RU2844240C1 - Method for transpedicular fixation of the thoracolumbar spine from a transaponeurotic approach (versions) - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: group of inventions relates to medicine, specifically to neurosurgery, traumatology and orthopaedics, and can be used for stabilizing operations on the thoracic and lumbosacral spine in the treatment of fractures, stenosis of the spinal canal, spondylolisthesis, hernias of intervertebral discs, in neoplastic processes and deformations of the spine. Method for transpedicular fixation of the thoracolumbar spine includes performing a median skin incision at the level of target vertebrae with access to the aponeurosis, subcutaneous fat is separated from an aponeurosis in lateral direction 2-3 cm above target vertebrae wherein the screws are supposed to be inserted. That is followed by X-ray controlled determination of Jamshidi needle points on the aponeurosis with following puncture of the aponeurosis and placing the needle on the bone in the screw insertion point within a lateral edge of the root of the spinal arch. K-wire is inserted through Jamshidi needle under control of X-ray image in lateral projection with further removal of needle with fixed position of wire. That is followed by incising the aponeurosis along the fibres in a wire insertion point of total length no more than 1 cm. A canal is formed around the wire in the thickness of the muscle with using an instrument providing blunt disengagement of the muscle fibres sufficient for inserting a screw. Cannulated screw is inserted along the wire into the vertebral body for minimally invasive transpedicular fixation, followed by the removal of the wire. Cannulated screws are inserted similarly in the remaining target vertebrae. Then rods are introduced and fixed in screw heads. Rod is closed in a thickness of a muscle in a cranial-caudal direction with using a rod holder. At the end of the operation, the incisions on the aponeurosis are closed with 1-2 interrupted sutures each, followed by layer-by-layer suturing of the superficial fascia and skin. According to the other embodiment, the method for transpedicular fixation of the thoracolumbar spine is performed by means of the navigation system.

EFFECT: method provides a minimally invasive installation of the transpedicular fixation system in the thoracolumbar spine, allows to avoid a large number of skin incisions, shortening the time spent on fixation, reducing the number of soft tissue injuries in the surgical area and accelerating the rehabilitation of patients, improving the cosmetic effect by making the original transaponeurotic approach.

8 cl, 10 dwg, 2 tbl, 2 ex

Description

Field of technology to which the invention relates

The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics, and can be used to perform stabilizing operations on the thoracic and lumbosacral spine in the treatment of fractures, spinal canal stenosis, spondylolisthesis, intervertebral disc herniations, neoplastic processes and spinal deformities.

State of the art

When a significant impairment of the supporting function of the spine is detected, the main goal of surgical intervention is to ensure adequate stability in the surgical area.

The classic method of stabilizing the thoracolumbar spine is transpedicular fixation with open screw installation. This fixation is used both for spinal fractures and for degenerative stenosis, and involves performing a median approach to the spine with subsequent insertion of special implants (transpedicular screws) into the bodies of adjacent vertebrae along a transpedicular trajectory, followed by fixation with two longitudinal rods. Transpedicular fixation (TPF) is performed under X-ray control or using computer navigation. The use of navigation technologies makes it possible to almost completely eliminate damage to nearby anatomical structures (nerve and vascular structures or adjacent facet joints), reducing the radiation load on the patient and the operating team.

It is known from the state of the art to perform a stabilizing operation on the spine using an open method (patent for invention RU 2285483), including transpedicular fixation with access to the back surface of the target vertebrae and complete dissection of the muscles attached to them. After this, using complete visual control using radiography or navigation, screws are inserted through the vertebral pedicles. Then, the rest of the transpedicular system is mounted on the screw heads, rods are inserted and fixing nuts are installed. The final fixation of the main units of the transpedicular fixation system is carried out after reclination of the spine.

However, the open method of inserting screws, accompanied by cutting off muscles from the posterior support complex of the spine, has disadvantages associated with large blood loss during access to the posterior structures of the vertebrae; with significant trauma to the muscles of the spine, which is accompanied by severe pain in the early postoperative period and a fairly long rehabilitation; with an increased risk of failure of the postoperative scar and prolonged wound healing (especially in patients with a high body mass index, systemic diseases, in patients operated on for purulent-inflammatory diseases of the spine).

Due to the above-mentioned disadvantages of traditional open screw placement techniques, minimally invasive surgical techniques of percutaneous transpedicular fixation (TPF) have gained popularity in recent years. They are characterized by fewer complications, less blood loss, and less perioperative muscle damage. Despite some technical difficulties in performing percutaneous TPF, when compared with open fixation, comparable results were obtained in terms of neurological improvement and orthopedic correction, while the accuracy of screw placement was higher in the group of patients operated on using minimally invasive surgical techniques [Paredes I, Panero I, Cepeda S, CastaÑo-Leon AM, Jimenez-Roldan L, Perez-NuÑez Á, AlÉn JA, Lagares A. Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures compared with open technique. J Neurosurg Sci. 2021 Feb;65(1):38-46. doi: 10.23736/S0390-5616.18.04439-9. Epub 2018 Jun 14. PMID: 29905430]. Based on MRI data and comparison of muscle strength before and after surgery, less damage to the spinal muscles (m. multifidus and m. erector spinae) was noted in the minimally invasive TPF group [Kim DY, Lee SH, Chung SK, Lee HY. Comparison of multifidus muscle atrophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976). 2005 Jan 1; 30(1): 123-9. PMID: 15626992; Wang H, Zhou Y, Li C, Liu J, Xiang L. Comparison of Open Versus Percutaneous Pedicle Screw Fixation Using the Sextant System in the Treatment of Traumatic Thoracolumbar Fractures. Clin Spine Surg. 2017 Apr; 30(3): E239-E246. doi: 10.1097/BSD.0000000000000135. PMID: 28323706]. When conducting a meta-analysis, which included studies describing the advantages and disadvantages of a minimally invasive method (a total of 937 patients), a significantly shorter period of disability and risk of infectious complications were noted in the group using a minimally invasive method. The incidence of adjacent segment disease after 10 years did not differ significantly in the two groups [Jeong TS, Son S, Lee SG, Ahn Y, Jung JM, Yoo BR. Comparison of adjacent segment disease after minimally invasive versus open lumbar fusion: a minimum 10-year follow-up. J Neurosurg Spine. 2021 Nov 5; 36(4): 525-533. doi: 10.3171/2021.7.SPINE21408. PMID: 34740178].

A method of percutaneous transpedicular fixation of the spine is known from the state of the art (patent RU 2479274). The method is carried out as follows: in the X-ray operating room, under general endotracheal anesthesia, with the patient in the prone position, trephines are punctured through the roots of the pedicles into the target vertebrae above and below the pathological fracture to the middle of the vertebral body. The process is controlled under an EOP. Stylets are removed from the trephines and guide pins are inserted in their places, after which the trephines are removed from the vertebral bodies, leaving the pins in the vertebral bodies. Using a specialized perforator and tap, transcutaneous marking of the screw placement sites is carried out along the guide pins, after which the soft tissues do not need to be separated from the spine, thereby reducing the level of blood loss, invasion, trauma and surgery time. In this case, the screw path is marked with a tap only to the depth of the vertebral pedicle to the border with the vertebral body. Then, trephines are installed again along the guide pins for vertebroplasty. The guide pins are removed. Bone cement is injected into the vertebrae through the trephines under EOP control. Guide pins for installing screws are inserted along the trephines immediately after the cement is injected. The trephines are removed and transpedicular screws are installed percutaneously along the guide pins and previously prepared passages for screws in the vertebral pedicles, before the cement hardens completely, using specialized instruments. EOP control of the position of the installed screws is performed. Then the screws are finally fixed with a rod, which is also inserted percutaneously. This achieves the maximum possible stabilizing effect of transpedicular spondylosynthesis with minimal blood loss, tissue trauma and a reduction in the duration of the operation.

However, despite all the advantages of percutaneous fixation, the known method is characterized by a long operating time required for screw installation, significant radiation exposure to personnel and the patient; difficulties in using navigation systems; the need to make a large number of small incisions, which from an aesthetic point of view look worse than one median one; multiple passage of instruments through wound channels, causing tissue trauma, which, being less than in the open method of TPF, remains quite significant.

The closest technical solution to the claimed invention is the paraspinal approach according to Wiltse. The method is implemented as follows: in the X-ray operating room, under general endotracheal anesthesia using neuromonitoring, with the patient in the prone position, bilateral access is performed through a midline skin incision or two paravertebral skin incisions. The lateral vertical incision is made approximately 3-4 cm lateral to the spinous processes of the target segment of the spine. Two paravertebral incisions allow for simultaneous bilateral stabilization/decompression of the spine, thereby reducing the time of the intervention. Longitudinal dissection of the skin, subcutaneous fat and aponeurosis (superficial and deep fascia) is performed. Using blunt dissection of the medial multifidus muscle and lateral longissimus muscle, the area of the junction of the facet joint and the transverse process of the target vertebra is reached. Next, after palpation and radiographic control, a Quadrant® (Medtronic) or Meyerding retractor is installed. The vertebral arch is skeletonized (from its root to the base of the spinous process). If necessary, decompression, discectomy, and cage installation are performed from this access. Under radiographic control, transpedicular screw installation is performed, after which rods are placed. Both fasciae are sutured with continuous sutures. Then the skin is sutured with an intradermal suture.

However, when using the known Wiltse method, there remains a pronounced cosmetic defect associated with the need to perform two parallel skin incisions to insert the screws. In addition, the use of the method is characterized by significant trauma to the aponeurosis associated with bilateral longitudinal dissection of the fascia by more than 4 cm on each side; a significant zone of vertebral skeletonization required for screw installation, and inevitable radiation exposure to personnel and the patient, since X-ray control is required at all stages, from access to screw installation.

Thus, today there is a need to develop a minimally invasive method of transpedicular screw fixation, which allows to overcome the above-mentioned disadvantages of analogues and the prototype. The technical problem solved by the claimed invention is to create a minimally invasive method of transpedicular screw fixation, which allows to avoid a large number of skin incisions, reduce trauma to soft tissues in the area of surgical intervention, reduce the time of fixation, reduce the radiation load on the operating team and the patient, and also to achieve a better cosmetic result on the skin of the back.

Disclosure of invention

The technical result, which the claimed invention is aimed at achieving, is the development of a method for minimally invasive installation of a transpedicular fixation system in the thoracolumbar spine by performing an original transaponeurotic approach, which allows avoiding a large number of skin incisions, reducing the time spent on fixation, reducing trauma to soft tissues (muscles) in the surgical intervention area, and, as a result, accelerating the rehabilitation of patients operated on using transpedicular fixators, improving the cosmetic result. At the same time, the implementation of the claimed method allows reducing the radiation load on the operating team and the patient.

The technical result is achieved by the method of transpedicular fixation of the thoracolumbar spine, including the following stages:

performing a midline skin incision at the level of the target vertebrae to gain access to the aponeurosis;

separation of subcutaneous fat from the aponeurosis laterally by 2-3 centimeters above the target vertebrae into which screw insertion is planned;

determination under radiographic control of the insertion points of the Jamshidi needle on the aponeurosis, followed by puncture of the aponeurosis and placement of the needle on the bone at the screw insertion point located in the area of the lateral edge of the root of the vertebral arch at the intersection with a line drawn through the middle of the transverse process in the axial plane for the lumbar region, along the upper edge of the transverse process for the thoracic region;

insertion of a Kirschner wire through a Jamshidi needle under radiographic control in the lateral projection, followed by removal of the needle with the wire in a fixed position;

after this, an incision is made in the aponeurosis (for example, using monopolar coagulation) along the course of the fibers at the point of insertion of the needle with a total length of no more than 1 cm (from the point of insertion of the needle at a distance of no more than 0.5 cm upward and 0.5 cm downward);

forming a channel around the spoke in the thickness of the muscle using an instrument that provides blunt separation of the muscle fibers, sufficient for inserting the screw;

insertion of a cannulated screw through a pin into the vertebral body for minimally invasive transpedicular fixation, followed by removal of the pin;

Cannulated screws are placed in the remaining target vertebrae in a similar manner;

after which the rods are inserted and fixed in the screw heads, while the rod is inserted closed into the thickness of the muscle in the cranial-caudal direction using a rod holder (or guide);

At the end of the operation, the incisions on the aponeurosis are sutured with 1-2 interrupted sutures each, followed by layer-by-layer application of sutures on the superficial fascia and skin.

Before fixing the rods in the screw heads, decompression of the spinal canal can be performed if necessary, with access being achieved through the formed channel for inserting the screw or through an additional incision in the aponeurosis made parallel to the spinous process of the vertebra on the side of decompression.

In another embodiment of the invention, the technical result is achieved by a method of transpedicular fixation of the thoracolumbar spine , including the following steps:

performing a midline skin incision at the level of the target vertebrae to gain access to the aponeurosis;

separation of subcutaneous fat from the aponeurosis laterally by 2-3 centimeters above the target vertebrae into which screw insertion is planned;

installation of a navigation system containing a navigation frame with a clip, which is fixed to the spinous process of the vertebra located in the center of the surgical frame, which is preliminarily skeletonized to a length of no more than 1 cm and a depth of no more than 1 cm;

subsequent puncture of the aponeurosis with a navigation pointer to the screw insertion point located in the area of the lateral edge of the root of the vertebral arch at the intersection with a line drawn through the middle of the transverse process in the axial plane for the lumbar region, along the upper edge of the transverse process for the thoracic region. In this case, control of the choice of the puncture point and subsequent control of the screw insertion is carried out using a 3D model of the spine formed by the navigation system;

after which the aponeurosis is incised along the fibres using monopolar coagulation from the point of insertion of the navigation pointer (at a distance of no more than 0.5 cm upwards and 0.5 cm downwards) with a total length of the aponeurosis incision of no more than 1 cm;

forming a channel around the navigation pointer in the thickness of the muscle using an instrument that provides blunt separation of the muscle fibers, sufficient for inserting the screw;

removal of the pointer followed by the formation of a bone channel for the insertion of a screw (for example, using a drill guide);

insertion of a screw into the vertebral body for minimally invasive transpedicular fixation;

screws are installed in the remaining target vertebrae in a similar manner;

after which the rods are inserted and fixed in the screw heads, while the rod is inserted closed into the thickness of the muscle in the cranial-caudal direction using a rod holder (or guide);

At the end of the operation, the incisions on the aponeurosis are sutured with 1-2 interrupted sutures each, followed by layer-by-layer application of sutures on the superficial fascia and skin.

Before fixing the rods in the screw heads, decompression of the spinal canal can be performed if necessary, with access created using a navigation system through an additional incision in the aponeurosis, made parallel to the spinous process of the vertebra on the side of decompression.

In the listed embodiments of the invention, two Farabeuf hooks can be used to form a channel around the spoke in the thickness of the muscle, with one hook placed on the lateral side of the spoke, the second on the medial side, with the formation of lateral and medial walls of the channel, respectively; a tube dilator or a cylindrical retractor (for example, a two-leaf retractor from the Aesculap endoscopic kit), installed along the spoke.

The claimed method differs from known minimally invasive methods of percutaneous transpedicular fixation in that the operation begins with a conventional midline incision, dissection of the skin, superficial fascia and subcutaneous fat is performed, and the screws are installed not through the skin, but through minimal incisions of the aponeurosis under the skin and fat. Thus, in addition to minimal trauma to muscle tissue, a better cosmetic effect is achieved (a cosmetic suture after a midline incision is aesthetically more acceptable), while the spinous processes are available for attaching a navigation frame, the use of which allows for a reduction in radiation exposure to the patient and staff, and a reduction in the time required to install the screws.

The claimed method, in comparison with the Wiltse method, allows to reduce the cosmetic defect (during bilateral work, two parallel skin incisions are not required), to reduce trauma to the aponeurosis, due to the absence of the need for bilateral extended dissection of the fascia, to exclude the stage of skeletonization of the vertebrae for installation of screws, to reduce the radiation load on the staff and the patient, since X-ray control is not required at each stage of the implementation of the claimed method, starting with access and ending with the installation of screws.

When fixation is performed in the stated manner using the original transaponeurotic approach, early and safe rehabilitation of patients is possible, since the muscles do not lose their attachment to the vertebral arches and all postoperative restrictions are associated only with skin healing (in degenerative diseases). The beginning of the rehabilitation period and the nature of rehabilitation measures are not limited to the spinal stabilization system.

Brief description of the drawings

The invention is explained by illustrative material, where Figure 1 shows an example of an image of the spine in the anteroposterior projection with spokes intersecting in the projection of the roots of the vertebral arches, obtained using a C-arm at the target level; Figure 2 shows an example of preoperative marking; Figure 3 - a midline incision of the skin and subcutaneous fat at the level of the target vertebrae with subsequent access to the aponeurosis; Figure 4 - separation of the subcutaneous fat; Figure 5 - insertion of the Jamshidi needle through the aponeurosis into the lateral edge of the root of the vertebral arch; Figure 6 - an image in the anteroposterior projection, obtained using a C-arm, made to control the position of the Jamshidi needle; Figure 7 - insertion of the Jamshidi needle through the aponeurosis into the pedicle of the vertebra; Figure 8 is an anteroposterior C-arm image taken to verify the position of the Jamshidi needle in the vertebral body; Figure 9 is a lateral C-arm image showing the Jamshidi needle in the target vertebral body; Figure 10 is a lateral C-arm image confirming the position of the Jamshidi needle in the middle of the vertebral body; Figure 11 shows the stage of forming a hole in the aponeurosis after the needle is inserted into the vertebral body.

Implementation of the invention

The operation is performed with the patient in the prone position. It is recommended to use a Jackson table (or any other radiolucent table) to achieve correct patient positioning and unlimited fluoroscopic view. Using a C-arm in the anteroposterior projection, a position is achieved at each target level in which the endplates of the vertebrae are clearly defined and the spinous process is strictly central (at the same distance from the center of each pedicle).

To plan the incision, anterior-posterior fluoroscopy is used, with the guide mark (pin) positioned so that its projection intersects the center of both pedicles in the cranial-caudal direction. In accordance with the obtained images and the location of the pins on the skin, marks are made with a surgical marker in the projection of the roots of the arches of the vertebrae of interest. Fig. 1 shows an example of an anteroposterior projection with spokes intersecting in the projection of the roots of the vertebral arches obtained using a C-arm at the target level. Fig. 2 shows an example of the resulting markings.

Next, using direct fluoroscopy, place the guide mark so that its projection coincides with the lateral wall of the target level pedicle and adjacent levels. Using a surgical marker, mark this plane on the patient's skin. Thus, the crosshairs obtained with the marker are projections of the screw insertion points. Next, use the marker to draw a line along the spinous processes with an indentation of 1 cm upward and downward from the transverse lines connecting the centers of the pedicles.

A midline incision of the skin and subcutaneous fat is made along the obtained line at the level of the target vertebrae with subsequent access to the aponeurosis (fascia propria). Subcutaneous fat is separated from the aponeurosis laterally by 2-3 centimeters, mainly above the vertebrae into which the screws are planned to be inserted. Figs. 3 and 4 demonstrate these stages, Fig. 3 - midline incision of the skin and subcutaneous fat at the level of the target vertebrae with subsequent access to the aponeurosis, Fig. 4 - separation of subcutaneous fat.

Under radiographic control, the insertion point of the Jamshidi needle on the aponeurosis is determined, after which the aponeurosis is punctured and the needle is placed on the bone at the insertion point (in the anteroposterior projection for the lumbar region, the lateral edge of the pedicle should be located at 3 o'clock on the conventional clock face, for the thoracic region - at 1 o'clock). The Jamshidi needle is inserted through the aponeurosis into the lateral edge of the root of the vertebral arch (Fig. 5, 6).

The Jamshidi needle is inserted through the vertebral pedicle under the control of the direct (AP) projection by 20 mm so that the tip of the needle at this depth is at the level of the medial edge of the vertebral pedicle (Fig. 7, 8). Then the position of the needle is checked in the lateral projection (LP), at this stage it should be at the border of the pedicle and the vertebral body (Fig. 9). Under the control of radiography in the lateral projection (LP), the needle is inserted into the center of the vertebral body (Fig. 10). A Kirschner wire is inserted through the needle and the needle is carefully removed, controlling the position of the wire.

Next, unlike the Wiltse approach, the aponeurosis is dissected by monopolar coagulation or a scalpel by no more than 1 cm, while the dissection is carried out from the point of insertion of the needle at a distance of no more than 0.5 cm upward and 0.5 cm downward, after which a channel (opening) is formed around the needle in the thickness of the muscle that straightens the spine (m. erector spinae), sufficient for inserting the screw.

The channel around the spoke in the thickness of the muscle is formed using an instrument that provides blunt separation of muscle fibers to a value sufficient for inserting the screw. Farabeuf hooks can be used as such an instrument (in this case, one hook is placed on the lateral side of the spoke, the second - on the medial side, with the formation of lateral and medial walls of the channel, respectively), a two-leaf retractor from the Aesculap endoscopic kit (catalog "Spinal Microsurgical Endoscopy", Aesculap Spine, Miaspas® TL, B. Braun, p. 12 Speculum), which are installed along the spoke.

After the canal is formed, a cannulated screw is inserted into the vertebral body along the spoke for minimally invasive transpedicular fixation. The screw is inserted under lateral radiography control. It is important to ensure that the Kirschner wire does not migrate beyond the anterior edge of the vertebral body when the screw is inserted. The screw is inserted using cylindrical retractors; after the screw is installed in the vertebral body, the Kirschner wire is removed.

When using a navigation system, after dissecting the skin, subcutaneous fat and superficial fascia, skeletonization of the apex of the spinous process located in the center of the surgical wound is performed. The spinous process is skeletonized over a length of no more than 1 cm, to a depth of up to 1 cm. As a rule, these dimensions are sufficient for secure fixation of the navigation clip. When using the latest generation navigation systems, this stage is not required. The navigation frame is installed. Intraoperative CT is performed. After the necessary system settings are made, the optimal point for screw insertion is selected on the surface of the aponeurosis with a specialized navigation pointer. Using this pointer, a puncture of the aponeurosis is performed, the pointer is placed on the surface of the vertebra at the point of planned screw insertion. Using monopolar coagulation, the puncture hole of the aponeurosis is expanded longitudinally to 1 cm. A cylindrical retractor is placed on the surface of the bone using the pointer. After the retractor is installed, the pointer is removed and the point of screw insertion is skeletonized with monopolar coagulation. Next, using a navigated guide and a drill, a channel is formed in the vertebral body for installing the screw. The screw is installed through the formed bone channel.

After all screws are installed, minimally invasive decompression of the spinal canal is performed if necessary before they are fixed. Depending on the type of spinal canal decompression, various access options are possible. In case of extraforaminal decompression, it is possible to use the wound channel of a screw located in the pedicle of the cranial vertebra of the target decompression level for access. In case of spinal canal decompression, an additional incision of the aponeurosis is made parallel to the spinous process on the side of decompression. When using a navigation system for decompression, it is possible to use the wound channel formed during installation of the navigation frame.

After decompression is complete, the screw heads are freed from soft tissue using cylindrical retractors (two-leaf retractor from the Aesculap endoscopic kit) on one side of the spinous processes. The retractors are positioned so that the slots are in the same plane, ensuring the passage of the rod through them. Then, using a guide, the rods are passed and fixed in the screw heads.

The screw heads are aligned. Then, a guide with a rod (implant) fixed in it is installed into the screw head. The rod (implant) is advanced until it contacts the saddles of the screw heads. The rod (implant) is fixed in the screw heads with fixing nuts using a screwdriver. After this, the rod guide is removed from the wound and the cylindrical retractors are removed.

The installation of screws is performed in a similar manner, followed by fixation of the rod (implant) on the opposite side from the midline incision.

The incisions on the aponeurosis are sutured with 1-2 interrupted sutures each. Then the sutures are applied layer by layer to the superficial fascia and skin.

In accordance with the proposed method, 15 surgical operations were successfully performed. Of these, 1 operation was performed on the thoracic spine as a result of trauma. Also, 7 patients with degenerative processes of the lumbar spine were operated on in the following segments: L2-L3 - 2 patients, L4-L5 - 1 patient, L5-S1 - 4 patients. 7 patients were operated on for inflammatory diseases of the spine.

The average time spent on installing 4 screws with navigation, from the moment of incision to the installation of the last screw was 48 minutes, this indicator for the prototype method, according to published data, is on average 110 minutes. Blood loss in all cases was estimated as minimal (less than 100 ml). During the operations, transaponeurotic access was used with a total length of the aponeurosis incision not exceeding 1 cm, due to which it was possible to avoid a large number of skin incisions, reduce trauma to soft tissues (muscles) in the surgical intervention area, and, as a result, accelerate the rehabilitation of patients operated on using transpedicular fixators, improve the cosmetic result. It should be noted that when using navigation with transaponeurotic access, the staff does not receive radiation exposure, while when using the standard transcutaneous method, the radiation exposure was significantly higher.

Clinical example 1.

Patient S., 28 years old, professional football player. She complained of severe pain in the lumbar region and right lower limb during training and matches, which limited her professional activity: the increase in pain during training limited their intensity and reduced athletic performance.

Upon admission, the following instrumental examination data were studied: disc degeneration stage according to Pfirrmann 3, disc height index (DHI) - 0.5; central angle of lordosis (CAL) - 28.7 degrees; hernia type: protrusive at the L4-L5 level, extrusive at the L5-S1 level. When assessing anthropometric indicators, the BMI was 19. In the neurological status: severe radicular pain syndrome along S1 on the right, hypoesthesia along the S1 dermatome on the right. Lower distal monoparesis in the foot on the right (decreased muscle strength in the gastrocnemius muscle of the right leg) up to 4 points. ODI on admission was 52%, VAS - 10 points. According to the results of MRI, on sagittal and axial sections at the level of L4-L5, a narrowing of the spinal canal is noted at the examined level, more pronounced on the right, the presence of a herniated intervertebral disc L5-S1.

MRI data showed that disc degeneration at the L5-S1 level was significant and extrusion caused significant compression of the nerve structures, unlike the L4-L5 level, which was also compromised, but did not manifest itself clinically. Given the nature of the patient's activities (professional athlete, need for a quick return to competitive-level physical activity), given the unfavorable indicators of the disc height index and the central lordosis angle, a conclusion was made about a high risk of disc herniation recurrence in case of refusal to fix the operated segment. A decision was made to perform a decompressive and stabilizing intervention on the lumbosacral spine: microsurgical decompression of the nerve structures in the L5-S1 segment, transpedicular fixation of L5-S1 with dynamic rods using a minimally invasive transaponeurotic approach to minimize soft tissue trauma and quickly remove restrictions.

A midline incision was made in the projection of the spinous processes of L5-S1. Through the minimal incision and after skeletonization of the upper third of the spinous process of S1, a clip of the BrainLab navigation system was installed, intraoperative CT scanning of the operated segment of the spine with autoregistration by the Brainlab navigation system was performed. The navigation system software constructed a three-dimensional image of the operated segment of the spine. The implants were installed using a three-dimensional model: vertical incisions no longer than 1 cm each were sequentially made in the aponeurosis, in the projections of the roots of the arches of the L5 and S1 vertebrae; the correctness of the direction was determined using the Brainlab pointer. Soft tissue retraction was performed using a unilateral Farabef retractor. Thus, the installation of 4 screws was performed through a midline incision of the skin, subcutaneous fat and 4 incisions of the aponeurosis in the projection of the roots of the arches on both sides, no more than 1 cm long each. Using a rod holder, PEEK rods were inserted through the holes on both sides and then fixed with nuts. Then, the inter-rod space of L5-S1 on the right was accessed, and a Panorama retractor was installed. An economical interlaminectomy of L5-S1 was performed to access the L5-S1 disc on the right, and using a surgical microscope, the disc herniation was removed, and microsurgical decompression of the dura mater and the S1 root on the right was performed.

The patient was verticalized 3 hours after the surgery. Complete regression of the pain syndrome in the right lower limb, as well as a decrease in the degree of hypoesthesia along the S1 dermatome on the right are noted. The next day, the patient began rehabilitation treatment with a therapeutic exercise instructor within the ward. Three days later, a control MRI of the lumbar spine was performed, which visualized decompression of the nerve structures at the L5-S1 level, minimal volume of surgical intervention, absence of deformation and significant dislocation of the multifidus muscles due to the minimal amount of fluid along the surgical approach. On the same day, the patient began classes with a therapeutic exercise instructor in the gym and in the pool (with a special waterproof sticker).

Six days after the operation, the patient began individual sports-specific training with restrictions: work with a soccer ball, such as dribbling, passing and kicking the ball, juggling the ball. Against the background of work with the ball, the patient notes a significant regression of paresis in the right foot. Fourteen days after the operation, the patient was allowed to run.

For three weeks, the patient continued training in the gym and in the pool with an instructor. 21 days after the surgery, the patient began sport-specific training with minimal restrictions. 26 days after the surgery, the patient returned to the general group. 32 days later, the patient took to the field in a national championship match.

The observation period was 4 months, the condition remains stable, there are no complaints of pain or weakness in the leg. The patient continues to participate in the national championship without restrictions. Below are the tables of assessment of life activity limitations due to pain in dynamics.

Table 1. Pain intensity assessment indicators using the VAS method

Observation (m.) VAS (points) Before surgery 10 After surgery 2 30 days after surgery 0

Table 2. Indicators of assessment of life activity impairment using

ODI questionnaire

Observation (m.) Oswestry (%) Before surgery 52 After surgery 6 30 days after surgery 0

Thus, due to the implementation of spine stabilization from the transaponeurotic approach, the period of full return to sports of patient S. after the operation was 1 month, which is several times shorter compared to other athletes who underwent microsurgical discectomy. For example, according to Watkins et al., the period of return to sports after microsurgical or endoscopic operations is on average 5.8 months [Robert G Watkins 4th 1, Robert Hanna, David Chang, Robert G Watkins 3rd Return-to-play outcomes after microscopic lumbar diskectomy in professional athletes // Am J Sports Med. - 2012 Nov. - №40(11). - P. 2530-5 https://doi.org/10.1177/0363546512458570]. In another study, Sedrak et al. indicate that the period of return to sports in elite athletes is on average 5.18 months. [Sedrak P, Shahbaz M, Gohal C, Madden K, Aleem I, Khan M. Return to Play After Symptomatic Lumbar Disc Herniation in Elite Athletes: A Systematic Review and Meta-analysis of Operative Versus Nonoperative Treatment. Sports Health. 2021; 13(5): 446-453. doi: 10.1177/1941738121991782]. According to Bäcker et al., 48.4% of surgeons typically recommend returning to high activity no earlier than 3 months later [Henrik C Bäcker, Michael A Johnson, Jack Hanlon, Patrick Chan, Peter Turner, John Cunningham. Return to sports following discectomy: does a consensus exist? // European Spine J, 2024 Jan; 33(1): 111-117. doi:10.1007/s00586-023-07776-4].

Clinical example 2.

Patient B., 67 years old, was admitted to the purulent surgery department of the State Healthcare Institution of Moscow, City Clinical Hospital No. 67 named after L.A. Vorokhobov, Department of Health of the City of Moscow with complaints of acute pain in the thoracic spine, which did not allow him to walk or even turn over in a lying position. The anamnesis included an increase in body temperature to 38°C. Examination revealed an increase in inflammatory markers: CRP up to 30 mg/l, leukocyte count up to 14.2*10 ³ /μl. CT and MRI of the thoracic spine - destruction of adjacent endplates of the Th10-11 vertebrae, inflammatory destruction of the intervertebral disc at this level with prolapse of the disc contents into the spinal canal, formation of an epidural abscess and compression of the spinal cord. The patient was diagnosed with spondylodiscitis Th10-11 with the formation of an epidural abscess at this level, type C2 according to Pola.

Antibacterial therapy was prescribed and a decision was made to perform surgical treatment in order to restore the supporting function of the spine, prevent the development of myelopathy and eliminate the source of the infectious process.

Stability of the spine in the postoperative period of spondylodiscitis treatment is an extremely important factor. It is not only a guarantee of pain relief, prevention of kyphotic deformation of the spine and secondary compression of the spinal cord, but also one of the most important factors in the fastest resolution of inflammation. The presence of instability is often the cause of ongoing inflammation, which does not go away despite all the antibiotics used. Stabilization of the spine can only be achieved by surgical fixation. On the other hand, fixation of the spine in conditions of ongoing inflammation is accompanied by a significant risk of infection of the system and its destabilization, as well as non-healing of the wound and subsequent long-term treatment. In order to reduce the risk of these complications, the surgeon should allow minimal contact of the structural elements with the source of infection. The technique of transaponeurotic minimally invasive fixation allows for maximum isolation of the system from the source and reduction of tissue trauma, which leads to faster wound healing.

Patient B. underwent transpedicular fixation of Th9-12 using transaponeurotic access, as well as drainage and debridement of the lesion in the intervertebral space of Th10-11. Transaponeurotic fixation was performed under the control of an image intensifier with cannulated screws using Kirschner wires.

In the postoperative period, immediate regression of the pain syndrome was achieved, which allowed the patient to be activated on the second day after the operation. Inflammatory markers returned to normal on the 10th day after the operation. The wounds after the operation healed without any peculiarities, the sutures were removed on the 8th day. The patient was discharged on the 14th day for outpatient treatment, where he continued taking antibiotics for 6 weeks. At the moment, the observation period is 2 months without any peculiarities.

Thus, the claimed method of transaponeurotic introduction of transpedicular screws, in contrast to the standard percutaneous introduction, allows to perform all manipulations from one midline skin incision, including decompression; use navigation instruments; reduce the time of the operation for installing the fixing structure, reduce the radiation load on the operating team and the patient, achieve a better cosmetic result on the skin of the back. The claimed method ensures the possibility of safe early rehabilitation - all postoperative restrictions are associated only with skin healing (in degenerative diseases). The beginning of the rehabilitation period and the nature of rehabilitation measures are not limited by the spine stabilization system, they are determined in the postoperative period only by the healing of the skin wound.

Claims (29)

1. A method of transpedicular fixation of the thoracolumbar spine, including performing a midline skin incision at the level of the target vertebrae to gain access to the aponeurosis; separation of subcutaneous fat from the aponeurosis laterally by 2-3 centimeters above the target vertebrae into which screw insertion is planned; determination under radiographic control of the insertion points of the Jamshidi needle on the aponeurosis, followed by puncture of the aponeurosis and placement of the needle on the bone at the insertion point of the screw, located in the area of the lateral edge of the root of the vertebral arch; insertion of a Kirschner wire through a Jamshidi needle under radiographic control in the lateral projection, followed by removal of the needle with the wire in a fixed position; after this, an incision is made in the aponeurosis along the course of the fibers at the point of insertion of the needle with a total length of no more than 1 cm; forming a channel around the spoke in the thickness of the muscle using an instrument that provides blunt separation of the muscle fibers, sufficient for inserting the screw; insertion of a cannulated screw through a pin into the vertebral body for minimally invasive transpedicular fixation, followed by removal of the pin; Cannulated screws are placed in the remaining target vertebrae in a similar manner; after which the rods are inserted and fixed in the screw heads, while the rod is inserted closed into the thickness of the muscle in the cranial-caudal direction using a rod holder; At the end of the operation, the incisions on the aponeurosis are sutured with 1-2 interrupted sutures each, followed by layer-by-layer application of sutures on the superficial fascia and skin. 2. The method according to item 1, characterized in that before fixing the rods in the screw heads, decompression of the spinal canal is performed, with access being achieved through the formed channel for inserting the screw or through an additional incision in the aponeurosis, made parallel to the spinous process of the vertebra on the side of decompression. 3. The method according to item 1, characterized in that two Farabeuf hooks are used as an instrument, wherein one hook is placed on the lateral side of the spoke, the second on the medial side, with the formation of lateral and medial walls of the canal, respectively. 4. The method according to item 1, characterized in that a tube expander or cylindrical retractor installed along the spoke is used as an instrument. 5. A method of transpedicular fixation of the thoracolumbar spine, including performing a midline skin incision at the level of the target vertebrae to gain access to the aponeurosis; separation of subcutaneous fat from the aponeurosis laterally by 2-3 centimeters above the target vertebrae into which screw insertion is planned; installation of a navigation system containing a navigation frame with a clip, which is fixed to the spinous process of the vertebra located in the center of the surgical frame, which is preliminarily skeletonized to a length of no more than 1 cm and a depth of no more than 1 cm; subsequent puncture of the aponeurosis with a navigation pointer to the point of screw insertion located in the area of the lateral edge of the root of the vertebral arch, while control of the choice of the point for puncture and subsequent control of screw insertion is carried out using a 3D model of the spine generated by the navigation system; after which the aponeurosis is incised along the fibres using monopolar coagulation from the point of insertion of the navigation pointer with a total length of the aponeurosis incision of no more than 1 cm; forming a channel around the navigation pointer in the thickness of the muscle using an instrument that provides blunt separation of the muscle fibers, sufficient for inserting the screw; extraction of the pointer followed by the formation of a bone canal for the insertion of a screw; insertion of a screw into the vertebral body for minimally invasive transpedicular fixation; screws are installed in the remaining target vertebrae in a similar manner; after which the rods are inserted and fixed in the screw heads, while the rod is inserted closed into the thickness of the muscle in the cranial-caudal direction using a rod holder; At the end of the operation, the incisions on the aponeurosis are sutured with 1-2 interrupted sutures each, followed by layer-by-layer application of sutures on the superficial fascia and skin. 6. The method according to item 5, characterized in that before fixing the rods in the screw heads, decompression of the spinal canal is performed, while access is formed using a navigation system through an additional incision of the aponeurosis, made parallel to the spinous process of the vertebra on the side of decompression. 7. The method according to item 5, characterized in that two Farabeuf hooks are used as an instrument, wherein one hook is placed on the lateral side of the spoke, the second on the medial side, with the formation of lateral and medial walls of the canal, respectively. 8. The method according to item 5, characterized in that a tube expander or cylindrical retractor installed along the spoke is used as an instrument.