RU2739671C1 - Method of treating patients with spinal compression fractures at lumbar level in combination with traumatic intervertebral disc injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery, and can be used for spinal stabilization in vertebral compression fracture combined with traumatic intervertebral disk injury. After the transpedicular system is installed, distraction is carried out on the rods, followed by the endoscopic port (EP) installation. Point in which the skin incision is made for the EP installation is placed in the plane of the cortical plate of the underlying vertebra at distance of 5-6 cm from the middle line and 2–3 cm lateral of the outer edge of the corresponding joint with X-ray marking in a straight projection and 2–3 cm above an upper edge of the corresponding joint with X-ray marking in a lateral projection. Angle of inclination of the EP shall be 45 to 35° to an imaginary line drawn vertically through the centre of the target intervertebral disc. Under the control of the endoscope and the X-ray unit, a disk is removed, after which an osteal spoon is inserted into the EP, which is followed by curettage before a contact of the instrument with a dense bone tissue - a cortical plate. Fragments of the fibrous ring are removed by turbinate chisels under endoscopic and X-ray control to visualize cortical plates of vertebrae free of connective tissue. Intervertebral space is filled with bone chips through the endoscope port under the control of the endoscope and the X-ray control. Endoscope is removed and the vertebra is compressed on the rods until contact between the bone tissues. Transcutaneous transpedicular system is fixed, the ports are removed, and the wounds are closed in layers. If the cortical plate of the vertebral body is not visualized by the endoscope, the curettage is repeated until the result is achieved.

EFFECT: method provides a significant reduction in the risk of developing postoperative neurological complications and pain syndrome due to the fact that one surgical intervention involves stabilization of the spinal column from a posterior approach using a transcutaneous installation of the transpedicular system and endoscopic discectomy with an endoscopic port of the bone graft.

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Description

The technical field to which the invention relates

The invention relates to medicine, namely to neurosurgery, and can be used to stabilize the spine with a compression fracture of the vertebra at the thoracic and / or lumbar levels in combination with traumatic injury to the intervertebral disc.

State of the art

If the intervertebral disc is damaged, it becomes necessary to perform a discectomy and place a bone graft between the damaged and intact vertebra. This manipulation can be performed from a posterior, posterolateral, or lateral approach. However, discectomy with the installation of a bone or other graft requires the organization of the second stage of surgical treatment, which significantly lengthens the patient's rehabilitation process.

In this case, the use of the posterior approach implies the performance of laminectomy or arkatomy, the displacement of the spinal cord and / or its roots to the side, exposure of the target intervertebral disc. However, this method does not allow avoiding the possible aggravation of neurological disorders with the displacement of the spinal cord and the vessels feeding it.

The use of a lateral approach for discectomy means access through the pleural cavity or retroperitoneal space using special instruments, including endoscopic ones. The disadvantages of this access are: the need for traction of the lung and abdominal organs with the potential for injury, the technical difficulty of stopping bleeding in a deep narrow wound, the development of an adhesive process in the pleural cavity in the postoperative period (for transthoracic approaches).

The use of a posterolateral approach for discectomy includes the use of costotransvesectomy (for the thoracic level of injury) or far-lateral access (for the lumbar level of injury). There are also a number of disadvantages when using such approaches: the potential for blood loss and significant postoperative pain caused by muscle dissection and bone resection.

To perform minimally invasive stabilization of the spine in a compression fracture of the vertebra at the thoracic and / or lumbar level, a transcutaneous transpedicular fixation system is used (Akhmet'yanov Sh.A. Minimally invasive decompression-stabilizing methods of surgical treatment of monosegmental stenosis of the lumbar spine. Novosibirsk, 2016).

Unlike all known methods, the claimed method is minimally invasive, that is, completely endoscopic; moreover, it is performed simultaneously, that is, in one operation.

Disclosure of invention

Technical result of the invention consists in one-step (in one surgical intervention) full stabilization of the spine from the posterior approach using transcutaneous technology for installing the transpedicular system and endoscopic technology of discectomy with the installation of a bone graft (bone chips) through the endoscopic port, which provides a significant reduction in the risk of postoperative neurological complications and pain syndrome. This effect is achieved due to the absence of dissection and retraction of muscles in the access zone, traction and displacement of the spinal cord, its roots and surrounding vessels during discectomy. Also, the method provides quick rehabilitation of patients due to the absence of an additional stage of surgical intervention, and the use of small-sized skin incisions minimizes the risk of infection of the postoperative wound and gives a positive cosmetic effect.

The specified technical result is achieved by implementing a method for stabilizing the spine in a compression fracture of the vertebra at the lumbar level in combination with a traumatic injury to the intervertebral disc, including a transcutaneous installation of the transpedicular system, discectomy, while after installing the transpedicular system, distraction is performed on the rods followed by the installation of an endoscopic port (EP ), while the point at which the skin incision is made to install the EP is placed in the plane of the cortical plate of the underlying vertebra at a distance of 5-6 cm from the midline and 2-3 cm lateral to the outer edge of the corresponding joint (with X-ray markings in frontal projection) and 2-3 cm above the upper edge of the corresponding joint (with X-ray markings in the lateral projection), while the angle of the EP should be from 45 ° to 35 ° to an imaginary line drawn vertically through the center of the target intervertebral disc, under control m of the endoscope and X-ray unit, the disc is removed, after which a bone spoon is inserted into the EP, which is performed curettage until the instrument comes into contact with dense bone tissue - the cortical plate, then fragments of the annulus fibrosus are removed by means of conchotomes under endosocpic and X-ray control until the cortical plates of the vertebrae are visualized , free of connective tissue, then through the endoscope port under the control of the endoscope and X-ray control, the intervertebral space is filled with bone chips, the endoscope is removed and the vertebrae are compressed on the rods, until contact between the bone tissues is ensured, the transcutaneous transpedicular system is fixed, auxiliary instruments are removed, wounds layer by layer sutured.

In the absence of visualization of the cortical plate of the vertebral body during control with an endoscope, curettage is repeated until the result is achieved.

Brief Description of Drawings

The proposed method is accompanied by the following graphic materials:

Figure 1 reflects the stage of installation of the endoscopic port (EP):

Fig.1A - intraoperative photograph from the screen of the X-ray machine,

1B is a view of the operating field with installed ports of the transpedicular system and EP.

Figure 2 reflects the stage of curettage of the disc (intraoperative photograph from the screen of the X-ray machine).

Figure 3 shows the stage of control of the cortical plates of the vertebrae (intraoperative photograph from the endoscope screen), the arrow indicates the cortical plate of the vertebra.

Fig. 4 reflects the stage of placing the bone chips:

Fig.4A is a photograph of the operating field,

Fig. 4B - intraoperative photograph from the endoscope screen (a fragment of bone chips is visualized),

Fig. 4B is an intraoperative photograph from the screen of an X-ray machine (the shadow of bone chips is determined).

Fig. 5A is a view of the operating field after wound closure,

Fig. 5B - CT of the lumbar spine, three-dimensional reconstruction. The figure shows a compression fracture of the L2 vertebra. The spine axis has been restored. The transpedicular system is visualized: the screws are installed in the bodies of L1 and L3 vertebrae, connected with rods. Disc spaces L1-L2 and L2-L3 are filled with bone chips.

Implementation of the invention

The invention is carried out as follows.

Computed tomography (CT) and magnetic resonance imaging (MRI) are preliminarily performed in the course of planned preoperative preparation. Based on the results of the studies carried out, attention is paid to the following aspects:

1. On CT - the integrity of the cortical plates, the height of the target intervertebral disc is more than 4 mm.

2. On MRI - signs of damage to the target intervertebral disc, the absence of anomalies in the structure of the spine and spinal cord, preventing the implementation of the method.

In the position of the patient on his stomach, markings are performed at the level of the intended intervention.

Next, the transcutaneous installation of the transpedicular four-screw system is performed according to the generally accepted technique, skipping the broken vertebra. After passing the rods of the transpedicular system, distraction is performed on the rods. This maneuver, firstly, allows you to stretch the intervertebral discs, which simplifies the installation of the endoscopic port, and secondly, does not allow the fragments of the vertebra (if any) to move towards the spinal canal due to the tension of the posterior longitudinal ligament (Fig. 1A).

Next, an endoscopic port is installed. The point at which the skin incision is made to install the EP is placed in the plane of the cortical plate of the underlying vertebra at a distance of 5-6 cm from the midline and 2-3 cm lateral to the outer edge of the corresponding joint (with X-ray markings in frontal projection) and 2-3 cm above the upper edge of the corresponding joint (with X-ray markings in the lateral projection), while the angle of inclination of the EP should be from 45 ° to 35 ° to an imaginary line drawn vertically through the center of the target intervertebral disc (Fig. 1B).

Under the control of an endoscope and X-ray control, a bone spoon is introduced into the EP, which is performed curettage (Fig. 2) until the instrument comes into contact with a dense bone tissue - a cortical plate.

Using the Kiresson nippers, fragments of the annulus fibrosus are removed under X-ray control until the cortical plates of the vertebrae free of connective tissue are visualized (Fig. 3), which indicates a fully completed curettage and the ability to proceed to the next stage.

Through the port of the endoscope, under the control of the endoscope and X-ray control, the intervertebral space is filled with bone chips (Fig. 4 A, B, C).

The endoscope is removed and the vertebrae are compressed on the rods, until contact between the bone tissues is ensured, the transcutaneous transpedicular system is fixed (Fig. 5 A, B).

The ports are removed, the wounds are sutured in layers.

Example 1.

Patient F., 80 years old, was admitted to the SRI SP on an emergency basis. Diagnosis: concomitant injury, closed chest injury, closed fractures of 8.9 ribs on the left, minimal hydrothorax on the left. Multilevel spinal spinal trauma: complicated compression comminuted fracture of the L1 vertebral body with compression of the spinal canal, uncomplicated compression comminuted fracture of the Tn10 vertebral body without compression of the spinal canal. ASIA D.

Objective status during hospitalization: general condition of moderate severity. BMI 25 kg / sq.m. Neurological status during hospitalization: level of wakefulness - clear consciousness. GCS 15 points. Pupil size and symmetry: D = S. Nystagmus: absent. Photoreactions: live. The face is symmetrical. Tongue in the midline. Paresis in the right foot up to 3 points. Reflexes from hands are reduced evenly. The right Achilles reflex is reduced. No sensitivity disorders were found. The functions of the pelvic organs are not impaired.

The patient underwent further examination in the volume of CT of the lumbar spine: CT signs of compression comminuted fracture of the L1 vertebral body with displacement of the fragment into the lumen of the spinal canal up to 4 mm, compression comminuted fracture of the Tn10 vertebral body without compression of the spinal canal.

Taking into account the multilevel nature of the spinal column injury, it was decided to perform neurosurgical surgery at the level of complicated trauma: transcutaneous transpedicular fixation at the Th12-L2 levels; endoscopic discectomy, interbody fusion with allograft Th12-L1

The postoperative period was uneventful, the sutures were removed on the 7th day. The patient was activated within two days after the operation in the thoracolumbar corset. In the postoperative period, the patient noted an improvement in the form of a decrease in pain. The patient was discharged with improvement. The follow-up was 5 months.

Example 2.

Patient K., 50 years old, was admitted to the Research Institute for Emergency Medicine with complaints of pain in the lumbar region. According to the patient, these complaints appeared 6 days before treatment during a fall from a height of growth. An outpatient MRI of the lumbar spine revealed a fracture of the L2 vertebral body.

Objective status during hospitalization: general condition of moderate severity. BMI 44.1 kg / sq.m. Neurological status during hospitalization: level of wakefulness - clear consciousness. GCS 15 points. Pupil size and symmetry: D = S. Nystagmus: absent. Photoreactions: live. The face is symmetrical. Tongue in the midline. Paresis of the muscles of the lower extremities were not identified. Reflexes from hands and feet are reduced evenly. No sensitivity disorders were found. There are no pathological foot reflexes.

The patient underwent an additional examination in the volume of CT of the lumbar spine: CT signs of a compression comminuted fracture of the L2 vertebral body with a decrease in height to 64% and displacement of the fragment into the lumen of the spinal canal up to 5 mm

After preparation, the patient underwent a planned neurosurgical intervention: transcutaneous transpedicular fixation L1-L3, endoscopic discectomy L1-L2 and L2-L3, installation of an allograft.

The postoperative period was uneventful, the sutures were removed on the 7th day. The patient was activated within 24 hours after surgery. In the postoperative period, the patient noted an improvement in the form of a decrease in pain. The patient was discharged with improvement. The follow-up was 6 months.

Example 3.

Patient B., 32 years old, was admitted to the Research Institute of the SP in a planned manner. According to the patient, and according to the provided medical documentation, 6 months. suffered an accident back (passenger). She was admitted to the hospital, where the examination revealed a compression comminuted fracture of the L1 vertebral body with displacement of fragments into the spinal canal. A neurosurgical operation was performed - transcutaneous transpedicular fixation with a T12-L2 titanium system. The postoperative period was uneventful, and was discharged in satisfactory condition. This hospitalization is planned for the second stage of surgery. The patient complains of recurrent pain in the thoracolumbar junction.

Objective status during hospitalization: general condition of moderate severity. BMI 24.2 kg / sq.m. Neurological status during hospitalization: level of wakefulness - clear consciousness. GCS 15 points. Pupil size and symmetry: D = S. Nystagmus: absent. Photoreactions: live. The face is symmetrical. Tongue in the midline. Paresis of the muscles of the lower extremities were not identified. Reflexes from the arms and legs are vivid, without lateralization. No sensitivity disorders were found. There are no pathological foot reflexes.

After preoperative preparation, the patient underwent neurosurgical intervention: transcutaneous endoscopic discectomy Th12-L1, placement of an allograft

The postoperative period was uneventful, the patient was activated within 24 hours after the operation, and was discharged on the 7th day. after operation. At discharge, the patient noted an improvement in the form of a decrease in the intensity of the pain syndrome. The follow-up was 4 months.

Claims (2)

1. A method of treating patients with compression fractures of the spine at the lumbar level in combination with traumatic injury of the intervertebral disc, including transcutaneous installation of the transpedicular system, discectomy, characterized in that after the installation of the transpedicular system, distraction is performed on the rods followed by the installation of an endoscopic port (EP), in this case, the point at which the skin incision is made to install the EP is placed in the plane of the cortical plate of the underlying vertebra at a distance of 5-6 cm from the midline and 2-3 cm lateral to the outer edge of the corresponding joint with X-ray markings in frontal projection and 2- 3 cm above the upper edge of the corresponding joint when X-ray marking in lateral projection, while the angle of inclination of the EP should be from 45 to 35 ° to an imaginary line drawn vertically through the center of the target intervertebral disc, under the control of an endoscope and an X-ray installation, removed the disc, after which a bone spoon is inserted into the EP, which is performed curettage until the instrument comes into contact with dense bone tissue - the cortical plate, then fragments of the annulus fibrosus are removed by means of conchotomes under endoscopic and X-ray control until visualization of the cortical plates of the vertebrae, free of connective tissue, then through the endoscope port under the control of the endoscope and X-ray control, the intervertebral space is filled with bone chips, the endoscope is removed and the vertebrae are compressed on the rods, until contact between the bone tissues is ensured, the transcutaneous transpedicular system is fixed, the ports are removed, the wounds are sutured in layers. 2. The method according to claim. 1, characterized in that in the absence of visualization of the cortical plate of the vertebral body during control with an endoscope, the curettage is repeated until the result is achieved.

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