the cervical intervertebral disc, osteophytes. It must be remembered that excessive removal of endplate tissues can lead to damage to the cortical layer of the vertebral body, which will lead to a decrease in the height of the disc space, the appearance of kyphotic or lordotic deformity.

The next stage of the operation is the installation of an intervertebral disc prosthesis. First of all, it is necessary to choose the size of the future implant using probes. Installation of the footprint template should be done in such a way that it covers anterior-posteriorly the endplate as much as possible. Control is carried out by means of an X-ray image in a lateral projection. Then the height of the intervertebral disc space is measured using the “trial head” instrument.

Next, it is necessary to perform an intraoperative CT study with subsequent integration of neuronavigation with CT data. One by one, the instruments are registered in the Brainlab system using a frame with reflectors and carrying out the corresponding stages of implantation of the prosthesis (Fig. 9). The first step is registering the fin-cutter tool to cut grooves for implant placement. It is necessary to orient it strictly in the middle of the vertebral body in the axial plane and parallel to the endplates in the sagittal plane. Then, after registering the “inserter” instrument in the neuronavigation system, the prosthesis is installed. In this case, it is also necessary to strictly observe the centering of the implant relative to the vertebral bodies and its installation over the end plates, which can be monitored in real time. (Fig. 10)

After installation, the correct position of the implant is assessed using intraoperative CT. The distractor and distractor pins are removed, the holes are filled with bone wax, and final hemostasis is performed using hemostatic sponges, oxidized cellulose foam or mesh, and bipolar coagulation.

The final stage is layer-by-layer suturing of the wound with the installation of drainage if necessary. The superficial fascia of the neck with the subcutaneous muscle of the neck, subcutaneous tissue and skin are subject to suturing.

Clinical example 1.

Patient B. was admitted to the Department of Neurosurgery with a diagnosis of "Paramedial hernia of the C5-C6 intervertebral disc on the left".

Clinically, radicular pain syndrome was detected along the C6 dermatome on the left. Pain syndrome 7-8 points according to VAS.

An operation was performed.

Operation protocol.

Under endotracheal anesthesia, a horizontal incision was made along the skin fold on the left, access was made to the anterior surface of the vertebral bodies. X-ray control. the disk C5-C6 of adjacent plates was removed. The hernia, disc and osteophytes were removed under O-arm control. A measuring device and a probe are installed in the opening of the disk. Then, a dynamic M6 intervertebral disc prosthesis was installed using neuronavigation. The wound was sutured in layers leaving vacuum drainage.

The drain was removed the next day.

During the control CT study, the prosthesis was installed correctly, with full coverage of the endplates, oriented in the center relative to the vertebral bodies.

The patient was discharged in a satisfactory condition, radicular pain syndrome regressed.

Claims (1)

A method for installing an M6-C intervertebral disc prosthesis using the Brainlab neuronavigation device, including an incision along the skin fold along the anterolateral surface of the neck in the projection of the desired level using fluoroscopy, dissection of the subcutaneous muscle of the neck, retraction of the esophagus and trachea medially, sternocleidomastoid muscle and of the neurovascular bundle of the neck lethally, control of the correct choice of the access level using an intraoperative X-ray machine, installation of the cervical retractor Caspar, skeletonization of the anterior surface of adjacent vertebral bodies, installation of pins for the cervical distractor and the actual distraction of the vertebral bodies, removal of the cervical intervertebral disc, osteophytes using Kerrison pistol nippers, curettes, selection of the required implant size using probes of various calibers with subsequent x-ray control, cutting grooves for the final installation of the implant using the fin-cutter tool, pre-registered in the system for neuronavigation, and the actual installation of the intervertebral disc prosthesis under the control of the Brainlab neuronavigation station with the inserter instrument, also registered in the neuronavigation system, hemostasis, followed by wound closure after confirming the correct position of the implant using CT control.

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