Spinal canal-spinal cord exploration

The spinal canal-spinal exploration is to determine the nature and extent of the lesions in the spinal canal through the laminectomy of the relevant site, to treat the lesions, and to relieve the compression of the spinal cord and nerve roots. Treatment of diseases: epidural abscess cervical disc herniation Indication 1. Acute closed spinal cord injury has the following conditions: 1 secondary progressive spinal cord compression symptoms, lumbar puncture confirmed cerebrospinal fluid circulation pathway obstruction. 2 have spinal cord dysfunction with intraspinal broken bone fragments or other foreign bodies. 3 severe spinal fracture or dislocation, accompanied by paraplegia and cerebrospinal fluid circulation pathway obstruction. 4 broken bone tablets compress the spinal nerves causing pain. 5 spinal fractures require surgical reduction. 2. Open spinal cord injury. 3. In the late stage of spinal cord injury, the following conditions have symptoms of compression: 1 giant osteophyte formation after spinal fracture. 2 damaged arachnoid or cyst formation. 3 damaging dural meningitis or hypertrophy of the ligamentum flavum. 4 foreign body in the spinal canal or granuloma formation. 4. Intraspinal tumors (including epidural, extramedullary, intramedullary and intramedullary tumors). 5. Epidural abscess. 6. Congenital spondylolysis with bulging of the meninges (spinal cord). 7. Severe cervical spondylosis or vertebral hyperosteogeny, spinal stenosis accompanied by obvious compression of nerve roots. 8. Disc herniation. Preoperative preparation 1. Non-urgent patients should start skin preparation before 3 days, and then disinfect and dress before surgery. If you are in an emergency, you should prepare your skin carefully and disinfect it. 2. Prevent the occurrence of hemorrhoids. If it has already occurred, he should be treated properly before surgery. 3. If the patient has urinary tract infection or high fever, it is necessary to control acute infection, and surgery should be performed after the body temperature drops. 4. For high paraplegia, respiratory insufficiency, should pay attention to prevention and control of lung infections, especially for the elderly. 5. Anemia patients should receive a small number of blood transfusions before surgery, and blood preparation during surgery is about 400ml. Surgical procedure 1. Position: lateral position or prone position, cervical spine surgery can take a seat. The lateral position has less impact on the patient's breathing and the anesthesia management is more convenient. In addition to the lesions need to use the left lateral position, the right lateral position is generally used to reduce the pressure on the heart and stomach. The neck pad is soft so that the longitudinal axes of the neck and thoracic vertebrae are identical. The right arm and the right shoulder should be extended forward, and the soft pillow should be placed under the right armpit to prevent the right upper limb from being pressed. The left hip has knee flexion and a soft pillow between the legs. The assistant can also see the surgical field in the prone position. The shoulders are placed on the head frame and the position can be slightly lower to reduce the loss of cerebrospinal fluid. For neck surgery, the head is slightly tilted forward to make the cervical kyphosis, to widen the spinous process and laminar space, and facilitate the operation. The sitting position is only suitable for non-injured cervical spine surgery. The patient sits on the sitting chair, the neck is bent forward, and the head is supported by the head frame. 2. Incision, exposure (for thoracic laminectomy, spinal exploration as an example): the median incision of the back, generally should include 1 to 2 laminas above and below the lesion, the length depends on the extent of the lesion. Cut the skin, subcutaneous tissue and fascia, reveal the supraspinous ligament, and cut the supraspinous ligament along the middle of the spinous process to reach the bone. Because the spinous process is sacral, when the muscle is attached along the bone edge, the blade should be close to the bone edge and slightly outward. When cutting to the edge of the spinous process, the blade is slightly inward to avoid cutting into the muscle, causing unnecessary Bleeding. Then insert the periosteal stripper, close to the spinous process and lamina, peel off the sacral spine muscle under the periosteum, reach the articular process, and then use dry gauze to fill the hemostasis. Use a relatively wide periosteal stripper when peeling off, always peel the laminectomy, hold the stalk of the periosteal stripper in the right hand, and stabilize the anterior segment of the periosteal stripper with the left hand to prevent the periosteal stripper from breaking into the ligamentum and inserting into the spinal canal. Cause accidental injury. Those who have had laminar damage should pay more attention. In this order, the side of the spinous process is first removed, and then the opposite side is peeled off until the spinous processes in the incision are all peeled off. Then, the dry gauze is taken out in order, the sacral spine muscle is retracted by the periosteal stripper, the residual muscles on the lamina are cut, and the large gauze is stuffed to stop bleeding. Wait a few minutes, after the hemostasis, use an automatic dilator to open the muscles and reveal the lamina. If there is still residual muscle or adipose tissue on the lamina, it can be cut off. If the muscle still has oozing blood, it can be stopped by hot saline gauze to stop bleeding or electrocoagulation. 3. Excision of the lamina: The spinous process of the thoracic spine is inclined downward, and the upper spinous process is pressed against the next lamina, and the upper and lower laminae are covered in a tile-like shape. Therefore, when the thoracic lamina is removed, one spine should be bitten up and down, and the lamina should be removed from the bottom up. The interspinous ligament is first cut, and then the spinous process is used to bite the spinous process at the root of the spinous process, so that the lamina in the midline is thinned and easy to be removed. First use the side angle head double joint rongeur to identify the ligament of the ligamentum flavum from the lower edge of the lowermost lamina to be removed, and bite a lamina outside the ligamentum flavum. The ligamentum flavum connects the superior and inferior vertebral arches, and the outer edge reaches the posterior edge of the intervertebral foramen. The ligamentum flavum is cut transversely with a knife, and the dura mater is placed in front of the lamina to separate the gap between the ligamentum flavum and the epidural fat. In order to avoid accidental injury to the dura mater when the lamina is removed. Then, the rongeur is placed from the gap, and the lamina is bitten down and up, and generally 2 to 3 are bitten first. It is best not to damage the joints on both sides of the lamina. Otherwise, spinal instability and low back pain will occur after surgery. If the articular process must be removed due to the removal of the lesion, it should not exceed 1 or 2, and try to keep the other joint. Sudden. The lamina adjacent to the articular process can be trimmed with a mastoid rongeur to achieve total laminectomy. If the lesion is estimated to be on one side or lateral side, it can also be treated with unilateral laminectomy and enlarged if necessary, so that some patients may preserve spinous processes and part of the lamina. No matter what kind of rongeur can not penetrate into the spinal canal when biting off the lamina, it will easily damage the spinal cord. The rongeur should be fully opened and placed in the spinal canal. The surgeon holds the forceps in one hand and holds the rongeur with one hand and bites with the upward force to prevent the rongeur from sliding down the bone edge and damaging the spinal cord. Bone bleed with bone wax to stop bleeding, epidural venous plexus bleeding can be used to stop bleeding by bipolar coagulation or gelatin sponge, generally easy to control. 4. Exploring the spinal canal and spinal cord: The incision is completely hemostasis, rinsed with normal saline, and the line around the wound can be used to detect the wound. Epidural exploration includes the presence or absence of destruction of the lamina, the amount of epidural fat, and the presence or absence of necrosis, the presence or absence of tumors, granulomas, or abscess formation. Then separate or remove the fat layer along the midline to reveal the dura mater, explore its color and pulsation, and use the fingers to palpate the tension of the dura mater and whether there is a localized bulge. If the lesion of the posterior margin of the vertebral body or the herniated disc (rare thoracic vertebrae) is suspected, the dura mater may be pulled open to one side for exploration, but the epidural venous plexus bleeding should be prevented. Dural exploration can be performed if deemed necessary. First, a traction line is sewed on both sides of the dura mater. The mosquito wire clamp is used to clamp and lift the traction line. A small knife is cut between the two traction wires with a sharp edge knife to cut only the dura mater and retain the arachnoid. Place the slotted probe to lift the dura mater. Cut along the slot with a sharp edged knife. Generally, you can cut 2 to 3 cm first, and then expand the incision and cut the arachnoid as needed. Intradural exploration involves observing the luster, color, presence of hypertrophy, arachnoid transparency and luster, presence or absence of adhesions, hemorrhage or cyst formation, thickness of the spinal cord, whether it is displaced, smooth, surrounded by No swelling, abnormal blood vessel distribution, etc. If you need to explore the front of the spinal cord, find the dentate ligament on the side of the spinal cord between the upper and lower nerve roots]. After being clamped with a mosquito-type forceps, the dentate ligament is gently pulled to the opposite side by 30° to 45°, and the front of the spinal cord can be probed, and the posterior edge of the intervertebral space is examined with a dissection device for disc herniation. This kind of exploration must be gentle, and it is not possible to loosen the spinal cord with a loose device to prevent damage. If the spinal cord is not pulsating, the presence or absence of obstruction above the incision should be explored. The soft catheter can be wetted with water and then slowly extended from the subarachnoid space. If there is no obstruction, it can be patency. If necessary, use the same method to explore downward. If the spinal cord has a localized bulge, and the lesion is confirmed by the frontal exploration of the spinal cord in the intramedullary can be seen, there may be fluctuations. If necessary, a fine needle can be used to penetrate along the posterior median groove; for example, aspirate fluid, hemorrhage or tumor tissue The spinal cord can be cut along the midline with a sharp-edged knife to detect the marrow and remove the lesion. 5. Close the dura mater and incision: After the exploration, flush the spinal cord cavity, completely suspend the suture and suture the dura mater without disposing the arachnoid membrane. If the spinal cord decompression is needed, the dentate ligaments on both sides can be cut, the dural is cut as much as possible, and the surrounding fascia is repaired and sutured. The sacral spine muscles are sutured in 2 to 3 layers, and the subcutaneous tissue and skin are also tightly sutured, leaving no dead space to avoid hematoma or cerebrospinal fluid leakage. After the operation, the extradural drainage tube was taken out from the incision and removed 24 to 48 hours.