Method for surgical approach to upper and lower cervical spines

FIELD: medicine.

SUBSTANCE: planned skin incision is first configured on an anteriolateral neck surface by projection zoning of a clavisternomastoid and a neck median line to be marked with colour graphic lines. A first line extends along a medial border of the clavisternomastoid. A second line extends from a suprasternal notch to the middle of a hyoid shaft. Both of the lines are then combined by drawing a perpendicular third line from a lower border of the middle of a hyoid shaft to the medial border of the clavisternomastoid, thereby forming a projection triangle. Cutaneofascial layers, platysma and subcutaneous fat are incised along the first and third lines to cut out a musculocutaneous flap, which is brought outwards. Underlying soft tissues are dissected to an anterior surface of cervical spinal bodies by splitting subcutaneous fat between a neurovascular bundle and a pharynx, detaching an intracervical fascia, splitting perioesophageal subcutaneous fat and displacing midline organs of the neck in the medial direction, and the neurovascular bundle - in the lateral direction.

EFFECT: method enables reducing a risk of treatment-induced traumatic injuries of the midline organs of the neck, an upper laryngeal nerve, upper and lower thyroid arteries, as well as a parenchyma and an excretory duct of a submandibular salivary gland with optimising topographo-anatomical relations of the incision wound structures, thus providing a surgical angle approaching 90 degrees.

1 ex

 

The invention relates to medicine, namely to neurosurgery, vertebrology, orthopedics and traumatology. This solution can be used in the implementation of surgical interventions in neoplastic and inflammatory lesions and traumatic injuries that require to perform the main stage of surgical intervention skeletonname bodies of C2-C7 vertebrae.

The complexity of the topographic-anatomical relations of the cervical spine with surrounding vital organs of the neck greatly limits the possibility of surgery on the vertebral bodies. The most difficult challenge remains the implementation of a rational surgical approach to carry out essential stages of radical interventions performed in inflammatory, neoplastic diseases of the vertebrae and traumatic injuries.

Individual topographic-anatomical conditions and the diversity of forms of pathology of the cervical spine define a differentiated choice of surgical approaches. At a pathology of bodies of the cervical vertebrae are used front and Antero-lateral approaches: top-corner, lower corner, the lower-middle corner, T-shaped, Samoobrona combined multi-zone, ecoreality. Of these accesses when performing expansion�enny volumes of surgical procedures applied bottom-corner, T-shaped, Samoobrona and combined accesses, allowing you to perform operational manipulation not only multiple abnormal vertebrae, but also the adjacent parts of the neck [Ramic E. A. trauma to the lower cervical spine: diagnosis, classification, treatment // Surgery of the spine. 2005. No. 3. Pp. 8-24; Ramic E. A. Injuries of the upper cervical spine: diagnosis, classification, characteristics and therapy/ spine Surgery. 2005. No. 1. P. 25-44].

The closest analogue to the claimed invention is an anterior cervical Samoobrona access [Kushkhabiev V. I. Surgery of the cervical vertebrae. Nalchik: Elbrus, 1976. P. 62-65], in which an incision along the medial edge of sternocleidomastoid muscle, then from the ends medially in the transverse direction cut through the skin and fascial layers at the top - the neck and submandibular folds, down - to the sternal end of the opposite clavicle. This cut surface and its own fascia of the neck together with platysma, third fascia of the neck, scapular-hyoid, Sterno-thyroid and Sterno-hyoid muscles, nutricianal the fascia. In the upper part of the wound also cross awl-hyoid, awl-pharyngeal muscle and the posterior belly of digastric.

However, this access, as all of the above, characterized obra�lo g an extensive area operating distance, that makes them, despite the convenience of meeting operational skills very traumatic. Trauma is determined by a significant number of cross muscles, work on all of the fasciae of the neck, extensive dissection of the deep cellular spaces, the possibility of intraoperative injury of the neurovascular bundle and submandibular salivary glands.

The objective of the claimed invention is to provide an anterior cervical surgical access to the bodies of C2-C7 vertebrae, which allows to reduce the risk of iatrogenic traumatic injuries of the midline of the neck, upper laryngeal nerve, upper and lower thyroid arteries and parenchyma and ductless podniesinski salivary glands in the optimization of topographic-anatomical relationships of structures of the wound, providing the angle of operative activity, approaching 90°.

The essence of the claimed invention is characterized in that in the method of surgical access to the upper and lower cervical spine determine the configuration of the planned incision of the skin on the anterior-lateral surface of the neck by setting projection zones of sternocleidomastoid muscle and the midline of the neck with the application of color codes marking the first line, passing through mediaremote sternocleidomastoid muscle, and the second line from the level of the jugular notch to the middle of the body of the hyoid bone, which are then connected by conducting perpendicular to the third line from the bottom of the mid-body of the hyoid bone to the medial edge of the sternocleidomastoid muscle, forming a flat triangle, perform the incision of the skin and fascial layers, platysma and fatty tissue of the first and third lines with cutting out a skin-muscle flap, which is removed outwards, carry out a dissection of soft tissues to the anterior surface of the bodies of the cervical vertebrae by delamination of fiber between the neurovascular bundle and throat, separation nutricianal fascia, bundles amlopidine tissue and displacement of midline of the neck medially and the neurovascular bundle laterally.

The technical result of the claimed invention.

By this technique, the incision specific configuration on the previously applied colour labelling in accordance with subcutaneously placed anatomical landmarks allows to form musculocutaneous flap without additional damage to the muscles, vessels, nerves and submandibular glands, as well as provide convenience to the mobilization of these structures, dissection of the cervical fascia, cellular spaces of the neck and stellerovaya bodies of C2-C7 call�s, including manipulation on the basis of the odontoid process of the C2 vertebra. The implementation part of the section in accordance with a third projection line held in the form of the perpendicular from the bottom edge of the mid-body of the hyoid bone to the medial edge of the sternocleidomastoid muscle, limits the possibility of iatrogenic traumatic injuries of the contents of the submandibular triangle, namely parenchyma podniesinski salivary gland and its capsule, by intactness soft tissue located above the short arm of the incision, forming a bed for the above cancer and preventing its "dislocation" in the surgical wound (unlike analog). This type of cut allows to exclude the execution of unwanted instrumental manipulation, in particular excessive traction retract the capsule and parenchyma of the submandibular gland, ligation of feeding this gland afferent and efferent blood vessels, as well as obdelavo vein, superior thyroid arteries and veins, the intersection of awl-hyoid, awl-pharyngeal muscle and the posterior belly of the digastric muscle. In connection with the foregoing described in this application surgical access is less harmful in terms of maintaining a sufficient amount of wound, her index and angle of operative activity, approaching 90°, which makes it�splash zones to perform the main stage of surgical intervention not only on the adjacent vertebrae, but on the level of the upper and lower cervical spine.

Performance of the proposed surgical approach allows to preserve the integrity of the sternocleidomastoid muscle, to avoid damage to the neurovascular bundle of the neck and its case, to eliminate impacti adjacent to the wound anatomical structures can be achieved only temporarily compromising the integrity of the small muscles of the median of the neck with the passage of the wound channel through the fascial-cellular layers without further restriction of the functions of the midline of the neck in the process of formation of postoperative scar.

Method of surgical access to the upper and lower cervical spine is as follows.

The indications for the use of the inventive surgical access are: multiple and combined neoplastic, inflammatory lesions and traumatic injuries of the upper and lower cervical spine, in which to perform the main stage of surgical intervention required stellerovaya bodies of C2-C7 vertebrae.

Before performing main stage surgery determine the configuration of the planned incision of the skin on the anterior-lateral surface of the neck. To do this, set the projection zones of sternocleidomastoid mystii the midline of the neck. Put colour-coded lines. The first line carried by the medial edge of the sternocleidomastoid muscle. The second line is carried out from the level of the jugular notch to the middle of the body of the hyoid bone. The first and second lines connect by holding perpendicular to the third line from the bottom of the mid-body of the hyoid bone to the medial edge of the sternocleidomastoid muscle, forming a flat triangle. Carry the incision of the skin and fascial layers, platysma and fatty tissue of the first and third lines with cutting out a skin-muscle flap, which is removed outwards. Carry out the dissection of soft tissues to the anterior surface of the bodies of the cervical vertebrae by delamination of fiber between the neurovascular bundle and throat, separation nutricianal fascia, stratification amlopidine tissue and displacement of midline of the neck medially and the neurovascular bundle laterally. If necessary, due to individual anatomical variability, mobilize the superior laryngeal nerve, the upper and the inferior thyroid artery. After you complete the basic stage of surgical intervention on the affected/damaged the cervical vertebrae surgical wound sutured in layers.

Example

Patient M., 43 years old, was admitted to the neurosurgical Department with a diagnosis�m: "complicated Closed injury of the cervical spine. Compression-comminuted fracture of the bodies of C4-C5 vertebrae injury and spinal cord compression at this level. Upper paraparesis, lower paraplegia. Infringement of functions of pelvic organs."

After clinical and intratropical examination established indications for decompressive-stabilizing interventions on the cervical spine with surgical access by the above procedure.

Perform this surgical approach provided good visualization of the bottom of the wound because of the wide availability zone to the bodies of C2-C7 vertebrae and the operating angle of 90° in the absence of "dislocation" submandibular gland, eliminating the need to perform additional unwanted instrumental manipulation.

The postoperative period is smooth, the wound healed by primary intention, the cosmetic result is good.

Method of surgical access to the upper and lower cervical spine, characterized by the fact that determine the configuration of the planned incision of the skin on the anterior-lateral surface of the neck by setting projection zones of sternocleidomastoid muscle and the midline of the neck with the application of color codes marking in the form of a first line passing through the medial edge of the sternocleidomastoid muscle and the second line from the level of the jugular notch to the middle of the body of the hyoid bone, which are then connected by conducting perpendicular to the third line from the bottom of the mid-body of the hyoid bone to the medial edge of the sternocleidomastoid muscle, forming a flat triangle, perform the incision of the skin and fascial layers, platysma and fatty tissue of the first and third lines with cutting out a skin-muscle flap, which is removed outwards, carry out a dissection of soft tissues to the anterior surface of the bodies of the cervical vertebrae by delamination of fiber between the neurovascular bundle and throat, separation nutricianal fascia, bundles amlopidine tissue and displacement of midline of the neck medially and the neurovascular bundle laterally.



 

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