Method for vertebroplasty

FIELD: medicine, traumatology.

SUBSTANCE: the present innovation deals with corporectomy in patients with pathological vertebral fractures. One should introduce an insertion into inter-body defect after pre-manufacturing it out of cement as a groove of 2-3 mm thickness to be placed into defect with its protuberance towards dural sac at 2-3 mm against it; in case of a great inter-body defect one should introduce drainages from the side of safe vertebrae with possibility for their removal. If additional fixation is necessary one should introduce metal rods into vertebrae being adjacent with inter-body defect which partially protrude into defect area that prevents neural structures against thermal and mechanic damage.

EFFECT: higher efficiency of vertebroplasty.

2 cl, 2 ex

 

The invention relates to medicine, namely to traumatology and orthopedics, and may find use in the removal of their bodies in patients with fractures of the spine.

Vertebral fractures often occur on the background of pathological changes in their bone structure, resulting in lower strength. The most common cause is osteoporosis and tumor. Often these fractures are accompanied by complete destruction of the vertebra with the formation of a large number of fragments, the deformation of the spinal canal with compression of neural structures and the development of deep neurological disorders. If the osteoporosis process of consolidation change in the conditions of stabilization of the spine occurs without specifics, when the tumor process without removal of the tumor tissue fusion is impossible. A necessary condition for surgical treatment of tumors is radical removal of the entire unit. So corporectomy is the method of choice in the treatment of certain benign and malignant (both primary and metastatic tumors of the spine. The second objective of the operation is the substitution formed after removal of the vertebral defect and restore the support ability of the spine. The main method of recovery support ability of the spine, including tumors, I have is autoplastic bone grafting of the defect of the vertebrae and metallicity. This method is widely used in the treatment of malignant tumors. However, first, it requires additional surgery to harvest autogenous bone and, secondly, in the period of perestroika, there are limitations on the mode of activation of the patient and the administration of radiotherapy and chemotherapy, which adversely affects the treatment of this patient.

Recently to replace an interbody defect after removal of their bodies, particularly when a tumorous lesion of the spine, increasingly began to use various rapid hardening biocompatible materials. Among them the most widely bone cement (methyl methacrylate). The methyl methacrylate (MMK) is used in combination with metal, and separately without additional fixation. The advantage of using bone cement is the best adaptation (contact) of the graft over the entire surface and form the switching plate of the vertebral body, which creates maximum stability on the border of the implant and bone. In this case, there is no need to perform additional surgery to harvest autogenous bone. Thus, these operations significantly reduce the duration of the rehabilitation period and allow you to assign radiation and chemotherapy in americaspace after the operation.

However, a significant problem in the use of MMK is that during the polymerization in the tissues, its temperature can reach 122°C. the Impact of temperature on adjacent biological tissue is accompanied by their necrosis. Therefore, the use of MMK in the immediate vicinity of the nerve structures (membranes of the spinal cord and roots) may be accompanied by serious complications associated with burns. To avoid these complications offered many different ways to protect the spinal cord from heat damage.

Closest to the claimed method is vertebroplastic with insulation content dural SAC, proposed N. Sundaresan et al. (N. Sundaresan, et al: Treatment of neoplastic epidural spinal cord compression by vertebral body resection and stabilization. J Neurosurg 63: 676-684, 1985), taken as a prototype. According to this method before the introduction of bone cement (MMK) in interbody defect on the posterior longitudinal ligament or dural bag placed foaming gel or loose fatty tissue, to prevent thermal effects on the spinal cord and nerve roots. Then top pour liquid cement to fill the defect.

The disadvantages of this method is that the use of free fatty tissue and gel, as the experience of their application, does not allow ravnomerno is to cover the dural SAC. As a result of this possible leakage of cement into the spinal canal with compression of neural structures and thermal effects on them. Moreover, to carry out the cooling of the spinal cord saline solution during the polymerization of the cement is impossible due to possible displacement of the free fatty tissue or rinse gel. The resulting complications can lead to burn and compression of neural structures, deep neurological disorders that require additional therapy (including reoperation) and increases the duration of treatment of this pathology.

The technical result of the present invention is to reduce the number of intra - and postoperative complications due to the preliminary introduction into the interbody defect cement paste.

This result is achieved by the known method of vertebroplastic, including corporectomy and the introduction of an interbody defect of liquid bone cement according to the invention previously from the bone cement is produced corresponding to the width and height dimensions interbody defect insertion in the form of a trough with a thickness of 2-3 mm, which after removal of their bodies placed in the defect to bulge dural bag at a distance of 2-3 mm from it, and liquid cement is injected in the resulting bed to fill the defect.

It is advisable when there is a large shopping Mall the interbody defect to enter from the side saved vertebrae drains can be deleted.

If necessary, additional fixing suitable adjacent to interbody defect of the vertebrae to introduce metal rods protruding 0.5-1 cm in the region of the defect.

Pre-fabrication of the trench corresponding to the size of the defect, allows after it is placed in the defect to bulge dural bag completely block access to a dural bag and thus to protect it from mechanical impact and burns when filling defect of the liquid bone cement, and, as we have shown empirically adequate for this is that the thickness of the gutter 2-3 mm.

The establishment of the gutter bulge to the dural sack at a distance of 2-3 mm ensures the tightness of the structure and at the same time allows him to avoid damage.

The subsequent introduction of liquid bone cement provides substitution of the defect and the stability of the spine without the risk of burn and mechanical damage to the neural structures.

If necessary, fill the large defect of the liquid bone cement the introduction of additional drains to a dural bag allows cooling with saline solution during the polymerization MMK and to prevent thermal injury to neural structures.

Additional metal rods in adjacent to the defect of the vertebrae before the introduction the of liquid cement can improve the fixation of the spine.

The essence of the method is illustrated by examples.

Example 1. Patient S., 41, and/b 8006

He entered the Department of pathology of the spine, RIICO them. Ren due to severe pain in the cervical and thoracic spine with irradiation in the right hand and left leg.

From the anamnesis: In April 2000, in the cancer clinic was left mastectomy for breast cancer. Subsequently, he received the planned courses of combination therapy. For the first time pain in the cervical spine appeared in August 2002, it was noted paresis of the right upper limb. On radiographs of the cervical spine from 16.09.02, revealed destruction of the body CV vertebra with a reduction in its height. On scintigraphy - pathological hyperfixation radiopharmaceutical with a gradient accumulation up to 100%. After the course of chemotherapy and bonefos pain disappeared, and recovered motor function in the hand. Since January 2003, there were pains in the thoracic spine, the lateral surface of the thorax.

When entering the x-ray marked pathological fracture CIV-VI vertebrae with abnormal kyphotic deformity CIV-VI, pathological fracture ThIX.

Diagnosis: Pathological fracture CV-VI, ThIX vertebrae on the background of metastatic cancer of the left breast. After mastectomy (2000). Verot progeny syndrome. SOP.: Osteochondrosis of the lumbar spine, disc herniation LV-SI.

At the Department of pathology of the spine, RIICO 13.11.03, under endotracheal anesthesia in the patient on the back or left on Bailey layers selected body III-VII of the vertebrae. X-ray control. During inspection body CV practically not visualized in its place is marked retraction with the apex of the kyphotic deformity. Resected body CV-CVI vertebrae together with the adjacent disks. The selected switching plates IV and VII of the vertebrae. Cement is made to insert in the form of a chute of a thickness of 3 mm in height and width corresponding to the size of an interbody defect. After polymerization (hardening) of the cement prepared by the insert fits tightly into the defect bulge to dural bag, at a distance of 2-3 mm from it. Given the large mobility of the cervical spine for the fixation of a defect in the switching plate adjacent bodies from the defect rigidly put metal rods with a diameter of 3 mm and a length of 30 mm so that the parts 10 mm was performed in the lumen of the defect. In a prepared bed around rods filled with liquid bone cement to fill the defect. Excess cement is removed with a sharp spoon. Roentgenologically control. The wound is sutured. Aseptic bandage.

Blood loss of 200 ml of the Duration of the operation - including 30 minutes

The patient is raised to a vertical position after 3 days after surgery. Sutures were removed after 10 days, and the patient was discharged without external immobilization. During examination 3 months after surgery, no complaints, weight-bearing capacity of the spine preserved, goes without external immobilization.

Example 2. Patient K., 47 l/b 482

He entered the Department of pathology of the spine, RIICO about pain in the thoracic spine, growing on the background of vertical loads with irradiation by intercostal space.

From the anamnesis: Pain in the thoracic spine appeared in October 1999, was Treated in the clinic on a residence diagnosed with osteochondrosis of the thoracic spine. In January 2000, the pain has increased dramatically, examined in the Department of neurology, where according to the radiographic examination revealed pathological fracture ThVIII vertebra, the metastasis of breast cancer. For examination the patient was referred to the Oncology center - diagnosis: Cancer of the right breast T3N×M1. Received standard chemotherapy and radiation therapy. 03.06.00, - performed a radical mastectomy on Modano right and bilateral ovariectomy. On scintigraphy 14.06.00 - hyperfinite radiopharmaceuticals ThVIII-IX. In September 2003, it was noted the progression of the disease: it is revealed metastases in the neck of the left femur and 5 rib on the right. On the computer the agreement tomography from 16.12.03. defined compression fracture of the body of Th VIII vertebra. The patient was referred to RIICO them. Ren.

When applying for an MRI from 21.01.04 - compression fracture ThVIII, destructive changes ThIX.

Diagnosis: Pathological fracture Th VIII, against the background of metastasis breast cancer ThVIII-Th IX vertebrae. After mastectomy T3N×M1 and bilateral ovariectomy (2000). Vertebrogenic syndrome.

At the Department of pathology of the spine, RIICO 24.01.04, under endotracheal anesthesia in position patient on left side in layers subperiosteal isolated and resected VIII edge, VII-e - mobilized by crossing on srednechrochnoy and anterior axillary line. Thoracotomy. Under radiological control the operation. Segmental vessels in the projection bodies ThVII-ThX coagulated and crossed. Mobilized lateral ThVII-ThIX vertebrae. During inspection body ThVIII vertebra roughly wedge-shaped deformed. Under x-ray control in ThVII and ThX vertebrae installed metal structure for fixing the affected segment. Completed the destruction of tel ThVIII-ThIX vertebrae. When bone tissue of the vertebral bodies was degenerative change with inclusion of the pink color. From the simulated cement paste in the form of a trough thickness of about 2 mm in height and width corresponding to the dimensions of mestel the first defect. Insert after hardening of the cement is tightly fitted into the defect bulge to dural bag, at a distance of 2-3 mm from it. Given the large size of the defect between the gutter and the Dura mater from the side adjacent to the defect of the vertebrae announced 2 of the catheter. In a prepared bed around rods filled with liquid bone cement to fill the defect. During the entire period of polymerization of the cement through the proximal catheter was applied to saline and to the distal connected electric pump, which removed the heated liquid. Excess cement is removed with a sharp spoon. Roentgenologically control. The wound is sutured. Aseptic bandage.

Capoterra - 700 ml. operation Duration is 3 hours and 20 minutes

The patient is raised to a vertical position after 3 days after surgery. Sutures were removed after 10 days, and the patient was discharged without external immobilization. During the examination 1 month after surgery, no complaints, weight-bearing capacity of the spine preserved, goes without external immobilization.

To date, this method operated 6 people with metastatic lesions of the spine. All completed the replacement of the defect with bone cement.

The proposed method is compared with the known has the advantage consists in the fact that it allows us as shown in the treatment of patients totally what Yu exclude the possibility of mechanical and thermal effects on the spinal cord, nerve roots and surrounding soft tissue.

The method developed in the Russian scientific research Institute of traumatology and Orthopedics named. Ren and was clinically tested in the Department of pathology of the spine in 6 patients with a positive result.

1. How vertebroplastic, including corporectomy and the introduction of an interbody defect of bone cement, wherein the pre from the bone cement is produced corresponding to the width and height dimensions interbody defect insertion in the form of a trough with a thickness of 2-3 mm, which after removal of their bodies placed in the defect to bulge dural bag at a distance of 2-3 mm from it, and liquid cement is injected in the resulting bed to fill the defect.

2. The method according to claim 1, characterized in that in the presence of a large interbody defect in it from the saved vertebrae enter drains can be deleted.

3. The method according to claim 1, characterized in that when the need for additional fixation in adjacent to interbody defect vertebrae injected metal rods protruding 0.5-1 cm in the region of the defect.



 

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