open reduction decompression and internal fixation

Special characteristics of Thoracolumbar Spine and Spinal Cord Injury and Requirement of Surgical Treatment 1. The thoracolumbar spine consists of chest 11, chest 12 and waist 1. It is the junction of the thoracolumbar and the chance of injury. The paraplegia occurring here accounts for about half of the traumatic paraplegia. This part has a large range of motion, which often causes instability of the spine after spinal injury and requires internal fixation to restore stability. Commonly used in the posterior internal fixation of RF, AF, the angle between the screw and the connecting rod can help to reduce the vertebral fracture. The front road is fixed with a Z-steel plate, etc. It is easier to install than the Kaned device and has titanium, which does not hinder the MRI inspection. 2. The fracture and dislocation of the spine should be rectified. The purpose of the rectification is to restore the normal physiological curvature of the spine and relieve the compression of the spinal cord. There are three aspects of the deformation of the spinal fracture and dislocation, namely dislocation, increased posterior arch angle and vertebral compression. Therefore, the criteria for reduction include: 1 complete dislocation of dislocation; 2 posterior arch angle of the spine returns to normal, within 10° of the thoracolumbar segment; 3 the height of the anterior margin of the compressed vertebral body should be restored to 80%. To achieve this standard, although the internal fixator can be used, it is best to stretch the spine up to 45°. When the over-extension is 30°, although the dislocation can be completely reset, the posterior arch angle of the spine often does not return to normal, and the anterior edge of the vertebral body is less than 80%. Therefore, when the operation is reset, the operating table needs to reach an extension of 45°. 3. The spinal cord of the thoracolumbar segment includes the lumbosacral spinal cord, the cone and the lumbosacral nerve root. The cone is compressed to cause sphincter and dysfunction. The recovery rate of nerve root injury is higher than that of spinal cord injury. For patients with incomplete paraplegia with cone and nerve root compression, decompression surgery has a good chance of recovery. Dislocation of the thoracolumbar spine can severely damage the upper spinal cord. Spinal injury can damage the root artery. In the absence of collateral circulation, spinal cord necrosis can be caused by the artery. The paraplegia planes of these two injuries are higher than the fracture dislocation plane, and the incidence can be as high as 30%. In other patients, spinal cord injury in the thoracolumbar region can affect the blood supply to the spinal cord, such as the anterior spinal cord, resulting in long-term ischemia of the spinal cord and spinal cord atrophy. MRI and selective spinal angiography can be diagnosed. Clinical neurological examination of the paraplegia plane is higher than the number of planes of the spinal cord injury, and the lower limbs become soft palate, which can be used as a basis for diagnosis. These conditions indicate that the possibility of severe recovery of spinal cord injury is very small and can be used as a reference for surgical treatment. For such patients, spinal injury should be used as the basis for selecting surgery. 4. Thoracic and lumbar spine injuries, the most common are compression fractures, fracture dislocations and burst fractures. Both the posterior or posterior vertebral bodies of the vertebral body compress the spinal cord and require lateral decompression. 5. About bone graft fusion. Thoracolumbar fracture and dislocation or fracture with posterior ligament injury, although it can heal after reduction, but the posterior ligament rupture becomes scar healing. If there is no interbody bone bridge formation, spinal instability may occur, so the acute injury is open and reduction. When the internal fixation is performed, bone graft fusion should be performed. Treatment of diseases: spinal cord injury Indication Open reduction and decompression internal fixation is applicable to: 1. Chest 11 ~ waist 1 fracture dislocation with paraplegia. 2. Thoracolumbar compression fracture with posterior ligament rupture, instability with paraplegia. Contraindications Old fractures and dislocations over 2 weeks will be difficult to reset. Preoperative preparation 1. There must be a clear X-ray film to determine the type of spinal injury, with or without joints, with or without burst fractures and fractures. Fracture and dislocation may also be accompanied by a burst fracture. After the reduction, the fracture of the front of the spinal cord should be examined for compression. 2. The extent of spinal cord injury should be estimated based on clinical neurological findings and X-ray findings to determine whether to detect the spinal cord. If the dislocation of the spine is not serious, accompanied by complete paraplegia or severe insufficiency, as long as the general condition permits, emergency surgery should be performed. 3. In order to achieve a good reduction, the appropriate operating table should be selected. When the patient is lying on the operating table, the upper half of the operating table can be raised 50° to the lower half, so that the spine is overextended. Surgical procedure 1. Incision revealed With the fracture and dislocation as the center, 4 to 5 laminae were exposed. 2. Reset For the dislocation of the jointless joint and the compression fracture or burst fracture, the extension and extension can be directly performed, so that the upper part of the operating table is gradually raised to make the spine overextension, and the assistant and the surgeon respectively lift the dislocation of the spinous process and up and down. Vertebrae. If the reset is not good, it can be lifted repeatedly (dislocation of the vertebra) - down pressure (in situ vertebra) - re-pull - then press down, cycle several times, more can be reset, the general operating table can stretch 30 ° Dislocation reset. However, in order to achieve the disappearance of the posterior arch angle and the compression of the vertebral body, it is necessary to extend 45°. The basis for achieving the reduction criteria during the operation was: 1 the upper and lower 3 spinous processes were equally wide; 2 the articular joints were completely repositioned; 33 laminas were in the same plane (the dislocated lamina was centered). For the reduction of joint interlocking, the reduction method is the same as that of the cervical vertebrae, but two periosteal screwdrivers are required to be inserted between the dislocated articular processes, and the dislocation of the lower joints to the lower vertebral articular processes (while pulling the spinous processes) , then stretch and reset. For the reduction of the burst fracture, such as the preoperative CT when the fracture block is displaced backward, the pedicle screw and the screw can be fixed. 3. Laminectomy to detect decompression and treatment of the spinal cord Inverted plate resection, exploration, spinal cord cold therapy and other indications and methods of the same neck and thoracic vertebrae, such as the front of the spinal cord, can be compressed by one side of the pedicle, or the reduction of the fracture block, the same way as the thoracic vertebrae. 4. Internal fixation The pedicle screw is fixed in the upper and lower vertebrae of the fractured vertebra and screwed into the pedicle screw. The transverse process of the supraspinal spine and the posterior lateral aspect of the superior articular process are revealed, and the intersection point of the transverse midline and the lateral aspect of the superior articular process is used as a nailing point. Here, there is often a secondary process to bite it off, and after the cortex is punched, Hand cone or guide cone or small curette, drilled into the pedicle, preferably without sharp drill to prevent drilling the pedicle cortex, using the curette method is not easy to scrape the pedicle cortex, scraping or drilling The direction of advancement is at an angle of 10° to the midline of the spinous process, parallel to the upper edge of the vertebral body. 5. Avoid pedicle screw position deviation In order to avoid the positional deviation of the pedicle screw, a Kirschner wire can be inserted first, and the position of the pedicle screw is determined by fluoroscopy or filming, and then the pedicle screw is screwed. Then over-retract and reset the upper connecting rod to level the operating table. 6. Bone graft fusion For patients with severe dislocation, patients with anterior interspinous and interspinous ligament rupture, there is instability of the spine after healing, and the dislocation gap can be fused. The joints on both sides of the dislocation gap were removed from the articular surface, and the surface was roughened. The two transverse processes were also rough, and the bone fragments of the same length from the posterior superior iliac spine were about 1.5 cm wide and A few pieces of thin bones are planted on the two transverse processes. If the transverse process is large enough, it can be fixed by one screw. Otherwise, it may not be fixed, and the bone piece is covered on the joint surface and the transverse surface of the transverse process. For those who have undergone disc herniation, the fibrous bone can be scraped and the broken bone is implanted between the vertebral bodies. 7. Close the incision The negative pressure drainage tube was placed and sutured layer by layer.