Subtotal vertebral resection, decompression and fusion for cervical spondylosis

Cervical anterior vertebral subtotal decompression is a currently used procedure. Compared with the enlarged decompression of the ring saw, the decompression range is large, and the normal bone sacrifice is sacrificed, so the circular saw has been gradually replaced by decompression. Treatment of diseases: cervical spondylotic myelopathy Indication Cervical spondylosis subtotal resection and decompression fusion is applicable to: 1. Cervical spondylotic myelopathy, with clear diagnosis, regular non-surgical treatment, no relief of symptoms and signs. 2. Cervical spondylotic myelopathy, clinical symptoms and signs progressively worsened, or sharply aggravated in the short term, should be operated as soon as possible. 3. Acute traumatic cervical disc herniation, caused by trauma, resulting in complete or incomplete paralysis of the extremities. 4. Mixed cervical spondylosis with spinal cord and nerve root compression, severe symptoms, affecting life and workers. 5. Multi-segment or severe cervical spondylotic myelopathy, where the spinal cord is compressed and has a wide range, it is necessary to expand the decompression. 6. Cervical vertebral fracture with spinal cord compression or old fracture and dislocation combined with incomplete spinal cord injury, and there are a wide range of pressure-induced substances. 7. Some cervical posterior longitudinal ligament ossification, such as continuous type, mixed type, multi-segment decompression can make the bones floating, which helps decompression. Contraindications 1. The general condition is poor, or combined with important organ diseases, can not bear the surgical trauma. 2. Combined with other diseases such as ossification of the posterior longitudinal ligament of the cervical spine. 3. The diagnosis is not clear. Although there are symptoms similar to cervical spondylosis, there are doubts about imaging examination and nervous system examination. 4. Older patients, who lose normal self-care ability, can not cooperate with preoperative preparation and postoperative treatment is not suitable for surgery. 5. Cervical spondylosis has a long course of disease, combined with quadriplegia, muscle atrophy, and joint stiffness, indicating severe spinal cord injury. Even if decompression, spinal cord function is difficult to recover. Preoperative preparation 1. Move the trachea and esophagus training Especially for intraoperative anesthesia with cervical plexus block, the trachea and esophagus must be trained before surgery. The anterior cervical approach is to reach the front of the vertebral body through the gap between the visceral sheath and the vascular nerve sheath. Therefore, the visceral sheath should be pulled to the opposite side during the operation to reveal the front or side of the vertebral body. If the preoperative traction is not satisfactory, the operation may be suspended due to the inability to pull the trachea. If it is barely carried out, it may damage the trachea or esophagus, and even cause postoperative laryngeal spasm and edema. The training method is that the patient or another person uses the 2 to 4 fingers to insert the visceral sheath and the vascular sheath gap on the side of the incision outside the skin, and continuously moves to the opposite side. At the beginning, it lasts for 10 to 20 minutes, and then gradually increases to 30 to 40 minutes. The trachea must be pulled through the midline and trained for 3 to 5 days. This kind of pulling is easy to stimulate the trachea to cause symptoms such as reflex dry cough, and it is necessary to repeatedly explain the importance to the patient. 2. Bed urination, defecation training There will be several days of bed rest after surgery. In order to reduce the urinary tract infection caused by postoperative urination, defecation, and catheterization, urination and defecation exercises must be performed before bed. Surgical procedure 1. Incision, exposure and positioning For the reduction during the operation, the right anterior oblique incision is used in the anterior cervical approach. The incision has a wide field of view and the incision is loose, which facilitates intraoperative traction. For patients who underwent anterior decompression alone, the right transverse incision of the anterior cervical approach may be used. The incision has a small scar and a good postoperative appearance. The length of the slit is generally 3 to 5 cm. Cut the skin and subcutaneous tissue, cut the platysma muscle, and perform blunt and sharp separation on the deep side of the platysma muscle after hemostasis, 2~3cm above and below, and expand the longitudinal exposure range. The medial edge of the sternocleidomastoid muscle and the visceral sheath are loose, which is an ideal surgical approach. Accurately determine the carotid sheath and the visceral sheath of the neck, and the fascia between the medial aspect of the sternocleidomastoid and the visceral sheath of the sternocleidosis is lifted and cut open, and the lesion is expanded upward and downward along the gap. The department is a loose connective tissue that is easy to separate. The scapular lingual muscle can be seen on the outside of the cervical visceral sheath and can be directly exposed from the inside or from the outside. During the operation, the fingers were blunt loosened along the separated gaps, and then gently separated deep into the vertebral body and the front of the disc. When the superior thyroid artery is exposed, the superior laryngeal nerve is seen above it. If not seen, there is no need to probe and dissociate to avoid damage. After the cervical visceral sheath and carotid sheath are separated, the trachea and esophagus are pulled to the midline by a hook, and the carotid sheath is pulled to the right side to reach the vertebral body and the intervertebral disc space. Use the long scorpion to lift the anterior fascia and then cut it layer by layer, then longitudinally separate the fascia, and gradually enlarge the exposed vertebral body and intervertebral space, usually 1 or 2 intervertebral discs. Separation of the two sides should not exceed 2 to 3 mm of the medial edge of the long neck muscle. If the lateral separation is too large, it may damage the vertebral artery and sympathetic plexus that pass through the transverse process. Fresh cervical spine trauma with vertebral fracture or anterior longitudinal ligament injury, can be positioned by visual observation. For old fractures or simple intervertebral disc injuries, it is sometimes difficult to distinguish under direct vision. The most reliable method is to remove the tip of the injection needle to retain the length of 1.5cm, insert the intervertebral disc, and take the lateral cervical X-ray film according to the X-ray film or C. The arm machine is positioned in perspective. 2. Open the vertebral body At present, there are many cervical vertebral body expanders. Screw the spreader screws into the center of the upper and lower vertebral bodies of the diseased vertebrae, insert the spreader on the open screw, and open the upper and lower ends. Opening the vertebral body is beneficial to restore the height of the damaged vertebral body and intervertebral disc, reduce the compression of the spinal cord, and facilitate the operation when performing vertebral body resection. 3. Decompression Determine the upper and lower intervertebral discs of the fractured vertebral body, cut the annulus fibrosus with a sharp knife, and remove the broken intervertebral disc tissue with the nucleus pulposus. The three-joint rongeur was used to bite the anterior cortical bone and most of the cancellous bone of the fractured vertebral body. When the vertebral body is close to the posterior edge of the vertebral body, the disc and the endplate are scraped off with a curette. The gap between the posterior margin of the vertebral body and the posterior longitudinal ligament is separated by a nerve stripper, and the thin impact rongeur is gradually inserted into the vertebral body. The posterior cortical bone is bitten, and a rectangular decompression groove is formed at this time, and the posterior longitudinal ligament is swollen. Carefully use the impact rongeur or curette to enlarge the bottom edge of the pressure relief groove and completely remove the pressure. If the posterior longitudinal ligament has scar formation, the posterior longitudinal ligament can be hooked with a nerve stripper or a posterior longitudinal ligament hook under direct vision, and the posterior longitudinal ligament is gradually removed with a sharp knife to complete the decompression. 4. Bone graft Adjust the height of the vertebral body expander to restore the height of the cervical anterior column to normal. A rectangular bone graft is drilled at the sputum, and after being trimmed, it is implanted into the pressure relief groove, and the vertebral body spreader is loosened to make the bone graft block tightly and the bone graft is completed. It is also possible to use a titanium mesh cage with a diameter of 10mm or 12mm to trim the length to match the height of the decompression zone. The cancellous bone obtained by the vertebral body resection is stuffed in the titanium mesh cage and implanted in the decompression zone to avoid cutting the humerus. The pain and complications that can occur to the patient. 5. Fixed For cervical vertebrae burst fractures, especially those with titanium mesh grafts, cervical anterior plate fixation should be used. Plate fixation allows for immediate stability of the cervical spine for post-operative care and early recovery. At the same time, the use of internal fixation is beneficial to the healing of the bone graft, and the height of the vertebral body is maintained during the healing process, and the bone graft is prevented from collapsing during the healing and crawling replacement process, thereby causing the cervical curvature to disappear. 6. Suture incision Rinse the wound repeatedly with saline, suture the anterior cervical fascia, place a half-tube drainage strip, and suture the incision layer by layer. complication 1. Spinal cord and nerve root damage. 2. Vertebral artery injury. 3. Esophageal and tracheal injuries. 4. Postoperative local hematoma formation. 5. Upper laryngeal nerve and recurrent laryngeal nerve injury.