RU2823457C9 - Method for two-stage surgical treatment of stage iv idiopathic scoliosis by selective hybrid fixation in patients with incomplete bone growth - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely traumatology, orthopaedics and vertebrology, and can be used for surgical treatment of stage IV idiopathic scoliosis, to achieve this, a method of two-stage surgical management of severe forms of idiopathic scoliosis with reduced length of fixation in patients with incomplete bone growth is proposed. Skin is incised in a projection of the spinous processes of the vertebrae throughout the spinal deformation, dissection of subcutaneous fat, superficial fascia, separation of soft tissues with a coagulator to expose the base of spinous processes and vertebral arches on both sides. LSZ laminar hooks are inserted in the thoracic and lumbar spine under the vertebral arches; a rectangular plate is placed on the right and left sides. Spine is corrected due to the fact that while the patient is growing, the spine is also growing, and the deformity is additionally corrected. At the end of the spinal growth, the above structure is removed and replaced with a transpedicular system only in the thoracic spine. Autobone-crumbs produced by decortication are placed in the metal structure bed. Two active drains are installed in the metal structure bed in the caudal and cranial edges of the incisional wound. Wound is closed in layers.

EFFECT: method provides more significant correction of spinal deformity, unobstructed spinal growth to completion of bone growth and reducing the length of spinal fixation at the moment of completion of spinal growth due to the fact that support points are established that do not prevent spinal growth at 1st stage of treatment, spinal growth takes place in a more correct position until the onset of maturity of the bone skeleton, an additional correction of the deformation is performed during 2nd stage of treatment, the length of the spinal fixation is reduced, lumbar spine remains free, which allows the patient to maintain the entire range of motion.

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Description

Field of technology to which the invention relates

The invention relates to the field of medicine, namely traumatology, orthopedics and vertebrology, and can be used for the surgical treatment of severe forms of idiopathic scoliosis.

State of the art

The prior art includes a method for surgical treatment of scoliotic deformities, in particular the medical technology: Surgical treatment of scoliotic deformities in adults (Permission to use new medical technology FS No. 2011/174 dated 16.06.2011)

A method of surgical treatment of severe forms of scoliosis in children is known (Sataev Valery Uralovich, Mironov Petr Ivanovich, Yunusov Damir Ildusovich, Farkhshatov Artur Vafirovich, Psyanchin Timur Syntimerovich Surgical treatment of severe forms of scoliosis in children // Medical Bulletin of the North Caucasus. 2016. No. 2-2.) including posterior instrumentation of scoliotic deformity using a transpedicular system.

However, the known method does not allow for a single-stage significant correction of the deformation, thereby reducing the potential percentage of correction of the spinal deformation and requires extended fixation of the spine.

A method is known for the USE OF LAMINAR LSZ HOOKS IN COMBINATION WITH TRANSPEDICULATORY FIXATION IN SURGERY OF SEVERE FORMS OF SCOLIOSIS IN CHILDREN WITH COMPLETED GROWTH POTENTIAL.

The disadvantage of this method is that it cannot be performed in patients with incomplete bone growth.

A method of dorsal surgical correction of spinal deformity using Cotrel - Dubousset instrumentation is known (Vetrile S.T., Kuleshov A.A., Kisel A.A., Prokhorov A.N., Enaldieva R.V. DORSAL SURGICAL CORRECTION OF SCOLIOSIS USING COTREL - DUBOUSSET INSTRUMENTATION WITH AND WITHOUT PRELIMINARY HALOPELVICTRACTION. "Spine Surgery". 2005; (4): 032-039.) In this method, transpedicular screws and laminar hooks are used to correct spinal deformity, which are inserted behind the vertebral arch.

However, with this method, laminar hooks perform a stabilizing function and do not contribute to the correction of spinal deformity in the frontal plane.

The closest to the claimed method is the method of surgical treatment of severe forms of scoliosis according to the patent of the Russian Federation No. 2582048, including access to the posterior bone structures of the spine and installation of supporting elements of endocorrectors, wherein after exposure of the spinous processes and vertebral arches, hooks of the fastening blocks of the two-plate endocorrector are installed under the vertebral arches, starting from the thoracic to the lumbar spine, wherein two pairs of hooks are installed in a row at the ends of the deformation on adjacent vertebrae, and subsequent hooks are installed through one vertebra, after fixing the hooks, profiling of the endocorrector plates is performed and installation of dynamic fixators to the threaded posts of the endocorrector at all levels of deformation, except for the apical vertebra, which is stably fixed to the plate, after tightening the endocorrector structure, drains are installed in its bed and the wound is sutured layer by layer, after the growth of the spine stops, an incision is made in the skin along the old scar and dismantling two-plate endocorrector, removal of articular processes of the cartilaginous layer, decortication of the semi-arches, articular and transverse processes of the vertebrae, after which a two-rod endocorrector with transpedicular fixation of the spine is installed, autogenous bone chips obtained during decortication are placed in the bed of the endocorrector, drains are installed and the wound is sutured layer by layer. The disadvantage of this method is the limitation of patient movement and the impossibility of using the solution for patients with incomplete bone growth.

The claimed solution is a modernization of this method. The modernization consists in selective fixation of the spinal deformity during the 2nd stage of surgical treatment with preservation of the lumbar vertebrae free, which allows the patient to maintain a full range of motion (bending, turning, etc.) and the possibility of using this method in patients with incomplete bone growth.

Disclosure of invention

The technical problem addressed by the present invention is the creation of a more effective method for surgical treatment of severe forms of idiopathic scoliosis in patients with incomplete bone growth.

The technical result, which the claimed invention is aimed at achieving, is the possibility of obtaining a more significant correction of the spinal deformity, unimpeded growth of the spine until the completion of bone growth and a reduction in the length of fixation of the spine at the moment of completion of spinal growth.

The technical result is achieved by the fact that a method is proposed for a two-stage surgical treatment of stage IV idiopathic scoliosis using the selective hybrid fixation method in patients with incomplete bone growth, characterized by the fact that it includes a skin incision in the projection of the spinous processes of 6 vertebrae along the entire length of the spinal deformity, dissection of the subcutaneous fat and superficial fascia, separation of soft tissues with a coagulator until the base of the spinous processes and vertebral arches is exposed on both sides, installation of LSZ laminar hooks in the thoracic and lumbar spine under the vertebral arches, installation of rectangular plates on the right and left sides and installation of two active drains in the bed of the metal structure in the caudal and cranial edges of the surgical wound with subsequent layer-by-layer suturing of the wound; After the spine has finished growing, the metal structure is removed and a transpedicular system is installed, placing it only in the thoracic spine; the autologous bone chips obtained during decortication are placed in the bed of the metal structure, followed by layer-by-layer suturing of the wound.

The combination of the above essential features leads to the fact that:

- support points are established that do not interfere with the growth of the spine at the 1st stage of treatment

- growth of the spine in a more correct position before the onset of skeletal maturity

- additional correction of the deformation is performed during the 2nd stage of treatment

- the length of the spine fixation is reduced

- the lumbar spine remains free, which allows the patient to maintain the full range of motion.

Brief description of the drawings

Invention of photographs, where Fig. 1 shows an X-ray of the spine in direct projection of patient T., 12 years old, with an established diagnosis of idiopathic thoracic scoliosis stage IV.

Fig. 2 shows an X-ray image of the spine in a direct projection of patient T., 12 years old, with an established diagnosis of idiopathic thoracic scoliosis stage IV after performing the 1st stage of surgical intervention.

Fig. 3 shows an X-ray image of the spine in a direct projection of patient T., 12 years old, with an established diagnosis of idiopathic thoracic scoliosis stage IV after the completion of bone growth.

Fig. 4 shows an X-ray image of the spine in a direct projection of patient T., 12 years old, with an established diagnosis of idiopathic thoracic scoliosis stage IV after performing the 2nd stage of surgical intervention.

Fig. 5 shows the assembled LSZ 1 laminar hook on a model of the spine - it shows how it is fixed

Fig. 6 shows the assembled structure in side view.

The positions on the figures indicate: 1 - LSZ laminar hooks; 2 - plates; 3 - shortening of plates due to spine growth; 4 - transpedicular screws.

Implementation of the invention

The claimed solution consists of the following actions:

Access to the spinal deformity is achieved by making a skin incision in the projection of the spinous processes of the vertebrae along the entire length of the spinal deformity and dissecting the subcutaneous fat and superficial fascia; the soft tissues are separated with a coagulator until the bases of the spinous processes and arches (vertebral arch or vertebral arches are an anatomical term denoting the posterior part of the vertebra Gaivoronsky I. V. Human anatomy: In 2 volumes. V. 1. The system of organs of support and movement. Splanchnology: textbook / I. V. Gaivoronsky, G. I. Nichiporuk, A. I. Gaivoronsky; edited by I. V. Gaivoronsky. - M .: GEOTAR-Media, 2014. - 688 p. - ISBN 978-5-9704-2804-7) of the vertebrae are exposed on both sides, Fig. 1, Fig. 2;

Next, sequential installation of laminar hooks LSZ 1 is performed in the thoracic and lumbar spine along the entire length of the deformation in pairs to the right and left of the spinous process of the vertebra (Fig. 5; Next, installation of plates 2 on laminar hooks 1 is performed (Fig. 3, Fig. 4, Fig. 6).

The hooks are installed behind the vertebral arches using a standardized technique (Zagorodniy N.V., Sampiev M.T., Lysenko I.S., Chemurzieva H.M. A treatment option for severe adolescent idiopathic scoliosis using a two-stage surgical technique, Medical Bulletin of the Ministry of Internal Affairs No. 5, 2023)

After the installation of the growing structure is completed, two active drains are installed in the caudal and cranial edges of the surgical wound (the drain is placed in the surgical area next to the structure, and is brought out onto the skin through an additional opening (the opening is created with a scalpel) (Zagorodniy N.V., Sampiev M.T., Lysenko I.S., Chemurzieva H.M. A treatment option for severe adolescent idiopathic scoliosis using a two-stage surgical technique, Medical Bulletin of the Ministry of Internal Affairs No. 5, 2023).

After installing the drains, the surgical wound is sutured layer by layer.

The second stage of treatment is performed after the completion of bone growth (bone growth is assessed by the Risser criterion on X-ray images of the spine) Idiopathic Scoliosis: the Harms Study Group. Treatment Guide, 2nd Edition Ed. by P. Newton, A. Samdani, H. Shufflebarger, R. Betz, J. Harms. An incision is made along the previous postoperative scar with excision of the latter. The previously installed structure is exposed. The structure is dismantled. After dismantling the structure, the facet joints in the thoracic spine are additionally exposed. After exposure, the facet joints in the thoracic spine are resected and pedicle screws 4 are installed (the transpedicular screws 4 are installed according to the standard generally accepted technique). For example, installation of screws in the lower 2 vertebrae on 2 sides, then paired installation in the vertebral bodies up to the upper thoracic spine. In the lumbar spine, installation of support points is not required, since according to the Huether-Volkmann law, more correct growth of the spine occurs during wearing of the growing structure, which does not require fixation and correction of the lumbar spine. Gizatullin Sh.Kh., Bitner S.A., Kristosturov A.S., Volkov I.V., Kurnosenko V.Yu., Dubinin I.P. Minimally invasive endoscopic foraminal decompression for degenerative scoliosis in adults: clinical observation and literature review // Spinal surgery. 2019. Vol. 16. No. 4. P. 54-62. The wound is sutured in layers.

Examples of implementation of the invention

Below is an example of a specific implementation of the claimed solution, which does not limit the options for its implementation.

Example. Patient T., 12 years old, figs. 1-5, was admitted with the diagnosis: Idiopathic thoracic scoliosis stage 4. Deformation angle 90°. A 2-stage surgical treatment was performed in the following volume: installation of a growing LSZ structure at the first stage of treatment, and replacement of the growing structure with transpedicular fixation at the second stage. After treatment, the angle of scoliotic deformity was <5° according to Cobb. Correction was 99%. No loss of correction was noted during the 10-year follow-up period.

A standard posterior approach to the spine is performed. The bases of the spinous processes and vertebral arches are skeletonized. The facet joints are not exposed. Then, laminar LSZ hooks are installed under the arches next to the bases of the spinous processes. The hooks are inserted behind the vertebral arch and fixed to the arch. The next step is to install rectangular plates measuring 6x4 mm. The plates are bent in accordance with the physiological curves of the spine. When the plates are prepared, they are placed along the spine and fixed on the hooks using clips with grooves Fig. 5. Fig. 6. As the structure is installed, the scoliotic deformation is corrected in 3 planes. After installing the system, the wound is sutured layer by layer with the installation of drains.

During the 2nd stage of surgical treatment, an approach similar to the 1st operation is performed. Scar tissue is excised, and the system is dismantled. After exposing the facet joints, standard transpedicular stabilization of the spine is performed with resection of the facet joints and correction of the spinal deformity in 3 planes. Along the course of the structure, posterior spondylodesis is performed with autobone. The wound is sutured layer by layer.

Claims (1)

A two-stage surgical method for the treatment of stage IV idiopathic scoliosis using selective hybrid fixation in patients with incomplete bone growth, characterized by the fact that it includes a skin incision in the projection of the spinous processes of 6 vertebrae along the entire length of the spinal deformity, dissection of the subcutaneous fat and superficial fascia, separation of soft tissues with a coagulator until the base of the spinous processes and vertebral arches is exposed on both sides, installation of LSZ laminar hooks in the thoracic and lumbar spine under the vertebral arches, installation of rectangular plates on the right and left sides and installation of two active drains in the bed of the metal structure in the caudal and cranial edges of the surgical wound with subsequent layer-by-layer suturing of the wound; After the spine has finished growing, the metal structure is removed and a transpedicular system is installed, placing it only in the thoracic spine; the autologous bone chips obtained during decortication are placed in the bed of the metal structure, followed by layer-by-layer suturing of the wound.