Method for posterior spinal fusion in traumatic injuries of upper cervical spine

FIELD: medicine.

SUBSTANCE: what is involved is a posteromedian surgical approach to an upper cervical spine. That is followed by a subperiosteal dissection with exposing an occipital bone, a posterior arch of atlas, a spinous process and a C2 vertebral arch. A posterior atlantooccipital fixation is carried out from both sides from a body mid-line with using a polyaxial combined screw and rod fixation according to Harms-Melcher procedure. A posterior spinal fusion of C1-C2 spines follows. For this purpose, a C2 spinous process is dissected away at an attachment to the vertebral arch. The C2 spinous process is split in a section with plane extending though a mid-height from an apex of the spinous process to its base to form two extended halves having a width matching that of the spinous process until it splits, and representing two autografts having a cortical layer from one side, and a spongy bone layer - from the other side. The posterior arch of atlas and the C2 vertebral arches are decorticated; each autograft are laid on C1-C2 vertebral arches from each side on the right and on the left from the body mid-line and along to provide a contact mating of the spongy bone layers with the pre-decorticated relevant vertebral arches. The autografts are fixed to the C1 and C2 vertebral arches.

EFFECT: method enables more stable fixation of the upper cervical spine with providing the optimum conditions for the autograft osteogenic modification.

2 cl, 1 ex

The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics, and may be used for traumatic injuries of the C2 vertebra with acute and chronic Atlanto-axial instability.

There are various ways posterior spinal fusion, which provide a record of the rear supporting structures due to different materials and designs [author's certificate SU for invention №1187805, No. 1690720, RU patent for the invention №2328235].

Known posterior spinal fusion of the cervical spine (Movshovich IA Operative Orthopaedics: a Guide for physicians. - 2nd ed., revised and enlarged extra - M.: Medicine, 1994. S-362). Pre-produce autotransplants, which is taken from the iliac crest or use allografts. Through the spinous processes of conducting wire or tape and tighten. Then on the arms of the stack of bone grafts and above them tightly sutured muscle. In some cases, the graft is fixed to the arch wire sutures. In other cases, before tightening the wire suture drawn through the spinous processes, remove megastate ligament between the spinous processes of lay bone graft, then tighten the wire seam and around the stack additional cancellous grafts.

However, in the case of cost the th autograft increases the invasiveness of surgical intervention due to the formation of additional operating zone, what causes pain syndrome, increases the risk of development of infectious-inflammatory complications, lengthens the period of postoperative rehabilitation. In the case of allograft may develop isoimmune incompatibility with graft rejection and delayed the process of remodeling, which significantly increases the time of the formation of high-grade bone block.

Also known way back occipitoparietal on Civano in the modification of Movshovich (Movshovich IA Operative Orthopaedics: a Guide for physicians. - 2nd ed., revised and enlarged extra - M.: Medicine, 1994. S-360), including the fixation of C2 vertebra by conducting wire through holes formed in the occipital bone on both sides of the midline and the hole in the spinous process of the cervical vertebra.

However, this method does not promote formation of bone block due to the lack of use of any plastic material. Fixing wire design for occipital bone and spinous processes is carried out only in one plane, not while rotating component stability Alloplant.

Also known for "the Way back spinal fusion" [inventor's certificate SU for the invention №1674821], including the dissection of the spinous processes and the placement of grafts posleduuschei fixation. Spinous processes cut along a plane passing through the side surface of the top on one side and the midpoint between the top and bottom of the opposite side. The remainder of the spinous process of the cut along a plane passing through the base of the Appendix to the first dissection. Both osteotomy is made with the preservation of the site of attachment of tissue to the spinous processes. A bed for the graft is formed by diluting the fragments of the spinous process.

However, this method of implementation rear fusion is not intended for use at the level of the upper cervical spine, namely the C2 vertebra that is different from the thoracic and lumbar vertebrae adjacent anatomical features. In addition, this method is associated with bone autograft of bone, which significantly increases the invasiveness of the treatment.

The closest analogue to the claimed invention is a method posterior fusion of the upper cervical spine (B.Ni, F. Zhoi, Q. Guo et al. Modified technigue for C1-2 screw fixation and fusion using autogenous bicortical iliac crest graft // Eur. Spine J., 8 (2011), p.8). Perform longitudinal incision in the midline from the external occipital protuberance to the spinous process of C3-C4 vertebrae. Subperiostal naked rear arc in Atlanta side of the middle line 1.5 cm lateral surface and the spinous processes and the pedicles of the axis' - to the outer edge of the facet joints C1-C2 vertebrae. Under the control of the electro-optical transducer is installed in the sagittal plane polyaxial screws cameronsino type in the lateral mass of C1 vertebra and pedicular part of the C2 vertebra on both sides of the midline of the body. Perform installation design by installing two rods in the screw heads with their subsequent strengthening of the locking nuts. To form a C1-C2 fusion produce bone autoplastic by setting tricortone graft taken from the iliac crest, between the arches of C1-C2 vertebrae. Additional fixation autotransplanted concluded between the arches of C1-C2 vertebrae, can be carried out with a wire design, held circular according to the method main ones. After surgery in a predetermined position craniocervical Department fixed collar.

However, this method is associated with bone autograft from the iliac crest, which is accompanied by more traumatic nature of the intervention and often leads to persistent pain in the donor area. In the case described above, the fixing figured transplant for arch of C1-C2 vertebrae is carried out using a wire, which greatly reduces the stability of the rise between the vertebrae and can contribute to its migration, and is accompanied by the risk of damage to the Dura mater at the time of the wire in the epidural space.

The task of the invention is to increase the stability of the fixation of the upper cervical spine due to the formation of fusion formed cortical-cancellous autografts was measured while ensuring optimal conditions for their osteogenic realignment contributing to the formation of high-grade bone block between C1 and C2 vertebrae.

The essence of the invention is characterized by the fact that you are doing the back-median surgical access to the cervical spine, perform subperiostal dissection with exposure of the occipital bone, the back arc Atlanta, spinous process and arc C2 vertebra; carry back Atlanto-axial fixation on both sides of the midline of the body polyaxial combined screw-rod design methodology Harms-Melcher; hold back the fusion of C1-C2 vertebrae, which perform clipping the spinous process of the C2 vertebra at the place of its attachment to the arch of the vertebra, produces a splitting of the spinous process of the C2 vertebra in cross section, the plane of which passes through the middle its height in the direction from the apex of the spinous process to its base, with the formation of two of its length is about-elongated one-half the width, the width of the spinous process prior to its splitting, and represent two of the autograft with one side of the cortical layer, on the other hand - a layer of cancellous bone, then do decortication rear arc Atlanta and the bows of the C2 vertebra and the arc C1-C2 vertebrae are placed on each side, right and left of the midline of the body along it, one received autograft with securing pin mapping layers of the spongy substance of the last pre-decorazione respective arms above the vertebrae, and the autotransplants fixed to the sides of C1 and C2 vertebrae.

States also way back fusion in traumatic injuries of the upper cervical spine, in which the fixation of autotransplants to the arches of C1 and C2 vertebrae is carried out using micro screws.

The technical result of the claimed invention.

The set of features of carrying out the inventive method allows for the posterior fusion of the upper cervical spine, creating optimal conditions for the formation of strong bone block between C1 and C2 vertebrae, which eliminates the possibility of fracture of the eruption and migration installed polyaxial helical structure at the expense of improving the stability of the Atlanto-axial fixation.

Use as retainers autotransplants, taken directly from the zone of the execution of the main surgical intervention and formed from the free spinous process, the removal of which would not violate the biomechanics of the cervical spine, reduces the time of surgical intervention, to reduce its invasiveness due to the lack of creating additional operating areas, to reduce post-operative rehabilitation, to maintain range of motion in the Atlanto-occipital and Atlanto-axial joints.

The possibility of obtaining from the spinous process of the C2 vertebra cortical-cancellous autotransplants with a specific structure of the bone, through the development of the principle of splitting it by passing a section plane through the middle of the height of the spinous process in the direction from top to bottom, most fully meets the requirements of bone reconstructive surgery, because along with the mechanical stability of cortical autocost trabecular bone increases the osteogenic potential of transplants and promotes rapid and complete their revascularization.

The implementation of bilateral laying formed bone autotransplants on the arms of the C1-C2 vertebrae after their preliminary decortication provides the establishment is their bone block in a shorter time by optimizing conditions remodeling of bone tissue.

The formation of posterior fusion between the C1-C2 vertebrae along with the application of the stabilizing combination of a screw-rod design provides three-point fixation of the upper cervical spine, eliminating pathological micromovement in terms of Atlanto-axial instability and inefficiency performed metallothionine.

Way back fusion in traumatic injuries of the upper cervical spine is as follows.

Selection criteria of patients for the performance of the proposed method are:

traumatic damage to the C2 vertebra with acute Atlanto-axial instability;

- chronic damage to the C2 vertebra with the formation of false joints odontoid process and the presence of chronic Atlanto-axial instability;

- simultaneous damage to the C1-C2 vertebrae with evidence of Atlanto-axial instability acute or chronic Atlanto-axial instability

Conduct preoperative clinical intratropical examination, taking into account the obtained results establish the diagnosis.

Lay the patient on the operating table in a prone lying position. Commit head to the bracket. Carry out back-median access to the upper cervical spine. Production is W ill result incision of soft tissues in the cervical-occipital region on the rear-median line from the external occipital protuberance to the spinous process of the C7 vertebra. Perform subperiostal dissection with exposure of the occipital bone, the back arc Atlanta, spinous process and the arc of the C2 vertebra. Carry back Atlanto-axial fixation on both sides of the midline of the body combined polyaxial screw-rod design by conducting compressicauda screws cameronsino type through pedicularia part of the C2 vertebra and the lateral masses of C1 vertebra and subsequent connection compressicauda screws fixing rods in accordance with the methodology Harms-Melcher. Perform intraoperative x-ray control provisions of metalloplastic using electron-optical Converter. Then perform back fusion of C1-C2 vertebrae. Why make the cut spinous process of the C2 vertebra at the place of its attachment to the arch of the vertebra. Produce a splitting of the spinous process of the C2 vertebra in cross section, the plane of which passes through the middle of its height in a direction from the apex of the spinous process to its base, with the formation of two long elongated halves with a width corresponding to the width of the spinous process prior to its splitting, and represent two of the autograft with one side of the cortical layer, on the other hand - a layer of cancellous bone. Make decortication for the her arc Atlanta and bows C2 vertebra until you see signs, the so-called "blood dew". On the arc C1-C2 vertebrae are placed on each side, right and left of the midline of the body along it, one obtained by splitting of the spinous process of the autograft with securing pin mapping layers of the spongy substance of the last pre-decorazione respective arms above the vertebrae. The autotransplants fixed with micro screws to the sides of C1 and C2 vertebrae, each of the stacked autotransplants enter, for example, four screws, two of which are fixed to the arc of the C1 vertebra, and the other two - to the arc of the C2 vertebra. To the area of surgical intervention set the active drainage, which is brought out through contraportada. Carry out layer-by-layer closure of surgical wounds. Cervical spine immobilized rigid orthosis.

Example.

Patient M., aged 35, was admitted to the neurosurgery Department with the diagnosis: "Closed uncomplicated injury of the upper cervical spine. Old fracture of the odontoid process of the C2 vertebra, type III by Anderson D Alonso. Pseudarthrosis of the odontoid process of the C2 vertebra. Chronic Atlanto-axial instability".

The patient received a closed injury of the upper cervical spine for three months before admission to the hospital. From the anamnesis it is known that the patient on Odessa treated in the trauma ward, where he underwent closed reduction odontoid process of the C2 vertebra and the fixation of the cervical spine in Halo machine. During the test intratropical survey noted restore correct anatomical relationship between the body and odontoid process of the C2 vertebra with signs of lack of consolidation in the fracture area. When performing functional tests mentioned redundancy inflections, extensii and rotation with the emergence of pain in the cervical-occipital region, which testified to Atlanto-axial instability.

Had undergone a surgical intervention by the above method, comprising the posterior Atlanto-axial fixation technique Harms-Melcher, posterior Atlanto-axial fusion of the cortical-cancellous autografts was measured, formed from the spinous process of the C2 vertebra, with additional fixation to arcs C1-C2 vertebrae with micro screws.

After surgical intervention was carried out by immobilization of the cervical spine rigid brace for a period of 3 months.

During x-ray study 6 months after surgical intervention, noted the satisfactory position of the metal and the formation of bone block between C1 and C2 vertebrae. the ri clinical examination revealed no signs of Atlanto-axial instability and preservation of range of motion in the Atlanto-occipital and Atlanto-axial joints.

1. Way back fusion in traumatic injuries of the upper cervical spine, characterized by the fact that you are doing the back-median surgical access to the cervical spine, perform subperiostal dissection with exposure of the occipital bone, the back arc Atlanta, spinous process and arc C2 vertebra; carry back Atlanto-axial fixation on both sides of the midline of the body polyaxial combined screw-rod design methodology Harms-Melcher; hold back the fusion of C1-C2 vertebrae, which perform clipping the spinous process of the C2 vertebra at the place of its attachment to the arch of the vertebra, produces a splitting of the spinous process of the C2 vertebra in the cross-section, the plane of which passes through the middle of its height in a direction from the apex of the spinous process to its base, with the formation of two of its longest-elongated halves with a width corresponding to the width of the spinous process prior to its splitting, and represent two of the autograft with one side of the cortical layer, on the other hand - a layer of cancellous bone, then do decortication rear arc Atlanta and the bows of the C2 vertebra and the arc C1-C2 vertebrae are placed on each side, right and left of the midline of the body along it, one is mu received autograft ensuring contact mapping layers of the spongy substance of the last pre-decorazione respective arms above the vertebrae, with autotransplants fixed to the sides of C1 and C2 vertebrae.

2. The method according to claim 1, characterized in that the fixation of autotransplants to the arches of C1 and C2 vertebrae is carried out using micro screws.